..•-v£3528 igj:.i>BJ§ u~~ ] !k«^MM ,1'" jjpH ".H.I1-'-- Br"*" SJSSgaiA^v. B&ftS" ;jjaa^>^ •^sraes i ,M.KWWWK; ^V*.. -__^j-jlj +-^~ mm*' ' •*-J*^**C*__ fc» ■ »■ » ^» a ■ * *♦— ►—.»••- — * J""^ , I»RV OF MEDICINE NLfl QQlObbbS 1 NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service NLM001066651 THE & PRACTITIONER'S MANUAL A CONDENSED SYSTEM OF MEDICAL DIAGNOSIS AND TREATMENT BY CHARLES WARRENNE ALLEN, M.D. Consulting Genito-Urinary Surgeon to the City (Charity) Hospital. Consulting Derma- tologist to the Randall's Island Hospital ; to the Hackensack Hospital ; to the Bayonne Hospital ; to the Infant Asylum of the Holy Rosary. Attending Surgeon to the Good Samaritan Dispensary (Department of the Skin), Etc. NEW YORK WILLIAM WOOD ANT) COMPANY 1899 we A425f 1899 "Qui Bene Dignoscit Bene Curat." Copyright, 1898, By WILLIAM WOOD & COMPANY PRESS OF THE PUBLISHERS' PRINTING COMPANY 32-34 LAFAYETTE PLACE NEW YORK PREFACE. La Bruyere said it was as difficult to select well as to origi- nate. Believing that verbosity is not a virtue, the writer, in his efforts to make a practical, useful, and at the same time concise book, has found selective condensation the chief diffi- culty. Arguing that there is an abundance of text-books, stu- dents' manuals, and systems of medicine, from which to sup- plement, this work is presented to the busy practitioner as affording a quick method of securing the views of the leaders in medical thought. In this respect it is practically a con- densed system, representing the writings of a large number of eminent authors. Much of the material is in the nature of original contributions, having been written in answer to a cir- cular letter announcing the scope of the work. To all those who have so courteously responded to the au- thor's request for personal methods and formulae or therapeutic suggestions, the writer desires to extend his grateful acknowl- edgments. Likewise to those authors who have so unhesitat- ingly given permission to quote their recent writings. By giving in succession the recommendations of several equally distinguished authors, the reader is enabled to select the one he will follow, or if one plan of treatment does not succeed another may be tried. "Cautions" have been freely interspersed, on the theory that to do no harm is often the equivalent of doing good. While single-drug medication, aimed at securing definite physiologic effect, is to be preferred to the shotgun prescription. aimed at nothing and expected to hit the mark, still judicious IV PREFACE. combinations are often of the greatest value, one drug enhanc- ing the effect of another. The smallest dose which will accom- plish the result is always preferable. Heroic dosage is never to be withheld because it "savors of old-time physic." The fathers of medicine were not all fools. The therapeutic value of water is recognized, and frequent reference has been made to hydrotherapeutic measures. When it was written, "Man doth not live by bread only," it might have been added, "and is not cured exclusively by water." Diagnosis must of necessity be at the foundation of all suc- cessful therapeutic effort. Proper remedies are difficult to find, only because accurate diagnosis (including remote causes and actual pathologic changes) is not easy. In order to keep within the bounds of required brevity, only the newer points in diagnosis and the essentials of treatment have been given in certain chapters, reliance being placed upon the reader's general knowedge of the subject and his ability to consult more pretentious works for further detail. Making scientific exactness and uniformity in nomenclature subservient to useful expediency, the author has allowed such symptomatic designations as "diarrhoea," "headache," and " jaundice" to stand at the head of certain chapters. Some subjects usually neglected in text-books have received lengthy consideration; conversely, others have been made brief. Tables of equivalents have been added in an Appendix, since many for- mulae have been published in the terms in which they were originally written. To Dr. E. Franklin Smith, Dr. Albert D. Mayer, and Dr. Jacob Sobel, the writer's especial thanks are due and are grate- fully extended for valuable aid in arranging the material, assisting in the proofreading, and making possible a prompt completion of the work. THE PRACTITIONER'S MANUAL. Abscess of the Brain. There is here often a history of injury about the head or of ear disease to arouse suspicions. Diagnosis.—The temperature is oftentimes subnormal, and is never very high unless meningitis or some other compli- cation exists. The pulse is slow, giving us a most valuable indication in the presence of headache and obscure mental disturbances, with vomiting, convulsions, and perhaps paral- ysis. Any existing cause for abscess, such as chronic otitis media, trauma, or cranial-bone disease, gives material aid in arriving at a diagnosis. Differentiation.—Tuberculous meningitis may give many of the same symptoms, but it runs its course much more rapidly. Traumatic apoplexy (one-side) may closely resemble it. Encephalitis (non-purulent hemorrhagic) likewise, but a beginning marked by high temperature opposes the diagnosis of abscess. Hysteria may be present to confuse, or the symptoms in abscess of otic origin may simulate it. Tumor of the brain is distinguished with difficulty when pressure symptoms predominate. In the latter there are local paralysis, choked disc, headache of gradual increase, absence of chill and sweat, and the course is slower. Treatment.—In suspected cases trephine. The physician who has not the courage to recommend an exploratory operation in a strongly probable case of abscess of 1 2 the practitioner's manual. the brain lest he may be wrong in his diagnosis, is more solici- tous for his own reputation than for the welfare of his patient. —ESKRIDGE. Abscess of the Breast. Threatened abscess is diagnosticated when overdistention occurs at the interruption of lactation, or when heat, swelling, knotting of the ducts, and tenderness follow a fissure or abrasion about the nipple during the nursing-period. Epidemic mastitis, presumably due to some infection, has been observed in a num- ber of nursing women subjected to the same surroundings, with- out skin lesion about the breast, or mouth lesion in the case of the infant, being discoverable. Severe rigor followed by high fever marked the onset. Prognosis is usually favorable. Extensive sloughing of the skin over the chest wall might prove fatal. In strumous subjects especially, chronic inflammation may result in pus collection, which is slow to reach the surface. Treatment.—To prevent before induration occurs, forcibly express by hand from half a pint to a pint of milk, under nitrous- oxide gas if necessary. Apply belladonna ointment freely and over it a large sponge compress; or put on a figure-of-eight bandage. Give aperients and small frequent doses of tincture of aconite. Lactation may produce recurrence and necessitate withdrawing the infant. Surgical measures when pus is lo- cated. In the chronic form, the infant should be weaned without delay.—Gross. Abscess of the Lung. If after a pneumonia or other inflammatory affection the chest presents evidences of cavity without manifestations of tuberculosis, abscess may be suspected. Diagnosis.—Copious expectoration of pus mixed with elastic ABSCESS, MEDIASTINAL. 3 fibres and blood pigment, together with a percussion note which is dull when the cavity is filled and tympanitic when the matter is coughed up, points to this condition. Deeply situated cavi- ties give out a respiratory tympanitic percussion note when empty, as after spontaneous discharge through the mouth. Small multiple abscesses of embolic origin are diagnosticated by the known primary source of sepsis likely to result in this condition. Pus may be located by an exploring-needle or by Paquelin- cautery opening and introduction of a director.—Carl Beck. Differentiation from phthisis by absence of tubercle bacilli. From bronchial disease by the presence of lung tissue or elastic shreds in the foul-smelling pus. Prognosis.—In multiple septic abscess due to embolism the outlook is bad. In single large abscess of benign nature con- traction of the walls may follow complete evacuation. Treatment.—Pleurotomy, pneumotomy, evacuation, and drainage for cavities externally situated. In a week after operation give strophanthus and caffeine.— Beck.21 Abscess, Mediastinal. Occurring almost as frequently as cancer in the same situation, we have substernal pain, chills, sweats, and occasion- ally history of injury to guide us. Diagnosis.—Dyspnoea is present only if the collection is of such dimensions as to press upon the organs of respiration. There are fever, throbbing, and perhaps fluctuation at the margin of the sternum or in the suprasternal notch. Caries, pyaemia, empyema, or lung abscess preceding pressure symp- toms should direct attention to this condition. Differentiation from growths causing pressure symptoms is difficult. Aneurism gives more pain and has its own peculiar signs. Cancerous growth, if of long standing, shows secondary 4 the practitioner's manual. metastatic deposits, cachexia, etc. Hemorrhage following in- jury develops rapidly. Treatment.—If the pus can be reached it should be evacu- ated. Abscess, Psoas. Whether the result of strain or of preceding spinal caries, the symptoms, which may be obscure, at times simulate those of chronic malarial poisoning, at others of perityphlitis, but in the latter there are intestinal instead of spinal symptoms, the constitutional symptoms are more marked, and the tumor appears more suddenly. Treatment.—After lumbar incision, irrigation, etc., such a tonic as— R Syrupi ferri, quininae et strychninee phosphatis................ § iv. S. Teaspoonful in water three times daily. —Potter. Acetonuria. Diagnosis.—This toxaemia, which derives its importance from being quite constantly found in the terminal stages of diabetes (probably producing at times diabetic coma), is diagnos- ticated by a sudden sharp attack of abdominal pain attended with nausea and sometimes vomiting, dyspnoea, panting res- piration, marked restlessness, delirium often developing within a brief period, irregular pulse, subnormal temperature, and a peculiar odor of the breath. Acetone, which in diminutive amounts may be found in the healthy urine, is here largely increased, and if accompanied by the presence of sugar may be regarded as pathognomonic of diabetes. The greater the amount of acetone excreted, the greater the danger of a rapidly fatal termination of the dis- ease. Diacetic acid, which may be present in mild cases, is found in severe ones in large amounts. Diacetic-Acid Test.—A solution of perchloride of iron is ACROMEGALY. 5 added drop by drop. If phosphates are precipitated, filter and add again the ferric chloride. A claret color forming and dis- appearing when the specimen is boiled indicates the presence of the acid. An ethereal extract of the urine can be treated in the same way, when, if the color disappears from the specimen within forty-eight hours, the presence of diacetic acid is like- wise indicated. Differentiation.—Besides being found in diabetes, aceto- nuria is at times present in typhoid, scarlet fever, measles, pneumonia, septicaemia, acute articular rheumatism, and acute miliary tuberculosis. In children it is thought, to have no special signification. Acetonuria may be observed after the administration of anaesthetics, and also as an auto-intoxication with symptoms of restlessness and even delirium preceding diaceturia, which is always pathological. Treatment.—If the patient has been on an exclusive and highly concentrated nitrogenized diet, the first indication is to add easily digested foods of a mixed nature. R Potassii acetatis..................................... gr. xx.-xxx. Give at dose well diluted every three hours. Saline purgatives; bitter tonics. R Sodii bicarbonatis......................................... 3 ij.-iij. To be taken during the twenty-four hours. Milk diet. If the pulse is small, digitalis, associated with ergot. If slow and soft, caffeinae citratis, 0.5 gm. at dose.—Eobin. Acromegaly. Diagnosis.—In this affection, characterized by deformity of the face, hands, and feet, the latter may reach an enormous size, and there is enlargement of the nose, of the malar prominences, and of the tongue. The forehead retracts and the chin projects, carrying the line of the lower teeth beyond that of the upper. 6 THE PRACTITIONER'S MANUAL. The skin is often dry and pigmented and the hair coarse. The hands are increased especially in their width and thickness. The fingers have been described as sausage shaped. The height is often markedly increased, and disorders of the special centres are to be looked for. This condition may be associated with giantism, which m itself predisposes to acromegaly, though the two are regarded as distinct. Among the constant objective symptoms are en- larged hands and feet, lengthened face, enlarged eyelids, nose, lips, and chin, prominent jaw, and abdominal respiration; among the subjective, loss of sexual instinct, polyphagia, and polydipsia. There is also general weakness, and perhaps melan- cholia. —Maximilian Sternberg. Differentiation.—The condition bears a superficial resem- blance to myxcedema. It is distinguished from osteitis defor- mans by the long bones not being implicated, and those of the face rather than those of the skull being affected. In myx- cedema the face outline is rounded, in osteitis deformans it is broad at the upper and narrow at the lower part, while in acro- megaly it is quite regularly oval shaped. The hypertrophic osteo-arthropathy of Marie is distinguished by its affecting sub- jects of preceding and long-standing pulmonary disease; the long bones being affected, the phalanges being bulbous, and the nails having a parrot-beak curve, while in acromegaly they are flattened and longitudinally striated. Peterson16 has described an instance in association with syringomyelia, and Walker81 one combined with giantism. Treatment.—Hitherto treatment has been of little avail. Dr. Cabot collected the histories of nine cases in which the thy- roid extract had been administered and ten in which the pitui- tary body was given. A number were benefited by both of these extracts, and for this reason Dr. Cabot advised their use conjointly. In an instance related by Dr. Hinke," the symp- toms of pain and helplessness were relieved and the physical as ACTINOMYCOSIS. 7 well as the mental condition of the patient was improved by the use of the above-mentioned remedies, both singly and combined. There was a marked diminution in the size of the tongue under the thyroid treatment. R Magnesii sulphatis......................................... § i. Give every second day. R Potassii iodidi............................................. gr. x. Potassii bromidi........................................... gr. xij. Aquae...................................................... q. s. M. Give three times daily. —Banks. The indiscriminate use of organ extracts is to be deprecated. Organ therapy is out of place in Graves' disease and acro- megaly. It is not unlikely that there is a close connection between the latter and diabetes.—Hausermann. The superficial resemblance between acromegaly and myx- oedema seems to justify the use of thyroid extract. Mixed pituitary and thyroid extracts produced great improvement in one instance after five months' treatment.—Eolleston.60 Actinomycosis. Lesions upon the skin usually escape early detection because the microscope is not resorted to. When the disease affects an internal organ before external evidences have appeared in the form of fluctuating sarcoma- like outgrowths of yellowish or purplish hue, chiefly in the region of the lower jaw, symptoms are present which vary with the location of the disease. A marked early symptom is the occurrence of trismus. When, however, the lung is implicated, characteristic granules of thread-like formation may be discov- ered in the sputum. If the urinary tract is implicated its secre- tion may contain actinomycosis spherules. Diagnosis.—The ray fungi, pearly-gray or yellowish gran- ules, which measure from one-half millimetre to two milli- metres in diameter, are usually not to be confounded with any 8 THE PRACTITIONER'S manual. similar pin-head-sized bodies when they pour out from glandular tumors or from an abscess which opens upon the surface or has been incised. If, however, doubt exists, a granule placed under the microscope after having been spread out by pressure on the cover glass is seen to be a star-shaped body made up of numerous threads showing more or less club-shaped extremities. A mycelium with several branching segments is quite charac- teristic. The suppuration which accompanies the fungus ap- pears to be an epiphenomenon. Since it is through carious teeth that infection most often takes place, the swelling usually first appears in the region of the jaw, whence it may spread to the neck, simulating the condition known as angina Ludovici. Subsequently, however, multiple openings are found resulting in fistulous tracts, leading from the skin to the deeper parts. The bucco-cervical is the most common type, showing indu- rated swelling usually in the upper part of the neck or behind the jaw. Differentiation is to be made from simple abscess and phlegmon. Because of the rarity of the affection, the diagnosis is usually not made until some of the small sulphur-yellow granules have been brought to light and subjected to the low power of the microscope as a confirmatory measure; Gram's method of staining making the club-shaped filaments much more distinct. To the unaided eye cultures of the fungus may resemble those of the tubercle bacillus. Under the microscope the rods are larger than tubercle bacilli. When the disease occurs in the apex of the lung the diagnosis is to be made from tuberculosis by spores being found in the sputum, but the re- semblance above mentioned must be borne in mind. Professor Poncet has described a pseudo-actinomycosis whose yellow grains are thirty or forty times as large as those of the true variety. Prognosis.—When actinomycosis is deeply seated in an in- ternal organ, such as the brain, giving symptoms of meningitis, encephalitis, or abscess, death is quite sure to follow. Lung actinomycosis. 0 implication has been fatal in eighty-five per cent of recorded instances. When, however, the lesions are superficially seated and can be operated upon in a thorough manner, good results follow; cutaneous forms show a mortality rate of about three per cent. The disease is of slow course and may extend over a number of years. Treatment.—Claims have been made for the beneficial action of silver solutions and carbolic acid. These or other caustics should be employed in any case after surgical proce- dure; the silver especially should be tried, since it is said to pos- sess properties antagonistic to the fungus. Iodide of potassium has been recommended, and in some instances has been adminis- tered with benefit. It should be given in daily dose of from one to four drachms by the mouth, or, if needs be, per rectum. When the disease is so superficially located that it can receive thorough surgical treatment by curettage, excision, etc., this is the course to pursue. Upon the surface the solid silver stick may be used. Darier and Gautier derived much benefit from the injection of a ten-per-cent solution of iodide of potassium, followed by insertion of platinum electrodes, through which a mild current passed for twenty minutes. A perfect cure resulted after a few sittings. If the disease is accessible scrape the tumors and inject a five-per-cent solution of carbolic acid in glycerin, and if sinuses are present cotton wool saturated with this fluid should be in- troduced into them.—Raffer. For obtaining successful results, iodide of potassium, in doses ranging from two to four grams a day extending over two or more months, is the only drug to be relied upon. It acts rather by its inhibitive power than as a destructive agent.—Jurinka. When the knife is not applicable, destruction may be accom- plished by caustics. Nitrate of silver has a very destructive effect upon the ray fungus.—Parker Syms. Sodium salicylate may produce amelioration.—Netter. 10 the practitioners manual. Addison's Disease. In the various affections of the suprarenal capsules known under this designation, a more or less deep bronzing of the skin is the chief objective symptom and usually the first one to attract attention. Diagnosis.—This discoloration begins habitually upon the exposed surfaces, and it is usually here that the bronzing be- comes the most marked. The other parts chiefly affected are the axillary and genital regions, the areola of the nipple, the re- gions of the joints, and the folds of the skin. The scalp, soles, and palms escape. The bronzing of the skin may be diffuse or in discrete patches, and is associated with subjective symptoms which include prostration with marked wasting of the body, es- pecially at first, attended with gradual loss of strength, vomit- ing which bears no close relation to the taking of food, feeble- ness of circulation, and anaemia. The greatest difficulty in diagnosis is experienced when, as sometimes happens, this train of symptoms occurs with little or no discoloration of the skin. In such instances diagnosis may depend, as Professor Nusser has pointed out, on changes in the arterial system with high tension of the pulse. Or there may be a very striking differ- ence in tension between the peripheral pulse and that of the abdominal aorta, other causes for this condition having been excluded. The form without bronzing is usually of rapid course, death occurring in coma within a few wreeks. Other symptoms to which Renner has directed attention are the occa- sional presence of numerous wart-like elevations scattered over the surface and an intolerable itching. For a positive diagnosis to be warranted, asthenia, vomiting, pain in the loins and abdo- men, and the other constitutional symptoms alluded to should be present. Differentiation.—The discoloration is distinguished from addison's disease. 11 other pigmentation of the skin by its greater intensity, which, in long-standing instances, results in patches of a chestnut or mahogany hue or a deep amber color. They begin, at times, as a yellowish tinge; the whole surface may, in exceptional cases, become of a uniform walnut-juice color, the pigment being deposited in irregular-sized and irregularly distributed groups; or more rarely isolated, rounded spots of pigmenta- tion may exist without showing a tendency to extension or confluence. Jaundice is excluded by the absence of sclerotic and conjunc- tival discoloration, these parts remaining free in Addison's disease. Pigmentation following sunburn is of more localized distri- bution upon exposed parts. All other forms of pigmentation, except possibly that of idiopathic multiple pigmentary sarcoma, are thrown out if small pigmented patches are found upon the mucous membrane of the cheeks, lips, and tongue. Indeed, it may be said that pigmentation of the buccal membrane is of the greatest diagnostic importance, for, although it is a possi- bility in other conditions, its occurrence greatly favors the diag- nosis of Addison's disease. In uterine chloasma the forehead and cheeks are mostly involved. In pityriasis versicolor characteristic spores will be found in the scraped-off scales. In argyria the discoloration is gray or grayish-black and confined to the face and hands, though at times here too the buccal membrane may be stained. In syphilitic pigmentation either the neck is the seat of the reticularly arranged deposit or rounded spots mark the site of preceding eruption, and, in any pigmentary syphilis, we would have evidences of infec- tion. In the discolorations in diabetics and following long-contin- ued irritation, as in scratching of phtheiriasic patients, especially 12 THE PRACTITIONERS MANUAL. those of advanced years, the skin is harsh and rough, while in Addison's disease it is usually smooth. Pigmentation following the use of arsenic shows less uni- formity in distribution; the lesions are not so bronze-like and are apt to take on more the form of lentigo. Large, brown, freckle-like stainings on the backs of the hands in elderly persons and subjects of rheumatoid arthritis would scarcely come into question in this connection. In lepra the plaques are more regularly rounded and occur upon the trunk rather than upon the exposed surfaces. In angioma pigmentosum we find concomitant atrophic and disfiguring manifestations, and it occurs as a family disease in more youthful subjects. Xeroderma pigmentosum likewise occurs in several children of a family and is characterized by new growths upon the face. Brighfs disease is sometimes simulated, especially when coma occurs, and, in the absence of bronzing, it should be ex- cluded by an examination of the urine. Sarcoma of the lungs or other tissues may be attended with involvement of the suprarenal capsules simulating quite closely Addison's disease. Idiopathic multiple sarcoma (Kaposi type) is distinguished by the presence of actual tumors. Prognosis.—Two years would seem to be the limit of life for the majority of cases, although some instances of recovery are recorded since the introduction of suprarenal medication. Death may occur after delirium or in collapse. Treatment in the past has been symptomatic, sustaining, and most unsatisfactory. Recently, however, there have been not a few reports of recovery and many more of marked im- provement. There would seem to be two courses of treatment open: one to detract suprarenal elements from the economy; the other, to add them. Thus, an instance of cure is reported by Hadra following the extirpation of a tuberculous develop- ADDISON'S DISEASE. 13 ment of the retroperitoneal glands and involving one of the suprarenal capsules in its growth. Osier considers treatment by suprarenal extract of great value. One patient, who when admitted was scarcely able to walk, left the hospital some four months later with a gain of nineteen pounds and was able to resume work. Either the fresh gland or the dried extract may be administered by the mouth, or a glycerin extract may be in- jected beneath the skin. No set rule can be laid down of the exact dosage, but the treatment may be persisted in until de- cided benefit is noted. If the fresh gland of the sheep or steer is employed, possibly two suprarenals of the former or one-half gland of the latter may be given daily, to be eaten raw. It is probably better to employ the dried extract in the dose of five grains in capsules three times daily, made by some reliable firm having a reputation for care in the selection of the glands from which the remedy has been manufactured. Progressive improvement has followed half-drachm doses of suprarenal extract three times daily; or the equivalent of three pig's glands daily.—Osler. In one instance the symptoms disappeared after the removal of one of the suprarenals, the seat of tuberculous disease; in another after removal of a tuberculous testis and a course of iodide of potassium combined with a strictly nitrogenous diet. In one instance great improvement followed the use of three suprarenal tabloids daily, gradually increased to twelve. Later on one and one-half ounces daily of a one-in-two suprarenal extract was employed. —E. Lloyd Jones. Of forty-eight cases treated by various adrenal preparations six are reported cured or practically well, twenty-two improved, eighteen unimproved, and in two instances an aggravation of the symptoms is stated to have occurred during treatment.— F. P. KlNNICUTT.49 The equivalent of fifteen grains of suprarenal extract in 14 the practitioner's manual. pill form three times daily, gradually increased.—Ringer and Phear. R Tinct. ferri chloridi, Spiritus chloroformi........................................aa, § i. Glycerini puri................................................ § vi. M. S. Dessertspoonful in water three times a day. —Greenhow. 34 For hypodermic use : R Glycerin extract of suprarenals. S. Inject ten to fifteen minims daily (Tq, xv. = gr. x.). —Wood and Fitz.9 Adiposis Dolorosa. Fatty deposit in the tissues attended with pain is a rare state, not to be confounded with myxoedema, which does not have the neuritic and pressure pains and affects more especially the hands, feet, and face. Treatment.—Thyroid extract.—Mills. Sodium salicylate; a diet free from fat-forming food ; baths, massage, electricity.—Dercum. Albuminuria, Functional. Just as we have a glycosuria which is not indicative of dia- betes and a nephritis without accompanying albuminuria, so we have an albuminuria which is not a positive sign of nephritis. It is usually cyclic or intermittent, and may continue for years without producing symptoms of ill health. Cardiac albuminu- ria points to venous stasis. Muscular exercise (bicycling) may cause a form of so-called "physiological" albuminuria. The condition may likewise be of hepatic, gastric, or nervous origin. In the cyclic variety albumin is scant or absent in the morn- ing, increased by noon, and disappears in the evening or at night. albuminuria, functional. 15 Albuminuria may result from exposure to cold, and is fre- quently associated with diabetes. Albuminuria minima is a term proposed by Talamon, which impresses me as a good one, under which may be included the various functional forms usually described as cyclic albuminu- ria, intermittent albuminuria, etc. It occurs mostly in young subjects, especially females. The morning urine is usually free. Diagnosis.—There may be no symptoms, the discovery being accidentally made, or there may be complaint of headache, pal- pitation, and a generally debilitated feeling. Differentiation.—True cyclic albuminuria is distinguished from transitory forms depending upon various reflex or other conditions, by its occurring only when the subject assumes the standing position and disappearing during horizontal repose or sitting. From nephritic disease, chiefly by the absence of pronounced symptoms; the intermittent nature; the long duration without effect upon the health; the absence of specific casts. (The presence of casts in small numbers does not always indicate organic disease.—Marie.) The form which occurs after eating or after great fatigue is thought by Arnozan to depend upon auto-infection. In dys- peptic albuminuria there are gastric hyperaesthesia, perhaps dis- tention, and usually pronounced constipation ; indican and oxal- uria, but no casts. Prognosis.—Intermittent alimentary albuminuria is cur- able. When continuous it is removed only in thirty per cent to thirty-five per cent of case.—Robin. If albuminuria appears in the course of another affection and persists more than four weeks, the prognosis is unfavor- able. A diminution in the amount of urea is a bad sign; also sudden diminution in the quantity of urine excreted.—Warren. The stress or congestion which befalls the kidney in cases of febrile anasarca may set on foot a morbid process that long 16 the practitioner's manual. works silently and unobserved, but at last declares its operation by symptoms.—Sir Thomas Watson. Treatment.—It is nearly always necessary to have recourse to a milk diet. If the patient grows thin under it, suspend. If it is found that there is less albumin under a meat than a vegetable diet, let this be ordered, and vice versa.—Robin. Diet is the most important element in treatment. Milk, or, better, kephir (of which two pints may be taken daily), white meats, birds, rabbits, sweetbreads, frogs' legs, calf brains, crabs, oysters, fish, spinach, oyster-plant, turnips, carrots, Brus- sels sprouts, stewed apples, prunes, pears, peaches, stale bread. —Simon. Keep the kidneys well flushed with plain or alkaline waters and hot water before meals; warm bathing, hygiene. Occasionally blue pill or nitrohydrochloric acid.—W. B. Vanderpoel. R Acidi gallici..............•................................ 2 l,-13- Acidi. sulphurici diluti..................................... 3 ss. Tinct. lupulini............................................. 3 l- Infusi lupulini.......................................q.s. ad 1 vi. M. S. Tablespoonful t.i.d. —AlTKEN. For Subcutaneous Injection—The following is Menella's formula: R Iodini..................................V................ °-20 cSm" Potassii iodidi........................................... <\&- Aqua; destillat.....................................q-s ad 20 cm. M. S. From one to two cubic centimetres, to be injected in the course of a day. Mousnier's formula: R Iodini.................................................... 4 Sm- Tannin.................................................... 1 Eucalyptol................................................ 40 Olei sterilizat..................................... q-S- ad 100 cm. M. Inject from a half to one cubic centimetre. —E. Boisson. In some forms, venipuncture.—Reginald Harrison. ALCOHOLISM. 17 Alcoholism. Acute alcoholism, when the patient is in an unconscious state, is frequently confounded with traumatism and the coma of apoplexy. In the absence of all history and even when an odor of alcohol is detected, it is often difficult to decide the point. If the tongue is found to be bitten, and especially if in- continence of urine and faeces has occurred, apoplexy is the more likely diagnosis. Differentiation.—The symptoms often simulate those of traumatism. Temperature subnormal, pulse slow, respiration stertorous, pupils dilated but of equal size, face congested (pos- sibly pale). Exclude injury by careful examination of whole surface, and fracture at base of skull by absence of hemorrhage from nose, mouth, and ears. In cerebral irritation from a blow upon the head there are restlessness, flexed extremities, cold surface, closed lids, contracted pupils, irritability, muttering, grinding of teeth. Chronic alcoholism presents symptoms of gastro-intestinal catarrh. There is diminished vitality, and evidences of fatty degeneration of one or more important organs may be made out. The nervous system is also much disturbed in its various functions, and the patient who has long had the alcoholic habit may show signs of imbecility, hallucinations, muscular unstead- iness, neuritis, and perhaps symptoms simulating those of gen- eral paralysis of the insane. Differentiation.—'Delirium tremens may present symptoms akin to those of meningitis, and a pneumonia at the apex may have as one of its symptoms a delirium scarcely to be distin- guished from that due to alcoholism; the same may be said of the delirium coming on occasionally in chloral habitues, if the drug be suddenly suspended. 18 the practitioners manual. Prognosis.—Inebriety is curable in one-third of the cases. Prognosis is not so good for women as for men. Dipsomania. Dipsomania is characterized by an irresistible obsession and impulse to drink. In the periodical attacks the patient aban- dons himself to the cravings. Between the attacks the mental and bodily health may appear normal, but there is probably in every instance a psychopathic constitution. Eccentricities, per- versions, erratic actions, may be the only abnormal manifesta- tions in the intervals. Crothers says these subjects frequently develop epilepsy. They live, he says, " on the frontier of insanity, crossing back and forth all the time." Prognosis is here extremely bad. Treatment.—In dipsomania treatment in institutions is ad- visable and often necessary, since alcohol must be entirely with- held. If the. time of approaching attack is known, sedatives may be freely used. Prophylaxis requires the avoidance of alcohol in the offspring of all presenting the conditions for the hereditary transmission of dipsomaniac tendencies. No drug treatment will make a liar truthful, a thief honest, nor a whore virtuous; neither will such "cure" a person of any habit or vice. The moral nature and the will power of the patient are alone competent for this task. Drugs aid the treat- ment by acting as nerve tonics, and giving the patient confi- dence. One of the best is strychnine in full doses, gr. ■£$ ter vel quater in die, by hypodermic injection. Another which has done good service in my hands during the last five years, while in charge of a special hospital for the treatment of inebriety (St. Mark's Hospital, San Francisco), is the solu- tion of the bromide of gold and arsenic commonly known as "arsenauro." I use it hypodermically in doses of tti x., ALCOHOLISM. 11) three or four times daily, with a very fine needle plunged into the deep tissues of the arm above the elbow, and have never made a sore in hundreds of cases treated.—S. 0. L. Potter. When in doubt concerning an unconscious state, act as if the case was one of traumatism Keep under observation until the effects of a debauch have worn off.—J. B. Huber. The Turkish bath associated with massage meets a wider range of conditions than any one remedy. Bromides when indicated should be given in large dose, gr. l.-c, but only for a few days. To relieve the insomnia strychnine nitrate, gr. ^ every four hours with bromides. The withdrawal of spirits should always be followed with calomel or saline purge, and a prolonged hot-air or hot-water bath followed by vigorous massage.—T. D. Crothers. Hypnotism acts best in periodic cases, the seances being given between the drinking-bouts.—Sparks. In the anaemic variety of acute poisoning with pallor, dilated pupils, feeble, rapid, and irregular pulse, give a hypodermic of nitroglycerin with atropine before using the stomach tube; then a hot pack.—Fabrictus. The basis of treatment is complete, compulsory, prolonged abstinence; discipline and efficacious surveillance. Treat the condition of the nervous system.—Montyel. R Strychninaa nitratis....................................... gr. viij. Acidi salicylici........................................... gr. iv. Spiritus.................................................. § i. Aquae..................................................... 1 iij. Make up antiseptically. tti xv. = ■£% grain of strychnine. S. TU xv. hypodermically two or three times a day. —Flint. To create a distaste for drink : R Tinct. stropbanthi................... S. Gtt. viij. in water three times a day. 3SS. 2(> the practitioner's manual. Chronic alcoholism: R Strychninaa........................ ........................ Sr- to- Hypodermatically for the first day. R Strychninaa................................................ S1'- air- Each day during seven days. Then— R Strychninaa................................................. gr- *• Ft. pil. No. lx. One pill daily each alternate week. —Jergolski. In nervous irritability requiring a sedative chloral combined with strychnine.—Hare. An influence akin to suggestion practised by the physician upon his unhypnotized patient is very useful in the treatment of inebriety.—F. A. Burrall. Strychnine nitrate removes the desire for alcohol and the distress at the epigastrium so common upon its withdrawal. It allays tremulousness and uncertainty of voluntary motion, restoring appetite and general physical vigor.—Breed. Drugs alone are of little value without moral training. A nourishing diet and plenty of fresh fruit are an essential part of any serious attempt to cure alcoholism.—McMichael. The "cure" as carried out at Bellevue Hospital: First day's injection: R Strychninaa nitratis...................................... gr. T^ Atropinaa sulphatis...................................... gr. 3^ Aquaa destillataa......................................... t\[ x. M. S. Inject t.i.d. Second day's injection : R Strychninaa nitratis...................................... gr. -^ Atropinaa sulphatis...............,...................... gr. ^ff Aquaa destillataa....................,....................v\x. M. S. Inject t.i.d. Stomachic mixture : R Tinct. cinchonaa conip.....................................v^ xv. Tinct. capsici............................................. ttj, ss.-i. Tinct. solani carolinensis...................................""1 ij. Vini ferri amari.........................................ad 3 i. M. S. 3i. t.i.d. Shake. ALCOHOLISM. 21 Sedative mixture (first and second nights if needed). R Potassii bromidi........................................ gr. xxxij. Chloralis............................................... gr. xvi. Tinct. valerianaa....................................... | i. Aquaa.................................................ad I iv. M. S. Teaspoonful, repeated once, if needed. Shake. Diet.—One-half to one glass of milk (hot or peptonized), alternating with hot beef tea or broth, every two hours. Stom- ach washing as necessary. On being discharged the patient is given: R Tinct. calumbaa............................................ 3 i. Tinct. capsici..............................................ttt, xv. Tinct. nucis vomicaa....................................... 3 i.-iss. Apomorphinaa............................................ gr. \. Tinct. cinchonaa comp...................................ad § iv. M. S. Teaspoonful in water after meals. C. L. Dana. Morning vomiting of drunkards : R Liq. potassii arsenitis...................................... gtt. iv. Aquaa...................................................... = i. M. S. Teaspoonful every half-hour. —Eddy. Premonitory symptoms of drink impulse at regular or irreg- ular intervals enable the physician to use preventive measures. In certain cases calomel and saline cathartics, with prolonged baths, rest, or exercise, according to the requirements of the cases, have been found curative.—T. D. Crothers. In place of alcohol, hot water, lemonade, lime juice, aro- matic spirits of ammonia, ginger, cinnamon, coffee, tea, or milk may be used.—Gentles. Strychnine nitrate, gr. -g1-^ or gr. -^ twice daily for ten days; then once daily for ten days.—McConnell. For a calming effect, liquor ammonii acetatis until free per spiration and diuresis. R Tr. avenaa sativaa......................................gtt. xv.-xx. Hot drinks, tincture of capsicum. Caidion.—Avoid establishing the capsicum habit. 22 the practitioner's manual. In confirmed drunkards give one-twentieth grain of strych- nine in half an ounce of whiskey three times daily.—Reagan. If ammonia be added to the liquor consumed, such a distaste for alcohol will be produced after a few doses that even the sight or smell of alcoholic beverages becomes unpleasant.— Baratier. R Auri et sodii chloridi...................................... gr. sV Strychninaa nitratis........................................ gr- ^V Nitroglycerini............................................. gr. Tfg-. Atropinaa sulphatis....................................... gr. ^J-tr- Digitalini................................................. gr. «tt- Sodii chloridi............................................. gr. i- M. et ft. tab. No. i. For hypodermic use. —Dunham. To produce emesis, if the patient can be induced to swallow. R Mustard....................................................... f ss. Lukewarm water..............................................O i. If subject is unconscious : R Apomorphina>............................................... gr. \, Aquaa destillataa.............................................. q. s. M. S. Inject subcutaneously. To relieve the symptoms of gastritis and the craving for alcohol: R Decoction of althaaa........................................... = v. Chlorine water................................................ 3 ij Cane sugar.................................................... 3 ij M. S. Tablespoonful every two or three hours. —Zedekauer. To create a disgust for alcohol atropine in small doses (less than gr. y^-) hypodermatically three or four times daily.— Carter. As a tonic, strychnine, gr. -gV three or four times daily.— Tyson. R Spiritus ammonii aromatici............................ ~ j,- Tinct. camphoraa........................................ - jsg Tinct. hyoscyami.......................................... Miss Spiritus lavandulaa comp.............................q. s. ad % ii M. S. One teaspoonful every hour. alcoholism. 23 When acute symptoms have been relieved: R Pulveris capsici......................................... gr. xxiv. Quininaa sulphatis............<.......................... gr. xxxvi. M. ft. caps. No. xii. S. One capsule before each meal and continued for several days. Mania a Potu. The first indication after withdrawal of alcohol is to procure sleep. Give hyoscine, gr. -£%, hypodermatically.—Tyson. Or— R Trional.................................................... gr. xx. Tinct. capsici.............................................. v\ x. Aquaa...................................................... q. s. For one dose. This should be preceded by a calomel purge. Or— Sulphonal.................................gr. x. increased to gr. xxx. —Bellamy. Caution.—If pushed, causes heart depression and unsteady gait. To prevent the adynamia which may follow the sudden with- drawal of alcohol: R Spt. amnion ii aromat........................................ 3 ss. Tinct. digitalis..............................................iU x. Strychninaa.................................................gr. ■£$. M. S. For one dose. Repeat every three hours. —Tyson. A bichloride cure for drunkenness, to extend over from three to six weeks. R Auri et sodii chloridi.......................................gr. -j^. Strychninaa nitratis.........................................gr. £$. To be given by hypodermic at 10, 12, 4, and 8 o'clock daily. R Chloride of gold and sodium................................gr. xij. Muriate of ammonium..................................... gr. vi. Nitrate of strychnine....................................... gr. i- Atropine................................................... gr. %. Comp.- fl. ext. of cinchona.................................. % iij. Fluid extract of coca....................................... 1 !• Glycerin................................................... 1 i- Distilled water............................................. I'1- M. S. A teaspoonful in water every two hours. 24 the practitioner's manual. During the course the patient is allowed whiskey if he can take it. This is said to be almost the same as the Keeley method, ex- cepting that in the latter absinthe and aloes are added to the above formula.—J. L. Gray. Caution.—Note that nitrate of strychnine enters into both prescriptions. Xitrate of strychnine, taken steadily in large doses, has a tendency, first, to impair the appetite for liquor; later, to make liquor an incompatible or sickening agent for the time being. The systematic effects of nitrate of strychnine seem to be not injurious. Yet I would be far from advising any private or injudicious use.—R. M. Phelps. Delirium Tremens. To produce a quieting effect the following combination is given at the Vanderbilt Clinic: R Potassii bromidi, Sodii bromidi............................................aa gr. xv. Chloralis gr. x. Tinct. zingiberis........................................... rq, x. Tinct. capsici.............................................nj, v. Spir. ammonii aromatici................................... 3 i. Aquaa...................................................... 3 ij. The poison should be eliminated by giving liquor ammonii acetatis, 3i., in water and repeating as required.—Kerr. To produce sleep : R Hyoscinaa hydrobromatis.................................... gr> 1 By the mouth or under the skin. As a sedative : A full bath at a temperature of 65° F., of from eight to fifteen minutes' duration, according to reaction repeated every two or three hours; the patient being immersed to the shoulders while water at the same temperature is poured over the head.—Letulle. AN.EMTA, 25 R Hydrargyri chloridi mitis.................................... gr. x. Followed by : R Pil. hydrargyri............................................... gr x Pulv. opii......................................... „r i M. In acute wild mania: Hydrargyri chloridi mitis, gr. xxx. or more, placed on the-back of the tongue, after chloroforming, if necessary.—William Murray."7 I never use opium or its derivatives, but rely on chloral, in full doses, gr. xxx. every two hours until sleep follows. If the heart will not bear chloral, I use duboisine, gr. T^ hypodermi- cally, and repeat if necessary after an hour to produce sleep. In any case I fill up the stomach with strong hot soup, contain- ing plenty of pepper in the form of Tabasco sauce.—S. 0. L. Potter. When bromides and sedatives do not act : R Pulv. capsici.................................................. 3j. Ft. bolus. S. At dose. —A. H. Smith. Should insomnia be an element: R Sodii bromidi............................................... ? ss Chloralis.................................................... 3 iiss. Syr. aurantii corticis......................................... ^ ss Aquaa....................................................ad § iv. M. S. A teaspoonful at bedtime and repeated during the night if necessary. R Methylol....................................................... 70 Aquaa destillataa (steril.)....................................___ 100 M= S. tit, xv. hypodermatically from one to three times in twenty-four hours. Or twenty centigrams of methylol, repeated if necessary every two hours.—Krafft-Ebing. Anaemia. In a large class of cases the condition of secondary anaemia is of such importance as to call for modification in the plan of treatment which is being carried out against the underlying constitutional disease. 20 THE PRACTITIONER'S MANUAL. Diagnosis depends largely upon the known presence of Bright's disease, syphilis, malaria, tuberculosis, affections at- tended by loss of blood, the presence of intestinal parasites, etc. In the simple anaemia there is, generally speaking, a poor- ness of blood affecting its various elements. The complexion is usually described as "muddy" or of a yellowish-white hue. Differentiation.—Simple anaemia is differentiated from chlorosis, pernicious anaemia, leukaemia, pseudo-leukaemia, and the still indistinct form of splenic anaemia as well as those of toxic origin, by the absence of the more or less characteristic features of these various affections, as shown chiefly by the examination of the blood. The table on page 27, prepared by Dr. W. Edwards Schenck,48 of Cincinnati, gives at a glance the differentiation by blood ex- amination between the several forms of primary and secondary anaemia. From chlorosis by the absence of the typically greenish pal- lor ; from pernicious anaemia by the rapid reduction in the lat- ter of the red blood corpuscles (one-fifth normal) while the haemoglobin percentage remains relatively high. Leukaemia shows a steady increase in the number of white cells and an equal decrease in the red; the spleen, liver, and lymph nodes are enlarged, but not in simple anaemia. Beginning phthisis is excluded by the absence of physical signs, and Bright's disease by absence of casts, etc. Organic heart disease is excluded by the flowing character of the anaemic murmur which always accompanies the first sound of the heart, and is audible in several arteries coincidently, occa- sionally disappearing when the circulation is tranquil, to return when the heart beat is accelerated. Anaemic manifestations, absence of signs of heart disease, and entire disappearance of the murmur under appropriate treatment directed to the anae- mic state, all point to the right diagnosis.—W. H. Harris.46 Anaemia should be sought for in the earliest stages of heart ■vma^v -J 3 5' B g 2 — so o o o Red Cells. Normal : Men, 5,000,000; Women, 4,500,000. X Size of Red Cells. c n- » 55 » s: EC 2 3 Z en S W 01 > 7 X - - s> SO - C J5 cr. ; 7 << - X X X 7- White Cells. Normal: 5,000 to 10,000. 0 — Young Cells. Small, Large, and Transitional Mononuclear, 20 to 30 Per Cent. c Adult Cells. Polymorpho- r. P X Nuclear Neutrophiles, 62 to 70 Per Cent. IC Old Cells. Eosinophiles, i^to4 Per Cent. N Myelocytes. Normal only in Bone Marrow. L>S THE PRACTITIONER'S .MANUAL. disease and treatment persisted in so long as the condition remains. The oedema of anaemia is generally diffused, while that of purely cardiac origin is apt to show first in the feet and legs.— A. H. Smith. If the percentage of haemoglobin falls below seventy-five, as shown by the haemoglobinometer, there is good reason to sup- pose that a heart murmur is anaemic if there is no definite evi- dence of organic disease.—Frank "YV. Jackson. Prognosis depends upon the primary condition. Treatment.—Easily digested iron tonic : 11 Ferri peptonati (Merck)................ ....................... 3 i. Elix. calisayae................................................ S i- M. S. 3i. t.i.d. Or— R Liq. ferro-mangan. peptonat.................................... 3 i. —Stanton. R Ammonii chloridi............................................ 3 ij- Tinct. ferri chloridi.......................................... 3 iv. Glycerini..................................................... § i. Aquae.................................................q.s. ad § iij. M. S. A teaspoonful. —Katzenbach. R Ferri sulphatis............................................... gr. i. For a pill to be freshly made without gum. Give three times daily for a week, then two grains at a dose for ten days, and so on until nine or even twelve grains are taken in a day. Then gradually reduce. The course should never be less than three months in duration. For those who cannot take pills give three or four large teaspoonfuls of saccharated carbonate of iron daily.—T. C. Allbutt. In loss of vasomotor tone, suprarenal extract. I always use the tincture of the chloride of iron in preference to any other form of iron, considering it much more efficient than any other. In cases which will not bear the strong tine- anaemia. 29 ture, I give it in liquor potassii citratis, thus partially altering it to a citrate.—S. 0. L. Potter. Medullary Glyceride.—A pound and a half of finely com- minuted calves' ribs should be macerated in a quart of pure glycerin, the mass being allowed to stand for several days and being frequently stirred. The glycerin is then strained through cheesecloth and given in doses of from one to four teaspoonfuls three times daily, with a few drops of peppermint essence. The immediate improvement in the state of the blood and subsidence of symptoms, which certainly go together, are no less wonder- ful than is the improvement that follows the use of thyroid ex- tract in myxoedema, though the gain is more permanent than in the latter.—Allan McLane Hamilton. Hydrcemic anaemias are greatly improved under thyroid, if iron be also given. In ancemic children : R Ferri carbonatis saccharati............................. ... gr. ss. Hydrargyri chloridi mitis.................................. gr. ^. Sacchari lactis............................................. gr. ij. M. S. For one tablet. Give in a teaspoonful of milk three times daily. —KOPLIK. If associated, as is often the case, with symptoms of scrofula, ferrum dialysatum mingled with simple elixir will be readily taken, and is particularly beneficial.—F. P. Henry. In the anaemia of pregnancy, associated with weak heart, but without organic lesion : R Spartein. sulph................................................ 0.01 Ferri oxalat................................................... 0.10 Ext. gentian., Ext. liquirit.... ............................................aa q.s. Ft. pil. No. i. D. tal. dos. No. xxx. S. Take one pill after each meal. —Cumston. Iron often acts better when oxygen is also administered artificially. One of the best tonics is furnished by sulphur baths. Much of the benefit obtained at Bad Nauheim and by the Schott BO the practitioner's manual. treatment is probably due to the relief of anaemia.—Beverley Robinson. Caution.—Do not give iron simply because there is anaemia. In all febrile anaemias it does mischief, as in acute articular rheumatism and in phthisis.—W. H. Thomson. In ancemic females : R Pulv. ferri.................................................. 3 i- Ext. hyoscyami.............................................. 3 ss. Ext. aloes pulv.............................................. gr. v. M. ft. pil. div. No. xxx. S. One t.i.d. —George F. Shrady. A powerful remedy is the extract of red bone marrow in tablespoonful dose.—Garrigues. Aucemia with weak heart action, and as a nerve tonic: R Tinct. ferri chloridi, Tinct. digitalis..............................................aa 3 v. Acidi phosphorici diluti....................................... § i. Aquae, Glycerini............................................aa q.s. ad 3 iv. M. S. Shake and take through a glass tube a teaspoonful in a wineglass of water after each meal. —A. Vander Veer. Acute anaemia caused by post-partum hemorrhage. Copi- ous rectal injections containing one and one-half teaspoonfuls of common salt to the quart of water. To meet the digestive defects : R Hsemogallol.............................................. 3 ij. Fel. bovis insp.......................................... 3ij. Ext. pancreatini......................................... 3 ij. Strychninaa sulphatis.................................... gr. i. Caffeinse muriat......................................... 3 i. Ext. colocynthidis....................................... gr. x. -xx. Ext. taraxaci............................................ 3 i. M. et ft. pil. xl. S. Two t.i.d. after meals. —Porter. Anaemia, especially when accompanied by cardiac disturb- ances, such as weakness and irregularity of the pulse: anemia, chlorotic. 31 R Iron b}' liydrogen, Powdered camphor..................,...............aa 3 iss. Extract gentian.......................................„ grs. cxxxv. Mucilage gum arabic................................... q. s. Make ninety pills. Dose, two or three thrice daily. —Edlefsen. In leucorrhoea accompanying antemia: R Acidi arseniosi............................................... gr. ^ Ferri reducti............................................ .... gr. v. Quininae sulphatis................................„.......... 3 i. M. ft. pil. xx. S. One pill three times a day after meals. —Hare. Anaemia, Cerebral. Syncope or acute cerebral anaemia, as it occurs after a decided loss of blood or in fainting, is attended by pallor, cold clammy perspiration, dilatation of the pupils, convulsions, and loss of consciousness. Treatment.—In a fainting-fit the patient should be placed so that the head is lower than the body. Iced or cold water should be dashed into the face, strong smelling-salts or am- monia placed beneath the nostrils, and, unless the patient re- covers sufficiently to swallow small doses of some stimulant, brandy may be injected subcutaneously. R Tinct. ferri chloridi.......................................§ i. Quininae sulphatis.......................................... 3 i- Solve et adde : Potassii bromidi................................ .......... % i. Aquae f ontanae.........................................<. § xxiv. Liq. potassii arsenitis............................ ......... 3 iiss. M. S. 3 ij.-1 ss. in a little water after each meal. —Pasquet. When there are epileptoid seizures : R Potassii bromidi.......................................... 3 '• Ferri bromidi............................................. gr. iv. Aquae...................................................... 3 'j- Syr. simplicis.............................................. 1 vi- M. S. Tablespoonful twice daily. —Bartholow. Anaemia, Chlorotic. Chlorosis, or the idiopathic form of anaemia which occurs in young girls, is attended, as the name implies, by a greenish hue 32 the practitioner's manual. of the pale skin, and must be distinguished from the essential anaemias, in which the color is more like that of straw. Diagnosis.--The condition is marked by pronounced lan- guor, irregularity of the menses, and "pearly" appearance of the eye, certain disturbances of the nervous system, dyspnoea, palpitation, and a venous hum in the vessels. Gastralgia is also a common symptom, and ulcer of the stom- ach is to be watched for. Digestive disturbances are found and constipation may exist Many instances of chlorosis as well as other anaemias are found in association with intestinal worms. The appetite is apt to be capricious, and many subjects show a fondness for such articles as slate pencils, clay, vinegar, pickles, or other unnatural things, as well as for sweets and starches. The haemoglobin, as shown by Gowers' haemoglobinometer, may be reduced to one-quarter the normal and the number of red blood corpuscles is decreased. The diagnosis should be largely if not wholly based upon blood examination. A symptom pointed out by Bouchard is a pigmentation upon the dorsal surface of the fingers near the joints. Almost all cases show at least a trace of albumin in the urine. Differentiation is also to be made from pernicious anaemia and from pseudo-chlorosis, which also occurs in men and at a more advanced age, and is usually an indication of some sys- temic affection. See table on page 27. Prognosis.—Chlorosis very rarely proves fatal. Treatment.—The loss of iron from the system is an indica- tion for its administration, and in many cases, if the proper form and quantity in which to administer it can be found, its action seems almost specific. The protochloride, the proto- iodide, the lactate, or the citrate of iron and ammonium may be given at first in moderate dose, but it is essential that it should become well digested. ANvEMIA, chlorotic. 33 Blaud's pills properly prepared are still the best means to cure chlorosis, to be preceded by a very mild laxative before breakfast.—Leonard Weber. Caution.—Chlorotic patients should rarely be sent to the seashore, where even the lymphatic type receives no benefit and may have the conditions aggravated. Very high altitude is also contraindicated in most instances. More torpid cases are better influenced by the seaside; more excitable by sheltered mountain resorts not too high. If there is considerable dilatation [of the heart], not above three thou- sand feet.—Hermann Weber. As adjuvants, country air, perfect rest, milk diet. No more medicine than is absolutely required. Weak sulphur and saline baths have frequently been found of much benefit. Compressed-air baths have, in a number of instances, been followed by noted amelioration. Hot-air bath, by placing several spirit lamps in a metal-lined box at the foot of the bed while the bed is covered with barrel hoops over which oilcloths are suspended, the patient being well covered excepting the head, to which an ice bag is applied. The temperature, at first 130° F., can be subsequently raised to 150° F.—Traugott. R Ferri et potassii tartratis, Liq. potassii arsenitis....................................aa 4 gm. Aquae destillatae....---.................................... 12 " M. S. Twice daily five to ten drops in wine before meals. As an adjunct to treatment, phosphorus.—Angelo Casati. R Liq. ferri sesquichloridi (Ph.G.)............................. gtt. i. Three times a day in a wineglass of water, gradually increased until twelve drops daily are given. —Israfl. When iron fails oris inadmissible : Give oxygen inhalations under the pressure of half of one atmosphere and diluted.—Corish. Or a suitable diet in which animal proteids, bone marrow, and dark beer are the principal constituents.—Simon. 3 34 the practitioner's manual. Without perfect rest iron will often be productive of very little good. Exercise may be injurious, especially in cardiac complications.—F. Taylor. Raw thymus gland of calf, 3 v., daily for a month, minced or in soup, gave excellent results.—Blondel. A combined treatment: Intestinal antiseptics followed by iron gives better results and a greater weekly gain in haemo- globin than either alone. Ii Naphthol (Beta)............................................. gr. ij. Ft. tab. No. i. S. One such three times daily. R Pil. Blaudii................................................. gr. v. Three daily. —TOWNSEND. Or in large dose, as many as forty-eight pills being given by the fourth day and continued for three or four weeks.—Bram- WELL. Bone marrow in glycerin extract.—John S. Billings, Jr. Bone marrow, 3ii-, in a wineglassful of sherry, t.i.d. Iron with manganese, protonuclein, strychnine, an occasional mer- curial cathartic followed by sodium phosphate as a routine laxative. Occasionally: R Manganese arseuiate..................,..................... gr. -fe, After each meal. —Bloom. R Ferri et potassii tartratis......................... ...... 10 gm. Ext. cinchona!........................... ............... 10 " Glycerini.............................................. 20 " Aquae destillatea........................................ 10 " Vini (Madeira)................................q.s. ad 1 litre. M. S. As a tonic. —Patein. In true idiopathic chlorosis, when iron is ineffectual, sul- phur will produce a marked amelioration. After sulphur is used, iron can again be resorted to, and it becomes very beneficial. Caution.—Sulphur should not be used when chlorosis is anaemia, chlorotic. *">- complicated with catarrhal or inflammatory conditions of the digestive tract.—Shultz. Neutral acetate of copper, one centigram dose.—Liegeois. Also— R Tinct. strophanti!i, Aquae amygdalae amarae.....................................aa 3 i j. M. S. Gtt. x. t.i.d. Also— R Pil. ferri carbonatis. Three thrice daily. —Vaczi. R Tinct. ferri chloridi........................................ 3 i. QuiniDae sulphatis.......................................... gr. xx. M. S. Gtt. xx. ter in die, in sweetened water through a tube. —S. D. Gross. R Vini ferri aniari............................................. | \ ij. Tinct. nucis vomicae......................................... 3 iv. Liq. potassii arsenitis....................................... 3 ij. M. S. 3 ij. in a wineglassful cf water after meals. —T. G. Thomas. R Ferri arseuiatis............................................. gr. ij. Ext. cinchonae............................................. gr. xij. M. ft. in pil. No. xij. S. One after each meal. —Bartholow. Diet.—Girls who are "worn out'' in the forenoon should have a hearty breakfast or drink half a litre of the best milk while still in bed, in small quantities at intervals of fifteen minutes. Dry friction on arising. Breakfast: Small cup of tea, buttered toast, and plenty of meat; two and one-half hours later bread and butter and two eggs, followed by a quarter litre of milk.—Carl Von Noorden. Diet is not alone sufficient to repair the losses of haemo- globin. Rest ameliorates but does not cure. Salt baths, not too strong, are often useful.—Le Gendre. The methodic application of hygienic measures constitutes the true treatment. Iron should hold the place of an adjuvant. —Fernet. 30 the practitioner s manual. The preventive agents of first importance are proper exercise and proper diet. The blood of girls whfc take abundant open-air exercise approaches that of the male. The tendency of cbloro- tics to avoid meat and green vegetables from which the iron supply is mainly derived must be checked.—Lloyd Jones. In chronic forms the following combination is most service- able: R Tinct. ferri perchloridi.................................nl x.-xx. Spt. atheris............................................^ x"xv Tinct. nucis vomica1....................................iU x. Tinct. quassiae.........................................^ xxx.-xl. Aqua................................................a(* 3 iss- M. S. To be taken twice a day, an hour before luncheon and dinner. —Latham. Anaemia, Pernicious. Pernicious anaemia is an idiopathic affection whose chief feature lies in the marked reduction in the number of red blood corpuscles. This reduction is determined by measure- ment, which shows often a million or less to the cubic milli- metre, which number can be increased by treatment to three times this amount. The haemoglobin is not decreased and at times may be relatively abundant. The average diameter of the cells is greater; nucleated red cells are present, as are also myelocytes, and as compared with the polymorphonuclear cells there is a relatively small percentage of lymphocytes. Diagnosis.—Clinically the pallor is greater in this than in the other anaemias and the skin has a lemon tint. There is little or no emaciation or change in the various organs, which examination will reveal. The urine is of high specific gravity. which may alternate with low gravity, and this in itself points to an idiopathic condition. Hemorrhages into the skin as mi- nute petechiae, and into the retina as seen with the ophthalmo- scope, or into the meninges, are sometimes present to distinguish the condition from one of simple anaemia. There are usually gastric disturbances, feebleness of heart action, possibly oedema an.emia, pernicious. ;j7 of the eyelids. An important point is that the spleen and lym- phatic glands are not enlarged. Fever of irregular type, with morning remissions, is sometimes noted. Upon puncture of the pale skin a drop of blood sufficient for examination is at times scarcely obtainable. Poikilocytosis (the projection of the sub- stance of the cell making it of irregular outline) is almost con- stant, and megaloblasts (large nucleated red cells) are habitually present, which fact is regarded by Ehrlich as almost distinctive of the affection. Hunter believes a characteristic symptom is the increased average size of the red cells and their contained proportion of haemoglobin. Differentiation.—Carcinomatous ulceration may present at times much the same clinical picture. Blood examination distinguishes the condition from many others including malaria. (See table, page 27.) Prognosis.—This is not so grave to-day as it was thought to be a few years ago. There is much to be hoped for in treat- ment, although most cases terminate fatally. The greater the proportion of megaloblasts, the graver the prognosis. Treatment should conform so far as possible to such etiologi- cal conditions as can be determined. In approaching the treat- ment of a case of pernicious anaemia, you ought always to at- tempt to ascertain whether the case before you is one of those connected with atrophy of the gastric tubules. In some of these oases the catarrhal symptoms are marked and the power of diges- tion is profoundly reduced; and such cases may properly be called pernicious anaemia of gastric origin.—Pepper. Rest in bed, careful feeding, milk being at first made an exclusive diet. From the very fact that these patients suffer from an auto-intoxication originating in their alimentary tract, such remedies as beta-naphthol, subgallate of bismuth, bismuth salicylate, resorcin, benzo-naphthol, and other intestinal anti- septics have here their indication. Intestinal parasites should be sought for and destroyed. Arsenic has been employed prob- 38 the practitioner's .manual. ably more often than any other drug, and in many instances is followed by happy results. Ferruginous tonics and especially the tincture of the perchloride of iron in large doses would nat- urally suggest themselves, and in fact iron has in many in- stances given surprising results and even apparent cures, but it must be long continued. Whenever a source of bleeding or a weakening discharge is found, it should be brought under control. Patera injected five milligrams of corrosive sublimate daily for two months with excellent results. Sinc^ syphilis is a fre- quent underlying cause, the benefit from mercury may be thus explained. Fowler's solution may be given in doses of from five to twenty-five drops three times daily. Caution.—If no marked improvement in the state of the blood has occurred within a reasonable time, pushing these drugs beyond the maximum dose must be guarded against. In case of gastro-intestinal disturbances arsenic by the mouth. Or— R Liq. potassii arsenitis, Aqua desti llata..........................................aa, gtt. x. S. Inject hypodermatically. Or— R Liq. potassii arsenitis.................................. Aqua destillata........................................ S. One drachm injected into the rectum morning and night In progressive pernicious auamia : R Salol.................................................... gr. x. _xv. To be continued for a long time. —DlE BALL A. Red marrow of the calf mixed with an equal quantity of glycerin rubbed up in^a mortar gives a pleasant-tasting prepa- ration, which can be eaten upon bread, or port wine may be added to it.—Alfred Stengel. ...... 3 ij —VlNAY. ANAEMIA, PERSISTENT AND PROGRESSIVE. 39 R Fowler's solution............................................ 3 iiss Acid phosphate.................,............................ 5 iij. Extract of bone marrow................................up to § viij. M. S. Dessertspoonful after each meal. —I. N. Danforth. In an instance of apparent collapse Ewald tried transfusion of eighty-five centimetres of defibrinated blood. Two weeks later the blood showed a gain of 1,000,000 red corpuscles to the cubic centimetre and an increase of four per cent in the haemo- globin. Five months later the corpuscles numbered three and one-half millions. To correct intestinal fermentation : R Ichthyol................................................. gr. iij.-v. In capsule an hour after each meal. Or— R Resorcin................................................... gr. xv. In capsule or dissolved in castor oil. Or— R Salol, Bismuthi salicylatis, Sodii bicarbonatis.......................................aa gr. v. In cachet. Strychnine in moderate dose, inhalations of oxygen. In advanced stages, oxygen, arsenic, and transfusion of nor- mal blood.—Clarke. Anaemia, Persistent and Progressive. Hodgkin's disease, pseudo-leukaemia, or lymphatic anaemia presents symptoms of anaemia along with or before the devel- opment of enlarged glands, which characterize the affection. There may be fever of variable degree. Differentiation is to be made from acute and chronic adenitis, chiefly by the subsequent developments, the glands in Hodgkin's disease becoming much larger and being usually of soft consistence. Tuberculous glands form masses closely 40 the practitioner's manual. adherent to each other and to the surrounding tissues, while in this affection they are loosely implanted and freely movable. The age in pseudo-leukaemia is usually greater than that in tuberculous disease and suppuration does not occur. Lymph- oma grows more slowly and is of harder consistence. Sar- coma in its earlier stages, involving groups of glands, might cause one to think of this affection, but surrounding tissue in- volvement and destructive ulceration would make the differ- entiation clear. One chief characteristic of lymphatic anaemia is the number of gland groups affected and the habitual ten- dency to spread. Leukaemia is excluded by absence of hemorrhages and diarrhoea. Prognosis.—Death usually occurs within two years. Treatment.—Nineteen recoveries in seventy cases treated by arsenic.—Kisel.4' Recoveries have been reported from the use of arsenic; only large doses seem effective. Fowler's solution as well as iodine preparations have been administered by injection, the former in dose of thirty minims daily. Sheej^s spleen lightly grilled, ameliorated the condition in one instance.—Bloomfield. Anchylostomum Duodenale. This variety of intestinal worm, found in European coun- tries, Asia, Africa, and South America, is very rarely observed in the northern part of the United States. It resembles some- what the oxyuris vermicularis, or rather more the intestinal trichinae. Dr. F. G. Molhau, of Buffalo, has reported an instance. There are no pathognomonic signs apart from the dis- covery of worms or ova in the dejections, anaemia, fulness, diarrhoea. ankcrism of the aorta. 41 Treatment.—After mild purgative : R Thymol, Sacchari lactis..........................................aa gr. xxx. Triturate and shake in water. Give on an empty stomach in the morning, followed in two hours by a second dose. If after eiglit days ova are found in the stools, repeat. Caution.—Thymol should not be given in solution, since, if absorbed in considerable quantity, it may prove toxic.—Stynsey. Aneurism of the Aorta. Diagnosis.—These blood-containing tumors of the aorta may be latent for a considerable period of time. The first evidences of their presence are often the pressure symptoms, producing sharp pain when a nerve is involved, or dull and boring when bone is implicated; dyspnoea, dysphagia, aphonia, or brassy cough, and other signs, depending upon the anatom- ical relations. These pressure signs may be insignificant or they may be so pronounced as to overshadow all other signs. Dysphagia may be detected before other signs are prominent, by having the patient swallow while a stethoscope is applied to detect the redoubled sounds. There is also a purring thrill, closely simulating contact with the body of a purring cat. The pulse is of great value as a diagnostic aid, as shown by the sphygmograph; the pulse of one side may be normal, while that of the other may show a curve less high and the secondary wave less pronounced. The physical signs are of aid only when the tumor has grown to large proportions or when the ascending aorta is im- plicated. The characteristic thrill, observed through the stetho- scope, is considered by some as almost pathognomonic; this thrill is also noticed on palpation. (Edema about the neck, face, or arms may be an early sign of pressure upon veins. There may be paralysis of the left vocal cord. Cervico-occipital neuralgia is an important indication of beginning aneurism of the aorta. 42 THE PRACTITIONER'S MANUAL. Caution. — When this symptom is present, do not treat with cold douches, mountain climbing, superalimentation, etc., which may hasteu a fatal termination.—Levachev. In the initial stage there may be pain confined to the walls of the vessels. Symptoms are more marked in arch cases. When evidence by other means is incomplete, an oesoph- ageal bougie, closed at the lower end, is passed into the oesoph- agus until the point has a little more than reached a position opposite the site of the suspected aneurism. The upper end of the bougie is connected, by means of a rubber tube, with a bent (manometer) glass tube. This is filled with water, and the result is even better when the bougie and rubber tube also are filled with water. The expansion of the aneurism, being confined within the chest wall, is sometimes so well trans- mitted through the adjacent structures as to be plainly shown in the glass tube. Caution.-—Do not pass the tube so far down as to be de- ceived by the heart's impulse. — William Porter. Rhythmic nodding of the head, ascribed to downward trac- tion of the left bronchus and trachea during systole, is at times present in aneurism of the arch. It must not be confounded with muscular contraction or with the rhythmic nodding of certain nervous diseases.—Teletti. Before the appearance of recognized physica-l signs there may be a systolic sound in the brachial artery, synchronous with the cardiac systole, sometimes accompanied by an arterial murmur. If aortic regurgitation can be excluded, a positive diagnosis of aneurism can be made.—Glasgow. Auscultation will also sometimes reveal an arterio-diastolic sound, not perceptible at the emergence of the aorta, produced by contraction or dilatation of the aorta. The pulsation is also a valuable indication in such cases; also a heart-systolic coarse rale.—Gerhardt. Differentiation.—Stenosis of the aortic orifice is distin- ANGINA, DIPHTHEROID. 43 guished by the characteristic wire pulse and the absence of tumor or of pressure signs. Cardiac hypertrophy may cause confusion in diagnosis at first, but later aneurism is excluded by the absence of charac- teristic signs. Treatment.— R Potassii iodidi............................................. 1-2 gm. Repeat three or four times daily. —Bartholow. R Acidi gallici............................................... 3 i. Ext. ergota, Digitalis.................................................aa gr. xx. M. ft. pil. No. xx. S. One every two hours. Or— R Plumbi acetatis......................................... gr. xxxvi. Ext. opii.............................................. gr. iv. Confect. rosae........................................... q.s. M. ft. pil. No. xij. S. One every four hours. —Potter. Antipyrin mitigates the pain of aortic aneurism.-—Martin. To render the blood more coagulable, or when beyond the reach of surgical intervention: R Gelatin ....................................................... 1 Salt solution (one per cent).................................... 100 First sterilize, then inject as much as fifty centimetres into the circulation. As much as two quarts has been used in a two months' course, with relief of the severe subjective symptoms.— Lancereaux. Angina, Diphtheroid. Pseudo-diphtheria or non-virulent angina has its chief im- portance in the necessity of distinguishing it from atypical diphtheria or from the non-membranous type. The term should include membranous laryngitis or croup. Diagnosis.—Many instances can scarcely be distinguished either by the local signs or general symptoms from the sore 44 the practitioner's manual. throat of scarlatina. It is by bacteriologic examination alone that we can be at all sure, and even with this aid laryngeal cases beyond the reach of the swab will baffle the expert. Prognosis.—Uncomplicated non-laryngeal cases do well. There is always danger of suffocating in croup, and many deaths occur. Treatment.—The treatment of tonsillitis and pseudo-mem- branous croup will be found elsewhere. Pseudo-diphtheria requires much the same management as that given under "Diphtheria," according to the mildness or severity of the symptoms, excluding of course antitoxin. In simple angina : R Potassii chloratis........................................... 3 iss. Potassii bromidi............................................ § ss. Ext. belladonna............................................ gr. iv. Syr. limonis............................................... § i. Syrupi...............................................q.s. ad § iv. M. S. Teaspoonful thrice daily. —Pepper. In infectious angina: R Essence of petroleum.................................... 20 gm. Sulphuric ether......................................... 5 gm. Powdered iodoform..................................... 0.5 cgm. Essence of mint......................................... gtt. xx. M. S. Apply. —DUMONT. In gangrenous angina: R Ext. cinchona............................................. 2 Aqua mentha piperita......................................... 18 Inf. anthemidis......................................... 20 Syr. althaa................................................... 40 M. S. Teaspoonful frequently repeated. —Descroizilles. Angina Ludovici. True idiopathic angina, as described by Ludwig, presents an acute phlegmonous cellulitis with features of great gravity. There are diffuse brawny oedema and a wood-like hardness of the tissues overlying the lower jaw, the suprahyoid region, or per- angina pectoris. 45 haps involving the face and extending down upon the sides of the neck, and sometimes implicating the tongue, which is thrust toward the palatal vault. The floor of the mouth, the tonsils, etc., may take part in the swelling. Diagnosis.—There is severe dyspnoea as an early symptom. Swallowing is painful and oftentimes opening the mouth suffi- ciently to eat is out of the question. A uniform and rapid spread with a constant bordering zone of unaffected cellular tissue, hard swelling beneath the tongue, and a deep red-colored or bluish appearance of the swollen tis- sues along the inner side of the lower jaw will serve as distin- guishing features. Differentiation.—Traumatic angina from injury in the region of the neck and direct septic infection may present much the same picture; so, too, inflammations extending through lymphatic channels from disease and operations about the mouth. Erysipelatous angina is distinguished by enlargement of the glands; actinomycosis by the discovery of the ray fungus in the discharges. Prognosis.—The diffuse phlegmonous inflammation of the intermuscular and subcutaneous tissues ma}T end in gangrene, in abscess formation, or in resolution. In forty per cent death results. Treatment is supporting, antiphlogistic, and surgical. Early incision and rigid antisepsis are required. Angina Pectoris. Diagnosis.—There is terrible pain, which occurs suddenly in the heart region, in this affection, accompanied by difficult breathing, a sensation of chest constriction, and distressing apprehension with a fear of impending death. The pain lasts for a few minutes or possibly only a few seconds, or the effects of an attack may persist for hours. There are pallor, cold sweat, and a drawn expression and fixed 46 THE PRACTITIONERS MANUAL. gaze, rigid extremities, weak heart action, diminished pulse volume, and what Richardson has called "syncopal unrest." The pain radiates down the left arm. Flatulency habitually follows the attack. Differentiation.—This is made from other pains similarly located and occurring in a similar manner b}7 their radiation in true angina to the shoulder and down the left arm. It is to be distinguished from pseudo-angina pectoris, which is. according to Huchard, at times a neuralgia of the cardiac plexus variously produced ; at other times a vasomotor neurosis, occurring chiefly in neurasthenics, hysterical women, and vic- tims of digestive disturbruiees. The pain here lasts for one-half hour or more. It differs from true angina, in that there is ab- sence of serious heart lesion, but it is often accompanied by ner- vous palpitation of the heart, followed as in the true form by copious micturition of light-colored urine of low specific gravity. In essential paroxysmal tachycardia the anginal pains resemble those of angina pectoris, radiating perhaps to both shoulders and arms, and are somewhat relieved, in part at least, by firm pressure upon the limb. In colic, at times suggested by the after-evidences of gas, the pain is lower, and not of the crushing, screwing, vice-like nature. The following table by Huchard gives the essential points of distinction between true and false angina pectoris: True Angina. Most common between forty and fifty years. Most common in men. Attacks brought on by exertion. Attacks rarely periodical or nocturnal. Not associated with other symptoms. Vasomotor form rare. Agonizing pain, and sensation of compressio?) by a vice. Pain generally of short duration ; atti- tude ; silenre ; immobility. Lesion, sclerosis of coronary artery. Prognosis, grave, often fatal. Hysterical Pseudo-Angina. At every age, even six years. Most common in women. Attacks spontaneous. Often periodical and nocturnal. Associated with nervous symptoms. Vasomotor form common. Pain less severe. Sensation of distention. Pain lasts one or two hours ; agitation and activity. Neuralgia of nerves. Never fatal angina pectoris. 47 The simple or coronary form is distinguished from that asso- ciated with dry pericarditis, in which the pain is situated at the base or middle of the sternum, in the epigastrium, or over the cardiac area, by auscultation showing a to-and-fro friction, heard coincidently with the cardiac movements. Hyperaesthe- sia in the precordial region is usually present, and a history of preceding tonsillitis and rheumatism. Here, too, vaso- dilators and stimulants do not give relief. — Pawinski.'" Prognosis.—Since the affection is in most cases associated with lesions of the heart, prognosis must be guarded. We are not justified in looking upon such attacks lightly, because of the serious disorders which may lie behind them, and for the further reason that an attack of true angina may terminate life through the sudden obliteration of the coronary arteries by thrombosis or embolism. However, when the pulse remains regular and without high tension, and in the absence of valvular lesions or disease of the myocardium, the patient may continue to have such attacks, extending through many years and producing many distressing symptoms, without any real danger to life. Sudden death may occur during the course, or at the end of a painful paroxysm, or by sudden syncope unattended by pain. If dilatation of the heart occurs, paroxysms may cease. The prognosis is more favorable in dilatation than in myocar- ditis or hypertrophy.—J. H. Musser.49 Treatment. —Prophylaxis must be directed to the underlying condition of the heart in the intervals of attack. All excesses, sudden or unusual exercise, and exertion are to be guarded against. R Erythrol tetranitrate.......................................... gr. i. Ft. tablet No. i. S. Every eight hours. j ^. j> 46 R Potassii iodidi............................................. gr- xv. Three times a day for twenty or twenty-five days of each month for several years, nitroglycerin being given in small doses in the intervals. —Huchard. 4N THE PRACTITIONERS MANUAL. Relieve exciting causes. Avoid applications of cold water to the body when an attack is excited by cold. Keep the hands gloved. Avoid mental worry, emotions, overexertion, and even needless exertion. Relieve visceral engorgement.—H. N. Heineman. Inhalation of the nitrite of amyl furnishes one of the quickest and best means of relieving the attack. Pearls containing three to five drops may be carried by the patient who is subject to attacks, to be crushed in a handkerchief and inhaled at the first premonition. Nitrogl}'cerin, gr. Tto or more> Diay be given with the same aim, or in some instances the most prompt relief is obtained by a full dose of morphine hypodermatically, angina patients often showing great tolerance of the drug. General tonics, oxygen gas.—A. H. Smith. Iodide of potassium to diminish the heart's work and pre- vent aortitis. Caution.—Do not give iodides in advanced degeneration of the arteries, interstitial nephritis, and cardiac dilatation. R Sodii nitritis............................................. gr. v.-x. Three times a dav. —Hay. To prevent an attack, avoid gastro-intestinal disturbances or relieve them with saline purgation, blue mass, or calomel. In flatulency, which often precedes an attack: R Spiritus atheris comp., Spiritus camphora, Aqua mentha piperita.....................................aa ? ss. M. S. Three teaspoonfuls in water or hot whiskey. —OSLER. In pseudo-angina treat the underlying hysterical or neuras- thenic condition. Sinapisms, mustard baths, moderate doses of Hoffman's anodyne, are often sufficient to cut short a parox- ysm, while here, too, at times the hypodermic injection of morphine may be demanded. In treatment, bear in mind the possibility of syphilis of the heart wall. angina pectoris. 49 In complicating cardio-sclerosis and paresis, digitalis. Caution.—The pulse tension being already high, digitalis as well as ergot is contraindicated for the affection itself. In renal insufficiency suppress all ptomain-forming food. When associated with pericarditis, leeches, cupping, warm applications. In later stages, moderate blistering. Digitalis, if indicated by the pulse.—Pawtnski. Caution.—Except in excess of dilatation digitalis is not to be given.—Musser.49 R Nitroglycerin.............................................. gr. iij. Tinct. capsici.............................................. 3 ss. Spt. vini rect., Aqua mentha piperita..................................aa 3 iij. M. S. Two to ten drops. Dose to be increased with caution as the patient grows accustomed to the effects. Pain is relieved within three minutes. —Schott. During the interval most careful and abstemious diet, espe- cially toward evening. Vascular stimulants in combination with cardiac tonics, especially arsenic. Exercise is to be avoided, and undertaken only when duly prepared for by the ingestion of some vascular stimulant.—Balfour. In rheumatic cases, sodium salicylate, rest, even temper- ature, and dietetic care are always important. Constitutional conditions underlying angina pectoris and capable of treatment include especially syphilis and gout. Gen- uine angina in a man under thirty-five years of age should arouse a suspicion of syphilis, and vigorous measures should be adopted. In gouty cases, free elimination by the bowels, skin, and kid- neys, and at intervals a course of colchicum. In the chronic form with dyspnoea and Cheyne-Stokes breathing, full doses of strvchnine, hypodermically, may be employed, from a fortieth to a twentieth of a grain, three or four times a da}T. Special care should be taken that the bowels are kept freely open.—Osler. 4 50 THE PRACTITIONER'S MANUAL. Instances of cure have been recorded under the use of pow- dered valerian root (Wichmann, Jurine), of asafcetida, of cam- phor, of extract of hemlock (Johnston), of sulphate of zinc (Perkins), of flowers of sulphur (Munk), of Fowler's arsenical solution (Alexander, Cahen), bicarbonate of sodium and bella- donna (Bretonneau).—J. Knott. In the attack, amyl nitrite by inhalation.—Lauder Brun- ton. R Nitroglycerin............................................... gr. T^. Three or four times daily for one or two weeks. In syncope, hypodermic injection of nitroglycerin, ether, or caffeine. WTien ordinary remedies and doses do not give relief, hyos- cine hydrobromate, gr. y1^- hypodermatically, may give speedy relief.—W. W. Bostwick. Caution.—This is large, especially for an initial dose. Nitroglycerin acts best in the pure angio-spastic forms of angina pectoris, not so well in the pain of aortic disease, and still less favorably in that due to myocarditis or fatty heart. It is of little value in the pains of aneurism, and is generally useless in the pure motor neuroses of the heart. Its action in different subjects can never be predicted. If toxic symptoms appear after the exhibition of a small dose, it is best to discontinue the drug. If no toxic symptoms appear, gradually increasing doses can be given with safety. It acts with remarkable rapidity, the height of its physiological effect being reached in two or three minutes. When several small doses are without effect, larger doses should be given. Some- times a single large dose acts best. More than one-sixty-fifth of a grain cannot be given in a single dose.—Schott. In the attack, chloroform may be poured on a sponge in a smelling-bottle, and the patient told to breathe it through the nose as deeply as possible. In a minute or two relief is ob- anosmia. 51 tained, and as the patient comes under the influence of the drug the bottle drops from his hand, and there is in this way no danger of an overdose.—Balfour. For the paroxysm : R Amyl nitritis. S. Place three to five drops on cotton wool in the bottom of a wineglass ; to be inhaled. —OSLER. Hot applications to the chest, faradization of the cardiac region, administration of diffusible stimulants, belladonna, and small doses of opium. R Spiritus glonoini.............................................. 3 ss. Spiritus chloroformi.......................................... 3 ss. Tinct capsici................................................. 3 i. Aqua menth. pip...........................................ad § i. M. S. A teaspoonful every four hours, with an extra dose immediately at the onset of the attack. Drachm bottles may be conveniently carried in the pocket for use in emergency, as well as for the regular daily dosage. As tolerance is established the dose can be increased, and, as long as well borne, pushed with a free hand. Caution.—Severe throbbing pain in the head should lead to "easing off" the dose.—Murrell. When cardiac or renal lesions exist: R Diuretin..................................................... 1 gm. Three such doses daily as maximum. —Lefert. m Caution.—A somewhat dangerous drug.—Gley. Anosmia. Loss of sense of smell is usually caused by injury to the head, as in a fall upon the occiput, though history of such in- jury may not always be forthcoming. The olfactory nerves ma}' be torn in their passage through the lamina cribrosa of the ethmoid. 5'A THE PRACTITIONER'S MANUAL. Treatment.—In essential form without nasal lesion, daily irrigation with Weber siphon and— R Quinina sulphatis...................................... 0.1 cgm. Bismuthi subnitratis.................................... 10 gm> To be snuffed three times daily. Then electricity. In hysterical, faradization to the root of the nose until ac- tual pain is produced.—Bibard.32 Anthrax. Malignant pustule, while rare in this country, is of suffi- ciently frequent occurrence in some portions of the world to make its differential diagnosis of importance. It may be trans- mitted to man by the stings and bites of insects. At the point of inoculation, which is frequently upon the face (lip) or neck, after a few hours or days a vesicle develops, which may increase in size and become filled with clear or sanious fluid drying up into a blackish crust. Similar vesicles may form in the neighbor- hood and be surrounded by inflamed and infiltrated areas. After a day or more there are fever, general weakness, and depression, pain in the limbs, diarrhoea, and often delirium preceding collapse and death. In internal anthrax affecting the gastro-intestinal mucosa we may have besides the above- named symptoms, vomiting, abdominal pain, enlargement of the spleen, dyspnoea, and even convulsion of an epileptoid char- acter, resulting in death within twenty-four hours. Differentiation.—From carbuncle, by its development upon exposed parts and not so often upon the back of the neck; by the occurrence of brawny oedema rather, than of boggy infiltration; by the blackened central crusts rather than multiple openings; by the presence of the characteristic an- thrax bacillus; by the inoculation of a guinea-pig if grave doubt is entertained. In internal forms the diagnosis is sug- ANTHRAX. 53 gested by the occupation, wool sorters and those who handle hides being more exposed to inoculation. Prognosis.—The prognosis is favorable only when the affection is of limited extent and can be radically attacked. Death most frequently occurs after brief delay, with symptoms of general pyaemia. General infection of the system with the bacillus is probably always fatal. In internal anthrax, it is stated that if the subject survives for a period of five days he may recover. Treatment.—Internal antiseptics of almost any kind are indicated, though no particular one can be said to be efficacious. In anthrax of the skin everything may depend upon early and thorough excision, if the lesion be sufficiently circumscribed. Eighty-five per cent of recoveries are said to follow this plan. Cauterization with fuming nitric acid or caustic potash thor- oughly carried out, scarification, curettage followed by the application of caustics and antiseptics, and when there are much surrounding infiltration and oedema, by the intradermic injec- tion of carbolic acid or other antiseptics. If there is much accompanying inflammation and lymphangitis exists, hot or cold fomentations. Injection of iodized water around the pustule, applications of oxygenated water, and inhalations of oxygen; or injection of a two-per-cent or three-per-cent solution of carbolic around the pustule thrice daily, and over it compresses wet with a solution of the same strength. Antistreptococcic serum. R Hydrargyri bicyanidi.......................................... 1 Aqua destillata................................................ 100 Cocaina salicylatis............................................ q. s. M. S. Inject from half to one syringeful subcutaneously and cover the area with sublimate compresses. —Kedroff. Injection of blood serum of goats immunized to anthrax.—■ Sclavo. 54 THE PRACTITIONER'S MANUAL. R Tinct. iodi................................................ 1 Sm- Aqua..................................................... 200 M. S. Inject ten drops subcutaneously around the pustule. —Verneuil. Apply ammonia externally, give some salt of ammonium in- ternally, and if general infection threatens make intravenous injections.—Avendano. Prophylaxis requires that the utmost care be exercised by those handling hair, hides, etc., and that treatment should be instituted upon the earliest manifestation. Aortitis, Acute. This may be secondary in the course of typhoid, variola, and other infectious diseases, as well as in rheumatism. Diagnosis.—Retrosternal pain is a common symptom, radi- ating similarly to that of angina pectoris. Dyspnoea is peculiar in that inspiration and expiration are both laborious, while the respirations do not exceed thirty or forty to the minute; there is often present the sensation of a heavy weight in the epi- gastric region, frequently associated with evidences of arterio- sclerosis. Differentiation.—From angina pectoris, uraemia, asthma, tuberculosis. Prognosis.—After three or four months' duration, death. Treatment.—In the attack, counter-irritation, blistering, morphine, oxygen inhalation, nitrite of arnyl. In threatened heart failure, injection of ether, caffeine, camphor. Between the attacks, iodides alone or associated with arsenic. In cardiac irritability and general nervousness, valerianate of ammonium.—Plicque. Treatment must be directed against aortitis by the use of APHASIA. 55 milk, iodides, and nitro-glycerin in the treatment of angina pectoris. —Huchard. R Potassii iodidi............................................... 1 gm. As daily dose. If there is much nervousness, potassium bromide may be added. If symptoms are severe, phlebotomy.—Rendu. During painful crises : R Potassii bromidi, Ammonii bromidi, Sodii bromidi...........................................aa 2 gm. Aqua laurocerasi.......................................... 6 gm. Infus. Valeriana....................................q.s. ad 100 c.c. M. S. Tablespoonful thrice daily. —Robin. Aphasia. The loss of power of articulate speech or of writing (agra- phia), while the power of thought, faculty of expression, pho- nation and hearing remain unimpaired, may be limited to an inability to pronounce some particular word or to recognize it in print (word blindness). Motor aphasia and word blindness may coexist. The term amnesic aphasia is applied to the form of sensory defect of memory in which a word escapes the memory until it is heard pronounced. Total aphasia, a combination of word deafness with other forms, exists when the middle cerebral or Sylvian artery is plugged by an embolism or thrombosed.—Byrom Bram- well. Diagnosis.—Motor aphasia with inability to utter words usually comes on suddenly and is complete at first, all articu- late utterance being abolished; or a recurring utterance may be repeated. In auditory aphasia word deafness is constant; imitative speech is sometimes retained.—Pershing. Differentiation.—Auditory aphasia or word deafness, 56 THE PRACTITIONER'S MANUAL. which is its most constant and characteristic symptom, is dis- tinguished from the amnesic form by commanding the subject to perform some act. This he will be unable to do only if the amnesic form is present. Visual aphasia is characterized by word blindness, written or printed words conveying no meaning. Differentiation must be made from hysterical aphasia due to nervous excitement, to transient glosso-labial paralysis; also from inco-ordination in inebriates. There are many modi- fications of the complete form as well as combined varieties, which make reference to works on nervous diseases a necessity. Aphasia is often present in acute softening of the brain. Functional temporary aphasia may follow an epileptic attack, hysteria, and other conditions. Prognosis depends on the site and nature of the anatomi- cal lesion. If this is incurable, no improvement can be looked for. Children, however, may be taught to speak even after extensive injury to the speech centres. Treatment.—In amnesic aphasia the attempt must be made to strengthen the defective recollection of words by com- mitting to memory such words as are forgotten. Practise in repeating exercises before a mirror so as to recall the necessary movements.—Karl Bok. Aphonia. The inability to speak above a whisper while articulation remains unimpaired may be catarrhal or hysterical in origin. A local lesion may cause the hysterical paralysis. Diagnosis.—In hysteria this depends at times upon an asso- ciation with other evidences, at others it is the only sign pres- ent. The patient may be able to cough, sneeze, and at times to talk in his sleep or to sing; there is often, too, an ability to raise the voice at such times as other hysterical manifestations are prominently present. APHONIA. 57 Differentiation.—From aphasia. Prognosis.—Recovery often takes place rapidly, but the condition may last one or two years. Treatment.'—A confident manner while predicting a speedy cure and the application of a harmless electric current over the larynx will usually give the desired result. An emetic has also promptly restored the voice. In the catarrhal form : R Zinci sulphatis........................................ gr. i.-gr. vi. Aqua................................................. § i. M. S. Use in inhalation from atomizer. And— R Ammoni i chloridi............................................ 1 ss. Strychnina sulphatis.......................................... gr. i Syr. pruni virginianse.......................................... § iij- M. S. 3 i. t.i.d. —Da Costa. In the hysterical form, strong impression made upon the patient by promise to cure, in connection with use of electricity. —Sanger Brown. Pinch the posterior part of the arytenoids between the thumb and index to produce approximation of the vocal cords. Atropine, in doses large enough to produce constitutional symptoms, is almost a certain cure.—Bartholow. In impairment of nerve function in carrying on the mechan- ical process of breathing: R Ext. Valeriana............................................ • • • 3 ss. Tinct. digitalis............................................... ^lxv- Ext. Scutellaria............................................. ^xv- For one dose, to be given in sweetened water. Repeat every two hours till relief is obtained. —Davis." In the hoarseness of singers : R Acidi nitrici diluti.........................................mv.-x. In water. —Bartholow. 58 THE PRACTITIONER'S MANUAL. Or a piece of borax, the size of a pea, to- dissolve in the mouth.—Ringer. Or, in laryngeal catarrh, inhalation of tincture of benzoin or oil of rue. Or— R Pulv. aluminis.............................................. gr. x. Aqua....................................................... 1 i. Use as a spray. Or— R Vini ipecacuanha.............................................. 1 i. Use as a spray. Or— R Liq. ammonia, Aqua.......................................................aa, § i. M. S. Teaspoonful in hot water to inhale. —Potter. Or in acute forms a Turkish bath.—Brunton. Apoplexy. Besides the sudden unconsciousness due to alcohol, opium, and other poisons, we have to distinguish that of cerebral hemorrhage from embolism, thrombosis, concussion and shock from head injury, epilepsy, uraemic and diabetic coma, and hysteria. If we have the history, as given by a friend or relative to guide us, often no great skill is required. This lacking, we seek evidences of one-side paralysis or loss of sensation by pricking the soles and palms, pinching the skin upon the two sides, while watching for difference in reflex, or by raising the limbs in succession and noting a difference in the manner of their falling, etc. Hemiplegia may be absent in true apo- plectic seizures. One widely dilated pupil usually gives evi- dence of hemorrhage on the same side. Right-side paralysis is attended with aphasia. APOPLEXY. 59 Diagnosis.—Cerebral hemorrhage occurs usually after the fortieth year. The most prominent symptoms are the sudden onset, loss of consciousness, convulsions, coma, and, if recovery follows, hemiplegia on the side opposite the lesion. The pulse is usually slow and full. The respiration is stertorous and may be Cheyne-Stokes. If the resulting paralysis is complete, there may be incontinence of both faeces and urine. Differentiation.—From the coma of alcoholism by the drawn appearance of the face, the more profound coma. Too great care cannot be exercised in supervising doubtful cases. From uraemia by its sudden onset and by the comparative or complete absence of premonitory symptoms. From softening, the result of embolism, by the age of the patient, the presence or absence of a cause of embolism, such as valvular heart disease or ulcerative endocarditis and syphilis, and the intensity of the symptoms. The paralysis from em- bolism is more commonly on the right side. From cerebral thrombosis, by the sudden onset, longer dura- tion of the paralysis and other symptoms, and by the incom- plete recovery. From catalepsy, by its recurrence not being constant, and by the eyes not being widely opened and the pupils not being so susceptible to light, and chiefly by the characteristic relax- ation of the muscles. " When a person has an attack of hemiplegia of a more or less typical character, the rise of temperature on the paralyzed side points to a hemorrhage rather than to a simple obstruction of an artery. On the other hand, when a person has a hemi- plegia and the disturbance takes the ordinary course without any difference in the temperature of the two sides, the likeli- hood of the trouble being due to a softening is much greater." —Dana. The following table gives an excellent differentiation be- tween the two conditions in question : 60 the practitioner's manual. Predispos i ng conditions. Inciting con ditions. Onset Course Hemorrhage. Frequent before three years of age and between forty and sixty. Peri-arteritis and miliary aneu- rism the usual antecedents. Heredity is often marked...... High ai-terial tension.......... Excitement, effort or shock... . No prodromata................ Sudden stroke usu*.l........... Coma marked................. Rectal temperature reduced and surface temperature elevated on the paralyzed side. Congested face, respiratory dif- ficulties. Pulse slow, full, bounding..... Motor loss usually hemiplegic and fully developed at once General convulsions common. . Rapid improvement in motion. Foot usually gains more rapidly than hand. Anasthesia usually fleeting.. . . Persistent aphasia exceptional. Postplegic athetosis, trembling, and chorea common. Postplegic convulsions rare.. . . Spasmodic weeping and laugh- ter common. Thrombosis. Common in old age and in young adults. Endarteritis, atheroma, endo- carditis, cachexia, and em- bolism. Heredity rare. Low arterial tension. Rarely excitement or effort, ex- cept in embolism. Sleep favors it. Prodromata common. Complete stroke rare. Coma slight or wanting. Temperature usually un- changed. Pale face, no respiratory dis- turbance. Pulse weak, soft, often frequent. Motor loss often monoplegic and inclined to extend. Limited convulsions common. Slow motor improvement. Ex- tension of paralysis often ob- served. Foot often gains less than hand. Parasthesia persists. Persistent aphasia and other cortical symptoms common. Postplegic athetosis, trembling, and chorea uncommon. Postplegic convulsions common. Spasmodic weeping and laugh- ter exceptional. —Archibald Church. Prognosis.—In any case of apoplexy due to hemorrhage into the hemisphere, if renal disease, Cheyne-Stokes respiration, or hyperpyrexia, either or all of them, or two of them, are pres- ent, the patient will almost certainly die.—Barr. Recovery is probable if none of the above signs occur. Grave associated disease, diabetes, chronic alcoholism, etc., render prognosis unfavorable. Treatment.—Headache, vertigo, or a sense of fulness in the head, one-side numbness, etc., especially in an instance in which there is atheroma of the vessels or when there is high arterial tension without atheroma, are symptoms which often apoplexy. 61 exist for a week before the apoplectic attack; these prodromal symptoms are often overlooked and in many cases ignored. Rest, vascular sedatives, nitro-glycerin, large enemata, will often modify the circulation and thus tend to avert the rupture of the artery. If it be possible, the patient should be laid down on a sofa or mattress in the room where the attack occurs, and no at- tempt at movement made for twelve or twenty-four hours. It is better slightly to elevate the head by pillows, since this prob- ably tends to modify the force of the heart's action in the cerebral vessels, and at the same time allows respiration to be carried on rather better than when the patient is perfectly flat. In regard to drugs in this early stage, there are practi- cally no therapeutic indications that can be successfully met. In regard to the custom of administering croton oil or some drastic purge during the early stage, although sanctioned by almost immemorial usage, it is not only useless, but exposes the patient to the risk of making dangerous exertions, besides putting him in a filthy condition. The same objections in part apply to blistering and to the use of mustard. It is important to attend to the bladder and draw off the urine at regular inter- vals. The throat should be kept as free from mucus as possi- ble.—Preston. Free purgation should be resorted to early. In paralysis due to hemorrhage, venesection is often indicated, while in embolism or thrombosis it will, as a general rule, be a mistake to bleed. Depletion is indicated only when arterial tension is high.— Hill. Caidion.—Before depletion be sure of the diagnosis, since in thrombosis, embolism, and.acute cerebral anaemia a loss or blood will do harm.—Gowers. 62 the practitioner's manual. R Ergotinin................................................ 0.05 cgm. Lactic acid...........................................'... 10 cgm. Aseptic vehicle..................................to make 100 cc. M. S. Inject a syringeful, equal to one-half milligram of ergotinin. —Huchard. If after bleeding and purgation the pulse continues bound- ing, tincture of aconite or tincture of veratrum viride, gtt. i., every half-hour until the pulse is influenced.—Tyson. To produce free purgation, a drop of croton oil should be placed upon the tongue. Or— R Ext. colocynth. comp....................................... gr. xx. Olei tiglii..................................................n ij. Ft. pil. No. iv. S. One as required. Blistering, if done at all, should be on the shaven scalp, over the top of the head between the ears. When the pidse is hard and tense, amyl nitrite, or, better, venesection. Place the patient on a water bed. Apply heat. Caution.—Supervise carefully the application of hot-water bottles, to prevent deep burning of tissues. Use the catheter when necessary. In coma, nutrient enemata, especially after the bowels are cleaned out. In threatened asphyxia, oxygen. In the stage of secondary cerebral inflammation, with quick feeble or quid: intermittent pulse, digitalis, strophanthus, strychnine. When acute changes have subsided (six weeks to two months) systematic voluntary movements, massage, electricity. —Byrom Bramwtell. In resulting cerebral softening or in threatening softening of the brain, phosphorus is the only drug which affects the nerve centres. (See "Embolism" and " Thrombosis.") — Wood.30 Above all things, stimulants are contraindicated during the APPENDICITIS. 63 acute attack, even though the pulse fails, as they increase the hemorrhage into the brain.—Hare.33 R Tinct. aconiti.................................................fi[ x. Aqua cinnamomi......................................q.s. ad § ij. M. S. A teaspoonful every quarter of an hour for two hours, then every half-hour. —Potter. 34 In seizures without succeeding hemiplegia, regulate the cir- culation, dilate the vessels by nitroglycerin, enforce perfect quiet, employ laxatives, cold applications to the head, and iodide of potassium, just as in other instances. Too great care cannot be taken to prevent hasty return to ordinary occupa- tions.—M. Allen Starr. Appendicitis. When called to a suddenly occurring attack of abdominal pain following a chilliness and attended with or soon followed by vomiting and fever (usually), constipation or perhaps diar- rhoea, the pain becoming localized in the right side of the lower abdomen, or right iliac fossa, appendicitis will almost invariably come into the physician's mind as a possible cause of the colic. Diagnosis.—An accurate and timely diagnosis is of the utmost importance. The history of previous attacks will aid; likewise a family history of appendicitis, for, strange as it may seem, a marked tendency to "run in families" is noted, and especially in those in which gout, rheumatism, biliary lithiasis, and obesity are prevalent. Always examine per rectum. An abscess may burrow downward and point behind this part of the gut, while the apex of a long appendix or one situated behind the caecum may reach far down toward the brim of the pelvis. A point of diagnostic significance is the reflex spasm which will take place in the abdominal muscles of the right side when the hand is passed gently over the suface, from the left. 64 THE PRACTITIONER'S MANUAL. Upon firm deep pressure the appendix may be palpated, and, if a mass of intestines caked with plastic lymph is already pres- ent, the tumor will be distinctly felt. The focus of greatest pain lies midway in a line drawn from the anterior superior spine of the ilium to the umbilicus (McBurney's point), and is an almost pathognomonic sign of appendicular inflammation in male subjects. The pain may, however, be peri-umbilical at first, or even in the epigastrium, or on the left side. Appendicitis may suddenly attack an individual who seems to be enjoying perfect health, and when an epidemic, as it were, of such instances occurs within a circumscribed area, we must suspect an infectious form bearing certain analogies to dysentery, as Golouboff has pointed out. Very light forms probably pass without absolute diagnosis, pain being referred to the epigastric or to the umbilical region, and, being attended with vomiting, constipation, anorexia, the attack may pass for one of gastric derangement. Careful ex- ploration of the right iliac fossa will, however, show the tender- ness to be in reality localized, and often the tumefied appendix may be itself palpated. Some attacks in young persons may suggest an analogy to rheumatic tonsillitis. The patient may be suddenly seized with colic and pain in the region of the caecum. Perhaps there is a rigor, and the temperature runs up to 102° or 103°, or more. Within two or three days the temperature drops, and the patient is well, save perhaps for a little thickening of the appendix, that slowly or rapidly subsides.—James F. Goodhart. Pressure deep enough to disclose distinctly the posterior' abdominal wall, the pelvic brim, and the structures between them and the examining finger, forms the whole secret of suc- cess in the practice of palpation of the vermiform appendix.— Edebohls. Determine accurately the length, breadth, position, and condition of the appendix in the interval of attack by deep pal- APPENDICITIS. 65 pation before expressing an opinion upon which the patient will depend.—R. T. Morris. Differentiation is to be made from tumors in this region —fibro-myoma not connected with the genital organs, muscular abscess, affections of the liver, gall-bladder, or biliary canals, all of which may present the signs of perityphlitis or inflamma- tion of the appendix. Occlusion of the small intestine by a biliary calculus has more than once been found at the operation or autopsy when the diagnosis of appendicitis had been made. Perimetritis is not infrequently diagnosticated when appen- dicitis is in reality present and vice versa, and when they coexist the latter may be overlooked. Infants may have tuberculosis of the appendix, and Karew- ski has reported actinomycosis of the organ. In all instances of abdominal pain in infants with constipa- tion or diarrhoea the examination for appendicitis should be carried out, including, for the doubtful cases, exploration per rectum. The diagnosis of appendicitis in the female is attended with peculiar difficulties bearing on the differentiation of symptoms associated with tubal and ovarian disease. Coe, Grandin, and others have shown that the painful point and tumor are below the situation of the region of the appendix; the swelling is rounder, nearer the uterus, and more circumscribed, and its connection can usually be traced to the tube or ovary by rectal or vaginal palpation. When, however, the latter cannot be done, the absolute diagnosis is often left in doubt. Usually, however, the previous history of menstrual troubles, the chronic character of the case, and the absence of the recognized symp- toms of recurrent appendicitis will help to a conclusion.— George F. Shrady. From acute catarrhal salpingitis by the pains being more violent, more strictly localized, not radiating toward the thigh, 5 66 the practitioner's manual. and by persisting and increasing in intensity instead of remit- ting toward the third or fourth day, as in salpingitis. If diagnosis is not otherwise possible, examine in narcosis. —VlNEBERG. Board belly is the principal differential sign between acute appendicitis and salpingitis. In adhesion of the appendix with the uterus or with the ovary, differential diagnosis becomes more difficult. If abscess is due to salpingitis, the pus may show presence of gonococci. The history is very essential in differentiation from diseased adnexa. Entero-colitis as well as influenza may cause tenderness in the vicinity of the appendix, but a study of the concomitant symptoms should suffice for purposes of differentiation. A tumor behind the uterus on the right side, resulting from tubal pregnancy, has been mistaken for a thickened appendix by a number of surgeons of distinction. — William T. Lusk. In differentiation of perityphlitis or appendicitis from tumor, insufflate the rectum. If there is a tumor present, the stiff- ened wall cannot be distended. If it be an exudation, disten- tion is distinctly made out.—Sonnenburg. Tuberculous peritonitis in and about the caecum with masses of adhesions, producing tumor and obstruction, may simulate appendicitis. The previous existence of the condition may not be known to the patient or it may occur in infancy. True tuberculous appendicitis has been described. Empyema of the gall bladder in an acute form causes symptoms of obstruction and colic, and in the absence of jaundice may be mistaken for appendicular abscess.—An- drews. In hysterical subjects neuropathic complications may make doubtful the reality of the appendicular lesion. Perforation by gastric ulcer, of which there has been no pre- appendicitis. 67 vious history, may occasion a suspicion of appendicitis, by the low temperature and pulse of perhaps 140. An attack may so closely simulate gall stones or renal colic as to be indistinguishable from them. Acute intestinal catarrh may also be simulated. If the appendix is displaced so that on palpation it is not found, an inflammation involving it may be overlooked. Pain and ten- derness of sudden onset, and particularly localized, should all be taken into consideration in arriving at a diagnosis. Instead of being referred to McBurney's point, the pain may be com- plained of in the sigmoid, hepatic, or epigastric region. Undescended and inflamed testicle on the right side as well as torsion of the ureter in connection with movable right kid- ney may be sources of error. Rigidity of the right rectus muscle should be a decided aid. A distinction must be made in neurotic subjects from the rigidity due to hypersensitiveness. Prognosis.—The chief cause of death is delay in one direc- tion or another. The prognosis is worse in operation during than after an attack. After the second attack a third is almost sure to follow. Each succeeding attack renders operation more difficult and dangerous. If in five or six hours there is no increase in urgency the patient is not in immediate danger, if kept at perfect rest in bed; if in twelve hours there is still no increase in the severity of the symptoms, the patient should soon begin to improve.— McBurney. In pronounced generalized septic peritonitis the prognosis is as bad as it can well be. Mortality is not so large as usually assumed—8.9 per cent of all cases and only 2.5 per cent of circumscribed cases die. Treatment.— Dieulafoy was in error when he uttered those 68 the practitioner's manual. almost tragic words, "There is no medical treatment of appen- dicitis." Everything depends upon the diagnosis. Were we able to predict from the start which cases would be mild in course and to say definitely which are of rheumatic origin, drug treatment would cure in many instances. As Morris says, however, we are dealing with a percussion cap which may simply snap or flash or result in an explosion, and in which way it is going to go off no man can tell. Every patient must have the benefit of prompt and properly directed medical aid from the start. Perfect rest, exclusive fluid diet, an enema to empty the lower bowel, morphine in moderation to quiet intestinal movement, and, if rheumatoid origin is at all suspected, salicylic acid in full dose appropriate to the age. Externally the cold-water coil or ice bag. If all goes well, the pulse rate does not run high and stay high, in spite of perhaps a falling temperature. We may treat symptomatically and advise operation any time after the attack is at an end. If pulse, fever, or both remain high after twenty- four hours, the surgeon is to be called. An appendix once diseased is always an element of danger, and subsequent attacks may not terminate so favorably as did the first. If perforation has taken place and diffuse peritonitis ex- ists, operation should not be delayed. Operation is called for in abscess formation. If the appendix is readily found, it may be resected. In infants and badly conditioned subjects it should not be sought for too deeply among adhesions nor for too long a time. In peritonitis, median laparotomy with saline washing, resection of the appendix (if found), and drainage. Operate before the entire system is involved in a toxaemia and the general peritoneal cavity is implicated. APPENDICITIS. 69 If adhesions and plastic lymph are setting up a protective barrier to the forming pus, respect their efforts; and if symp- toms are favorable wait before incising the abscess cavity. If seen early, absolute rest, fomentations, salines every half-hour until four or six fluid stools are produced.—Jonas. Adhere to medical treatment when that is adequate to the emergency. Experience has shown that immediate intervention gives no better results in diffuse peritonitis than if delayed for a few days, and that in local suppuration the time of election for operation is not during the acute symptoms, but between the twelfth and fifteenth days.—Talamon. It is not unreasonable to suppose that catarrhal appendici- tis can be relieved without an operation as well as catarrhal salpingitis. R Sodii salicylatis.............................................. 3 iij. Ft. chart. No. xij. S. One every two hours. __LESSER Caution.—Avoid opium, since it obscures the diagnosis and does actual harm. In children do not operate when there is generalized perito- nitis. Even when peritonitis is circumscribed but complicated, put off operation.—Renvers. The results of purely medical treatment are not sufficiently bad and those of surgical treatment not sufficiently satisfactory to justify operative intervention in all cases.—Furbringer. The opium treatment relieves pain and discomfort, but en- tirely masks the symptoms at a most important time, for it is in the first twenty-four hours from the beginning of the attack that we can decide not only as to the diagnosis, but as to the probable course and result of the case.—McBurney. For the vomiting: R Menthol................................................... gr. viij. Cognac................................................... I iss. Laudanum................................................ 3 v. M. S. Take from ten to twenty drops several times a day, in a little sweet- ened water. __Ptpk" 70 THE PRACTITIONER'S MANUAL. If at the end of twenty-four or thirty-six hours the patient is not improving, advise operation.—G. E. Armstrong. The near future will demonstrate that treatment belongs to the field of medicine and not to surgery. Of one hundred cases properly treated from the earliest manifestation of the disease by rest in the recumbent posture, abstinence from all food and drink except ice for first twenty-four hours, opium sufficient to relieve pain and give rest to the bowels by quieting peristalsis, emptying the bowel by large enemas, and the application to the abdomen of leeches and hot poultices, ninety cases will end in recovery without the intervention of surgery.—E. H. Rich- ardson. Every case of appendicitis is in the province of the surgeon and should be under his constant scrutiny in readiness for oper- ation.—Beurnier. In fulminating cases, early operation. In those of moderate severity, wait until the height of the at- tack is passed.—Reclus. Remove the appendix even in mild cases that begin "storm- ily," particularly if there is any chronic tendency.—Rotter. Under liquid diet, opium, and complete rest, forty-five pa- tients recovered out of forty-six treated.—Hood.1' Artorio-Scler osis. Atheromatous inflammation of the blood-vessels, particularly of the arteries, is readily recognized when those in the region of the temples especially are tortuous, dilated, and have a pul- sating appearance. Diagnosis.—Vertigo is a frequent symptom, especially on awakening with dull diffuse headache. Chest constriction may follow slight effort and be attended with cold perspiration of the face and weakness of the limbs. It is a condition chiefly of advanced years, but general arterio-sclerosis is seen also in arterio-sclerosis. 71 middle life. In the wrist, popliteal space, and other situations in which the vessels are superficial, they are found firm and hard to the touch and are compressed only by the exertion of some force. Hypertrophy of the left ventricle is usually an accompani- ment, and signs of chronic heart disease with dilatation are not unusual. The Roentgen rays may be utilized to detect calca- reous deposits in the course of suspected vessels. Differentiation from simple increase of vascular tension alone. Attacks of vertigo, with pallor of countenance producing grave apprehension, are to be differentiated from mild cerebral apoplexy and from various digestive disorders. In diffuse arterio-sclerosis there is high arterial pressure, but not in senile endarteritis pure and simple.—Councilman. Prognosis.—Muscular weakness and tottering gait may be a result, and in very old subjects gangrene of the lower ex- tremities. Apoplexy is a frequent consequence or death may result from heart implication. Treatment.—Treat such causes as may be discovered in gout, syphilis, rheumatism, lead poisoning, etc. Iodide of potassium is a drug of value, even in instances of non-specific cause. Diet, rest, avoidance of excitement, tepid baths. For the vertigo : R Ergotini................................................. 0.1 cgm. Ext. physostigmatis..................................... 0.02 cgm. Ext. gentiana........................................... q- s. S. For one pill. One to twenty such daily, according to patient's tol- erance. For the vertigo with sensation of impending death, if the frontal artery be found tortuous or there are present arcus senilis, a clanging heart sound, increased pulse tension, scanty urine, and a possible trace of albumin: 72 the practitioner's manual. R Potassii iodidi........................................ gr. xxx.-xc. Daily for months together. —Church. Or— R Sodii iodidi................................................. 3 ij. Aqua destil................................................. 1 viij. M. S. One or two teaspoonfuls three times a day; out-of-door exercise; a quiet life, avoidance of tobacco, alcohol, and a too exclusively meat diet. The sodium iodide may be continued for years. —Goarcon. Or— R Sodii nitritis............................................. gr. v.-x. Three times daily. —Hay. In weak heart in elderly subjects, associated with pain, arsenic is indicated.—Balfour. In distressing palpitation with cardiac weakness: R Chloral hydrate, Sodium bromide.....................................aa 4 gm. Codeine................................................ 0.1 cgm. Water, Syrup of orange peel..................................aa 45 gm. M. S. A dessertspoonful every two hours till the heart is quieted. Caution.—In aortic regurgitation due to arterial sclerosis digitalis may produce ill effects.—Handford. R Potassii iodidi........................................... gr. v. Hydrargri chloridi corrosivi.............................. gr. gV-Jr- To be continued for a long time. —Tyson.3 R Spiritus glonoini........................................ gtt. xxx. Aqua destillata.......................................... | x. M. S. From three to six dessertspoonfuls during the twenty-four hours. To increase elimination of calculi-forming salts, especially in the cardiac complications, watery solution of sodium bicar- bonate to which sufficient lactic acid is added to neutralize. ARTHRITIS, gonorrhceal. 73 R Sodium bicarbonate........................................ 10 gm. Neutralize with : Lactic acid................................................ q. s. Then add -. Lactic acid, Syrup...................................................aa 10 gm. Distilled water............................................ 180 gm. M. To be taken in the twenty-four hours. —Rumpf. Arthritis, Gonorrhceal. The term gonorrhoeal rheumatism has been applied to a complexity of symptoms including inflammatory involvement of the eye as well as of tendons, fasciae, and other tissues; the joints are, however, the parts most particularly impli- cated and more especially the larger ones, often one only at a time. The knee and ankle are the joints most commonly affected. Diagnosis depends largely upon the above fact, the history of present or preceding gonococcic infection, and the absence of family and personal history of rheumatism proper. Differentiation.—From rheumatic fever, by the absence of sweating, the mild general reaction, the less inflammatory nature of the swelling about the joint in many instances, and the greater amount of hydrarthrosis. If iritis or conjunctivitis is coincidently present, the suspicion of gonorrhoea as a cause is strengthened. Likewise, involvement of parts around the joint in an obstinate chronic process, which does not give way to antirheumatic remedies, should arouse suspicion and lead to investigation of the urine. It does not as a rule tend to affect the heart, although cases of gonorrhoeal endocarditis do occur, nor does it tend to shift so rapidly from joint to joint. Gonorrhoeal rheumatism is peculiar in attacking certain joints which are rarely involved in acute rheumatism—as the sterno-clavicular, the intervertebral, temporo-maxillary, and the sacro-iliac.—Osler. Prognosis.—Recovery in six weeks is to be regarded as a 74 THE PRACTITIONER'S MANUAL. favorable termination. If the diagnosis is not made early and appropriate means are not employed, a protracted course is to be expected. It is liable to recur and is an affection of extraordinary ob- stinacy. —Osler. Treatment. —In the beginning : Ext. jaborandi fid................................................ 3 ss. For a dose. Repeat every half-hour for four doses. —Heaton. In plethoric subjects, temporary ease may be obtained by the use of leeches; or flaxseed poultice with laudanum.—R. W. Taylor. For acute synovitis, repeated applications of large blisters at a little distance from the affected joint. Thermo-cautery to allay pain and reduce swelling. In chronic, wash well with hot water and soap until the skin is reddened. Apply flannel soaked in tincture of capsicum so as to cover the whole joint, extending well above and below. Over this apply oiled silk with a firm bandage for half an hour each night.—Jonathan Hutchinson. Baths, to which is added, according to the susceptibility of the patient, a greater or smaller amount of the following: R Tinct. saponis mollis............................................ 200 Spt. terebinthina............................................... 100 —Balzer. In hydrarthrosis, not relieved by blistering, the fluid may be drawn off and the joint irrigated. Mild massage may bring rapid improvement, in cases which have proven refractory to other methods. In the acute stage, cotton soaked in absolute alcohol and applied to the joint by means of a bandage gives great relief. Perfect rest of body and limb is a first essential. arthritis, rheumatoid. 75 Apply locally: R Ichthyoli..................................... Ung. belladonna............................. Lanolin».................................... Adipis........................................ M S. After rubbing in, apply a flannel bandage Or, if great pain : R Guaiacol, Glycerin....................................................aa § ss. M. S. Apply with camel's-hair pencil and cover with protective. Treat the blennorrhagic inflammation by local rather than by general methods. First of all treat the urethra and other possible foci of in- fection. In acute, rest, fixation of the joints by splints, blisters, thermo-cautery.—Wood and Fitz. In subacute urethritis, deep urethral and bladder irrigation with nitrate-of-silver solutions. In chronic, general hygienic measures. Tonic medication, massage, baths, passive motion. Potassium iodide is sometimes of service. As a last resort, surgical intervention; opening the joint. Arthritis, Rheumatoid. Arthritis deformans, osteo-arthritis deformans, progressive polyarthritis deformans, nodular rheumatism, or, as it is often called, rheumatic gout, is to be differentiated from both the affections whose names go to form the latter hybrid designation. Diagnosis.—There are pain in the joints and atrophy of muscles connected with them, while the bony structures be- come enlarged and distorted. It is a progressive polyarthritic form of chronic rheumatism. —Baumler. Differentiation.—Rheumatism is simulated in the early 3 ij.-iv. 5Ss. 3 ij. 76 the practitioner's manual. stages before deformities occur, when the type is chronic from the first. When, as is usually the case, it is subacute from the onset, it is distinguished from gout by the absence of the char- acteristic acute paroxysms of the latter. It differs from acute articular rheumatism by being a disease of general nutrition, in part inflammatory, but also in part degenerative. There is also anaemia of pseudo-chlorotic type. In chronic arthritis the process is limited to the synovial membrane and peri-articular connective tissue, whereas in ar- thritis deformans the process advances to the cartilage and bone. —Strumpell. Heberden's nodes indicate rheumatoid arthritis rather than gout.—Riesman. In chronic rheumatism there may be connective-tissue anky- losis, a condition which is never seen in arthritis deformans.— Von Leube. Arthritis deformans is most frequently seen in individuals between thirty and forty years of age. It may, however, be seen in children of from ten to fifteen years, and Koplik 64 has reported its occurrence in a child of seven. Anatomical lesions may be differentiated from those of gout, and other affections may be excluded by a?-ray examination. Prognosis.—Hopeless deformity and often helplessness re- sult from the chronic progressive rheumatism. Early recog- nition of the condition permits institution of means to prevent impairment of function. Treatment.—General hygienic measures, massage, hot- air baths, change of climate, flannel next the skin, careful diet. Iodides, especially in combination with arsenic, do good. Prevent contracture of the affected joint by extension appa- ratus. Strontium bromide influences the pain and may have a power to limit the progress of the disease.—Riesman.21 Cod-liver oil, arsenic, and iron. ARTHRITIS, RHEUMATOID. 77 In the early stages, carbonate of guaiacol.—Hingston Smith. Absolute rest.—Gibney. R Creasotol................................................th, v. -xx. Or— R Benzosol................................................ gr. iv. Or, preferably— R Guaiacol carbonate...................................... gr. v.-xv. Externally guaiacol and olive oil, equal parts.—Bannatyne. Oil of cloves best masks the odor.—Da Costa. When there are excessive pain and irritability, baths at 92° to 94° of ten to twenty minutes' duration, through which the galvanic constant current is passed. The alternating current may also be used.—Steavenson. Piperazin water with phenocol to combat irritating pains. R Sodii bicarbonatis....................................... 30-40 gm. As daily dose for weeks together, usually combined with quinine. —Charcot. Between the acute painful attacks, iodides, arsenic. Or the latter alternating with— R Tinct. iodi.............................................. gtt. iv. -x. Syr. aurantii............................................ 3 i. At dose. Or arsenical baths : R Sodii arseniatis........................................ 1-8 gm. Sodii bicarbonatis.................................... 100-150 gm. For each bath. Hot-air baths (as described under chronic rheumatism). This is the most valuable of all treatment.—James Stewart. In old cases: R Acidi lactici................................................ gtt. x. Given when the stomach is empty and allowing no food for an hour and a half afterward. Gradually increase to forty drops daily. —Zolotavine. Plaster-of-Paris cast, massage; make persistent effort before pronouncing any given case hopeless. 78 the practitioner's manual. Ascaris Lumbricoides. The presence in the intestine of the round worm, which re- sembles in a measure the common earthworm, occasions symp- toms of bowel irritation. Diagnosis.—There are disordered digestion with colic, alter- nating diarrhoea and constipation, coated tongue, and fetid breath. Nervous symptoms often bring into question such severe disorders as chorea, epilepsy, and insanity, while convul- sions are now and then observed. It would seem that the adult worm is alone affected by remedies, since young ones, it is said, are never observed in the discharges. The colic, according to De la Feuente, is characteristic by reason of its suddenness, it seizing the child in the midst of play, by its early severity, and by its being confined to a limited area, the rest of the ab- domen being free from pain on palpation. There is also bilat- eral narrowing of the visual field. Occasionally we observe dilatation of the pupils, itching of the nose, salivation, vomiting, and migraine.—Strumpell. Differentiation.—From grave nerve disease by the prompt disappearance of symptoms under proper treatment. In young adults symptoms of typhoid fever have been closely simulated (Chauffard). The tongue is foul rather than red, and. without tremor; the breath gives an odor more of putrefaction; there are no rosy spots, and the fever yields to appropriate drugs. Prognosis.—Good. An instance has been related by Mitra" of fatal diarrhoea, during the course of which one hundred and eleven round worms were passed. Treatment.—Quite as important as the administration of anthelmintics is the regulation of the quantity and quality of food according to the child's age. Getting rid of the offending parasites will be followed by but slight improvement unless ASCARIS LUMBRICOIDES. 79 proper treatment, including dietetics, accompanies the drug medication. Anthelmintic for children : R Benzonaphtholi.............................................. 2 gm. Santonica................................................... 1 " Sacch. albi.................................................. 5 " M. ft. pulv. div. in chart. No. xx. S. Three to five powders daily. Or for a child of three to five years: R Santonini................................................... gr. iij. Hydrargyri chloridi mitis.................................. gr. iij. Sacch. albi................................................. q. s. M. ft. chart, div. No. ij. One night and morning. —S. M. Ward. Or— R Santonini..................................................... 0.2 Olei ricini.................................................... 70. M. S. Teaspoonful every two hours. —WlEDERHOFER. Caution.—Great abdominal tenderness, especially in the right iliac region, rapid breathing, abundant golden yellow urine followed by suppression, salivation, progressive rise of temperature, feeble pulse, jaundice, and prolonged stupor are symptoms of poisoning which may prove fatal.—J. S. Taylor.15 R Ext. spigelia fld.............................................. 3 x. Ext. senna fld................................................ 3 vi. Olei anisi.....................................................v^ v. Olei cari......................................................ttj, v. M. S. For a child of two years half a teaspoonful two or three times daily ; for a child of from four to ten years a teaspoonful. —C. W. TOWNSEND. R Naphthol.................................................. 15 cgm. For one wafer. S. One three times daily. —Dubois. R Hydrargyri chloridi mitis.................................... gr. ij. Santonini.................................................. gr. iss. Sacchari lactis.............................................. gr. xv. M. S. One dose in one drachm of honey ; for a child of two years. —BOUCHUT. 80 THE PRACTITIONER'S MANCAL. R Olei chenopodii........................................ gtt. lx. - 3 i. Mucilag. acacia....................................... 3 ij. Syr. simplicis........................................ § i. Aqua cinnamomi..................................... § ij. M. S. Give a teaspoonful three times a day for three days, and repeat after several days. —Meigs and Pepper. R Spigelia, Senna......................................................aa § ss. Magnesii sulphatis............................................. 3 ij. Fceniculi...................................................... 3 i. Aqua ferventis................................................O i. M. Macerate for two hours in a covered vessel. Dose, a tablespoonful for a child two years old, once or twice daily, or every other day, so as to procure two or three evacuations in the twenty-four hours. —G. B. Wood. R Ext. spigelia.................................................. § i. Ext. senna.................................................... § ss. M. S. Teaspoonful for a child of from three to five years. Santonin in grain dcse may be added to the above. —J. Lewis Smith. Or— R Santonin.................................................. gr. xx. Podophyllin............................................... gr. v. Sugar..................................................... gr. xxx. M. S. Divide into five powders; give one every four hours until it acts freely on the bowels. The dose of podophyllin can be varied according to the age of the child. —Deray. Turpentine emulsion: R Oil of turpentine, White of egg...............................................aa § ij. Glycerin, Syrup, Water......................................................aa §iv. Mix the white of egg and glycerin together, add the oil of turpentine, and shake thoroughly; then add the syrup and lastly the water, shaking them well together. A teaspoonful will contain about eight minims of turpentine. ASCARIS VERMICULARIS. 81 R Olei chenopodii........ ....................................... 3 i. Olei terebinthina rectificati.................................... 3 ij. Emulsionis olei ricini (50 per cent)......................q.s. ad § ij. M. S. Teaspoonful twice daily. —Powell. Or— R Ext. filicis maris ath.......................................... 4 Hydrarg. chloridi mitis....................................... 0.4 Aquae destillata, Sacchari albi................................................aa 15 Gelatin........................................................ q. s. M. S. At a dose. Or— R Ext. filicis maris ath., Tinct. vanilla.................................................aa 3 Olei terebinthina................................................ 4 Aqua destillata................................................. 25 Gum. arabici pulv............................................... 2 M. S. One dose, to be taken in milk. Ascaris Vermicularis. The oxyuris vermicularis, threadworm or pinworm, indi- cates its presence in the lower segment of the rectum by a recurrent itching, usually nocturnal. If this leads to an ex- amination, one or more thread-like, actively wriggling, white worms are usually disclosed. The male is about five milli- metres and the female about twenty millimetres in length. The diameter corresponds to about No. 24 thread. Occasionally convulsions may be caused by the intense irritation set up, espe- cially when these pinworms are numerous, and even in the adult treatment will often be demanded. In girls the worms may enter the vagina, give rise to intense itching, and thus lead to masturbation.—Strumpell. Treatment.—All milk and water given should be boiled, and meats well cooked. Frequent purgation; enemata of cold or warm water; cleanlin ess. —S ansom. 6 82 the practitioner's manual. R Santon in................................................... gr. f. Calomel.................................................... gr. iss. M. One such cachet to be taken before breakfast every day for three days. Also, every evening for the same number of days, a little of the following ointment should be inserted within the anus: R Glycerite of starch......................................... 2 parts. Mercurial ointment........................................ 1 part. M. R Tanaceti................................................... 2 gm. Make an infusion with : Water..................................................... 200 " Add: Glycerin................................................... 20 " Inject after evacuating the bowels. Or— R Asafoetida................................................. 3 gm. Yellow of one egg. Water..................................................... 150 " Or— R Mentholi............................................... 0.25 cgm. Olei oliva.............................................. 60 gm. Or— R JEtheris.................................................... gtt. xx. Glycerini.................................................. 30 gm. Aqua..................................................... 150 gm. To inject after an evacuating enema. —COMBY. Or— R Salt........................................................... i ss. Water.......................................................O i. Or— R Vinegar..................................................... z j Water........................................................q \ M. S. Inject once daily until there are no further signs of worms, then gradually decrease. Or, turpentine in emulsion.—G. T. Monroe. Enemata fail because the habitat is not the rectum alone but the whole large intestine. ASCITES. 83 In obstinate cases, injections through a long flexible tube. R Santonini pulv.............................................. 3 i. Resina jalapa.............................................. gr. ij. Cocoa..................................................... 5 i. M. et div. in troch. No. xx. S. One in the morning on an empty stomach for an infant of two years ; two or three for older children. —Guichon. R Tinct. rhei................................................. gtt. xx. Magnesii carbonatis........................................ gr. iij. Tinct. zingiberis.......................................... gtt. i. Aqua..................................................... 3 iij. M. S. This is to be given three or four times daily, according to the effect produced upon the bowel. —Sidney Martin. Or— R Benzonaphthol, Santonica...........................................aa gr. xxx. Sacch. albi............................................. 3 ij. M. S. Div. in chart. No. xx. Two to five powders daily. R Acidi carbolici.......................................... gtt. x.-xx. Glycerini............................................... § i. Potassii chloratis...................................ad saturandum. Aqua.................................................. § viij. M. S. Use as an enema. —W. H. Van Buren. R Acidi carbolici............................................. gr. xx. Aqua .................................................... O i. Or, infusion of quassia or solution of quinine (1-5,000). Enemata of lime water or boric acid or bichloride (1-10,000). Santonin every second night for a week. Exercise and general diet.—Nicholson. To relieve itching, unguentum hydrargyri.—Strumpell. Or, unguentum belladonnae.—Osler. Ascites. Though a symptom, abdominal dropsy producing a uniform rounded fuluess must be at times carefully differentiated from other conditions. 84 the practitioner's manual. Diagnosis.—Inspection shows only the fulness, glistening skin, perhaps enlarged veins and striae, prominent or protruding umbilicus, and dilatation of any hernial sac that may be present. CEdema elsewhere is suggestive. Breathing and heart action are interfered with. Palpation gives a distinct "wave" between the hands. Percussion shows dulness over the fluid and a tympanitic note over the intestinal area, which changes with alteration in the patient's position. Tyson21 has recently directed attention to the fact that, while the absence of tympany in the flanks is generally thought to be characteristic of ascites, many instances show it to be present. If the intestinal canal be free from faecal contents, the region of the caecum and the descending colon will emit a tym- panitic sound on percussion, even though the adjacent regions are occupied by dropsical fluid.—H. M. Lyman. Differentiation is to be made from tympanites by the per- cussion note and wave impulse in ascites. From pregnancy, by deep palpation and vaginal examina- tion. From distended bladder by the use of the catheter. From ovarian and other abdominal tumor by irregular enlargement, by vaginal and rectal exploration, and by the fact, dwelt upon by Niemeyer,31 that in the area between the crest of the ilium and the last rib no tympanitic sound from the large intestine is elicited in ascites, while in ovarian tumor percussion usually gives full resonance. Ascites. Expansion more marked laterally. Fulness uniform. Umbilicus protruding at times. Palpation gives fluctuation beyond bor- der of dulness. Upper border of dulness concave. Ovarian Cyst. More marked longitudinally. Greater on one side than on the other. Never. Fluctuation limited to dull area. Straight or slightly convex. ASCITES. 85 Prognosis depends upon the producing cause and possibility of removal. Treatment.—Attention to the underlying condition, gen- eral tonic treatment, diet, excluding fluids to a large extent. Dry heat. R Triturations elaterii......................................... gr. \. Frequently repeated. Or— R Potassii bicarbonatis........................................... § ss. Mellis......................................................... §i. M. S. Teaspoonful at frequent intervals. Or— R Pulv. jalapa comp........................................ 3 i-- 3 ij. Given in the morning. Or— R Hydrargyri chlor. mitis......................................gr. v. Pulv. jalapa comp.......................................... 3 ss. Given in the morning. To give prompt relief from pressure symptoms, tapping. (See Surgery.) Tap either at the sides or midway between the pubes and umbilicus. Caution.—See that the bladder is empty if the latter pro- cedure is adopted. When associated with general dropsy: R Ext. senna..................................................... 3 i- Magnesii sulphatis.............................................. § i. Given in water every second day. Or— R Hydrargyri chloridi mitis, Pulv. digitalis, Pulv. scilla................................................aa gr. i. For one pill. Three such daily. —Carpenter. 86 THE PRACTITIONER'S MANUAL. Or— R Hydrar. chlor. corrosiv....................................... gr. -fa. Pulv. digitalis, Pulv. scilla...............................................aa gr. i. S. One such pill three times a day. When diuretics do not act: R Strychnina sulphatis........................................ gr. tV Ferri citratis................................................ gr. iij. For one pill. To be repeated three times a day. —N. S. Davis. Caution.—Should not be long continued. Ascites of cirrhosis : R Strychnina sulphatis........................................ gr. ^. Pulv. digitalis, Pulv. scilla...............................................aa, gr. i. S. One pill four times a day. —Delafield. R Hydrargyri chloridi mitis.................................... gr. iij. Pulv. opii................................................... gr. £. S. Repeat three times daily for four days. In general oedema, vapor baths, alcoholic baths. R Resina copaiba...................... ...................... 3 iij. Alcoholis.................................................... 3 v. Spt. chloroformi.............................................. 3 i. Mucilag. acacia.............................................. § ij. Aqua......................................................ad ? xij. M. S. Tablespoonf ul three times daily. —Potter.34 Asthma. Here we have to distinguish between bronchial asthma proper, the dyspnoea accompanying capillary bronchitis, car- diac asthma, spasm of the glottis, and spasm of the diaphragm. In the attack of bronchial asthma accompanying acute or chronic bronchitis there is dyspnoea implicating both lungs, accompanied by an oppression which is at times most distress- ing, and anxiety which may be called respiratory in contra- distinction to the cardiac anxiety of angina pectoris. Diagnosis.—The attack may come at any time, but espe- ASTHMA. 87 cially at night, and after exposure to inclement weather, etc. It may be preceded by headache, vertigo, or drowsiness, and especially by nervous disturbances. There is a tightness across the chest, with pallor and cold perspiration, and a characteristic feature of the breathing is the slight motion of the chest wall and the difficulty in expelling the air. The patient is forced to sit up, or is inclined to lean out of an open window, or to stand bend- ing over with his weight supported in the struggle for breath. The frequency of respiration is diminished and the inspiration is short. The expiration is prolonged and attended with a characteristic wheezing-sound which can be heard at a dis- tance. Aside from loud sibilant and sonorous rales, the coexist- ing bronchitis or emphysema gives bronchial rales of more or less moist quality, diffused over the chest. The moist bron- chial rales are, however, rarely pronounced during the parox- ysm. There is no dulness on percussion. The attack itself may vary from half an hour to several days, or, especially when chronic bronchitis coexists, dyspnoea may occur nightly, awakening the patient from sleep. As the spasm of the bronchi relaxes and expectoration comes on, gela- tinous masses are coughed up, which, if spread out on a glass and held above some dark object, may be seen to contain cer- tain twisted or spiral forms. Under the microscope these are found to be made up of mucin in spiral arrangement (Cursch- mann spirals), including cells from the bronchi and alveoli, be- sides epithelium and Charcot-Leyden crystals and eosinophile cells. While these forms may also be found in pneumonia and in fibrinous and capillary bronchitis, they are much more common in asthma. Differentiation.—In cardiac asthma the dyspnoea affects inspiration as well as expiration, and in one of its forms there are cyanosis, passive congestion, oedema of the extremities, and symptoms pointing to the underlying valvular or muscular car- diac lesion. In cardiac dyspnoea, unless oedema of the lungs 88 the practitioner's manual. is present, there is an absence of rales. The expiratory form of dyspnoea excludes spasm of the glottis. The decreased frequency of respiration already mentioned excludes capillary bronchitis, which is attended with increase in the number of respirations. In bronchial asthma there is expiratory dyspnoea. In car- diac asthma the dyspnoea is mixed. In oedema and spasm of the glottis, spasm of the laryngeal adductors and paralysis of the crico-arytenoideus posticus, as well as in tracheal and bronchial stenosis, there is inspiratory dyspnoea. In spasm of the glottis the patient's head is inclined back- ward and the larynx makes wide excursions during the act of breathing. In bronchitis the typical sounds are moist; in asthma they are dry. Cough is always present in the former, often absent in the latter, and the sputum, if there is any, is not purulent. In emphysema the respiration is never free; in asthma the overdistention of the lung disappears rapidly and respiration may be perfectly free between the attacks. The intercostal depressions are obliterated in emphysema; in asthma they are exaggerated, especially during inspiratory effort. In asthma the lower border of the lung is normal between the attacks. In emphysema the lungs are always larger.—von Leube. The differentiation from dyspnoea in cardiac disease is given below: In heart disease. The paroxysms are of a few minutes' duration. The dyspnoea is of a gasping, panting kind, rather a breathlessness than a difficulty of breathing. The respiration is hurried, the move- ment deep, and the rhythm not changed. The patient feels as if dying. In asthma. The paroxysms may last for hours, or even days. The breathing is tight, constricted, and difficult. The respiration is often slow, the move- ments are superficial, and the expira- tion is prolonged. However difficult the breathing the patient feels there is no danger. ASTHMA. 89 In asthma. The breathing is accompanied by prolonged, sibilant, and musical rhonchi, especially at expiration. Exertion alone will not immediately produce a paroxysm in tranquil breathing. Each paroxysm, as a rule, passes off with an access of expectoration. The tendency of emotional excitement is curative; often completely and suddenly. Periodicity is often well marked. —George E. Pike. Prognosis.—In the adult, unless the exciting cause can be discovered and remedied, paroxysms are to be anticipated throughout life. Especially is this the case when the family history points to an hereditary predisposition. The younger the subject, the more favorable the outlook. Emphysema, chronic bronchitis, with or without hyper- trophy of the right ventricle, may be predicted in after-years. Treatment.—The hypodermic administration of a full dose of morphine may cut short an attack. Most subjects find more or less relief in the inhalation of smoke from the burning of saltpetre paper, cigarettes made from the leaves of belladonna, stramonium, or similar herbs. The inhalation of nitrite of amyl, or of chloroform, ether, or pyridin (Germain See), may be effective for a time during the attacks. Internally chloral, Hoffman's anodyne, tincture of lobelia, etc., may be given. Caution.—Alarming collapse may result from chloroform. Local sources of irritation are first of all to be sought out and removed. Asthma of reflex origin from nasal disorders must be re- lieved by curing the cause, whether this be polypus, septal deformities, adenoids, or other like condition.—Greville Mac- donald. The first importance must be given to the removal of exos- There are commonly no bronchial rales. Exertion in tranquil breathiug is an adequate immediate cause of a paroxysm. The paroxysm is not followed by ex- pectoration. The tendency of emotional excitement is to induce a paroxysm. No true periodicity. 90 the practitioner's manual. toses with the nasal saw and the reduction of turbinated proc- esses by chromic acid fused on an applicator or by other means. —A. K. Amos. In the attack: R Moi phina sulphatis......................................... gr. \. Strychnina sulphatis....................................... gr. ^V Hyoscina hydrobromatis..................................... gr. xhs- M. S. Administer by hypodermic injection each night. R .(Ethereal tincture of lobelia.................................... § ij. Tincture of asafcetida......................................... § i. Tincture of opium............................................. § ss. Potassium iodide.............................................. 3 ij. Syrup of tolu................................................. § iv. M. S. From one to two teaspoonfuls every one or two hours for an adult, according to the severity of the case. R Ammonii bromidi............................................ 3 vi. Ammonii chloridi............................................ 3 iss. Tinct. lobelia................................................ 3 iij. Spir. atheris comp.......................................... 3 i. Syr. acacia................................................ad \ iv. M. S. Dessertspoonful in water every hour or two during paroxysms. —Pepper. For inhalation : R Potassii nitratis.............................................. § ss. Pulv. anisi fruct.............................................. § ss. Pulv. stramouii fol............................................ § i. S. Use a thimbleful, place on plate, light with match, then inhale fumes. In spasmodic asthma the patient should not only take arse- nic but should smoke arsenic cigarettes. The ordinary arseni- cal cigarette is made by saturating paper with a solution con- taining fifteen grains of the arsenite of potassium in an ounce of water. The portion of the paper which comes in contact with the lips should not be impregnated, or, better still, a mouthpiece should be used. In addition to smoking these cigarettes the patient should use this fuming inhalation at bedtime: R Powd. anise fruit...........................................:. . 3 i. Powd. fennel fruit............................................ 3 ss. Powd. sumbul root............................................ 3 ij. Powd. stramonium leaves...................................... 3 ij. Iodide of potassium........................................... 3 i. Powd. nitre.................................................. 1 ij. ASTHMA. 91 The ingredients should be perfectly dry and intimately mixed. A tablespoonful should be ignited and the fumes in- haled.—William Murrell. Or— R Fol. elect, herb, belladonna................................... 0.36 Fob elect, herb, hyoscyami.................................... 0.18 Fol. elect, herb, stramonii.................................... 0.18 Fol. elect, phellandrii aquat................................... 0.06 Extract, opii................................................. 0.008 Aqualaurocerasi ............................................. q.s. The leaves are macerated in the cherry-laurel water and carefully dried, and from them cigarettes are made, of which the patient smokes one or two during the attack.—Trousseau. R Pulv. stramonii, Pulv. belladonna fol.....................................aa, § i. Pulv. potassii nitratis....................................... 3 iss. Pulv. opii..................................................gr. xv. Burn a little and inhale the fumes. Or— R Ether......................................................... § i. Oil of turpentine.............................................. 3 iv. Benzoic acid.................................................. 3 iv. Balsam of tolu................................................ 3 ij. To be inhaled during an asthmatic attack. Or— R Potassii nitratis............................................... 1 iij- Aqua........................................................O ss. Dip blotting-paper into this solution and burn when dry. Or— R Lobelia^ pulveris, Stramonii pulveris, Thea nigra pulveris, Potassii nitratis..................................aa, partes aquales. Misce bene et fiat pulvis. A little to be burned and the vapor inhaled, or may be rolled into a cigarette and smoked at the time of attack. Ice pack over pneumogastric in region of neck.—Sanger. In the intervals between the paroxysms sodium nitrate, gr. i gradually increased to gr. v., three or four times daily.— S. Solis Cohen. 92 the practitioner's manual. Tincture of quebracho, teaspoonful p.r.n.—Penzoldt. Remove the patient to mountains or seashore. Colorado offers the best climate for asthmatic patients.—Seaton Nor- man. R Phenacetin................................................. gr. ij. Quinina................................................... gr. i. Ammonii chloridi.......................................... gr. iij. Capsici..................................................... gr. £ Strychnina................................................. gr. ^ M. et ft. capsula No. i. Take three times daily. —Mays. R Extract, euphorbia pilulifera..............................ttj, iij. Nitroglycerin.............................................. gr. ^ Sodii iodidi................................................ gr. ij. Potassii bromidi........................................... gr. ij. Tinct. lobelia.............................................. TU ij. M. ft. pil. vel. capsul. No. i. S. From one to four three times a day. —Hare.33 R Potassii iodidi................................................ 3 iiss. Tinct. lobelia................................................ 3 iv. Syr. sarsaparilla comp.................................q.s. ad § ij. S. Teaspoonful every two hours until relieved. Nocturnal attacks may be guarded against by hypodermic injections of small doses of strychnine and atropine in com- bination, and atropine may be given hypodermatically in the paroxysm. At the onset of attack to cut it short, spray chloride of methyl rapidly up and down the patient's back, making the effect proportionate to the severity of attack and delicacy of the subject's skin. Or paint the nasal fossae as far back as possible with: R Cocaine hydrochlorate....................................... gr. 1 Water...................................................... 20 Or spray the nose and pharynx with same for several min- utes. —Dieulafoy. External Irritants.—Feather beds, animals, kerosene lamps, arsenical wall paper, various kinds of dust, and many other ob- ASTHMA. 93 jects, when found to be excitants, may be easily removed; but others cannot be, and yet it may be possible to remove the patient from them.—F. I. Knight. Spasmodic asthma : R Tinct. lobelia atherea....................................... ""1 xv. Spirit, atberis............................................... ttl xx. Tinct. chloroformi comp. (B. P.)............................. t^L v. Aqua camphora..........................................ad § i. M. S. To be taken when breathing is difficult. Or- R Extract of belladonna.......................................gr. iv. Saturated solution of potassium iodide....................... 3 iiss. Chloroform................................................. 3 iiss. Fluid extract of valerian.................................... 1 i- Mucilage of acacia...................................q.s. ad § vi. M. S. Shake well before using. Take a teaspoonful in a wineglassful of water half an hour before meals and at bedtime. Bronchial asthma: R Sodii iodidi................................................... 3 i. Ammonii carbonatis.......................................... 3 i. Tinct. lobelia................................................. 3 ij. Spir. chloroformi...............................•.............. 3 iv. Vini ipecacuanha............................................. 3 i. Infus. senega...................................•......Qs- a(* 3 vl- M. S. A tablespoonful in a wineglassful of water every four hours. —Rainear. Or— R Ammonii iodidi............................................... 3 ij. Ext. grindelia robusta........................................ 3 ss. Tinct. lobelia, Tinct. belladonna...........................................aa, 3 i- Syrup, pruni virginiani........................................ 1 1- Aqua destillata............................................a ,ss Syr. scilla.............................................. 3 ss- Syr. tolutani............................................ 3 1- Aq. mentha piperita.............................qs- a^ 3 u3- M. S. 3 i. at a dose. —Powell. R Vini antimonii............................................... ° 'J' Liq. ammonii acetatis........................................ 3 l- Syr. tolutani.................................................. -> V1- Aqua........................................................ 3 1V M. S. Teaspoonful to a dessertspoonful every four hours. When the symptoms are only slight: R Ammonii muriatis......................................... Sr- x- Spt. chloroform i............................................ tti xx. Vini antimonii............................................. ^ x- Aqua camphora........................................ar* o l ■ M. S. Dose to be taken every four to six hours. —Fenwick R Ammonii chloridi, Potassii chloratis.......................................aa gr. xxx. Syr. senega............................................... 3 iv. Syr. ipecacuanha^ ........................................ 3 iij. Syr. tolutani.............................................. 3 v. Extr. glycyrrhiza......................................... 3 i. Aqua cinnamomi..................................q.s. ad 5 iv. M. S. A teaspoonful. —G. H. BOSLEY. Or— R Tinct. aconiti............................................. gtt. xij. Syr. ipecacuanha.......................................... 1 ss.-i. Liq. potassii citratis..............................q.s. ad 3 iij. M. S. 3 i. every three hours. For later stages : R Ammonii chloridi............................................ 3 i. Ext. glycyrrhiza fluidi....................................... 3 iv. Aquadestil...........................................q.s. ad 3 iij. M. S. 3i. t.i.d. —Hare. BRONCHITIS, ACUTE. 119 Or— R Tinct. veratri viridis........................................ TH, xij. Syr. scilla comp............................................ 3 ij. Syr. tolutani................................................ th, xiv. M. S. 3 i. every two or three hours. —J. Lewis Smith. Or— R Potassii citratis............................................ 3 i. Syr. ipecacuanha........................................... 3 i.-ij. Tinct. opii camphorata..................................... 3 i.-ij. Syrupi..................................................... 5 ss. Aqua................................................q.s. ad § iij. M. S. Teaspoonful every two or three hours. —Meigs and Pepper. Caution.—Balsamics should not be used in the acute stage of bronchitis, as they can at this period only irritate the already inflamed mucous membranes. Congestion of the respiratory passages has often been seen to follow a too free administration of syrup of tolu.—Gingeot. In the treatment of acute bronchitis in children give warm baths, whenever the rectal temperature, taken every three hours, exceeds 102° F., the temperature of the bath to be 101.5° F., and the duration seven or eight minutes. Stimulants may be given if required during the bath, and water at the tempera- ture of the room is to be applied to the head. Quinine sulphate as a general tonic.—Renaut. R Oxymel. scilla................................................ 3 ss. Spt. atheris nitrosi, Tinct. camph. comp........................................aa 3 i. Mist, amygdal..............................................ad 3 i. M. S. Dose to be taken every six hours. In children in the febrile stage : R Vini ipecacuanha............................................ 3 iss. Syr. simplicis................................................ 3 ss- Tinct. camph. comp.......................................... 3 iij. Liq. ammonii citratis........................................ 3 ss- Aqua......................................................ad 3 ij. M. S. 3 i. every two hours. —Charteris. 120 the practitioner's manual. A stimulating expectorant in a child of twelve mouths: R Ammoni i carbonatis....................................... gr. xvi. Spirit, atheris composit................................... 3 iss. Syrupi tolutani, Aqua..................................................f.a § i. M. S. A teaspoonful every two hours. —J. M. Da Costa. To diminish secretion and lessen the severity and frequency of cough : R Phenocol.............................................. gr. xv.-xxx. Camphor monobromate.............................. gr. ij. Caffeine citrate....................................... gr. ij. Mix and make twelve powders. S. One every four hours. —Dillon Brown. Warm baths, 100° F., of seven or eight minutes' duration. In bronchitis in children I have had signal success with the following, in addition to diet and hygienic procedures: R Powdered ipecac, Tartar emetic...........................................aa gr. -fa —H. E. Tuley. In infancy, if the stomach is loaded with partially digested food: R Pulv. ipecacuanha....................................... gr. i.-ij. Syr. ipecacuanha......................................., § i. M. S. Teaspoonful every few minutes until emesis. If secretion becomes very profuse : R Antimonii oxidi............................................ gr. ss. Syr. senega................................................. 3 i. Syr. acacia................................................. § iij. M. S. Teaspoonful every two hours. —Perrier. To apply to the chest: R Oil of cloves.................................................. 3 ij. Camphorated oil.............................................. ^ ix. —J. Lewis Smith. BRONCHITIS, CHRONIC. 121 Bronchitis, Chronic. Chronic bronchial catarrh presents a troublesome cough of cold weather, usually worse at night or in the early morning, with expectoration of either muco-purulent or purulent sputum, which may resemble that of phthisis. Though expectoration is usually scanty, a condition of bronchorrhcea may be set up. If developing as a consequence of systemic, gouty, rheumatic, or nephritic states, the symptoms will vary somewhat with the severity of the underlying disorder. As a rule, the clear percus- sion note, the diffuse moist and dry rales heard, and the persis- tent cough following an acute bronchitis or one of the exanthe- mata, or occurring as a complication of a severe constitutional disorder, make the diagnosis clear. Differentiation.—Phthisis is excluded by the physical signs being more pronounced near the angle of the scapula and not at the apex. Tubercle bacilli are also absent. Mucous rales are more abundant in the chronic than-in the acute forms. There is lack of fever, and emphysema, which is more frequently found in association with bronchitis, gives its characteristic signs. The respiratory murmur is roughened and the percussion note clear. The cough is distinguished from that produced in aneurisms by the absence of stridulous breathing, but the possibility of tumor pressure as a cause of long-continued cough must be kept in mind. Here a dilated bronchus must not deceive one into believing in the presence of cavity. Prognosis.--The course is long, without notable impairment of health. There are exacerbations, or it may persist during the summer season. Treatment.— Projltylaris.—Chronic bronchitis associated with asthmatic attacks in elderly persons may be prevented by avoiding stimulants, too hearty meals, and too large a quantity of farinaceous food, which sets up fermentation. The last meal 122 the practitioner's manual. at night should be light and easily digestible. Malted food and those containing diastase seem especially advantageous. Eucalyptol, ten minims in emulsion every four hours.— Brain lrd. Extract coccillanse fluid., niv.-xxv., as required.—Wilcox. Surgical treatment is required when chronic bronchitis in children is due, as it frequently is, to adenoids in the naso- pharynx. The tonsils are to be ablated, the adenoids destroyed, and granulations scraped and burned away.—Chaumier. R Phenol salicylate............................................ 3 i- Terpin hydrate.............................................. 3 i- Codeine sulphate............................................ gr. ij. M. Make twenty capsules or pills. Dose, one every four hours. —SOLIS-C'OHEN. R Morphina hydrocbloratis................................. gr. v. Extracti hyoscyami...................................... gr. viij. Racl. belladonna pulv., Rad. glycyrrhiza pulv., Mellis..................................................aa gr. xiv. Balsam, tolutani, 01. theobroma.........................................aa gr. lxxv. M. ft. pil. div. No. c. S. One every five or six hours. t-, —RlCORD. R Potassium citrate............................................. 3 ss. Lemon juice................................................. § i. Syrup of ipecac.............................................. 3 ij. Water.....................................................ad § iij. M. S. One-half ounce four or six times a day for an adult. —H. C. Wood. R Ext. euphorbia pilulifera................................... § iss. Syrupi pruni virginiana.................................... 3 iiss. S. Teaspoonful everv three hours. TT ~ -... ,-, —H. G. McCormack. R Creosote...................................................... 3 i j. Almond soap................................................ . q. s M. ft. pil. No. lxxx. S. Eight or ten daily. This is more satisfactory than creosoted wine. If pulmonary congestion be marked : R Ergotini..................................................gr. v. Pulv. opii................................................ gr. i.-ij. Ext. hyoscyami......................................... gr. \ 01. theobroma................................... ........ q.s. M. ft. supposit. S. Introduce into rectum each night. __t vrT»r BRONCHITIS, CHRONIC. l2o Arsenical waters.—Pall. In the catarrhal form, sulphurous waters. Caution. —Since the tendency of sulphur is to congest the bronchial lining membrane, these should be ordered only in the declining periods when secretions are tenacious. Copaiba gives the best results if one can get the patient to take it—often accomplished if given in capsules—but next in value is oil of eucalyptus, ttiv.-x. ter die, on sugar.—Potter. /// very chronic cases : R Ext. hydrastis Canadensis..............................ni xx.-xxx. Four times daily. ■—Sanger. In bronchitis of the aged: R Benzoic acid.............................................. gr. ivss. Tannic acid............................................... gr. ii^. M. For one cachet. S. Take four or five such cachets per diem. —Maragliano. For irritative coughs: R Phenacetin............................................. gr. xx.-xl. Ext. glycyrrhiza....................................... gr. xx. Sacch. albi............................................. 3 ij. Fiat pulvis, in chartulas 20 dividendus. S. One to be taken at one, two, or three hours' intervals. For the same of more obstinate character: R Phenacetin..... ........................................ gr. 1. Ext. glycyrrhiza........................................ gr. xx. Codeina sulphatis................ ..................... gr. ij.-iv. Sacch. albi............................................. 3 ij. Fiat pulvis, in chartulas 20 dividendus. S. One to be taken every two, three, or four hours. —Crook. Or— R Ammonii carbonatis........................................ 3 ij. Acidi salicylici.............................................. 3 iiss Aqua cinnamomi.........................................ad § ij. M. S. Teaspoonful in a little water every three hours. —Slack. 124 the practitioner's manual. R Potassii iodidi ............................................... 3 iij Tinct. tolutana, Ext pruni virginiana.....................................fui 3 i. Syrupi..................................................... | i Spt. atheris comp............................................. 3 ij. Aqua................................................. q.s. ad 3 iv. M. S. A teaspoonful. —E. G. Janeway. R Ammonii carbonatis.......................................... gr. 1. Potassii iodidi............................................... 3 iij. Syr. pruni virginiana, Spt. anheris comp..........................................aa 3 iss. M. S. A teaspoonful. R Apomorphina hydrochloratis..............................gr. ss. Syr. pruni virginiana....................................... § ij. Syr. picis liquida......................................... § iv. M. S. Tablespoonful three times a day. —Murrell. Or— R Acidi carbolici............................................ gr. xxv. Tinct. opii camphorata.................................. § iij. M. S. A drachm added to one-half pint of hot water in the inlialer. Use three times a day, —N. S. Davis. R Potassii iodidi................................................ 3 i. Tinct nucis vomica, Tinct. sanguinaria.........................................aa 3 ij. Glycerini.................................................... g i. Aqua ........................................................ | v. M. S. Tablespoonful four times a day. —Delafeld. Or— R Acidi hydrocyanici diluti, Chloroformi purificati......................................ila 3 i. Tinct. hyoscyami, Syrupi tolutani, Aqua camphora, Mucilaginis acacia........................................aa 5 i. M. S. A teaspoonful. —W. H. Katzenbach. R Quinina sulphatis......................................... gr. vi. Acidi sulphurici dil...................................... gtt;. xij Syr. simplicis............................................ | ss Aqua.............................................q.s. ad § iij. M. S. Teaspoonful every two hours. —Meigs and Pepper. bronchitis, chronic. 12o In bronchorrha3a, ergot, hyoscyamus, and arsenic in full dose.—Lyon. In chronic bronchitis with excessive muco-purulent expec- toration, tincture of mix vomica, nix.-xx.—Delafield. In putrid bronchitis: R Argenti nitratis................................................ 5 Aqua destillata................................................ 100 M. S. Inject into the trachea one to two cubic centimetres. This amount does not produce excessive cough.—Rosenfkld. Or— R Hyposulphite of sodium.................................... 15 gm. Distilled water.............................................. 60 " Simple syrup............................................... 25 " Dessertspoonful every three hours. —POLLI. Or— Inhalations of oxygen. Injections of eucalyptol (subcu- taneously).—Lyon. R 01. santali................................................. gtt. v. Four times daily. —Da Costa. In fetid bronchitis: R Sorlii hyposulphatis......................................... 4 gm. Mucil. acacia............................................... 20 Syr. eucalypti.............................................. 40 By the mouth. At the same time give by the rectum to avoid stomach in- tolerance : R Sodium hyposulphite..................................... 10 gm. Laudanum (Sydenham's).................................. 6 gtt. Distilled water............................................ 180 gm. Large doses are not to be feared.—G. Lyon. R Acidi carbolici............................................... 0.5 Ichthyolis.................................................... ° Spiritus vini................................................. '" Aqua destillata.............................................. 1W S Use as inhalation. —Neusser. 12t) THE PRACTITIONERS MANUAL. R Spts. terebinthina......................................... tij, xxx. Picis liquida.............................................. tti, xxx. Bals. tolutani.............................................. 3 iss. Sodii benzoati............................................. q.s. M. etft. pil. No. lxxx. S. One six or eight times dnily. T F ° —Lyon. Or sodium hyposulphite, " Ii. — 3 iii- as daily dose. Caution.—Contraindicated when there is tendency to haemop- tysis, as in phthisis.—Dumas. R Spt. chloroform i............................................ ttl xx. Acidi hydrohromici......................................... 3 ss. Syr. scilla.................................................. 3 i. Aqua................................................q.s. ad 5 i. M. S. For one dose, three times a day. -,-, —FOTHERGILL. In subacute bronchitis : R Amnion, carb................................................ gr. xl. Amnion, iodid.............................................. 3 ks. Ext, scilla fld., Ext. senega fld..........................................aa 3 i. Tinct. opii. camph.......................................... 3 vi. Aqua...................................................... § i. Syr. pruni virginiana....................................ad 3 iv. M. S. 3 i. in water every three hours. __m R Acidi benzoici............................................ gr. ix. Tannin.................................................... gr. ivss. M. et div. in chts. No. xl. S. Four to be taken daily. Or- R Ammonii chloridi............................................ 3 ij. Ext. glycyrrhiza fluidi...................................... 3 ij. Aqua destillata.............................................. = iij. M. S. 3 i. every four hours. __rr When associated with emphysema and asthmatic attacks: R Bromoform............................................. 0.50 cgm. In a capsule four or six times daily. —Stepp. Chronic bronchitis with asthmatical condition : R Ammonium chloride......................................... 3 iij. Fluid extract grindelia. Fluid extract quebracho, Fluid extract lobelia.......................................aa, 3 ss. Comp. licorice mixture....................................... § iss. M. S. The mixture is to be well shaken and a teaspoonful administered everv three hours. —ESHNER. BRONCHITIS, CHRONIC. 127 Bronchitis with difficulty in coughing up secretions : R Ol terebinthina.......................................... 3 ij.-iij. Mucil. acacia............................................. q.y. Aq. cinnamomi........................................... z [ Aqu'a..............................................q. s. ad § vi. M. S. A tablespoonful in a little water every four hours Or— R Potassii iodidi................................................ 3 ij. Ammonii carbonatis.......................................... 3 i. Tinct. lobelia................................................. 3 ij. Spts. chloroformi.............................................. 3 iv. Vini ipecacuanha............................................ 3 i. Inf. senega............................................q.s. ad § vi. M. S. A tablespoonful in a wineglass of water every four hours. Emphysema and asthma : R Morphina sulphatis......................................... gr. -^ Potassii iodidi.............................................. gr. v. Tinct. belladonna ......................................... tti v. Spiritus atheris com posit................................... ni xlv. Aqua................................................q.s. ad 3 ij. Dose. I ij. —Roosevelt Hospital Formulary. Inhalations : R Acidi carbolici fluidi..................................... Tq, x.-xv. Aqua.................................................... O ss. M. S. To be placed in an ordinary inhaling bottle and used three or four times a day. —Meigs. R Acidi carbolici fluidi................................. . gtt. xv.-xx. Tinct. conii........................................... 3 i.-ij. Aqua destillata........................................ O ij. M. S. For inhalation. —Alfred Stille. R Acidi tannici............................................... gr. iij. Ext. hyoscyami............................................ gr. ij. Aqua destillata........................................... 3 i. M. S. To be inhaled night and morning. —Beigel. 117/'// there is much dyspuoua, with tenacious sputa, spray the throat with wine of ipecac, pure or diluted with water, for ten minutes three or four times daily.—Arthur Davies. I// tracheitis, inhalations of peppermint essence, menthol, etc. 12S THE PRACTITIONER S MANUAL. If secretion is very abundant, inhalations of a five-per-cent alum or tannin solution. Or— R Zinci sulphatis................................................ 1 Aq. destillata.................................................. 100 —Neusser. hi children : R Aluminis..................................................... 3 ss. Vini ipecacuanha............................................ 3 iss. Syr. tolutani................................................. § ss. Aqua.................................................q.s. ad § iij. M. S. 3 i-ij. every three hours. —POWELL. R Tinct. scilla................................................. m xv. Spt. atheris nitrosi.......................................... 3 i Liq. ammonii acetatis....................................... 3 i. Tinct. hyoscyami............................................. 3 ss. Aqua camphora..........................................ad § i. M. S. Taken three times a day. ^ 0 ^ J —George St. George. R Spiritus terebinthina....................................... 3 iij. Acid i acetici............................................... 3 ss. Vitelli ovi................................................... No. i. Aqua rosa.................................................. 3 iiss. Olei limonis................................................. 3 i. M. S. To be rubbed, morning and evening, over the chest, back, and sides of n<-*(*k —Meath. Hospital, Dublin. R Vini ipecacuanha, Acidi nitromuriatici diluti................................aa tti. x. Tinct. hyoscyami............................................ tti, xx. Tinct. gentiana composita................................... 3 ij. M. S. For one dose. Take in water thrice daily. ,, —Greenhow. R Potassii iodidi................................................ 3 iij. Tinct. opii camphorata............................,.......... § ss. Decocti senega............................................... 1 iv. Syr. tolutani................................................. = iss. M. S. Two teaspoonfuls a day. TTT _. —William Stokes. R Potassii nitratis............................................ gr. i. Spiritus atheris nitrosi, Syrupi ipecacuanha......................................aa ttj, xxx Syrupi pruni virginiana .................................. 3 ij. Aqua...............................................q.s. ad \ i. M. S. A teaspoonful. . .__ _, —A. R. Robinson. Exclude rickets, adenoids, hypertrophic rhinitis; give cod- liver oil, arsenic, bitter tonics. BRONCHITIS, CAPILLARY. 129 Bronchitis, Capillary. This suffocative catarrh of infancy and old age is diagnosti- cated by the signs of inflammation extending to the smaller bronchi, distributed over extensive areas on both sides, and at- tended with signs of suffocation from badly aerated blood. There is beside an anxious expression other evidence of a more severe affection than ordinary bronchitis, or even of broncho- pneumonia. It may be primary, or gradually succeed a bron- chial catarrh. Diagnosis.—In infants extreme dyspnoea with rapid super- ficial inspiration and difficult expiration is rather distinctive. The alse nasi are widely dilated and there is difficulty in nurs- ing, while with each inspiration there is a recession of the soft parts over the chest wall. The cry is moderate, peevish, and muffled. The temperature may reach as high a point as 104° F., and this is distinguished from the fever of pneumonia by the fact of its not remaining long at so high a point. Very often the temperature is of a distinctly remittent type, a morning temperature of Wc to 100° F., and an evening tem- perature of 101°-105° F.—Delafield. Chills may precede the fever. Differentiation.—In broncho-pneumonia which runs a slower course, rales are sometimes confined to one lung, but there is greater prostration and greater severity of all symp- toms present. Chills do not mark the invasion of a broncho- as they do of a lobar pneumonia.—Delafield. Broncho-pneumonia, however, may develop during the bron- chitis of measles and whooping-cough, and small areas of con- solidation are difficult to map out by percussion, because of the resonance produced by the surrounding lung tissue. From bronchitis by the paroxysms of cough, which come oftener and are more severe, and by the whistling rales of high 9 130 the practitioner's manual. pitch along with fine moist rales, especially low down behind. There is also greater tendency to prostration. The further dif- ferentiation will be found under broncho-pneumonia. Prognosis.—If cyanosis, apathy, and stupor supervene sud- denly, and especially if convulsions occur, most active measures are required to prevent a fatal termination. In children there is coma after a convulsion; in the aged without the latter. Trlatment.— R Tinct. digitalis............................................ ttj, viij. Tinct. opii camphorata.................................... 3 i. Syr. ipecacuanha'.......................................... v\ xxx. Syr. tolutana............................................ad § ij. Dose, I i. every three hours. —KOPLIK. When surface is pale and cool, and child is languid: ty Liq. ammonii acetatis....................................... § ss. Syr. ipecacuanha........................................... 3 i. Liq. morphina sulphatis (gr. 1.-31.)......................... Ttixl. Syr. acacia.................................................. 1 i. Aqua....................................................... 3 iss. M. S. Teaspoonful every two hours. For a child of two years. —Meigs "and Pepper. R Ext. serpentaria.............................................. § ss. Ammonii carbonatis.......................................... 3 ij. Syr. tolutani.................................................. z iss. M. S. Teaspoonful every two to four hours. —Potter. In children : R Ammonii carbonatis...................................... gr. xxiv. Syr. tolutani............................................. 3 vi. Spt. vini gallici.......................................... 3 iij. Syr. senega.............................................. 3 iiiss. Syr. acacia........................................q.s. ad § iij. M. S. 3 i. every three hours. —Powell. Or— R Moschi....................................................... 0.10 Tinct. opii camphorata....................................... 5 Syr. tolutani................................................. jg Aqua aurantii florum........................................ 60 M. S. Teaspoonful —Descroizilles. bronchitis, plastic. 131 In extreme excitation : R Chloral.............................................. 0.50 Tinct. moschi............................................ 20 gtt Aqua..................................................... GO As an enema. —Simon. Caution.—Musk is dangerous in its effect on children. In adynamia and asphyxia, brandy by the mouth. Mus- tard to the legs. Wool jacket. Ether and caffeine alternately by hypodermic. Camphor in sterilized olive oil by hypodermic. 1// intense pulmonary congestion, tepid mustard bath or "mustard pack;v i.e., wrap around the chest cloths which have been dipped into mustard. Remove in twenty minutes or one- half hour.—Heubner. In suffocative form, stimulants and emetics. Lukewarm bath followed by cold douche. Watch child. Be careful of collapse. —Heubner. In tropical variety with great debility, quinine.—Meigs and Pepper. Bronchitis, Plastic. Fibrinous bronchitis may be diagnosticated when fibrinous casts of bronchi or shreds of membrane are coughed up. Haemoptysis, or expectoration streaked with blood, is fre- quently present in these rare cases. The acute form is especially rare and frequently fatal, while the chronic may affect the health but little. There may be entire absence of respiratory signs over the affected lung area, while the percussion note remains clear and pulmonary.—Leube. Differentiation.—In the young a one-sided lack of respira- tory sounds, especially if not preceded by catarrhal symptoms, might be considered due to bronchial obstruction by a foreign body. J32 THE practitioners manual. Prognosis is relatively favorable in uncomplicated cases. Treatment.—Inhalation of medicated steam and sprays, especially of alkaline solutions; lime water. Or— R Sodii bicarb............................................... gr. xxx. Aqua..................................................... 1 i' ■ —Tyson. R Potassii iodidi..........'....................................... 1 Aqua fontis................................................... 1 ^1' Syrupi corticis aurantii......................................• lr' S. To be taken during the day. —Neusser. After the casts have loosened, expectorants. The best is: ' R Apomorphina............................................. gr. -J,,-! By subcutaneous injection.—Mason. In the intervals, potassium iodide, tonics, and general meas- ures. A course of inunctions with mercurial ointment has occa- sionally proved of service.—Strumpell. Caisson Disease. Workers in tunnels, caissons, or air-tight chambers, who support from thirty to fifty pounds to every square inch of their body surface instead of the normal atmospheric pressure of half this amount or less, may suffer from a compressed-air illness. Diagnosis.—Paraplegia or other paralysis following pain in the legs in those with a history of being subjected to the above conditions could scarcely be mistaken for other affections. Pains are mostly about the knees and may prevent use of limbs. Cystitis is a frequent complication, auditory vertigo an occa- sional one. Prognosis is usually good. Symptoms may persist from a few days to several months, or death may follow symptoms of myelitis. Prophylaxis requires that in passing from the lower to the cancer of breast. 133 higher pressure five minutes' time should be consumed by divers.—A. H. Smith. Treatment.—Morphine or other measures to relieve pain. Stimulating liniments. For cases seen early, ''recompression'' in a medical air-lock, constructed from a boiler divided by a diaphragm, with an outer and inner door, so that patient can enter without lowering the pressure. The pressure is rapidly raised until pain or other symptoms are alleviated.—E. H. Snell. Cancer of Bowel. The symptoms are those of obstruction. It is only in the advanced stages that a tumor can be palpated. In elderly sub- jects acute obstruction should lead to exploration per rectum. In a recent instance of cancer of the duodenum reported by Czyan, the following points led to the diagnosis: 1. The high nitro- gen excretion. 2. The great dilatation of the stomach pointed to obstruction near the pylorus. 3. The free and combined hydrochloric acid in the stomach contents made it probable that the stomach was not involved. 4. A splashing between the tumor and the liver pointed to an origin in the intestine. 5. The absence of leucin, tyrosin, and bile from the stomach con- tents, and the absence of icterus, made it likely that the situ- ation was between the pylorus and the ductus choledochus. Cancer of Breast. The early diagnosis is alone of interest to us here. The onset is insidious, and, unfortunately for the success of treat- ment, patients usually delay too long before seeking advice. Diagnosis.—There may be little or no pain. If it exists at all it is of neuralgic character. If a small nodule is painful, it is more likely to be fibrous than cancerous.—Dowd. 134 the practitioner s manual. The swelling is of extreme hardness, and firmly embed- ded in the breast tissues, not movable upon them. The skin is not reddened in the early stages, but may resemble that of a scalded pig. If the nipple is puckered in, it is a sign of value unless such is the natural condition in the patient. Hard- ness about the areola confirms the danger sign. If outlying glands are enlarged, this is an additional sign of value, but not finding them so is no proof of the benign character of the growth. Differentiation.—The great majority of breast tumors are carcinomatous; sarcoma, cysts, and the various forms of ade- noma form but about seventeen per cent. Adenoma is of slow growth, and may have been several years in developing. The tumor is movable, the nipple is not retracted, and the axillary glands are not involved. Adeno-fibroma gives a defined outline and is not adherent to the skin. Adeno-cystoma may suddenly enlarge, cause skin ulceration, and a fungoid mass may protrude, but the margins are not hard and infiltrated, nor do glands become involved in the same way as in cancer. Adeno-sarcoma is elastic but of unequal consistence and nodular; the skin is not attached; growth is rapid, without involvement of axillary glands. Sarcomata may feel almost fluctuating. The overlying veins are enlarged at an early stage, but the skin is not attached. They occur earlier in life than carcinomata, are movable and not fixed to the chest wall; the nipple is not drawn in; pain is severe. The skin does not become infiltrated even when fun- gating masses protrude in a later stage. Prognosis.—Nothing short of very early and very complete operation gives a chance of recovery. Treatment.—Surgical.—Radical removal of breast, together with the involved axillary and subclavicular glands. cancer of skin. 135 In ulcerative stage, to check offensive odor: R Potassii permanganatis.................................... gr. xl. Aqua......................................................Oi. M. S. Apply as a lotion. Or— R Acidi carbolici................................................. 5 Aqua camphora.............................................. 30 Aqua.......................................................... 100 M. S. Apply as a lotion. In resulting cachectic state : R Syrupi ferri et mangani iodidi................................§ iv. M. S. Teaspoonful three times a day. —Bartholow. Cancer of the Pancreas. The symptoms are variable; there is usually deep-seated epigastric pain with anorexia, nausea, vomiting, and emaci- ation ; there may be jaundice with light-colored fatty, offensive stools; and glycosuria is frequently present. Differentiation.—When attacking the head of the pan- creas, it is not to be distinguished from carcinoma of the bile ducts. From impacted gall stone it is distinguished by the jaundice being deeper. Treatment by drugs is only palliative. Cancer of Skin. Epithelioma or the skin surface of the face, beginning usually as a small warty growth, papule, or pimple, which is scratched or irritated and subsequently becomes ulcerated, is distinguished from lupus by the sinuous and slightly elevated border, of waxy appearance and firm feel. The subject's age is greater, while in both the progress is slow. The situation is usually upon the nose, between the nose and the eye, or upon the lip. 136 the practitioner's manual. Syphilitic ulcer has no indurated raised border; the surface of the base is more rough, the course more rapid, and adequate internal treatment should produce rapid improvement. Chancre may at times closely resemble epitheliomatous ulceration. Treatment. — Wide excision is unquestionably the best treat- ment for growths favorably situated for operation. Many are inoperable by reason of location, or because of repeated return after operation, or for the reason that the patient will not con- sent to the use of the knife. In these, properly applied caustics will cure. Electrolysis has at times its advantages. In inoperable epithelioma of the face: Potato poultice, containing 1 to 100 solution of corrosive sublimate, to soften ulceration. Remove loosened tissues with galvano-cautery and apply: R Methylene blue............................................ gr. xv. Alcohol, Glycerin................................................aa tti lxxv. M. Touch stained parts with chromic-acid solution; reapply the blue solution. Dress with compresses wet with sublimate solution. Repeat every two or three days.—Du Castel. A paste of the consistence of butter, made with arsenious acid and powdered gum acacia mixed with water, is our most valuable agent. The strength should vary according to the case—never weaker than equal parts and never stronger than two of acid to one of acacia.—A R. Robinson. In cutaneous epithelioma the best paste we have at present is that of Bougard: R Wheat flour..................... ....................... 60 gm. Starch.................................................. 60 Arsenious acid.......................................... 1 Red sulphide of mercury (cinnabar)..................... 5 Chloride of ammonium................................. 5 Corrosive sublimate..................................... 0.50 Solution of chloride of zinc at 52'........................ 245 M. cancer of skin. 137 The first six substances are separately ground and reduced to fine powder. They are then mixed in a mortar of glass or china, and the solution of chloride of zinc is slowly poured in while the contents are kept rapidly moving with the pestle, so that no lump shall be formed. A thick layer of this is spread on cotton and left in position twenty-four hours, and then man- aged in every way as Marsden's paste.—Daniel Lhwis. In superficial cancer without ganglionic involvement: R Acidi arseniosi............................................. 1 gm. Alcoholis (ethylici), Aqua destill.............................................aa 75 " M. S. Paint the surface once daily. As the eschar thiclfens increase the strength to 1 in 40. —Cerny and Trunecek. Escharotic paste : R Wheat flour................................................ 3 vij. Starch..................................................... § ij. Corrosive sublimate........................................ gr. xx. Pure iodol, Croton chloral, Bromide of camphor, Crystal carbolic acid.....................................aa 3 iiss. Oxide of zinc.............................................. 5 yij- Water, enough to make a homogeneous mass of the consistence of putty. —Felix. Marsden 's paste : R Acidi arseniosi. Pulveris acacia............................................aa p.a. Mix with a few drops of water to form a paste at the time of application. Marsden's paste (modified) : R Acidi arseniosi............... ........................... 3 ij- Pulveris gummi arabici.................................. 3 i. Cocaina hvdrochloratis................................... gr. xviij. M. To be made into a paste of the consistence of rich cream by adding water. Apply on a small piece of cloth, which is left on from eighteen to thirty-six hours, and repeat as often as is necessary. A weaker preparation contains only one drachm of arsenious acid and twelve grains of cocaine. 138 the practitioner's manual. Caustics : R Zinci chloridi.................................................. 1 Pulveris althaa radicis........................................ 2 Aqua......................................................... q- s. M. R Chloride of zinc............................................... 1-2. Flour..........................................................5 M. Make caustic arrows to be inserted into base of tumor. —Bartholow. Cauqnoin^spaste : R Zinci chloridi, Farina......................................................5a p. a. Mix with water. Vienna paste : Potassa cum calce. — U. S. P. Areas of limited extent and those too near the eye for caus- tics can be operated upon with advantage by electrolysis. Cancer of particular internal organs will be found considered elsewhere. Here are included a few formulae for the manage- ment of inoperable cases in general. As a local application in inoperable cancer, antipyrin dusted over the surface.—Bahnson. R Extracti chelidonii, Aqua destillata'. Glycerini....................................................aa, 20 Spiritus chloroformi........................................... 0.2 M. S. Inject a syriugeful into the tumor at different points near the horder. Internally, chelidonium in aqueous solution, gm. i.-v. daily. —Deniceuco. In inoperable cancer, injections of alcohol into and about the growth.—Hasse. Or morphine, associated with cocaine, given in large doses for a long time, exercises a favorable and curative action upon carcinomatous neoplasms and retards recurrences.—Snow. To overcome the fetor of cancerous ulcers and alleviate the pain: R Iodoformi................................................. IS gm. Quinina sulphatis.......................................... 3 " Spiritus mentha piperita................................... 2 " Carbo. ligni................................................. 15 " M. S. Dust upon the ulcerated surface as required. CANCER OF SKIN. 139 When much cachexia : R Tinctura ferri perchloridi, Acidi phosphorici diluti...................................aa tit, xv. Aqua....................................................... 1 ij. M. S. At dose two or three times daily. As gargle and wash in cancer of throat, tongue, fauces: R Sodii boratis............................................... 1 ss. Glycerini.................................................. 3 ij. Aqua....................................................ad O iss. M. As an anodyne, giving equal relief to that from a larger dose of morphine: R Extracti hyoscyami......................................... gr. iv. Extracti conii............................................. gr. i. Morphina hydrochloratis................................... gr. i M. S. At dose. —Marsden. Caution.—When an active preparation is used gr. i. is the dose of extract of hyoscyamus. I)) inoperable cancer of rectum: R Naphthol................................................. 0.10-0.20 Aqua..................................................... 100 S. To wa°h out the intestines. Give salol or benzonaphthol with bicarbonate of sodium by the mouth. The diet should be chiefly vegetable.—Dujardin- Beaumetz. To relieve pain and straining of intestinal cancer, enemata of water.—Ringer. Carcinoma.—Although local treatment is useless in carci- noma, in cases of doubt, as when there is ulceration or fissure, the following ointment is useful. If healing does not take place in two weeks, operate, as carcinoma never heals in this way. R Balsami peruviani, Unguenti hydrargyri nitratis................................aa 3 i. Petrolati....................................................... I i- M. —J. H. Hearn. 140 the practitioner's manual. Cancer of the Stomach. Since gastric carcinoma may occur without symptoms, physi cal exploration becomes of the greatest importance in the early diagnosis of obscure cases, and since about forty per cent, of al1 instances of cancer occur in this region, the point need not be further insisted upon. We should not at the present day wait for the cachexia, oedema of the joints, enlargement of the glands, fissured tongue, emaciation, obstinate coffee-ground vomiting, insomnia, vertigo, and the presence of a tumor to be made out by palpation. While tumor is the only pathogno- monic sign, it must not be waited for. In most instances after middle life, symptoms of chronic gastritis with increased pain after eating, frequent vomiting, and emaciation coming on after loss of appetite, point to this disease as a cause, especially if characteristic cachexia begins to show itself. . Diagnosis.—Two periods here engage our attention: one before tumor is to be made out, when an early diagnosis may lead to early operation; the other when the time for operation has passed. The chief factors are age, pain increased by taking food, anorexia, distaste for meat, dilatation, vomiting of fragments containing cancer cells and coffee-ground-like masses of altered blood. A "raw-beef" tongue may be a sign of value, especially in the diagnosis of doubtful instances in old age. Pruritus. anaemia, loss of weight, and insomnia are symptoms often pres- ent, especially in advanced cases late in life. Clogging of the eye of the stomach tube by small masses of clotted blood is an indication of carcinoma.—Ewald. A continued persistent absence of free hydrochloric acid is a sign of some diagnostic value; but the mere absence of acid without the concomitant symptoms cannot be depended upon to establish the diagnosis.—Pepper. The rapidly occurring muscular weakness of the stomach cancer of the stomach. 141 and the high degree of its intensity, so that a light meal is not digested after six or seven hours, is, according to Huber, a strong point in favor of carcinoma. This observer regards the frequent occurrence of the long threads of bacilli of Boas and Oppler as having no specific worth as a sign of carcinoma, since they are often absent in this dis- ease and often present in benign stenosis of the pylorus. If, however, lactic acid is shown to be abundantly present, it is a point of great value. To examine for it, a dilute solu- tion of neutral ferric chloride may be added to the filtrate, causing it to turn to a canary-yellow color. Uffelmanns reagent is prepared by adding two or three drops of pure carbolic acid to 20 c.c. of water containing a few drops of tincture of ferric chloride; the amethyst-blue solution which results from the thorough shaking of this mixture is so unstable that it must always be freshly prepared. The reagent is a delicate one, and even o.l per cent of lactic acid will give a distinct canary-yellow color in its presence.—Manges. There is ground for hoping that the ^-raya may give material aid in early diagnosis of this most important affection. Dilata- tion of the superficial venules on each cheek, forming a wine-red discoloration, is an early valuable diagnostic point.—Bogdan. Differentiation.—Carcinoma of the pylorus is the form most readily diagnosticated, since the motor disturbances are here pronounced at an early stage. The difficulty is to distin- guish cancer from other disease of the stomach. This can at times be accomplished early by the discovered entire absence of free hydrochloric acid (as shown by the Congo red, tropaeolin, and other tests after a test meal of flour soup), and the pres- ence of lactic acid. The chemical signs may long antedate the occurrence of a tumor which can be palpated. The mere absence of hydrochloric acid is not in itself suffi- ciently convincing, as it occurs in other gastric and general dis- eases. —Bennett. 142 the practitioner's manual. From ulcer of the stomach the fact that the epigastric pain is not relieved by vomiting as it is in ulcer, and that it is not so intense or so circumscribedly located, will help in the diagnosis. Besides, in stenosis from ulcer anachlorhydria is rare. It is well to remember that the cancerous tumor may be simulated by an epiploic inflammation, by a faecal mass, in the transverse colon, by subphrenic abscess, circumscribed perito- nitis, etc., and that even partial contraction of the recti muscles may suggest a cancerous growth: gall stones and gall-bladder tumor, as well as pancreatic tumor, must be excluded. Pro- gressive pernicious anaemia may be simulated by the symptoms when tumor is not to be felt. Chronic catarrh of the stomach and enteroptosis are the conditions most likely to occasion error.—Schule. If the stomach presumably empty in the morning constantly contains remnants of food from the previous day, and if we find lactic acid invariably present, and in addition numerous thread bacilli, we can almost positively diagnosticate the case as one of pyloric carcinoma.—Boas. Kelling's Modified Test.—Take the filtrate of the stomach contents and dilute it from ten to twenty times. Add two drops of a five-per-cent solution of ferric chloride. This will give a greenish-yellow color, showing lactic acid. Strauss'' Test.—This consists in filling a burette, graduated at 5 and 25 c.c. respectively, up to the 5 c.c. mark with the stomach filtrate, and adding sulphuric ether up to the mark 25; this is well shaken, and through a stopcock at the bot- tom the burette is emptied to 5 c.c. and again filled to 25 c.c. with distilled water. To this are added two drops of a ferric chloride solution (one to nine) and the whole is shaken. According to Strauss, if lactic acid up to one per cent is pres- ent, an intense green appears, and if the percentage is lower a pale green is noticeable.—Aaron. Iodide-of-Potassium Test.—When iodide of potassium is cancer of the stomach. 143 swallowed by a healthy person it can be detected in the saliva within ten or fifteen minutes; but when cancer exists, there will be no trace of the iodide until the lapse of an hour or an hour and a half.—Lyman. For test see under poisoning by iodine. Boas' Meal Test.—A tablespoonful of oatmeal flour in a litre of water given at bedtime after thoroughly washing out the stomach. Withdraw the contents in the morning and examine for lactic acid. Arnold's Test for Lactic Acid.—Solution No. 1, consisting of saturated alcoholic solution of gentian violet, 0.2 c.c. ; distilled water, 500 c.c. Solution No. 2, solution of ferric chloride (U. S. P., 1S90), 5 c,c.; distilled water, 20 cc. The method of applying the test is as follows: Into a small porcelain capsule place 1 c.c. of solution No. 1, and add from a pipette one drop of solution No. 2. The violet color of solution No. 1 changes to a bluish-violet after the addition of the ferric chloride. To this mixture add drop by drop the filtered gastric contents. If lactic acid is present, the color of the solution changes from a bluish-violet to a green or greenish-yellow. Alcohol, glucose, butyric acid, acetic acid, and phosphates, in quantities below two per cent, do not interfere with the re- action as they do in L'ffelmann's test. The reaction, is not interfered with by acetone or albumoses; sulphuric, nitric, and hydrochloric acids do not give the reaction. This, it is claimed, is more reliable than the Uffelmann test. Treatment.—Early diagnosis may lead to the only cure, viz., early extirpation. Most instances, however, require the physician's aid in com- bating symptoms as they arise in the course of inoperable growths. The diet should usually consist largely of vegetables, and especially peas, beans, lentils, etc.; tender game, gelati- nous substances. Articles likelv to cause fermentation, such as 144 the practitioner's manual. bread, cheese, sausage, should be excluded, as well as milk, when it is not well borne. As drink, good qualities of beer, malt extract, champagne diluted with carbonated water. To sharpen the appetite, give Condurango wines, or— R Bark of white condurango.................................. 15 gm. Water.................................................... 250 gm. M. Boil down to 150 gm., filter, and add syrup. S. A dessertspoonful a quarter of an hour before eating. To assist in artificial digestion in the stomach, give midway during the meal: R Pepsin.................................................... 0.5 gm. Maltin..................................................... 0.1 " Pancreatin................................................. 0.1 " M. S. For each close. To prevent vomiting : R Picrotoxini.............................................. 0.05 gm. Morphina hydrochloratib................................ 0.05 " Atropina sulphatis (neutralis)........................... 0.01 " Aqua laurocerasi...................................... 10 " M. S. Five to eight drops at at a dose. —Robin. For hcematemesis, small pieces of ice swallowed and ice applied externally. Ergotin injected hypodermatically or er- gotin internally: R Tannini................................................. 1 gm. Pulveris opii............................................. 0.50 cgm. Pulveris cinnamomi..................................... 1 gm. M. ft. chart. No. x. S. One every two hours. Or— R Ergotin................................................... gr. xxx. Gallic acid................................................ gr. vij. Turpentine................................................ f\l\. Syrup.................................................... 1 iv. M. S. A dessertspoonful to a tablespoonful every half-hour in broth. R Ergotin.................................................. gr. lxxv Hydrochlorate of morphine................................ gr. i. Antipyrin.............................................. gr. xx. Sulphate of sparteine...................................... gr. iij. Sulphate of atropine...................................... gr. ^ Distilled water..........................enough to make 3 iij. M. CANCER OF THE STOMACH. 145 Of this twenty minims may be deeply injected into one of the muscles of the back or chest, and if necessary the injection may be repeated in half an hour should the danger be pressing. —Capitan. To control vom iting of mucus and food : R Morphina hydrochloratis, Cocaina hydrochloratis................................aa 0.10 gm. Aqua laurocerasi........................................ 10 " M. S. Five drops before each meal. —Huchard. In vomiting due to obstruction and with retention of food particles, wash out the stomach with chloride of sodium, one per cent; boric acid, two per cent; salicylic acid, 1 to 1,000; or naphthol, 1 to 1,000. On awaking in the morning the following suppository: R Pulveris opii............................................ 0.10 cgm. Pulveris belladonna foliarum............................. 0.02 " Olei theobromatis....................................... q.s. R Sodii iodidi............................................. gr. x.-xv. Liquoris potassii arsenitis............................. gtt. ij.-v. M. S. After each meal. In the absence of ulceration .- R Acidi hydrochlorici dil......................................... 1 i. M. S. Ten drops in half a glass of warm water after meals. —Lyman. To retard cancer growth and delay death, begin opium before pain demands it. To withhold it till pain compels its use is simply barbarous.—H. Snow. Chlorate of sodium, Iij. to 3iv., daily.—Brissaud. Anticancerous serum.—Reclus. To diminish pain, increase appetite, stop vomiting and hcemedemesis : R Sodii chloratis........................................... 3 iiss.-iij. Aqua................................................... 1 v.-vij. To he taken in divided doses during the day. Caution.—Gastric irritation is produced by larger doses than the above. 10 146 the practitioner's manual. Aristol is useful after the stage of ulceration has been reached: R Aristol........................ ............................ gr. iss. For one pill. Give three or four daily. —Huchard. As a tonic : R Extract of condurango........................................ 3 iij- Sulphate of strychnine....................................... gr. $ Dilute hydrochloric acid..................................... 3 iij. Elixir of gentian........................................... § vi. M. S. A tablespoonful in a wineglassful of water through a tube after meals. In anosmia : R Sol. ferri et mangani (Parke, Davis & Co.)...............§ vi. Liquoris potassii arsenitis............................... tti xlviij. M. S. Tablespoonful thrice daily. —Hemmeter. Sedative and antiseptic mixture : R Cocaina hydrochloratis...................................... gr. iv. Chloralis.................................................... gr. xl. Aqua mentha piperita.................................... 3 iss. Aqua................................................q.s. ad § iij. M. S. Tablespoonful every two hours. —EWALD. Lavage should be reserved for early cases and not be applied to the later stages, because of the danger of auto-infection.— Collignon. For the cachexia : R Sodii glycerophosphatis................................... 0.20 gm. Aqua.................................................... 20 " Inject five to six grams daily. —Robin. Cancer of the Uterus. The diagnosis is not usually very difficult after certain prog- ress has been made, and especially when a non-operable point has been reached. Hemorrhage between the periods late in menstruating life and especially that occurring after normal menstruation has ceased should cause suspicion. Pus dis- charged from the cervix furnishes strong presumptive evidence. cancer of the uterus. 147 A serous discharge in elderly women often has a serious meaning. Pain is a most unreliable symptom, though almost never wholly absent. An early diagnosis is frequently possible by microscopical examination of uterine scrapings. Differentiation.—Chronic cervical catarrh with hyper- trophy, ectropium, retention cyst, etc., is most likely to cause mistake in diagnosis. Senile endometritis gives a fetid dis- charge which might lead to faulty conclusions. Leucorrhcea moderate in amount, ill-smelling, accompanied by hemorrhage, suggests cancer of the corpus uteri.—Mish. Foreign substances in the uterine cavity may even occasion purulent discharge, and polypus, when sloughing away, may strongly suggest malignant disease until exploration is made through a dilated cervix. The less friable the tissues under the curette, the less likeli- hood is there of malignancy. A firm scrape will bring away a distinct piece of tissue in cancer, but will only cause bleeding in its absence. —Sinclair. Treatment.—As a palliative : R Sodii chloratis................................................ 3 v. Syrupi aurantii florum........................................ ? i- Aqua destill................................................. 1 iij- M. S. Tablespoonful twice, gradually increased to eight times daily. Locally: R Sodii chloratis, Bismuthi subnitratis......................................aa 3 iiss. Iodoformi................................................... 3 i. M. S. Apply on tampon. __DUVRAC. As a deodorizer : R Acidi salicylici............................................. J?1'- vi- Sodii salicylatis............................................. 3 nj. Tinctura eucalypti................................ ......... 3 vi. Aqua destillata............... ............................. 1 vl M. S. Three tablespoonfuls to a pin of water as an injection. Or— R Carbolic acid.............................................. Sr- viiJ- Glycerin.................................................. I viiJ Essence of thyme.......................................... 3 nj- M. S. A tablespoonful to two quarts of water. 148 THE PRACTITIONER'S MANUAL. To Control Bleeding.—Place patient in knee-chest position and pack the uterus with gauze containing some antiseptic powder.—N. G. Bozeman. When the bladder is implicated and becomes perforated, carry out irrigation with clear or disinfecting water and drain- age.—N. G. Bozeman. Of the cervix uteri: Tampon with gauze impregnated with tannin, iodoform (ten per cent), and powdered quinine.— Marocco. R Methylene blue, Tannin................................................aa 0.25 cgm. Powdered opium.........................................0.05 cgm. Olive oil................................................. 15 gtt. Cacao butter............................................. 4 gm. M. S. For one suppository, to be introduced daily into the cervical canal and kept in place by means of a tampon. Or— R Tannin, Iodoform.....................................................aa 15 M. S. Apply with powder blower and then pack. If much hemorrhage: R Liq. ferri subsulphatis........................................ § i. Aqua destillata.............................................. § iij. M. S. Inject into the uterus. —Barnes. R Extracti chelidonii, Aqua (or weak antiseptic solution)........................... aa. 50 M. S. Saturate cotton tampon and apply directly against cancer mass. —Freudenberg. Carbuncle. Common anthrax in its early stage presents an infiltration of the skin quite similar to that of furuncle, but usually much more extensive, ranging from one hundred to four hundred millimetres in area. The tissue is firm and almost immovable, especially at the nucha, which is one of its most favorite sites. Diagnosis.—The extreme pain, fever, and possibly sopor or delirium accompanying the above local signs usually suffice. CARBUNCLE. 149 Differentiation.—The process being much the same as that occurring in furuncle, the distinction is to be made chiefly be- tween these two affections. It is much larger in surface area, more diffusely flat, and is characterized by the occurrence of multiple openings through the skin surface instead of a single central opening as in the boil. The sieve-like openings also serve to distinguish it from other diffuse phlegmonous processes attended with suppuration, as well as the circumscribed brawny border of the former, which is not found in phlegmon. Prognosis.—Furuncular anthrax or carbuncle is a serious affection at all times, and may in any case produce symptoms of pyaemia or cerebral oedema, while diabetics or otherwise debilitated persons or those of advanced years make a guarded prognosis necessary. Treatment.—Make crucial incisions, scrape with a sharp spoon, and cauterize with actual cautery; then pack with steri- lized gauze moistened with a ten to twenty per cent solution of chloride of zinc, moisten the dressing as often as indicated, but do not employ oiled silk or other protective covering. Stimulate the activity of the liver, and combine with internal antiseptics remedies calculated to arrest suppuration and re- lieve pain. Protect the parts from all irritation.—W. E. Shaw. It has been claimed that an injection of ten drops of a six- per-cent solution of cocaine into the swelling will allay the in- flammation and abort the process. Avoid irritation, pressure, warmth, and moisture (as in poulticing), incisions, and stimulants. Apply the following ointment, spread one-third of an inch thick on the woolly side of lint: R Extracti ergota fluidi......................................... 3 ij. Zinci oxidi................................................... 3 ij. Unguenti aqua rosa.......................................... 1 ij. M. Cover this with cotton batting and give sulphuret of calcium, gr. \, every two hours. 150 THE PRACTITIONER'S MANUAL. Occasionally, as required, the following laxative and refri- gerant tonic: R Magnesii sulphatis............................................ 3 iv. Ferri sulphatis................................................ 3 i. Acidi sulphurici dil.......................................... 3 iij. Syrupi zingiberis........................................... 1'\. Aqua......................................................ad - iij. M. —BULKLEY. Apply ice most energetically and make deep incisions so as to open as many foci as possible.—Kaposi. Early incision, extending into the surrounding healthy tis- sue, one of the three manners of incision being employed, according to the situation and size of the anthrax. After incision curettage. Then disinfection with a five- per-cent carbolic solution or a 1 in 1,000 sublimate solution. Dressings of ten-per-cent iodol or xeroform gauze. Dressings to be changed morning and evening. Internally the following is given: R Quinina hydrochloratis, Pulveris glycyrrhiza radicis...................................aa 4 Ext. glycyrrhiza...............................................q. s. Ft. pil. No. c. S. Take one pill four times daily. If more inflammatory infiltration appears, the incision is repeated. —Cumston. When disintegration sets in, warm fomentations or disinfec- tant dressings are indicated. Calcis sulphuratae, gr. ss. to gr. i. Hot bathing and hourly poultices.—French. Use cocaine, remove all necrosed tissue after incision, apply pure carbolic acid, pack with iodoform gauze, and surround the parts with a ten-per-cent permanganate-of-potassium solution. —C. A. Gray. Surround the carbuncle with a deep incision and remove the whole mass, and swab with— R Zinci chloridi............................................... gr. xl. Aqua....................................................... 1 i. catalepsy. 151 If all tissue cannot be cleanly removed apply— R Carbolic acid.................................................... 1 Alcohol......................................................... 1 Methyl violet.................................................... 1 Water.......................................................... 10 M. S. Duet with iodoform and pack with gauze. —J. O'Connor. To abort: R Pulveris opii, Unguenti hydrargyri, Saponis dura...............................................aa § ss. M. S. Apply spread on thick leather. —Buxton Shillitoe. R Tinctura iodi.................................................. | j. S. Apply so as to encircle the carbuncle until it produces vesication. —Jordan. R Farina lini, Fermenti...................................................aa, q.s. Fiat cataplasma. —Ellis. Unguentum hydrargyri spread upon a piece of cloth is ap- plied over the carbuncle and left there, while the skin around it is rubbed every two hours with a piece the size of a pea.— Roth. I always give attention to the antiseptic treatment of the skin in the vicinity after opening, so as to prevent the recur- rence in ring form around the original carbuncle or boil, due to migration of micro-organisms.—S. 0. L. Potter. Catalepsy. A paroxysmal suspension of sensation and voluntary mo- tion, lasting from a few minutes to an indefinite number of hours, or even days, without the respiration or circulation showing effort on the part of the subject, serves to distinguish this condition. The skin is completely anaesthetic and the mus- cles retain the limbs in the position in which they happen to be at the moment of seizure. Differentiation.—From apoplexy we distinguish it by the 152 the practitioner's manual. susceptibility of the pupils to light; by the eyes remaining open, by the absence of stertorous breathing, and by the fixed position of the muscles. When the history can be obtained we learn that the state is a recurrent one. In ecstasy, the consciousness is not completely lost, but the subject is so engrossed as to be oblivious to surrounding influences. The diagnosis of hysterical catalepsy is made by the pres- ence or history of unmistakable signs of hysteria. Prognosis.—Recurrence is the rule. Danger to life is slight. Treatment is essentially that of hysteria. The attack may cease under the influence of irritation of a hysterogenic zone. Cholelithiasis. Severe abdominal colic, attended or not with jaundice, is the most common symptom of gall stones or biliary calculi. Inflammation of the gall bladder or catarrh of the bile ducts may give much the same symptoms, and, on the other hand, good-sized calculi may pass into and through the intestines with little or no disturbance. Diagnosis.—The pain is sudden, severe, and well localized, and when followed by vomiting, not attributable to errors of digestion, furnishes an important indication. The only symptom present may be jaundice and recurrent rigors. An absolute diagnosis of gall stones can be made by washing the dejecta after an attack of suspected colic, and thus finding a calculus. If the latter be faceted, as is usually the case, it indicates that other stones are, or have been, pres- ent. Failure to find calculi under these conditions is no evi- dence of their non-existence. A stone which has caused biliary colic may pass again into the bladder, become impacted, or ulcerate its way through the abdominal wall. The fact that gall stones are more common after the age of forty, and in cholelithiasis. 153 women, especially those leading sedentary lives and given to indulgences of table, is a point not to be lost sight of. A typi- cal severe attack is attended with repeated vomiting of bile- stained fluid and a colic which doubles the patient up in agony, demanding immediate relief. If the pain is referred to the epigastrium, it is more likely to be due to gall stones than to anything else. A number of paroxysms may occur, until finally relief is obtained by the passage of the stone or by its falling back into the gall bladder. During the period of succeeding jaundice there are symptoms of slight gastritis and tenderness over the liver. At times occasional slight dyspeptic symptoms, or evidences of mild "biliousness" alone, are complained of, but, as Graham has claimed, if in the absence of icterus, frequent and careful ex- amination of the urine is made for bile, it will be found, especially if cholecystitis be present. An invasion of pyogenic organisms may occasion symptoms of localized peritonitis, sudden pain, tenderness, high temperature, anorexia, nausea, and vomiting. Differentiation.—In the absence of jaundice the diagnosis of biliary colic is, according to Graham, distinguished only with difficulty from painful distention of the stomach and spasmodic closure of the pylorus. Acute pancreatitis, especially when associated with jaun- dice, might lead into error, but the tenderness is more to the left, is usually more severe, and attended with symptoms of collapse. Pancreatic calculus gives at times symptoms scarcely to be distinguished from those originating in the gall bladder. If the attack were due to peritonitis with perforation, there would be rigidity of the abdominal walls, with swelling, ten- derness, and tympanites. The pain of appendicitis is usually considerably lower in the iliac fossa; still it may be simulated. In kidney stone the pain follows the course of the ureter and is reflected to the penis or testes, while the urine soon shows evi- dences of gravel. In pyonephrosis it shows pus. 154 the practitioner's manual. The pain from gastric ulcer comes sooner after eating, is more apt to follow certain kinds of food, and is referred more directly to the region of the stomach. The history of preced- ing similar attacks is of value, especially if jaundice has fol- lowed, and such a history may give aid in obscure cases of intestinal obstruction. In hysterical and nervous women pseudo-biliary colic is dis- tinguished by the absence of jaundice. In chronic impaction there may be a chill, the temperature reaching 103° F. or over, followed by sweating, simulating an attack of ague, and, espe- cially when recurrences correspond to one of the well-known types, continuing perhaps through several weeks, a faulty diagnosis of malarial fever has been made. The localized pain and persistent jaundice should be sufficient to distinguish the affection. Obstruction of the small intestine by a large biliary calculus which has ulcerated through may lead to confusion as to its exact nature, until a laparotomy or autopsy makes it clear. When a tumor is formed by a distended gall bladder, it is distinguished from movable kidney and other abdominal swell- ing, by the jaundice usually present, bile in the urine, history of attacks of colic, movement of the tumor with respiration, and mobility of the lower portion while the upper is fixed. Treatment.—Prophylaxis.—Moderate diet excluding fats, sweets, and alcohol, and the daily use of sodium phosphate with glycerin. In the attack : R Morphina sulphatis........................................ gr. $-% Atropina sulphatis......................................... gr. -j-^ M. S. Inject. And give— R Chloroformi................................................ m, xxx. Aqua laurocerasi.......................................... 3 i. Spiritus atheris compositi................................. 3 i, M. —W. Gilman Thompson. cholelithiasis. 155 When pain is of moderate intensity but almost continuous : R Potassii iodidi............................................ gr. v. -x. Twice daily. —DUNIN. Large quantities of warm water to which bicarbonate of sodium may be added. Oil, fatty acids, sodium and potassium salts are all good solvents of cholesterin, which is the gall stone's chief ingredient. R Olei oliva.................................................. § vi. Spiritus vini gallici......................................... § ss. Mentholi.................................................... gr. ij. S. From two to twenty ounces daily. If not borne by the mouth, ten ounces per rectum.—Brock- bank. Or an ounce at first, increased rapidly to six or eight ounces at a dose.—Clarke. Regulate excretion of bile by flushing the bile passages by the abundant use of water. Avoid too long fasting. As a biliary antiseptic nothing is better than salicylate of sodium. There is no hope of effecting solution of concretions. Their seat cannot be reached.—William Hunter. R Olei terebinthina.......................................... tti, v. Syrupi acacia.............................................. § ss. Sodii sulphocarbolatis...................................... gr. xx. Spiritus atheris compositi..................................TIL xv. Aqua mentha piperita.................................q.s. ad § i. M. S. To be taken twice or thrice daily. Hot poultices should also be applied to the hepatic area.— Balfe. To stop short the attack, glycerin, pure, up to an ounce at a dose. In dose of a drachm to three or four drachms daily it prevents new attacks.—Ferrand. Biliary calculi with angiocolitis, chills, fever, etc.: R Calomel.............................................. gr. iv.-viij. S. Every two or three days. —Ranglaret. 156 the practitioner's manual. Hepatic colic: R Valerianate of amyl, Sulphuric ether..........................................aa, gtt. iij. M. For one capsule. Let twenty such capsules be made. S. Two capsules every half-hour until six have been taken. Or sulphate of morphine subcutaneously and large quantities of very dilute lemonade.—Thudichum. When there is intolerance for morphine : R Nitroglycerin.............................................. gr. ^ —TURNBULL. When severe, cold full baths at from Yl° to 82° F.—Molliere. An alkaline course combined with baths and diet is of bene- fit, not only in causing expulsion of stones, but in preventing their formation. Olive oil, beginning with two ounces and increasing to half a pint twice daily, acts chiefly as a cholagogue.—R. B. Duncan. During the attack : R Glycerini.................................................. 3 i. Spiritus chloroformi........................................ 3 i. Tinctura belladonna....................................... Til xxx. Tinctura opii camphorata.................................. tti xx. Aqua...................................................... 1 v. M. S. Tablespoonful at a dose. —Le Gendre. If vomiting is present: R Chloroformi, Tinctura myrrha........................................aa ttl xv. Mucilag. acaciaj............................................ 3 ij. Syrupi..................................................... § iiiss. M. S. Tablespoonful every fifteen minutes. Or— R iEtheris sulphurici ........................................... 3 i. Syrupi acacia................................................ § iv. M. S. Same as above. —Lemoine. Ice and iced drinks. Turpentine stupes and hot applications, moist or dry. In threatened collapse, chloroform anaesthesia.—Thudichum. cholelithiasis. 157 The family physician should relegate cholagogues, cathartics, and opiates to their proper and very limited sphere, and in these conditions, after having such insignificant beginnings and which become menacing and dangerous so suddenly, turn to the sur- geon at the right moment. An ever-increasing number of hu- man beings will thus be rescued from death and from severe suffering.—J. Adler. For the immediate relief of the patient, hypodermic injec- tions of morphine. When the pain is so atrocious that mor- phine seems to be inadequate, chloroform or ether may be given by inhalation. The general prolonged hot bath is of signal benefit. Emetics should be rigorously proscribed.—Ouchter- lony. When a large amount of fat is introduced into the stomach, a corresponding amount of bile is excreted for its proper solu- tion. This great increase in the biliary flow causes a mechani- cal pressure which induces a gradual distention of the ducts and a propulsive power upon the engaged calculus. R Sweet oil.................................................. § v. -vij. Brandy................................................... | iss. Menthol.................................................. 3 ss. Yolks of two eggs worked smoothly in. S. One dose. —Siegfried Rosenberg. Caution.—Oil affects the system injuriously in adhesive cholecystitis, is useless in ascending suppurative infection, and injurious by reason of impairing digestion and giving extra work to the liver.—Barth. R Extracti belladonna.........................................gr. ss. Every two or three hours. —MURCHISON. R Chloroformi................................................. 3 ss. Olei amygdala dulcis...... .................................. 3 i. Syrupi acacia................................................ § iss. M. S. Tablespoonful every quarter or half hour. —TOURASSK. Sodium phosphate, a heaping teaspoonful in plenty of water 15S THE PRACTITIONER'S MANUAL. thrice daily, kept up for several weeks, is very efficient treat- ment. The crystals must be used freshly pulverized, as the granulated salt is inert. Put three heaping teaspoonfuls into a pint of boiling wTater; when cold, drink it with seltzer water of any kind added, during the day.—S. O. L. Potter. Cholera. Asiatic cholera comes into question only at times of epidemic prevalence and is then to be distinguished from cholera nostras, cholera infantum, poisoning by arsenic, and some varieties of peritonitis. The microscopical test shows comma bacilli lying in groups, which Koch believes is characteristic. A minute particle of mucus from the dejecta is stained with a dilute solution of carbolic fuchsin and examined directly. This is reliable only when the bacilli exist in a state of almost pure culture. The slower method of culture in an alkaline medium of peptone, gelatin, or agar-agar gives positive results. Diagnosis.—Aside from the aid furnished by bacteriological examination we have the rapid development of collapse after vomiting and rice-water stools in those who have been exposed to infection. The skin is cold, the breath icy, and the character of the colic agonizing. The whole body is bathed in perspira- tion, with facies of a pinched, pale, and shrunken appearance, with cheeks slightly flushed. During the period of reaction in cholera, an erythematous or urticarial eruption, or one resem- bling scarlatina, coincides with the rise of temperature. It is, however, marked on the backs of the hands and forearms, but may cover all the limbs as well as the back. In some cases it is slightly hemorrhagic. Desquamation usually follows. The tongue is red at the borders and thickly coated in the centre. Upon this appearance and the following symptoms, Dr. J. M. Byron lays particular stress in the early recognition of cholera: bluish hue of lips, slight congestion of conjunctivae, CHOLERA. 159 and a peculiar rather stupid look in the eye. One of the most important and earliest symptoms, he says, is a compressible pulse of 108 to 120, without accompanying elevation of tempera- ture. Differentiation.—In cholera morbus, whose symptoms may closely approximate those of Asiatic cholera, the stools remain bile stained and contain faecal matter and perhaps blood instead of taking on the rice-water features. In gastroenteritis from copper and other mineral poisons, as well as in ptomain poisoning, there is much less cyanosis and collapse is not so marked. Prophylaxis.—In the prevalence of an epidemic, the safest rule in practice is to treat every case of diarrhoea, no matter how slight, with the utmost care, and on the principle that it may be premonitory of a grave attack of Asiatic cholera.—E. C. Wendt. Isolate patient, disinfect clothing and dejections, and see that drinking-water is recently boiled and food properly cooked before being used.—Frank Abbott, Jr. The only likely preventive is the use of pure water during epidemics.—Elmer Lee. The introduction of arsenious acid into the circulation (a theoretical suggestion).—Reginald Leach. Haffkine Virus Antidote.—It is still too early to form a final opinion as to the method's value. Inoculations have seemed in several instances to afford protection; four per cent of those vaccinated and over twenty-one per cent of those unprotected contracted the disease in one instance. The method will prove of inestimable value as a means of protecting bodies of men, such as European troops in India, when temporarily stationed in a region in which cholera is en- demic, and communities exposed to occasional visitations of the epidemic disease.—Andrew Davidson. Treatment varies with the different stages. 160 the practitioner's manual. In first stage, warm bath, warm bed. R Hydrargyri chloridi mitis................................. gr. x Enteroclysis or intestinal irrigation. Introduce such a tube into the rectum as is used for stomach washing, and let flow from a douche cup or bag a two-per-cent solution of tannic acid at 110° F. Let fluid flow in slowly. The introduction of a quart should consume ten or more min- utes. The fluid should be retained for some time. Repeat every hour.—Byron. At the onset of profuse vomiting and diarrhaia: R Tinctura cinchona composita, Spiritus atheris compositi...................................aa 15 Acidi hydrochlorici diluti..................................... 2.5 Olei mentha piperita.......................................... 0.3 Quiuina hydrochloratis........................................ 2 M. S. Twenty drops three or four times a day. —BOTKIN. For intestinal antisepsis in the premonitory and up to the fully developed stage, salol.—Shakspeare. Wash out the blood by hypodermoclysis or the subcutaneous injection of warm normal salt solution,— R Sodii chloridi................................................. 0.6 Aqua destill................................................ 100 or approximately two teaspoonfuls of table salt to a quart of distilled sterilized water, heated to 110° F. before using. At- tach a fine aspirating-needle to the end of a fountain-syringe tube, and introduce it deeply into loose subcutaneous tissue under strict antisepsis. Through this one or two quarts may be introduced in an adult every hour or so, the process itself consuming about half an hour. If absorption is delayed and a tumor forms and persists for some time, it has bad prognostic significance. —Byron. To favor reaction, especially in cases of medium severity, hot baths in association with transfusion or other treatment. The temperature should be 40° or 42° C. and the duration 15 or 20 minutes.—Marcellin. CHOLERA. 161 For hypodermic injection: R Chloralis..................................................... 3 iij. Morphina sulphatis.......................................... gr. i. Atropina sulphatis......................................... gr. i Aqua chloroformi, Aqua.....................................................aa § ss. M. S. Twenty minims, repeated in ten minutes, and subsequently pro re nata. —Bartholow. 1. Stimulating drinks are to be given—tea, coffee, brandy, rum; the bo'dy is to be warmly covered and hot-water bottles or hot bricks are to be applied to the feet. 2. For the diar- rhoea, a teaspoonful of the following every fifteen minutes: R Acidi lactici................................................. 10 gm. Syrupi limonis............................................... 2 " Syrupi simplicis............................................. 90 " M. And pour into a quart of water. 3. For the vomiting, as well as for diarrhoea, twenty-five drops of the following as often as either threatens: R Spirit, atheris composit., Extr. valerian, ether....................................aa, 5 gm. Tinctura opii............................................. 1 " Spiritus mentha piperita................................. 0.30 " Pieces of cracked ice may also be swallowed or aerated drinks given.—Paris Cholera Commission. Introduce high up into the bowel a 1-32 solution of hydro- zone.—John Aulde. R Chloroformi, Tinctura opii, Spiritus camphora, Spiritus ammonia aromatici.............................aa 3 iss. Creosoti................................................... gtt. vij. Spiritus vini gallici....................................... 3 ij- M. S. Ten to twenty drops in ice water every five minutes. —Horner. As a prophylactic and also in threatened collapse: R Strychnina sulphatis........................................ gr. | Acidi sulphurici diluti...................................... 1 ss. Morphina sulphatis......................................... gr. ij. Aqua camphora............................................ § ii iss. M. S. One teaspoonful every hour or two. Dilute it well. —Bartholow. 11 162 THE PRACTITIONER'S MANUAL. For vomiting and diarrhoea during reaction .- R Acidi carbolici............................................ gr. viij. Bismuthi subnitratis...................................... 3 ij. Mucilag. acacia, Aqua laurocerasi.......................................aa § i. M. S. One teaspoonful every hour or two. —Carpenter. R Tinct. opii depurati, Spiritus camphora, Tinctura capsici...........................................aa § i. Chloroformi purificati........................................ 3 iij. Alcoholis (95 per cent).................................q.s. ad 3 v. M. S. For persons over 18 years of age, 3b; for persons 14 to 18 years of age, 3 ss. ; for persons 6 to 10 years, gtt. xxx. ; for persons, 2 to 6 years, gtt. x.-xxx. ; for infants, gtt. i.-x., according to age. To be taken in water. Re- peat dose after each movement. —E. R. Squibb. R Tannini................................................... 3 i.-1 ss. Vini opii (Sydenham's) .................................. gtt. xxx. Pulveris acacia........................................... § i. M. S. This to be added to two quarts of water at a temperature of 100° F. or 104° F. Use as a high rectal injection after each evacuation. To prevent the thickening of the blood: R Sodii carbonatis............................................ gr. xl. Sodii chloridi............................................... 3 i. Aqua destillata............................................ § iv. M. S. Heat to temperature of 100° to 104° F. and inject subcutaneously. When injection failed and prognosis became grave : R Pulveris ipecacuanha..................................... gr. xxx. Aqua destillata.......................................... O ij. Ft. injectio. (Let stand two hours before using.) For the cramps, dry friction and counter-irritation with mustard or turpentine. For the vomiting, ice pellets, iced champagne, tincture of iodine in water.—Cant ant. R Extracti cannabis indica.................................. gr. xvi. Camphora................................................. 3 ss. Chloroformi............................................... ? ss. Olei terebinthina.......................................... 3 ij. Mucilag. acacia, Syrupi simplicis.........................................aa, § ss. Aqua cinnamomi......................................... § i. M. S. Tablespoonful every one or two hours. —G. B. Thorston. cholera infantum. 163 R Creosoti .................................................... gtt j Aqua camphora, Infusi gentiana compositi.................................aa 3 vi. M. S. One dose. Repeat every two hours. —J. T. Jones. R Tinctura rhei composita1.................................. n| v Tinctura rhei spirituosa.................................. Til ij. Tinctura opii, Tinctura Valeriana atherosa (G. P.), Tinctura mentha piperita, Spiritus atheris compositi..............................aa 1 ij. Olei mentha piperita..................................... t^ xxiv. Extracti nucis vomica.................................... gr. ivss. M. S. Dose fifteen to twenty drops. —Inosemzeff. No. I. R Tinctura opii, Tinctura camphora......................................aa 10 gm. Tinctura rhei.............................. ............... 20 " M. No. II. R Tinctura opii, Tinctura capsici, Tinctura cardamomi composita, Zingiberis....................................................aa 15 M. —Hamlin. Cholera Infantum. An acute catarrhal diarrhoea occurring in a child during the summer, especially where the hygienic surroundings leave much to be desired, and when each attempt to give nourish- ment or medicine is followed by vomiting, the condition can usually be thus designated with propriety. Diagnosis.—The stools soon become greenish, watery, sour, and attended with colicky pains. The abdomen is at first dis- tended with gas, but retraction soon takes place. Cases are often seen first in this stage of collapse, which has been preceded by twenty-four hours of perhaps watery passages. The child, whose skin was previously dry and hot, and who was restless, with a temperature reaching possibly to 104°, now presents cold and clammy extremities and general coolness of the surface, 164 THE PRACTITIONER'S MANUAL. while the thermometer in the rectum shows a temperature which may reach 106°. This may be followed by brain symptoms. The distinctive features are the marked restlessness, the high temperature, and the quickly following collapse with pinched features and sunken fontanelle, dyspnoea, and cyanosis. After an attack of sudden vomiting, preceded or accompanied by severe pain,, there are repeated evacuations of the bowels with pain especially referred to the neighborhood of the umbilicus, paroxysmal in character, which doubles the patient up. The pulse is rapid, the expression anxious, and the whole surface covered with perspiration, especially noticeable on the forehead. After the first vomiting of the stomach contents, renewed efforts bring up bitter greenish fluid. The subsequent pas- sages are watery and profuse. Between the paroxysms the patient secures some relief and rest, but usually they are so ap- proximated as to keep the patient very active. Differentiation.—The only affections at all likely to be mistaken for this are ordinary diarrhoea or entero-colitis. The former would be distinguished by the absence of both vomiting and the severe symptoms threatening collapse. The usual temporary nature of the process would also distinguish it. From ileo-colitis the distinction may not be possible during the first day or two, since vomiting in both is severe; after this, however, the appearance of blood and mucus in the stools with continued pain will point to the latter affection. The abdomen too is tense, while in cholera infantum it is usually flaccid. While acute gastritis is sometimes simulated and the taking of irritant poisons much more strongly suggested, the former is attended with a small tense pulse and hot dry skin, and in the latter the vomiting and purging do not occur simultaneously, as is commonly the case in cholera infantum. From cholera, it is distinguished by the absence of rice-water dejecta and the other severe symptoms as enumerated in the chapter on this epidemic and malignant disease. CHOLERA INFANTUM. 165 Prognosis depends largely upon our ability to place the suf- ferer promptly in cool and hygienic surroundings, since all severe cases end fatally, especially in crowded cities and tene- ment districts. Many infants cannot be saved under the most advantageous circumstances. Emaciation and exhaustion are apt to be rapid and extreme. Treatment.—Sterilized milk is a perfect safeguard against it. — Whitla. In the early stages with high temperature, a warm bath gradually cooled to S')° F. may be given and repeated at each access of fever.—H. Bryan Donkin. It has been recommended to administer glycozone in medi- cinal doses, after which the patient is to remain on the right side in the recumbent position for one-half hour. Inject a 1 in 32 solution in distilled sterilized water into the lower bowel as high up as possible by means of a soft rubber catheter (the patient lying on the left side with the hips well elevated).— John Aulde. R Quinina bihydrochlorici............................... 30 gm. Aqua destillata ebullata........................q.s. ad 100 cm. Sodii chloridi.......................................... 0.60 cgm. M. S. Inject two (Lewin) syringefuls (equal 1.2 gm. of the bihydrochlorate) on the first day ; later on from one to two syringefuls once daily. —NlEDZWIEDCKI. When there is great general irritability, with collapse, sunken fontanelle, stupor, coma, or convulsions, frequent small doses of brandy, plenty of cold water, or barley water. R Morphina sulphatis......................................... gr. tijtj For an initial hypodermic to be frequently repeated. If vomiting continues, brandy or ether subcutaneously.— H. Bryan Donkin. R Naphthalini........................................... gr. xx.-lxx. Olei bergamotta...................................... gtt- i - —* J ■ M. et ft. chart. No. xii. S. One powder every two or three hours. —Holt. 166 THE practitioner's manual. R Tinctura opii deodorata.................................. gtt. xvi. Spiritus ammonia aromatici.............................. 3 i. Bismuthi subnitratis...................................... 3 ij. Syrupi simplicis........................................ 3 iv. Mistura creta............................................ § iss. M. S. Teaspoonful every two or three hours for a child of one year. —J. Lewis Smith. R Acidi hydrochlorici diluti.................................... 2 Spiritus atheris compositi.................................... 6 Bismuthi salicylatis........................................ 6 Acidi carbolici (C. P.)...................................... 0.12 Glycerini.................................................... 12 Aqua mentha piperita....................................ad 60 M. S. A teaspoonful every hour, according to age. —ROSAHUSKY. To correct defective secretion: R Hydrargyri chloridi mitis.................................... gr. yj Sodii bicarbonatis.......................................... gr. i Sacchari lactis.............................................. gr. i. M. S. Give every two hours. At the onset: R Olei ricini............................................... 3 ss.- 3 i. Spiritus mentha piperita................................ gtt. i.-ij. M. S. Give in hot milk. For collapse : R Beef tea...................................................... § ij. Brandy....................................................... 3 ij- By enema followed by a warm bath. If serious, ether or aromatic spirits of ammonia, by hypo- dermatic injection. Or rectal injection of starch and warm water. Broths (mutton, beef, veal) are better than peptonized milk; or give no food for twelve or twenty-four hours—(occasional sips of hot water). Rub chest and abdomen with whiskey or whiskey and water, and wrap in cotton wool or flannel.—F. Percy Elliott. Diet. Antiseptics. Irrigation of the bowels, sedatives to allay peristalsis, restoratives.—Symes. After all other means fail: R Artificial serum............................................ 50 gm. Inject morning and night. (See page 160). T cholera infantum. 167 In urgent cases, one quart and a half of artificial serum, either by hypodermoclysis or by intravenous injection.—Durodie. R Chloride of sodium....................................... 7 gm. Sterilized water.......................................... 1,000 c.c. Or— R Sulphate of sodium....................................... 10 gm. Chloride of sodium........................................ 5 gm. Water (sterilized)..................................„..... 1,000 c.c. Inject into the subcutaneous tissue, one ounce; make from three to six injections a day.—Lesage. To arrest vomiting and purging : R Bismuthi subnitratis...................................... 3 ss. -iss. Spiritus myristica........................................ tti xx. Spiritus vini gallici....................................... 3 iij. Syrupi acacia............................................ § iss. Aqua cinnamomi....................................q.s. ad § iij. M. S. Teaspoonful every two hours. —Powell. R Acidi sulphurici aromatici.................................tij, xxiv. Liquoris morphina sulphatis (U. S. P.).................... 3 b Elixir curagoa........................................... 3 ij. Aqua...............................................q.s. ad § iij. M. S. Teaspoonful every three hours for a child of one year. —GOODHART AND STARR. R Tinctura opii.............................................. gtt. xij. Mistura creta............................................. § iss. M. S. Teaspoonful every two or three hours to an infant of one year. —J. Lewis Smith. R Hydrargyri chloridi mitis, Plumbi acetatis............................................aa gr. i. M. et ft. pulv. No. iv. S. One powder every three hours for a child from ten to twenty months old. —T. D. Mitchell. R Hydrargyri chloridi mitis.............................. gr. ij. Bismuthi subcarbonatis................................ gr. xvi.-xl. Pulveris ipecacuanha et opii........................... gr. i.-ij. Pulveris sacchari albi.................................. gr. xij. M. S. For eight powders ; one to be taken every three hours for two or three days, or until the tongue and mouth become moist and the alvine discharges change in color and consistence. —Thomas Hay. 168 the practitioner's manual. In threatening cases: R Acidi carbolici (crystal).................................... gtt. iij. Glycerini................................................... § ss. Tinctura opii camphorata.................................. § i. Aqua..................................................... 1 ss. M. S. Twenty drops every half-hour, till vomiting ceases ; then every four hours. —N. S. Davis. In severe cases: R Salicylate of bismuth........................................ 3 ij. Sulpho-carbolate of zinc..................................... gr. iv. Chalk mixture.............................................. § i. Paregoric, Water....................................................aa § ss. M S. Teaspoonful every two hours until the bowels are controlled, fol- lowed by : R Hydrargyri chloridi mitis.................................. gr. i. Sodii sulphocarbolatis...................................... gr. xx. Pepsini saccharati......................................... gr. xix. M. Divide in ten powders. S. Give one every three hours. —13ROUGHTON. To correct the greenish stools and vomiting: R Hydrargyri chloridi mitis.................................. gr. i. Sodii carbonatis (exsiccata)............................... gr. viij. Creta preparata........................................... gr. xij. Sacchari lactis............................................. gr. vi. M. ft. cht. No. v. S. One every two to three hours. —Tuffs. Cholera Morbus. Cholera nostras, or sporadic cholera, as it is sometimes spoken of^ comes on suddenly, often in the night, with purging, severe abdominal cramps, and vomiting. Vomiting is usually the first symptom, but pain may precede as well as accompany it. The contents of the stomach are first ejected, then fluid bilious matter, and later on what seems almost like pure water. The stools become progressively more liquid and are finally not dif- ferent from the rice-water dejections which are supposed to characterize Asiatic cholera. The passages are attended with ■^ CHOLERA MORBUS. 169 tenesmus and tenderness over the abdomen. There may be pain in the calves of the legs. The face is pinched, with anx- ious expression, covered with cold perspiration, and the pulse is rapid. It is a disease of adult life, spoken of at times as acute serous diarrhoea. Differentiation.—Poisoning by arsenic, antimony, and mushroom fungi are to be distinguished chiefly by tests applied to the vomited fluid. Cholera nostras is distinguished from Asiatic cholera by the less rapid development of collapse, by the fact that the stools remain bile stained or contain faecal matter, and possibly blood, but not the cholera bacillus. The cyanosis, icy breath, and ex- treme pinching of the facies seen in cholera are here usually absent. Prognosis.—The attack is usually over within twenty-four hours, but considerable exhaustion follows, rarely collapse, and only occasionally do symptoms of gastro-intestinal catarrh re- main. Fatal cases occur chiefly in the very aged and the very young. Treatment.— R Hydrargyri chloridi mitis................................... gr. iij. Sacchari lactis.............................................. q. s. Ft. tab. trit. No. xxx. S. One every hour until the passages become brown. R Hydrargyri chloridi mitis......................!.............gr. i. Ft. tab. trit. No. x. S. One every twenty minutes. R Spiritus camphora......................................... § ss. Olei caryophylli............................................ ttl xxx. Chloroformi................................................ 3 iij. Tinctura opii deodorata.................................... 3 ij. Tinctura capsici........................................... 3 ij. M. S. Shake well and give thirty to forty drops in water from every half- hour to every two hours, p.r.n. —Wood and Fitz. R Extracti opii................................................ gr. vi. Olei theobromatis.......................................... q. s. Fiant suppos. No. vi. S. Introduce one every two hours or after each evacuation. 170 the practitioner's manual. Mistura anticholeraica (" Sun Mixture") : R Tinctura opii, Tinctura capsici, Tinctura rhei, Spiritus camphora, Spiritus mentha piperita.................................aa 15 gm. M. S. Twenty to sixty minims. R Acidi sulphurici aromatici, Extracti hamatoxyli.......................................aa 3 ij. Spiritus chloroformi......................................... 3 ss. Syrupi zingiberis.......................................q.s. ad § iij. M. S. Teaspoonful every two hours. —Hare. To aliay vomiting : R Creosoti, Acidi hydroeyanici diluti..................................aa, tti ij. Mucilag. acacia.............................................. 3 ss. Aqua.................................................q.s. ad ? i. M. S. One dose. To restore the mucous membrane to normal condition: R Hydrargyri chloridi mitis................................... gr. -^ Pulveris aromatici......................................... gr. ij. Extracti pancreatici................ ....................... gr. v. Bismuthi subnitratis........................................ gr. x. M. ft. cht. No. i. S. Every three hours. —F. A. Packard. R Tinctura opii, Tinctura capsici, Spiritus camphora.........................................aa § i. Chloroformi................................................. 3 iij. Alcoholis.............................................q.s. ad § v. M. S. Twenty to forty minims, p. r.n. —Squibb. R Acidi nitrici diluti......................................... 3 i. Tinctura opii.............................................. gtt. xl. Aqua camphora........................................... | i, M. S. One-fourth to be taken every three or four hours. —Hope. Or, as modified by Thompson: R Acidi nitrici diluti............................................ 3 ij, Spiritus camphora, Tinct opi i.................................................aa 3 i. Syr. zingi beris................................................ 3 i v. Aqua mentha piperita.....................................ad § vi. M. S. Tablespoonful at dose. t CHOLERA MORBUS. 171 R Tinctura lavandula composita.............................. § ij. Tinctura opii, Tinctura rhei............................................aa 3 iv. Olei sassafras............................................... gtt. xl. M. S. A fluid drachm after each movement. Should it fail to act, add tinct. catechu, 5 i. -LOOMIS. " Hot Drops": R Tinctura opii, Tinctura capsici, Spiritus camphora, Spiritus mentha piperita....................................aa, 3 ij. Aqua........................................... ............. \ i. M. S. A teaspoonful. For a child : R Tinctura opii, Spiritus camphora.....................................aa, tti xxxij. Spiritus mentha piperita................................. tti, lxiv. Tinctura catechu composita............................. 3 iij. Mistura creta.....................................q. s. ad § ij. M. S. A teaspoonful. —G. H. Bosley. For nausea and vomiting : R Acidi carbolici.............................................. gr. iv. Bismuthi subnitratis........................................ 3 ij. Mucilag. acacia............................................ § i. Aqua mentha piperita..................................... § iij. M. S. Tablespoonful every two, three, or four hours. —Bartholow. R Olei terebinthina.............................................. 3 ij. Olei gaultheria............................................... 3 ss. Tinctura opii................................................. 3 ij. Mucilag. acacia.............................................. 3 iv. Sacchari albi................................................. 3 vi. Rub together thoroughly and add : Aqua........................................................ I iij. M. S. Shake and give to children between eight and eighteen months old from eight to twelve minims every three, four, or six hours, according to the frequency of the discharges. -p^ 22 In protracted cases, liquor ferri nitratis, in suitable doses thrice daily, and— R Quinina tannatis....................... ................... gr. iij Pulveris opii............................................... gr. ij. Hydrargyri cum creta,...................................... gr. iij. Sacchari albi............................................... gr. xx. M. etft. pulv. No. vi. S. One at bedtime. ^ 22 172 the practitioner's manual. R Morphina sulphatis........................................ gr. & Spiritus chloroformi....................................... ^l xxx. Mucilag. acacia........................................... 3 i. Aqua mentha piperita..................................ad 3 ij. M. S. Half in half an ounce of hot water. ■—Hare.2 Chorea. It is especially in the young that St. Vitus' dance, like other spasmodic affections, is encountered. The history of an injury acting as an irritant to the nervous system, or some pathological process acting in the same way, may point to the origin. A history of fright may sometimes be elicited from children who have not recently passed through scarlatina or rheumatic fever, either of which might have acted in a causative manner. Diagnosis.—The spasms being continuous during the wak- ing hours, the consciousness not being affected, and there being freedom from permanent muscular contraction, are factors which make the diagnosis comparatively easy. Differentiation.—Chorea is distinguished from the spasms of acute cerebral disease by its being non-febrile and without accompanying delirium. From tetanus, by the absence of tonic spasms. From apoplexy, by entire freedom from unconsciousness and from nocturnal spasms or convulsions. From paralysis agitans by the persistent tremor which takes the place of spasmodic contractions, and by the presence of evi- dences of general nervous debility in persons much older than those habitually attacked by chorea. Facial spasms may be said to be of uniform intensity, limited, as a rule, to certain groups of muscles upon one side only of the face. Writer's cramp presents a muscle jerk only on attempts at writing, and other occupation spasms (ironer's, engraver's, typewriter's) are readily distinguished by their occurrence in those whose profession leads to the particular form discovered. CHOREA. 173 The condition in hemiplegia may closely simulate ordinary chorea, especially when the latter is unilateral, but rigid con- tractions are found in the former alone. Hereditary chorea presents constant rhythmical motions, seldom developing before puberty. In walking, the subject, after a few steps, assumes a dance-like motion of the limbs, one being brought up to the other with a sudden, quick jerk. Prognosis in this form is bad, and no treatment influences the condition in the slightest. Senile chorea, whose spasms are similar to those seen in childhood, has a grave prognosis. Chorea major may be sporadic or epidemic; the latter is illustrated in the "jumpers," the "whirling dervishes," and the "salaam bowers." This is the tic convulsif of the French. Treatment here consists in hygienic and general measures, since no specific medication is of great value. Hysterical chorea gives rapid movements of the limbs or spasms of the face, often with a thrusting out of the tongue. It may be so closely allied to hysteria that it is equally proper to speak of it as hysteria with choreic manifestations. Reflex chorea is occasionally seen during the pregnancy of nervous women, and may be attended with such continuous movements as to cause exhaustion. Treatment should therefore here be prompt and energetic. The drugs recommended by Wood and Fitz are chloral, opium, antipyrin, and the bromides. The strength must be kept up, and, if necessary, abortion may be produced. When the muscular contractions are so great as to prevent sleep, the patient should be placed between freshly ironed sheets or warmed blankets, and the following administered: R Chloralis..................................................... 3 ij. Sodii bromidi............................................... § ss. Aqua destillata.......................................q.s. ad § iij. M. S. Teaspoonful every five hours for three doses. —Hare. 174 THE PRACTITIONER'S MANUAL. In chorea of Sydenham, or chorea minor, salophen, gr. x. at each dose.—Pierre Marie. Or, arseniate of sodium, 0.005 mgm., gradually increased to 0.020 or 0.030 mgm.—Gassicourt. Arsenic in large and progressive doses. One centigram from the first day, increased each day half a centigram up to four centigrams, in plenty of water or mucilaginous menstruum. Repose in bed; milk diet. Having reached a daily dose of four centigrams, run down the scale in the same way and stop. Cure in eight days.—Comby. R Zinci valerianatis.......................................... gr. xl. Cinchonina sulphatis....................................... gr. xx. M. ft. pil. No. xx. S. One thrice daily. —Da Costa. R Strychnina sulphatis........................................ gr. ij. Aqua....................................................... § i. M. S. Five drops three times a day to child of fifteen years. —Hammond. R Extracti cimicifuga, Elixir simplicis..........................................aa § iss. M. S. Two teaspoonfuls four times a day. —Bartholow. In aggravated chorea, attended with severe pains in the limbs and persistent rheumatic swellings: R Liquoris potassii arsenitis.................................> . tti, ij. Potassii bicarbonatis.................................... . . gr. iij. Potassii iodidi.............................................. gr. ij. Aqua camphora........................................... ^ ss. M. S. For one dose. Give thrice daily to child of five. —Thomas Hillier. R Zinci sulphatis............................................. gr. ij. Extracti conii.............................................. gr. iij. M. et ft. pil. S. Take every night. —Andrew. R Liquoris potassii arsenitis.................................... 3 iSs. Vini ferri amari.......................................q.s. ad ? iij. M. S. Teaspoonful after meals. —Powell. Hyoscyamine will be found useful in chorea which has re- sisted other remedies.—Da Costa. chorea. 175 In children, arsenic, with antirheumatic or antimalarial drugs. Re-education of co-ordination. Put the child to bed warmly clad and give a diet containing an abundance of milk, fruit, and vegetables, and no red meat. Bathe twice daily with tepid water, giving spinal douches followed by brisk rubbing and massage. During the first week give a laxative every second or third day to do away with any intestinal irritation of faecal toxins. Give cod-liver oil for the anaemia, preferably in capsules, rather than iron. Re-educate the limbs by gymnas- tics and Delsartean exercises, always insisting on rest after the exercises. Use salicylates for rheumatic pain, either ammo- nium salicylate with ammonium bromide in liquor ammonii acetatis or elixir calisaya. Fowler's solution of arsenic, in- creased from three drops thrice daily by addition of one drop a day until toxic symptoms are produced, is the most satisfactory general method of treatment.—J. Madison Taylor. R Potassii iodidi................................................. 3 ss. Aqua........................................................ 3 iv. M. S. Tablespoonful three times a day. —Semening. Rheumatism of the brain is the name given to chorea by Andrew Clark. Dyce Duckworth says it is a variety of rheu- matism in which the brain is affected instead of the joints. R Sodii salicylatis............................................ 3.6 gm. Ft. pulv. No. xii. S. One four times daily for a child four to six years of age. If child is anozmic : R Liquoris potassii arsenitis................................... 5 gm. Spiritus atheris compositi.................................. 20 gm. M. S. Begin with five drops three times a day after meals, increasing bj one drop every day until a dose of ten to fifteen drops is reached. For violent jactitations : R Chloralis....................................................... 4 Decoctionis radicis althaa...................................... 90 Syrupi simplicis................................................ 90 M. S. Teaspoonful three times a day for a child six to ten years old. —FlLATOW. To cure within a week, solution of arsenite of potassium, gtt. xv.-xx., continued for a few days.—Wm. Murray. 176 THE PRACTITIONER'S MANUAL. Fowler's solution till physiological effects. Fluid extract of cimicifuga in half-drachm doses. Hyoscyamine, y^- gr. Bromide of zinc.—Scurr. For children of full habit and good general health, the galvanic current is to be preferred. For those who are weak and anaemic, the faradic current is far more grateful and is followed by better results, both immediate and permanent. No method of electric treatment equals the depolarizing method of central and peripheral galvanization together with general faradization. Static electricity is also sometimes of use in calming nervous excitability.—Rockwell. Chorea Magna.—Pay careful attention to the general health, looking out for anaemia and the results of overstudy, improper food, or some attack of illness. Tonics, especially chalybeates, and change of air are to be ordered. Arsenic is to be admin- istered in the same manner as in chorea minor.—Sinkler. When habit chorea is due to error of refraction, mere cor- rection does not cure. Medical treatment must supplement glasses or tenotomy. Exalgin is superior to antipyrin, relieving insomnia, mus- cular weakness, and digestive derangements.—Moncorvo. Dose, gr. iv., increased by an equal amount daily up to gr. xv. as daily dose for a child of six or seven years.—Fere. More serious cases should be put to bed, exclusion as well as rest being thus secured. Not only is recovery facilitated but a diminished liability to heart complication is also attained.— Tyson. In consequence of the close relations between chorea with its attending arthritis, and rheumatic arthritis, it is reasonable to expect that the salicylates might be useful, but such expecta- tion has not, as yet, been realized.—Tyson. Fowler's solution in increasing doses up to gtt. xv.-xxv. three times a day. Toleration will be facilitated by diluting with carbonated water. Or by hypodermatic injection.—Seguin. CHOREA. 177 Chorea Minor.—Antipyrin, gr. viii. uptogr. xv., three times a day, in conjunction with the bromides (gr. viii. three times a day gradually increased to gr. xxv.).—Roth. Antipyrin (gr. xxv. daily) relieves the motor trouble within a week.—Marfan. Massage, gradually increased, and when patient is suffi- ciently calmed passive motions.—Fedorov. In recent cases: R Tinctura belladonna....................................... tti, xxx. Every four hours for ten days. Caution.—To be used only in such large dose in a hospital ward where patient is kept in bed, the urine daily measured. If it becomes diminished or the eyelids become puffy, give small doses of potassium acetate. Arsenic may be given at the same time, especially in obviously rheumatic cases.—Overend. 1. Absolute rest, avoiding any external excitation whatever, and placing the patient in a dark room. 2. The ascending electric current along the spinal cord—the best results with a gentle current, progressively increased. 3. Arsenic in large doses, commencing with twenty drops of Fowler's solution each day for children, and double this amount for adults. When the chorea ceases the medicine should be continued, for the dis- ease returns readily.—De Renzi. Chorea minor: R Lactophenin, Quinine hydrobromate...................................aa gr. ii£. M. One such powder to be taken three times a day in the case of children from five to ten years old. Or— R Lactophenin, Quinine hydrobromate ,..................................aa gr. xii. Cacao butter............................................... gr. cl. M. Make a suppository. One to be used at bedtime in children from ten to fifteen year3 old. 12 178 THE PRACTITIONER'S MANUAL. Cocainism. An habitual user of cocaine shows signs of general ner- vousness, oppression, palpitation, irritability, curtness in speech, and of becoming readily fatigued. He loses color, ability of application, and strict regard for the truth, resorting to all manner of subterfuge to secure the drug and find favorable op- portunity for self-administration. The skin is usually pale, clammy; there is little tendency to sleep, but rather a desire to keep in motion; the pulse is rapid, the pupils are dilated, the muscles twitch, the tongue shows tremor, and hallucination of sight as well as of cutaneous sensibility may exist. Magnan's sign is sometimes present. This consists in a sensation as of a spherical body existing underneath the skin, which varies in size in the sufferer's imagination from that of a small grain to that of a nut. This sign has a peculiar value in differentia- tion, since it exists in none of the other intoxications. Prognosis depends largely upon whether the habit was first formed in the attempt to cure morphinism or to alleviate some severe and painful chronic affection. It is also made less favor- able by the coincident existence of the alcohol habit. Treatment.—The subject should be put under restraint, often best by treatment in an institution, or under the constant watchfulness of an attendant. The drug can be much more rapidly withdrawn in safety than is the case with morphine. Drug treatment of less harmful nature should supply the necessary stimulus to the various organs. For the insomnia, trional, gr. xv., repeated as necessary. To quiet excessive irritability, hyoscine, gr. -j-j^-, hypoder- mically. For the mental depression, caffeine, gr. ss.-i., or strong coffee, during the day only. During convalescence nutritious and stimulating food and general tonics. COLIC. 179 Colic. This is a symptom which may be present in a great variety of intestinal disorders. It may be hepatic, pancreatic, renal, uterine, or due to the ingestion of lead or other poisons. The pain is sudden in onset. When accompanied by tympanites and relief of pain follows the discharge of gas, and especially if the pain is located about the navel, gastro-intestinal indigestion is usually the cause. Cramps in the muscles of the limbs and a history of error in diet will help confirm this view. Differentiation.—Attacks of acute enteralgia in colica pictonum, besides the history of exposure, chiefly in those whose occupation predisposes them to lead poisoning, will be attended with obstinate constipation but no vomiting. In pseudo-mem- branous or mucous colitis the colic will be followed by typical evacuations. In renal colic, the location of the pain over the kidney region or pain extending along the course of the ureter will point to the true origin. Enteralgia as a true neurosis comes on much more slowly and perhaps lasts for days instead of for hours. Although the pain here, also, is usually located about the umbilicus it is relieved by deep pressure. In hepatic colic, while the pain is for the most part referred to the region of the liver, it also radiates toward the back and into the shoulder. Here, too, vomiting and jaundice, if present, will lend valuable assistance in diagnosis. The pain of uterine colic is referred more particularly to the pelvis. If due to extra-uterine preg- nancy a sudden and intense pain is accompanied by collapse or by signs similar to those of internal hemorrhage. The pain in appendicitis is at times of a distinctly colicky nature, and when referred to the umbilicus tends to mislead for a time the most experienced examiner. It is usually relieved by eructa- tions, but not by the discharge of gas per rectum. Tenderness at McBurney's point and the presence of fever simplify the 180 the practitioner's manual. diagnosis. In peritonitis there is habitually some fever at first or upon recurrence of the pain. In intussusception, especially of infancy, the symptoms include bloody passages and tenesmus. In faecal accumulation or an obstruction of the gut by large gall stones, a local tumor may be made out by palpation, espe- cially in the ileo-caecal region, where the pain is often located. Rheumatism of the abdominal wall gives great tenderness of the muscles upon pressure; muscular pains are apt to occur in other regions at the same time, and the urine is rich in uric- acid crystals and urates. In lumbo-abdominal neuralgia tender points may be found corresponding to the perforation of the fascia by the nerves. In all abdominal colic, in which excessive tympanites does not make it impossible, careful palpation of the region of the ap- pendix should be carried out. An important point is the pres- ence of fever, which opposes the diagnosis of simple colic. Ad- hesions of the gall bladder may be a cause of pain resembling that of biliary colic. Any patient presenting himself with severe abdominal colic should be suspected of appendicitis.—McBurney. Treatment.—In infantile colic, the following is a prompt and satisfactory combination. R Sodii bicarbonatis......................................... gr. viij. Olei anisi................................................. it[ viij. Mucilag. acacia........................................... | ss. Aqua mentha piperita.............................q. s. ad § ij. M. S. A teaspoonful every half-hour. Two or three doses are often sufficient, but it may be given ad libitum.—Crutchfield. Colica intestiua: R Bismuthi subnitratis............................................ 15 Pulveris cinna momi............................................. 4 Sacchari albi.................................................... 60 M. S. Half a teaspoonful each day before dinner. —Rosatinsky. colic. 181 Flatulent colic: R Tinctura nucis vomica....................................... 3 i- Acidi nitromuriatici dil....................................... 3 ij. Spiritus chloroformi.......................................... 3 i. Infusi gentiana...........................................ad § vi. M. S. Tablespoonful three times daily after meals. Intestinal flatulence: R Powdered coriander, Powdered peppermint, Powdered vanilla..............................................aa 5 Powdered senna.................................................. 1 M. S. A teaspoonful two or three times a day. —MONIN. Flatulency : R Olei terebinthina.............................................. 3 i. S. Three to five drops on sugar. —Bartholow. Wind colic of infants : R Extracti zi ngiberis fluidi..................................... 3 iss. Tinctura asafcetida.......................................... 3 iij. Aqua mentha piperita, Aqua cinnamomi..........................................aa § i. Syrupi simplicis.......................................q.s. ad § iv. M. S. Teaspoonful t.i.d. in water before food. Though difficult to take, its potency is great.—Guv C. M. Godfrey. Infantile Colic.—Instead of using opiates: R Mistura asafcetida...................................... 3 i. Sodii bromidi............................................ gr. iij.-v. M. S. This is a dose for a child from one to four months old. —Bartholow. R Tinctura lobelia............................................ gtt. i. Aqua....................................................... 1 i- S. Teaspoonful at a dose ; give warm and repeat p.r.n. —HOLTON. Or, after hydrargyri chloridi mitis, gr. y^, thrice daily: R Aqua mentha piperita, Aqua fceniculi, Aqua destillata...........................(................aa, 30 Aqua laurocerasi............................................. 1 Tinctura opii................................................ 0.06 Syrupi simplicis.............................................. 10 M. S. Teaspoonful every two hours. —ESCHERICH. 182 THE PRACTITIONER'S MANUAL. Hypodermatic injection of morphine at once to relieve the pain. The cause can be treated subsequently. Pancreatic Colic.—Preceded by dull constricting pain above the epigastrium, due to obstruction of the excretory ducts of the pancreas by calculous formation. Colic of Intestinal Lithiasis.—Passage of gravel of intestinal origin in gouty subjects, is preceded by abdominal distention, nausea, pain referred to large intestine, with multiple irradia- tion, membranous and muco-purulent evacuations. Differentiation from hepatic colic by the special composi- tion of the gravel (organic matter derived from the faeces to- gether with salts of lime and magnesium). Treatment as in other forms of lithiasis.—Dieulafoy. To end an attack of hepatic colic : R Glycerini purificati...................................... 20-30 gm. To prevent a new attack : R Glycerini purificati...................................... 5-15 gm. To be taken each day in a little alkaline water. —Ferrard. Or, subcutaneous injection of sulphuric ether or Hoffman's anodyne in the hepatic region.—Kums. Colic of Intestinal Acidity.—Tincture of asafetida, nixx. to 3i. in milk of magnesia. In severe abdominal pain and shock, which may be due to colic, intestinal obstruction, perforation of a viscus, rupture of an appendicular abscess, or some other grave condition, give at once: R Brandy...................................................... | i. Milk......................................................... I iij. M. S. By enema. Wrap hot blankets round each leg and one about the chest. Cover the abdomen with a hot flannel cloth, which can be re- moved for the examinations, which will determine the exact nature of the affection.—Greig Smith. COLIC, LEAD. 183 When pain is located loiv down in the bowels: R Cannabis indica..............................................gr. i In violent spasmodic attacks associated with distention of stomach and intestines: R Spiritus cajuputi, Spiritus ammonii aromatici, Spiritus chloroformi.......................................aa p. a. M. S. Teaspoonful in a wineglassful of water every half or quarter hour. In flatulent dyspepsia, nerve tonics.—Stephen McKenzie. After indiscretion in diet: R Chloroformi................................................ I iss. Tinctura opii deodorata.................................... 3 i- Camphora.................................................gr. xv. Olei cajuputi............................................... 3 i- Aqua................................................q-s. ad § ij. M. S. Dessertspoonful every two or three hours. Colic, Lead. R Antipyrin..................................................... 3 i. S. To be given in divided doses during the day. —Devic and Chatin. R Epsom salt.................................................... 1 i- Dilute sulphuric acid......................................... 3 i. Water........................................................ I iv. M. S. A tablespoonful three times a day, preceded by ten grains of potassium iodide. —Brunton. R Extracti colocynthidis compositi............................ gr. ij. Extracti opii................................................ gr. ss. Extracti belladonna......................................... gr. £ M. et ft. pil. S. This pill to be repeated until pain is relieved and the bowels are opened. —William Pepper. R Sulphuris loti, Mellis despumati...........................................aa, § iv. M. S. One and one-half tablespoonfuls to be given three consecutive days ; then dose gradually diminished. On the third day the acute pain has dis- appeared. Or— R Chloroformi................................................. 3 ss. Alcoholis diluti............................................. § ss. M. et adde: Aqua....................................................... 1 viij. M. S. To be given as an enema. —Lutz. 184 THE PRACTITIONER'S MANUAL. R Aluminis........................................ ............ 3 ij- Acidi sulphurici diluti....................................... 3 b Syrupi limonis................................. ............. ? i. Aqua........................................................ 3 iij. M. S. Tablespoonful every hour or two. —Bartholow. Purgatives, sulphuric lemonade, sulphur baths.—Paul. (See also under poisoning by lead.) (For treatment of nephritic colic, see "Nephrolithiasis;" for that of hepatic colic, see "Cholelithiasis.") Constipation. Constipation, as distinguished from obstruction, is a chronic condition without urgent symptoms. The difficulty of evacua- tion constitutes the chief factor in diagnosis. The attendant symptoms, however, include headache, dizziness, sluggish men- tal state, sallow complexion, and lack of normal appetite. Con- stipation exists as a symptom of severe disease, possibty of the brain or spinal-cord paralysis, or of conditions of general mus- cular weakness; so that, in the matter of treatment, we must decide what causes have been operative in its production. Ten- derness of a particular part may indicate the presence of peri- toneal adhesions, or faulty stomach digestion may indicate that treatment is to be especially directed to the latter organ. When there is faecal accumulation, the outline of the large intestine may be defined by palpation and percussion. When hard masses are felt in palpating the abdomen, the softer con- sistence of faeces will distinguish it from malignant disease, cal- careous deposits, or biliary calculi, although the size of the tu- mor may equal that of a large orange. Flatulency and hypo- chondriacal symptoms may exist along with the other symp- toms. Treatment.—Much depends upon the formation of correct habits, as to regularity in the time of going to stool, and the avoidance of acquiring in early life a cathartic-drug habit. constipation. 185 Among general measures are to be recommended the em- ployment of bread made from the whole grain; abdominal mas- sage (perhaps with the aid of a firm ball); marmalade contain- ing bits of hard orange skin; stewed prunes (a bag containing senna leaves may be suspended with the fruit while cooking); an abundance of pure water; mineral waters; and plenty of exercise. In stubborn constipation in women : R Ferri et ammonii citratis................................. gr. xxx. Extracti cascara sagrada fluidi........................... tU xxxij. Sacchari.................................................'gr. viij. Aqua destillata.......................................... 3 iss. M. S. Half-teaspoonful before each meal. —Lutaud. In chronic constipation : R Pulveris rhei (radicis)........................................... 20 Sodii sulphatis.................................................. 10 Sodii bicarbonatis............................................... 5 M. S. From what one can take on the point of a knife up to a teaspoonful, according to requirements, stirred up in a large glassful of hot water at bedtime. —EWALD. In scanty and defective bile secretion : R Acidi arseniosi............................................ gr. i. Hydrargyri chloridi corrosivi.............................. gr. i. Pulveris ipecacuanha...................................... gr. ij. Hydrargyri chloridi mitis.................................. gr. xvi. M. div. in tab. No. xv. S. One or two tablets daily. —W. H. Porter. In the chronic form, four or five grains of a combination of caffeine and chloral dissolved in water, given by injection.— Ewald. In habitual constipation, damiana is effective in neurotic subjects, being analogous to strychnine. When all other means have failed : R Extracti cascara sagrada fluidi................................. 100 Tinctura nucis vomica, Tinctura belladonna.........................................aa 5 Spiritus anisi.................................................. 10 Chloroformi.................................................... 2 M. S. Take a teaspoonful in a little water after breakfast and dinner for a week, and then pro re nata. —J. DlAS RlBIERO. 186 THE PRACTITIONER'S manual. R Cream of tartar............................................. gr. xl Powdered anise seed, Powdered fennel seed....................................aa 3 i. Powdered senna pods, Washed sulphur..........................................aa 3 ij. Powdered licorice root...................................... 3 iiss. Sugar...................................................... 3 i- Mix well. S. One dessertspoonful in water at bedtime, or whenever most convenient. —Dujardin-Beaumetz. R Strychnina sulphatis....................................... gr. i. Extracti belladonna........................................ gr. v. Pulveris ipecacuanha....................................... gr. x. Extracti colocynthidis compositi............................gr. xv. Pulveris rhei............................................... gr. xv. M. div. in capsula No. xxx. S. Take one after meals. Intestinal fermentation with constipation : R Extracti aloes............................................... gr. vi. Pulveris rhei................................................ gr. vi. Benzosoli.................................................. gr. ix. Extracti hyoscyami........................................ gr. vi. Misce et ft. caps. No. xii. S. One after meals. —Thomas Hunt Stuckey. Constipation of pregnancy: R Aloini....................................................... gr. i Extracti belladonna......................................... gr. i Cascara sagrada............................................. gr. ■£ Strychnina sulphatis........................................ gr. -fa M. S. For one pill. —Hirst. R Sulphuris loti, Potassii bitartratis, Sodii bicarbonatis, Potassii et sodii tartratis.......................................aa 15 M. S. A tablespoonful, mixed with sweetened water. —E. A. Maxwell. In the habitual constipation of delicate persons with feeble digestive organs: R Extract of cascara sagrada.................................... gr. ij. Extract of nux vomica....................................... gr. i Extract of belladonna........................................ gr. i Powdered capsicum......................................... gr. i M. One such tabloid after food, once daily, should be taken; increased, if necessary, until two tabloids are taken thrice daily. CONSTIPATION. 187 This dose should be maintained until the habit of regular action is established, when the number should be gradually reduced and at length discontinued. Remedy the lack of fluids in the body by giving an abun- dance of water, either hot or cold.—Cutter. In gastric hyperacidity with constipation : R Magnesia, Rhubarb...............................................aa 7.50 gm. Bicarbonate of sodium, Carbonate of sodium, Powdered sugar........................................aa 15 gm. Oil of peppermint........................................ q.s. M. S. Half to one teaspoonful in water two hours after each meal. A hygienic mode of living, regular habits, outdoor life, and exercise are of greatest importance in preventing constipation. Abstain from administering cathartics in slight transient dis- turbances of digestion. Never put a patient on a one-sided diet for too long a time. The patient should be impressed with the importance of not worrying about his bowels; train him to have an evacuation once a day at a certain time, either giving him no drugs whatever, or administering a very slight cathartic for a short period, then gradually diminishing and ultimately dis- continuing its use.—Max Einhorn. In habitual constipation, dilate the sphincter ani once each week with the anal dilator or with the finger. If digestion is poor: R Papoid..................................................... gr. xx. Dilute hydrochloric acid.................................... 3 iij. Glycerin................................................... § ss. Tincture of gentian..................................q. s. ad 3 iv. M. S. Half to a teaspoonful before meals in water. Also five to ten grains of bicarbonate of sodium two hours after meals. —J. M. Perkins. Diet.—Vegetables in abundance, either cooked, as spinach, cabbage, broccoli, Brussels sprouts, cauliflower, carrots, tur- nips, parsnips, and the like; or raw, as tomatoes or celery. Fruits are of advantage—melons, apples, oranges, and figs. 188 the practitioner's manual. When stewed prunes are inefficient in keeping the bowels open, some senna leaves may be tied in a bag and placed in the re- ceptacle in which the prunes are to be stewed; this plan has often been successful when the ordinary stewed prunes have failed. Sugars in themselves are useful laxatives. A favorite addition to the breakfast is marmalade, which contains vegeta- ble salts and sugar.—T. Lauder Brunton. When there is a lax and torpid muse id ar coat : R Sodii valerianatis....................................... gr. xxxvi. Tinctura nucis vomica................................. tti, lx. Tinctura capsici........................................ v\ xlviij. Syrupi aurantii florum.................................. 3 iss. Aqua................................................ad § vi. M. S. Dessertspoonful half-hour before meals. —J. Mortimer Granville. A small dose of quinine added to salines increases their power of acting on the intestinal canal, as— R Magnesii sulphatis........................................... 3 i. Quinina sulphatis........................................... gr. i. M. S. To be taken in a tumbler of water, every morning. ■—William Thompson. gr. uss. In habitual form: R Podophyllin........................................... Extracti aloes, Extracti rhei............................................aa gr. xlv. Extracti taraxaci.......................................... q. s. M. et ft. pil. No. xl. S. One or two at bedtime. —NOTHNAGEL. Or— R Podophyllin, Extracti belladonna.......................................aa gr. i. Capsici...................................................... gr v Pulveris rhei.........................................._ ^ j M. etft. pil. No. xx. S. One t.i.d. Or— R Extracti gentiana.......................................... 3 i_ Extracti nucis vomica, Podophyllin.............................................aa gr. iiss. Olei cajuputi.............................................. gtt xx M. et ft. pil. No. xx. S. One twice daily. —Da Costa. constipation. 189 Or— R Extracti aloes............................................... 3 ss. Extracti nucis vomica...................................... gr. vi. Extracti hyoscyami......................................... 3i. Pulveris ipecacuanha............ .......................... gr. i. M. et ft. pil. No. xx. S. One at night. —W. H. Van Buren. Or— R Sulphate of magnesium........................................ § ij. Glycerin...................................................... § ij. Oil of turpentine.............................................. § ss. Water.......„................................................ § ij. M. S. Use as an enema. —C. P. Noble. Or— R Confectionis senna............................................ § i. Potassii bitartratis............................................. 3 ij. Sulphuris pracipitati, Ferri subcarbonatis..........................................aa, 3 i. Mellis despumati.............................................. q.s. Make an electuary. S. Teaspoonful after meals. —J. F. Meigs. Or— R Extracti aloes (purif.), Extracti hyoscyami......................................aa 3 i. Extracti nucis vomica..................................... gr. xij. Olei anisi.................................................. gtt. x. M. et ft. pil. No. Ix. S. One after each meal. —Metcalf. Or— R Massa hydrargyri, Cambogia, Ext. aloes, Pulveris zingiberis......................................aa gr. xxx. Olei mentha piperita..................................... tti iv. Tinctura aloes............................................ q. s. Mo et div. in pil. No. xxiv. —TOWNSEND. Or— R Aloes, Scammonii, Massa hydrargyri.....................................aa gr. xlviij. Olei tiglii............................................... tti, ij. Olei cari................................................ tti, ix. Tinctura aloes et myrrha............................... ttl xij. M. et div. in pil. No. xl. —John W. Francis. 190 the practitioner's manual. Or— R Cascarin, Aloin.....................................................aa ^r. i Podophyllin................................................. gr. i Extract of belladonna........................................ gr. % Strychnine................................................. gr. ^ Gingerin................................ •................ gr. i Make one pill. S. As required. —HlNKLE. To overcome spasmodic contraction and help in evacuation of retained and hardened fseces, large oil enemata.—Kussmaul. The desideratum must be to drop medicines. Increase vegetables, fresh or dried fruits, and grains. To promote absorption of food and peristalsis of small in- testine, mineral waters containing substances belonging to the group of common salt (Wiesbaden, Kissingen); or of the large intestines, aperients and laxatives. To keep contents of large intestine less solid, sodium or mag- nesium sulphate, or other salts difficult of absorption.—Franz Pfaff. In old age: R Extracti colocynthidis comp................................ gr. viij. Extracti hyoscyami....................................... gr. ij. M. et ft. pil. No. i. —Napheys. R Ichthyol.................................................... gr. iij. Make keratin-coated pill. S. One such once, twice, or thrice daily. —GUNSBURG. R Extracti aloes............................................. gr. xx. Pulveris rhei.............................................. gr. x. Extracti nucis vomica.................................... gr. v. Extracti taraxaci......................................... gr. xxx. M. et div. in pil. No. xx. —W. T. Lusk. Or— R Cambogia, Scammonii, Aloes, Hydrargyri chloridi mitis, Potassii bitartratis.......................................aa, gr. xx. Extracti taraxaci.........................................,. q. 8 M. et div. in pil. No. xx. —Miller. CONSTIPATION. 191 Or— R Cambogia, Pulveris digitalis, Pulveris scilla, Antimonii sulphurati....................................aa gr. xlv. Extracti taraxaci.......................................... q.s. M. et div. in pil. No. cxxv. —Helm. Or— R Resina podophylli.......................................... gr. x. Aloes...................................................... gr. xx. Extracti belladonna, Extracti nucis vomica...................................aa gr. v. M. et div. in pil. No. xx. —Jane way. Or— R Massa hydrargyri........................................gr. xxiv. Aloes....................................................gr. vi. Olei tiglii................................................ gtt. i. M. et div. in pil. No. xii. —Crane. Or— R Resina podophylli........................................ gr. ii£. Cambogia............................................... gr. vi. Aloes.................................................... gr. xxiv. Hydrargyri chloridi mitis, Pulveris zingiberis, Pulveris capsici........................................aa gr. xij. Extracti taraxaci......................................... q. s. M. et div. in pil. No. xxiv. —E. G. Jane way. Or— R Resina podophylli........................................ gr. vi. Extracti belladonna...................................... gr. iij. Pulveris capsici, Sacchari lactis.........................................aa gr. xxiv. Pulveris acacia........................................... gr. vi. Glycerini................................................ tti, vi. Syrupi.................................................. qs- M. div. in pil. No. xxiv. —Squibb. 192 THE PRACTITIONER'S MANUAL. Constipation in Infants. In the chronic form : R Extracti belladonna....................................... gr. ss. Aloes purificati............................................ gr. xij. Olei theobroma............................................ 3 ij- M. et ft. supposit. No. xii. S. Twice a day and at night. ■—Starr. R Tinctura nucis vomica..................... ................ TU ss. Tinctura belladonna........................................ TR, v. Infusi senna................................................ ttj, xx. Infusi gentiana compositi................................ad 3 i. M. ft. haustus. S. To be taken three times a day at eight to twelve months of age. Oatmeal should be substituted for other starchy food. A lack of sugar can be corrected by giving, previously to every feeding or nursing, some tepid water or oatmeal water in which a piece .of loaf sugar has been dissolved. Older children will take honey to advantage. Regular doses of cod-liver oil, given two or three times daily, will obviate or relieve constipa- tion, besides fulfilling other indications. Rectal injections, friction and kneading of the abdomen, and electricity are often useful. Calcined magnesia (five to ten grains a day), either alone or combined with rhubarb, is indi- cated when there is an excess of acid in the gastric and intes- tinal contents. Nux vomica, to which may be added some pur- gative extract, is indicated in insufficient muscular action of the intestine. As an occasional purgative, for the purpose of relieving the intestinal tract of indigestible and injurious masses, castor oil is probably the best and mildest. Calomel or compound licorice powder, or the fluid extract of rhamnus frangula, is valuable for this purpose.—A. Jacobi. Abdominal massage, with the palm of the hand well oiled, especially over the course of the large intestine, is of service ten minutes each morning.—De la Carriere. Give no laxative before the third month and no purgative during the first year. To correct, give cow's milk, four parts, CONSTIPATION IN INFANTS. 193 and sweetened water, one hundred; rectal lavage by means of the urethral catheter, employing two tablespoonfuls of oil with the yolk of an egg mixed with four drachms of water; mas- sage; electricity. Or, as a tepid enema: R Sea salt...................................................... gr. i. Water...................................................... 3 i. M. —Marfan. In children : R Extracti rhei fluidi...................................... Tq, xvi. Extracti ipecac, fluidi.................................. tti, iij. Sodii bicarbonatis....................................... gr. xxxij. Glycerini............................................... 3 vi. Aqua mentha piperita................................. 1 ij. M. S. One-half to one teaspoonful, two or three times a day. —E. R. Squibb. Or— R Tinctura opii, Tinctura rhei aromatica, Spiritus camphora.........................................ail 3 ss. Tinctura cardamomi composita.............................. 3 ij. Aqua anisi............................................q.s. ad 3 iv. M. S. A teaspoonful. —SWEEZEY. Or— 1} Tinctura opii camphorata, Syrupi rhei aromatici..............................,..,.....aa, 3 iv. Liquoris calcis................................................ = ij. M. S. A teaspoonful. --W. H. ACKERMAN. Or— R Sodii bicarbonatis............................................ 3 i. Tinctura nucis vomica...................................... tti, vi. Tinctura cardamomi composita, Syrupi simplicis...........................................aa 3 ij. Aqua chloroformi (B. P.).................................... 3 ss. Aqua........................................................ 5 ij. M. S, Teaspoonful every six hours. —Eustace Smith. Or, when associated with dyspepsia: R Sodii bicarbonatis, Magnesia.............................................aa, 0.25 cgm. Pulveris nucis vomica................................... 0.01 " M. S. To take in a spoonful of sugar and water morning and night for ten days of each month. 13 194 THE PRACTITIONER S MANUAL. Caution.—The dose of nux vomica should not surpass half a centigram a day for each year of the child's age.—Comby. Or— R Bicarbonate of sodium..................................... 3 iij. Powdered rhubarb......................................... § ij. Sulphate of sodium...................................... 3 i. Oil of peppermint.......................................... gtt. xx. M. S. Half to one teaspoonful before breakfast. Coryza. Rhinitis or simple acute inflammation of the nasal mucous membrane, causing the symptoms of sneezing, fulness, and watery discharge commonly known as "cold in the head," is to be distinguished from the catarrhal stage of rubeola, and, in infants, from "snuffles," which is so frequently an early symp- tom of lues. Differentiation is also to be made from the annually re- curring attacks of autumnal catarrh which we have referred to under the name of hay fever, and in which asthmatic parox- ysms are so likely to accompany the nasal discharge. There is likewise more itching about the eyes and nose, and the throat is more decidedly implicated. The history of predisposition and previous attacks will point to the true nature of the affection. In measles there is suffusion of the eyes, also some photo- phobia, and the watery discharge soon becomes purulent. Prognosis.—The affection is disagreeable rather than dan- gerous, but there is always a possibility of the process extending downward into the bronchi, especially in children. Treatment.—Prophylaxis.—Sulphate of quinine, gr. x., in capsule at bedtime. Or Dover's powder, gr. x., at bedtime. Or— R Atrophia................................................... gr. i. Mentholi................................................... gr. ss. Aqua camphora............................................ z { M. S. Spray a small quantity into each nostril. Caution.—This should be used very sparingly in children.— Morrill. CORYZA. 195 R Acidi tannici............................................. gr. x. Acidi borici............................................... gr. x. Cocaina hydrochloratis.................................... gr. iiss. Aqua...............................................q.s. ad § i. M. S. Use as a spray. —Guy C. M. Godfrey. R Cocaina hydrochloratis...................................... gr. vi. Bismuthi subcarbonatis...................................... 3 ss. Talci........................................................ 3 iss. M. S. Enough to cover a silver five-cent piece insufflated into each nostril every two hours. —Sajous. To abort a cold my favorite measure is the frequent inhala- tion of a small quantity of chloroform; just a few whiffs every half-hour or hour the first day.—S. 0. L. Potter. R Antipyrin.................................................. gr. x. Aqua destill................................................. § i. M. S. Use as a spray. Caution.—This is at times so painful that cocainization should be resorted to.—Elsberg. Or, large and frequent doses of carbonate of ammonium.— Beverley Robinson. Or— R Sodii bicarbonatis..................................... gr. xx.-xxx. Aqua................................................ 1 ij- —S "j- M. S. Every half-hour until three doses are taken ; a fourth dose at the expiration of an hour. Repeat course after two to four hours if necessary. —L. D. BULKLEY. Or, inhalations of menthol-chloroform in the strength of five to ten per cent. A few drops are placed upon a handker- chief, and five or six deep respirations taken. The nasal secre- tion is augmented at first, but afterward diminished, and the sore throat and laryngeal symptoms are relieved. The following nasal spray may be employed after the inha- lations : R Ichthyoli........................................................ 1 .Etheris........................................................ 1 Alcoholis...................................................... 1 Aqua destillata............................................... 97 —WUNCHE. 196 THE PRACTITIONER'S MANUAL. R Acidi carbolici, Spiritus ammonia..........................................aa, 3 iss. Alcoholis..................................................... 3 iij. Aqua^......................................................ad 3 iv. M. S. Place ten drops upon blotting-paper and inhale through the nostrils for a minute or two. R Camphora (trit.), Sacchari albi................................................aa 3 ij. M. S. A small pinch in each nostril every two hours. ■—Bamberger. R Saloli....................................................... gr. xv. Acidi salicylici............................................ gr. iij. Acidi tannici............................................... gr. ij. Acidi borici................................................. 3 i M. S. Insufflate into each nostril. Caution.—Do not continue more than half a day.—Capitan. R Sodii salicylatis............................................... 3 ij. Spiritus ammonia aromatici................................... 3 i. Syrupi aurantii florum......................................ad § ij. M. S. One teaspoonful every four hours. Irrigation of the nasal passages may be carried out by means of a pint of normal saline solution at a temperature of 122° F. Caution is necessary to avoid setting up an otitis media.— COURTADE. General Catarrhal Conditions and "Colds." — In incipient "cold in the head," coryza, and also in chronic catarrh, fill a wide-mouthed two-ounce bottle one-third full of the following: R Acidi carbolici.................................................. 10 Alcoholis....................................................... 10 Aqua ammonia................................................ 12 Aqua destillata................................................ 20 M. S. Introduce absorbent cotton so that the whole will be gradually absorbed by it. Inhale at frequent intervals. —Herman Hager. To dissipate the headache, an uncomfortable sensation of stuffiness, and frontal pressure characteristic of acute nasal catarrh: R Tinctura euphrasia.........................................gtt. x. S. Repeat every ten or fifteen minutes for two or three hours. CORYZA. 197 An abortive influence is effected by: R Tinct. gelsemii semper..................................... gtt. xx. S. As a single dose or added to half a tumblerful of water and a teaspoonful taken every ten minutes until diaphoresis. In the stage of abundant discharge : R Atropina.................................................... gr. ^ S. Once or twice daily. —H. B. Whitney. R Tinctura aconiti.............................................. 3 ij. Tinctura opii deodorata...................................... 3 vi. M. S. Eight drops in water every hour or two. —Bartholow. Catarrhal symptoms with febrile movement and myalgia : R Pulveris Doveri, Phenacetin..............................................aa gr. x. M. et ft. capsulas No. iv. Give two, followed immediately by a hot bath. After the bath a hot lemonade or rum punch, and repose between several thicknesses of heated blankets. If, after half an hour, perspi- ration is not abundant, give the remaining two capsules and let the patient perspire for an hour, after which the skin is dried slowly and the patient retires for the night.—H. B. Whitney. Bad Cold.—Gelsemium judiciously employed may avert pneumonia, pleuro-pneumonia, or other serious disease, begin- ning in the form of a bad cold. It arrests profuse nasal secre- tions, quiets headache, subdues cough and pain, and favors re-establishment of secretions. R Extracti gelsemii fluidi...................................... gtt. x. (A reliable assayed preparation must be used.) Aqua destillata............................................. 3* iij. M. S. Teaspoonful every ten or fifteen minutes for an hour; then at less frequent intervals, according to the effect. —John Aulde. To relieve the acute stage : R Chloral...................................................... gr. x. Castor oil.................................................... § ss. M. S. To be applied to the nasal mucous membrane. Or, introduce into the nasal cavities suppositories containing alumnol, oil of valerian, and menthol.—Thomalla. 198 THE PRACTITIONER'S MANUAL. As a snuff: R Coca ine..................................................... gr. v. Menthol.................................................... gr. iv. Salol........................................................ 3 iss Boric acid................................................... 3 iij. M. S. A small pinch to be drawn into the nose every hour. —Lermoyez. Or a less irritating snuff: R Cocaina hydrochloratis...................................... gr. v. Meutholi.................................................... gr. ij. Bismuthi salicylatis, Sacchari lactis...........................................aa 3 i. M. S. Draw well up into nostrils several times daily. ( Or— R Cocaina hydrochl^rntis.................................... gr. iiss. Meutholi................................................. gr. i v. Acidi borici................................................ 3 ss. Pulveris caffea............................................ gr. viij. M. S. A small pinch in each nostril every two or three hours. —Coupard Or— R Camphor, Tannin...................................................aa 20 gm. Lactose..................................................... 4 To insufflate. —Sanger. Or— R Subnitrate of bismuth................................... 3 i. Powdered camphor........................................ gr. x. Powdered boric acid...................................... gr. xxx. Hydrochlorate of morphine............................... gr. i. Hydrochlorate of cocaine.................................. gr. i. Powdered benzoin......................................... gr. xv. M. Or— R Powdered tab"............................................. 3 j, Antipyrin................................................. gr. xv. Boric acid................................................ 3 ss. Salicylic acid............................................. gr. iv. M. S. Snuff freely. —Capitan. Or— R Acetate of uranium....................................... gr. f-iss. Finely powdered roasted coffee........................... 3 iiss. M. S. A pinch to be snuffed up the nostril two or three times a day. coryza. 199 A few drachms of dry salicylic acid are placed in an ordinary paper pill box, in the cover of which small pinholes are made. The box is shaken, and the nostrils are applied to the openings. This may be repeated time and again until sneezing is in- duced, or as indicated by the amount of hyperemia of the nasal mucous membrane.—A. J. Wegg. R Pulveris cubeba............................................... 3 i. Pulveris sacchari albi......................................... 3 ij. M. S. Use by means of insufflation. — Wyeth. R Morphina sulphatis.......................................... gr. i. Bismuthi subnitratis......................................... 3 iij. Pulveris acacia............................................. 3 b M. S. Use by insufflation. —Ferrier. R Pulveris belladonna folia................................. gr. xx. Pulveris morphina sulphatis............................... gr. ij. Pulveris acacia.........................................ad 3 ss. M. S. Blow into the anterior and posterior nares. Or— R Pulveris camphora........................................... 3 i j. Acidi tannici................................................. 3 ss. Pulveris sacchari albi.......................................ad 3 ss. M. S. Insufflate thoroughly twice daily. —Lefferts. R Betol.................................................... 2.5 gm. Menthol................................................. 0.25 cgm. Cocaine.................................................. 0.5 cgm. Powdered burnt coffee.................................... 1.5 gm. M. S. Use freely in each nostril. —Grellety. Cold in the head in infants : R Argenti nitratis................................................ 2 Aqua destillata................................................ 100 M. S. Apply with a soft brush to the throat, care being taken that the fluid does not drop into the larynx. —Bermann. In children : R Pulveris acidi borici........................................... 3 ss. Glycerini..................................................... 3 i. M. S. Two drops in each nostril t.i.d. —Powell. 200 the practitioner's manual In children to keep the crusts moist: R Iodoformi................................................. 3 ss Olei eucalypti............................................. § ss.-I. Petrolati.......................... ................q.s ad § ij.-iij. M. S. Use as an antiseptic ointment. —GOODHART AND STARR. Chronic nasal catarrh with congested mucous membrane : R Extracti hamamelidis fluidi (destill.), Aqua destill................................................aa, § ss. M. S. Use in atomizer after cleansing the nasal cavities. „ Or— R Morphina hydrochloratis.................................... gr. ij. Bismuthi subnitratis........................................ 3 ij. Pulveris acacia............................................. 3 iss. M. S. Use as snuff when the swelling of the mucous membrane begins to subside' -J. C. Wilson." For the rhagades, touch with a one-per-cent nitrate-of- silver solution. R Sodii chloratis................................................ 0.5 Acidi borici.................................................. 1 Aqua destill................................................. 100 M. S. Use lukew^arm and allow to flow into the nostrils twice daily. Then boroglyceride-lanolin, put up in a tube to keep it pure. Nasal and fancied catarrh : R Acidi carbolici (liq.)....................................... tti, xxx. Sodii biboratis, Sodii bicarbonatis.......................................aa 3 i. Glycerini.................................................. 3 iiiss. Aqua...............................................q.s. ad 1 iv. M. S. To be used as a spray. ~ ■^-L'OBELL. Or. Dobell's solution: R Sodii boratis.................................................. 3 i. Glyceriti acidi carbolici....................................... 3 ij. Sodii bicarbonatis............................................. 3 i. Aqua.......................................................ad O i. M. S. Use as a spray. In catarrhal affections of the respiratory tract, formalin, one or two drops in a Jeffrey's apparatus for inhaling the vapor. CORYZA. 201 In nasal catarrh: R Acidi carbolici..... Sodii boratis....... Sodii bicarbonatis.. Glycerini.......... Aqua rosa........ Aqua............. M. S. Use as a spray. In the atrophic nasal catarrhs and glandular affections in children, as an alterative: R Syrupi acidi hydriodici....................................... | iij. Vini xerici................................................... | i. M. S. One teaspoonful twice daily. —Clarence J. Blake. For "a cold": R Ammonii carbonatis.......................................... 3 ij. Syrupi tolutani, Aqua rosa.................................................aa § iss. Tinctura opii camphorata.................................... 3 ss. M. S. One teaspoonful in water every two hours. —Clarence J. Blake. To relieve discomfort of a cold, pour half a pint of boiling water over a drachm of powdered camphor and inhale the va- pors for ten or twenty minutes. Extractum hydrastis fluidum, gtt. xx.-xxx., in a little sweet- ened water, is found superior to most other anticatarrhal reme- dies.—Saenger. For paroxysmal cough, a teaspoonful of moderately hot water every time the paroxysm comes en.—C. E. Page. Reflex Cough.—Accretion of cerumen in the ear is an occa- sional cause of cough, which will abate when the offending material is cleaned out.—T. J. Mays. Nervous cough, with intact abdominal and thoracic organs and freedom from pertussis, hysteria, and beginning phthisis; which is monotonous, involuntary, and always the same in each patient, is not improved by medication, but disappears after a sea voyage or trip to the mountains.—Koch. ...........3i. ........... 3i ........... 3i ........... Si ........... § i ........ad Oi —Lefferts 202 THE PRACTITIONER'S MANUAL. For irritative coughs: R Phenacetin................................................... 3 i. Extracti glycyrrhiza.......................................... 3i. Sacchari albi................................................. 3 ij. M. ft. chts. No. xx. S. One to be taken at one, two, or three hours' intervals. Or, for same of more obstinate character: R Phenacetin.................................................. 3iiss. Codeina sulphatis........................................... gr. ij. Sacchari albi................................................ 3 ij. M. et div. in chts. No. xx. S. As above. —James Crook. Or, in that left after a cold: ^ Morphina1 acetatis.......................................... gr. i. Acidi hydrocyanici dil..................................... TTI xvi. Syrupi pruni virginiana, Aqua.....................................................aa § i. M. S. Teaspoonful three times daily. Or— R Spiritus atheris compositi, Balsami peruviani............................................aa 3 i. M. S. Place a teaspoonful in a cup of boiling water and inhale the fumes. Or— R Morphina sulphatis......................................... gr. ij. Aqua....................................................... 1 iv. M. S. Use as a spray to be inhaled. Coxalgia. The early discovery of hip disease is as important as it is difficult, and to make out the etiological form which the process is taking requires attention to minute details. Diagnosis.—In the absence of history of injury, when there is pain, lameness, especially in the morning, and muscular con- tracture, and when the pain is intensified by increased inter- articular pressure, the strongest suspicions should be awakened. When there is fulness behind the trochanter and in the groin, synovial inflammation is probable. When the pain is persistent without effusion, bone implication is to be feared. CRETINISM. 203 Alexandroff gives, as a diagnostic point, a hypertrophy of the subcutaneous cellulo-adipose tissue, which he believes is one of the first indications of the process. It may exist when all other symptoms are wanting. On the affected side a fold of skin lifted up is found to be from one to four millimetres thicker than on the well side, and when atrophy of the member coincides with this hypertrophy it points to a tuberculous osteo- arthritis. For differentiation by the position of the limb, etc., works on surgery or orthopaedics may be referred to. Prognosis depends upon early recognition. Though the joint may recover, visceral tuberculosis frequently proves fatal before mature age. Treatment.—Absolute rest for the affected part, secured by recumbency and traction, or plaster of Paris, or fixation appara- tus. General treatment as indicated for tuberculosis elsewhere. Cretinism. Cretinoid idiocy develops soon after birth or before the age of fifteen. Symptoms differ, according to the age at which they begin to appear. By sporadic cretinism we understand a peculiar condition, similar in many of its clinical features to endemic cretinism, supervening either in utero or some time after birth. In congenital cretins (rare) the thyroid is practically lacking; the skin lies in thick folds, is markedly cedematous; the neck is thick; the arms and legs are short; the belly protrudes; the thickened tongue often lies between the teeth; and the body temperature is subnormal. In the endemic form synthesis of the sutures of the cranial bones takes place early, while in sporadic cretinism we find a tendency to lack of synthesis, the fontanelles and sutures remain open a long time, and dentition is delayed.—H. Koplik. In the acquired form dwarfing and other symptoms similar 204 the practitioner's manual. to those of myxoedema begin to show themselves, usually be- tween the age of two and five years. In sporadic and endemic cretinism it may be even years before the evidences of the con- dition are recognizable. Differentiation.—Rachitis presents many of the same ap- pearances, both in the instances of infants which perish in utero and those which pass into childhood, but the mental de- velopment is slower, the thyroid is absent, and myxcedematous swelling points to cretinism. The changes in the bones of the legs under the weight of the body and the accompanying symptoms resemble rickets. In the dwarf with idiocy there are no signs of myxoedema, the body temperature is normal, the expression of the face is neither cretinoid nor prognathous.—H. Koplik. The Mongolian idiot resembles the cretin quite closely. There is the stunted growth, the open mouth, thick lips and large tongue, often protruding, the hoarse guttural voice, men- tal apathy and sluggishness, sometimes subnormal temperature, dry skin and coarse hair, flabby musculature, etc. ; but there is no myxoedema, and the hands, though flat, are not saucer-like, the little finger of each hand is bent slightly at an angle inter- nally, the skin has not the greenish hue, and the prognathous expression is not marked.—H. Koplik. Hydraemic anaemia resembles myxoedema only in the puffi- ness of the skin of the face; the rest of the body shows no cre- tinoid manifestations, and the mental development is normal. Prognosis.—Life may extend to thirty or forty years, but after the twentieth year there is little or no growth or change. Ewald knew of no instance of life prolonged beyond the thirtieth year. Osier,49 in his collected cases, has seven beyond this age. Treatment.—Chiefly, as in myxoedema, by thyroid extract The dose should be as large as the patient will stand (gr. iss., twice daily), and increased when relapses threaten.—West. CROUP. 205 In children the growth under thyroid is much greater and more regular than in the adult, and lateral curvature, so often present, is apt to be increased under the stimulus to growth caused by thyroid feeding. Cretins whose bones show softening should be kept lying down.—John Thomson. Thyroidin has resulted in wholly reducing the swelling of the skin and restoration of menstrual function. The psychical features were not much improved.—Kraeplin. General improvement, including growth of several inches, diminution of deformities, increased intelligence, etc., may fol- low thyroid treatment.—Rushton Parker. Caution.—Thyroid extract may produce softening of bony tissue and increase bowing of legs; for example, as in rickets. Small doses are advised.—Kinnicutt." Croup. Spasmodic, catarrhal, or false croup, in contradistinction to membranous or pseudo-membranous laryngitis, or to true diph- theria, is characterized by a dry metallic cough, with crowing inspiration and husky voice, in children between one and five years old. Diagnosis.—The attack usually comes on about midnight, with dyspnoea and a peculiar barking cough, due to a combina- tion of spasmodic action and retained secretion within the glot- tis. The day following the attack the child is as well as usual, but for one or two successive nights a recurrence may be safely predicted. Differentiation.—Diphtheria is naturally the disease most often suggested by the symptoms and the one most dreaded by the parents. Since in children with acute laryngitis there may be some prostration accompanied by febrile movement and head- ache, and since in its severe form considerable obstruction may exist, the differential points must be carefully weighed. In acute catarrhal laryngitis of pseudo-membranous form, 201) the practitioner's manual. having a decided crowing cough at night and hoarseness lasting throughout the day for several days in succession, the throat may present upon examination a pseudo-membrane in which the Klebs-Loeffler bacilli are not found, but which occasions marked laryngeal obstruction. The latter is, however, much more promptly relieved by appropriate treatment than is the case in diphtheria. A greatly enlarged thymus surrounded by swollen bronchial glands has produced symptoms simulating croup.— Biedert. Prognosis in false croup is usually good, but there is always a possibility of extension culminating in bronchitis. The possi- ble occurrence cf oedema of the glottis is also not to be over- looked in the prognostication. Treatment.—To cut short the attack, an emetic of ipecac; hot bath at temperature of !»s3 to 102° F.; inhalation of steam from a croup kettle. Tablespoonful of mustard in a quart of hot water, to make wet application about the throat.—Stimpson. To overcome spasm, inhalation of chloroform. Caidion.—Employ sparingly and with careful oversight. Apply a cold towel to the neck and give: R Vini ipecacuanha, Tinctura opii camphorata, Spiritus atheris nitrosi......................................aa. 3 ij. M. S. Ten drops every hour. —Caille. R Pulveris aluminis........................................... 3 iiss. Mellis albi................................................... 3 x. M. S. One-half teaspoonful every hour, and powdered alum blown into the throat every four hours. —Trousseau. In infants : R Pulveris ipecacuanha..................................... gr. ss.-i. Sacchari albi q.s. M. S. To be repeated every twenty minutes until vomiting takes place. After age of one year, double the dose. —T. H. Tanner. R Hydrargyri subsulphatis flavi............................ gr. iij.-v. S. If emesis does not occur within fifteen minutes, repeat the dose. CROUP. 207 At next visit, if the child has quick pulse, hot skin, hurried breathing, and an occasional ringing cough: R Tinctura veratri viridis.............................. gtt. xvi.-xxx. Spiritus atheris nitrosi.............................. 3 ij. Syrupi............................................. I1- Aqua............................................... S* v' ■ M. S. Teaspoonful every second hour. —Fordyce Barker. R Potassii chloratis.............................................. 3 i. Ammonii chloridi............................................ 3ij. Syrupi....................................................... 3 i- Aqua......................................................... I ij- M. S. 3 i. every twenty minutes to half an hour, continued night and day until cough becomes looser. —J. Lewis Smith. R Tinctura aconiti.......................................... gtt. vi. Syrupi ipecacuanha, Spiritus atheris nitrosi..................................aa 3 ij- * Aqua cari (vel anisi)...................................... § ij. M. S. Teaspoonful for a child of two years. —J. J. HlGGINS. R Tinctura tolutani............................................. 3 iss. Syrupi scilla................................................. 3 ij. Tinctura opii camphorata.................................... 3 iij. Glycerin i.................................................... § iss. Aqua................................................q.s. ad § vi. M. S. A half-teaspoonful to be given every three hours during the day, and every four hours d ring the night. For a child of eight months: B, Aqua destillata............................................... § i. Potassii chloratis, Potassii iodidi..............................................aa 3 i. Mucilag. acacia,.............................................. § ij. Extracti ipecacuanha fluidi, Olei copaiba................................................aa, 3 i. M. S. Shake. A teaspoonful every ten minutes. After free vomiting ensues continue the same dose every half- hour or hour till the disease is cured. The dose may be regu- lated according to the age for other children.—Johnson. In mild or sujierficial form : R Syrupi ipecacuanha.......................................... 3 ix. Syrupi scilbe composita..................................... 3 iss. Tinctura opii camphorata................................... 3 ij. M. S. Half-teaspoonful every three or four boms. —N. S. Davis. 208 the practitioner's manual. In pseudo-membranous croup, treat as in diphtheria, omit- ting antitoxin. R Potassii bichromatis.......................................... gr. i. Aqua destillata............................................ § ij. Gives good results in three-drop doses.—Millican. R Vini antimonii................................................ 3 ij. Syrupi papaveris.............................................. 3 iv. Syrupi tolutani............................................... 3 ij- Aqua........................................................ § i- M. S. Give every hour in as large dose as possible without producing vomiting. —Delafield. Inhalations: R Liquoris calcis................................................ 1 i. For one inhalation. Repeat every two hours. Or— R Acidi tannici........................................... gr. ij.-xx. Aqua................................................... % i. For inhalation. Or— R Potassii bromidi.......................................... gr. v.-x. Aqua.................................................... 1 i. M. —Herman Beigel. R Extracti hyoscyami fluidi................................. tti iij.-x. Aqua destillata.......................................... § i. M. —Da Costa. Oxygen inhalations.—Potsdamer. Topically or by atomizer : R Argenti nitratis............................................... 3 ss. Aqua destillata.............................................. 3 ij. M. Dip a curved rod of whalebone, with a small sponge made fast to its lower end, into this solution, press down the tongue of the child, and endeavor to reach the entrance of the glottis with the sponge. The muscular contraction which follows com- presses the sponge, and a small portion of the solution reaches the larynx.—Felix von Niemeyer. CYSTITIS. 209 R Liquoris ferri subsulphatis.................................... Z \. Glycerini..................................................... 3 ss. M R Acidi carbolici fluidi......................................... 3 b Aqua........................................................ I vi. M. R Bromi..................................................... 3 ij. Potassii bromidi.......................................... gr. xlv. Aqua..................................................... fb M. S. Twenty-four to x'orty drops should be added to an ounce of water. —J. Lewis Smith. To dissolve false membrane : R Acidi lactici.................................. ............... 1 ss. Aqua destillata.............................................. § x. M. S. In atomizer. —Morell Mackenzie. During the intervals of attack, spray the throat with a two- per-cent cocaine solution.—A. O. Stimpson. Cystitis. The chief point in the diagnosis of catarrhal inflammation of the bladder, especially in the chronic form, is to determine the source of the pus found. Diagnosis.—Speaking in a general way, pus and albumin originating in the bladder are found associated with an alkaline urine and with considerable mucus. A history of an acute at- tack following paralysis, stricture, enlarged prostate, over-dis- tention, etc.; or infection, as from gonorrhoea or instrumenta- tion; or the presence of stone, etc., will materially aid. Differentiation.—Interstitial nephritis is simulated in some mild attacks; the absence of hyaline casts excludes it. From pyelitis, which may.occasion bladder spasm, by wash- ing the bladder until the stream returns clear. Leave the catheter in situ, with the extremity just within the bladder neck and the outer end plugged. In ten or fifteen minutes draw off the accumulated urine, if this be turbid from pus wash 14 210 THE practitioners manual. the bladder again. If washing returns clear, or nearly so, the probable source is above the bladder. Cystitis from stone in the bladder is suspected when pain is referred to the glans penis, when jolting motions and exercise increase the bladder symptoms and the quantity of blood passed, and when the stream is suddenly interrupted in the passing of urine. Treatment.—The first steps must be to seek out the under- lying cause in some portion of the genito-urinary tract and treat it. In catarrhal cystitis, acute and subacute, especially in women, bismuth and boric acid are very useful, applied in the following manner: to a pint of warm boiled water add a teaspoonful of a powder made up of seventy-five per cent of bismuth and twenty-five per cent of boric acid. Use a soft catheter, to which a small glass funnel has been attached. Pour into the empty bladder half of the mixture, which must be kept well stirred, and let it run out; the other half should now be poured in and permitted to remain in a few minutes, when it maybe voided per vias naturales.—S. S. Jones. In cystitis complicated by rheumatism : R Sodii salicylatis..................... ...................... 4-6 gm. Syrupi limonis, Aqua mentha piperita.....................,...........aa, 60 " M. S. Teaspoonful every hour. In acute blennorrhagic cystitis: R Sodii biboratis............................................. 30 gm. Sodii bicarbonatis.......................................... 10 " S. Two teaspoonfuls during the day in a quart of lemonade. The urine may become slightly yellowish-green.—Balzer. In tuberculous cystitis creosote takes the first rank. The diet should be abundant and extremely nourishing. Local treatment must be cautiously applied, as the bladder is exqui- sitely sensitive. Corrosive sublimate is beneficial in very weak solutions.—Guion. CYSTITIS. 211 R Olei santali................................................gtt. vi. Make capsule No. i. Give up to sixteen in twenty-four hours. — WlCKHAM. In painful tuberculous cystitis : R Guaiacol....................................................... 5 Iodoform...................................................... 1 Sterilized olive oil............................................. 100 M. S. Inject one or two grams into the bladder once or twice daily. —Colin. For senile cystitis : R Extracti hydrangea.......................................... 3 ij. Tinctura gentiana composita................................ 3 iv. Tinctura staphisagria, Tinctura cannabis indica..................................aa 3 i. Syrupi aurantii........................................q.s. ad 3 iv. M. S. A teaspoonful three times daily. —Hopkins. Irritability of the bladder after delivery : R Salol, Tincture of hyoscyamus.....................................aa 3 ij. Infusion of buchu......................................q.s. ad § vi. M. S. Teaspoonful three times a day. —FOTHERGILL. R Liquoris potassa............................................. 3 i. Mucilag. acacia............................................... § ss. Tinctura hyoscyami....................................q. s. ad § ij. M. S. Dose a teaspoonful. In acute catarrhal form with malodor : R Ainyl nitritis............................................... gtt. v. Aqua destill.............................................. 3* iv. M S. Add | ss. of this solution to the proper quantity of water for a vesical injection. In chronic cystitis : R Acidi borici................................................... 3 ss. Glycerini..................................................... 3* i. Aqua destillata............................................... 3" x. M. S. For an injection into the bladder. At moment of employment, mix it with an equal part of warm water. —Ultzmann. R Acidi oxalici............................................. gr. xvi. Syrupi aurantii............................................ § i. Aqua ..............................................q.s. ad 1 iv. M. S. Teaspoonful every four hours. —A. W. Marsh. 212 THE PRACTITIONER'S MANUAL. To prevent decomposition of urine, lycetol is superior to salol.—Hamonic. Cystitis in Females.—To neutralize alkaline urine, five grains of benzoic acid in capsule every three hours. Large draughts of water after each dose. In ammoniacal decomposition, five grains of salol, in cap- sule, every two hours until the urine is acid.—Bloom. For washing out bladder : R Argenti nitratis........................................... gr. xv. Aqua destill................................................ O ij. In ammoniacal cystitis, irrigate with— R Acidi citrici.................................................gr. x. Aqua destill................................................ O i. followed by a ten to twenty per cent solution of bynin (liquid extract of malt).—Sir William Roberts. For irrigation, potassii permanganatis (1-1,200 to 1-4UU solution), or acetanilid (1-200). In gonorrhojal vesical irritability in females, after cleans- ing the urethra with bichloride solution apply pure ichthyol and give: R Ichthyoli..................................................... ttHj. Olei santali...........„...................................... tti,v. M. S. In capsule every three hours. —Bloom. Dengue. Breakbone fever of tropical and subtropical countries oc- curs also in the southern portion of this country, but rarely ex- tends so far north as New York. It is an epidemic disease of mild form and short fever period, but is attended with very severe pains closely simulating those of muscular and articular rheumatism. There is, also, more or less constantly observed an eruption of a scarlatiniform variety of erythema. Diagnosis.—.The incubation varies from two to five days, followed by sudden onset. There are rigors, with headache and general deep-seated pains, as though located in the very DENGUE. 213 bones. The fever may reach as high a point as 106° F. Anorexia is marked; vomiting not uncommon; the tongue has a peculiarly yellowish coating. The pulse keeps pace with the attending rise of temperature. The eves are red, and the face is usually turgid. There may be two paroxysms of fever, though usually the fever range takes a sudden upward course, with a lull after it attains its maximum, on about the second day. The eruption occurring about the fifth day has no con- stant features, at times resembling urticaria, at other times being more finely papular, and it occurs in groups, first upon the upper portion of the body. It is accompanied by most in- tense itching and is followed by desquamation. Glandular enlargements are observed after the second access of fever, and implicate the lymphatic system of the neck, arm- pits, and groins. The distinguishing feature is the tendency to relapse after apparently full recovery. Differentiation.—This disease is especially to be distin- guished from yellow fever by its lasting some five days longer, by the yellowness of the tongue, by the eruption, absence of jaundice, albumin, glandular enlargements, mild course, and the fact that the pulse does not become slower, while the tem- perature rises, as is the case in yellow fever. In distinguishing dengue from influenza, the climatic condi- tions, the absence of respiratory involvement, and the more fre- quent presence of eruption aid us. From malaria it is to be distinguished bjr an examination of the blood. From the exanthemata by the eruption (morbilli- form, rubellic, scarlatiniform), not always occurring early, not having definite distribution, being followed by desquamation and itchiness, by the absence of catarrhal symptoms, etc. Prognosis is favorable. Treatment.—It is well to administer calomel at the onset, but, it being a self-limited benign fever, symptomatic treatment is usually sufficient. 214 the practitioner's manual. For an adult at the onset: R Hydrargyri chloridi mitis................................... gr. vi. Phenacetin................................................ 3 ss Quinina bisulphatis....................................... gr. xv. M. et div. in capsulas No. ix. S. Three every three hours. —Hamilton West. To cut short an attack : R Morphina sulphatis......................................... 81'- i Atropina sulphatis......................................... J-U- tjtj Hypodermatically. Supplemented by: R Phenacetin.................................................. g1'- x- Antipyrin................................................... gr. v- M. S. Every two hours. In prostration give alcoholics.—Tyson. To relieve violent pai)is: R Tinctura colchici eminis..................................... 3 i. Spiritus atheris nitrosi........................................ 3 iv. Potassii nitratis...............................................3ij- Aqua.......................................................ad = iv. M. S. Tablespoonful every two hours until profuse diaphoresis. —Carpenter. Diabetes Insipidus. Polyuria is a symptom in a great variety of conditions, including hysteria, cerebral syphilis, fibroid nephritis, as well as in the affection under consideration. Here it may develop gradually or suddenly. The urine has a specific gravity little over 1000, is passed in large quantities, is attended with exces- sive thirst, and in mild cases there may be no further symptoms. In the more severe form there may be headache or neuralgia, dryness of the skin, vertigo, weakness, hebetude, and loss of flesh. The condition may be associated with, and perhaps de- pend upon, polydipsia. Differentiation.—In hysteria the polyuria is of short dura- tion, and other manifestations of hysteria will show themselves. The increased quantity of urine due to chronic interstitial nephritis will present other manifestations of this disease DIABETES INSIPIDUS. 215 That due to syphilis is distinguished by the history and the occurrence of other cerebral symptoms. In diabetes mellitus sugar is found on testing. Prognosis.—The condition may persist throughout life with- out seriously affecting the general condition. Polyuria depending upon syphilis is about the only form strictly amenable to treatment. It may be a forerunner of general paralysis of the insane or of serious brain or spinal disease. Treatment.—Electrization of the Medulla Oblongata.—The positive pole was applied to the back of the neck by means of a large electrode; the negative insulated almost to the point was passed along the floor of the nostril until it rested on the cervi- cal spine. Gradual increase from half to five milliamperes, for from one to five minutes.—Robertson. R Pulveris opii................................................ gr. iv. Acidi gallici................................................ 3 ij. M. ft. chart. No. xii. S. One, three or four times daily. -H. C. Wood. Or— B Extracti ergota fluidi............... S. To be given in water three times daily Or— R Acidi gallici................................................gr. xv. Pulveris opii............................................... gr. i. M. S. For one powder. Three such daily. When of specific origin, potassium iodide, alone or combined with mercurials. In nervous and excitable subjects, elixir ammoniae valeria- nates, ^iv. Dessertspoonful every three or four hours. In children, cod-liver oil; ferruginous preparations; gly- cero-phosphate of iron (Robin); diet free from sweets and with a minimum of liquids. ........ 3 ss.-i. —Da Costa. 216 THE PRACTITIONER'S MANUAL. Diabetes Mellitus. Many instances of this affection progress for a considerable period before coming under observation. Many others are de- tected, as it were, accidentally, through life-insurance examina- tions or when careful examination of the urine is made for any cause. There are certain indications, however, which should always lead to investigation in this direction. These include dryness of the skin; the occurrence of furunculosis, carbuncle, eczema not attributable to other cause; pruritus, especially about the genitals; loss of flesh and strength without known cause; the development of excessive thirst and a desire for sweets, and excessive appetite not appeased by ordinary amounts of food, the thirst perhaps being greater just after a meal; and, last, but not least, marked decrease in sexual power. The urine is increased in amount and in specific gravity, which may reach 1(145, and it is shown by tests to contain sugar. When diminution of the sugar occurs there may be an in- crease in the quantity of oxalates. Diagnosis.—The first symptom which may attract the pa- tient's attention, if he be a male, is the fact that white specks are deposited upon the trousers legs and shoes from the spatter- ing in urinating, or the last drops that lodge upon dark clothing may leave upon evaporation a similar minute dot of sugar. The skin soon becomes dry from lack of perspiration, and is affected with itching. In the acute and rapid form the bodily weakness increases almost from day to day, which fact the patient cannot reconcile with his ravenous appetite and the amount of food taken. In the more gradual onset, especially of advanced life, glycosuria may exist for a long time without occasioning prominent symptoms. In the prodromal stage there may be obesity, gastro-intestinal disturbances, diminished sex- ual inclinations, nervousness, perhaps hypochondriasis, shooting pains, and skin changes.—Stern. diabetes mellitus. 217 Failure of sight is due to an affection of the retina in which circular spots of white have a grouped arrangement over the fundus. The appearances are said to be typical of the affec- tion, especially when some of the spots have pigmented borders. If Fehling's solution is used to detect the sugar, it should be freshly prepared or the ingredients kept in two separate bottles, to obviate error. R. T. Williamson says that diabetic blood removes the blue color from a solution of methyl blue much more completely than does non-diabetic blood. The following is the exact method employed: In a narrow test tube is placed forty cubic millimetres of water (the capil- lary tube of a Gowers hsemoglobinometer, which is marked for twenty centimetres, may be used for measuring the fluid) ; twenty cubic millimetres of blood is added, and then one cubic centimetre of a 1 in (IjxiO watery solution of methyl blue and afterward forty cubic millimetres of liquor potassae. The tube is then placed in a capsule or vessel containing water, which is kept boiling. At the end of four minutes the blue color disap- pears and the fluid becomes yellow if diabetic blood has been used, but in the case of non-diabetic blood the blue color re- mains. The Phenyl Hydraziu Test. A small quantity of the crystal- line scales is warmed with twice its weight of sodium acetate; an equal volume of suspected urine is added, and, on boiling and cooling, yellow crystals are deposited if sugar is present. To detect diabetes in its earliest stage, or even the hereditary tendency to it, give one hundred grains of grape sugar. In the incipient diabetic this produces glycosuria, but has no effect on a healthy subject.—Von ?\oorden. Differentiation.—Symptoms referable to the stomach may cause this organ to be suspected for a long time as the seat of trouble unless the urine is carefully examined. Traumatic glycosuria, due to a variety of causes, including the too free 218 THE PRACTITIONER'S .MANUAL. use of sweet wines, may even be attended with crops of boils and still not justify the diagnosis of diabetes. Sugar is also present in some instances of disease of the pancreas. Essential or symptomatic polyuria may bring diabetes into question, but a test shows sugar to be absent. Prognosis varies with the patient's age, and the period at which treatment is begun and the etiological form present. When the disease has established itself firmly, undetected or untreated, in the young adult, the prognosis is most unfavor- able. When, on the other hand, it attacks the gouty, rheu- matic, and especially the obese subject beyond the middle years of life, recovery may take place, at least up to a point at which the symptoms no longer occasion distress or alarm, provided necessary treatment and diet be observed. In diabetes depend- ing upon nerve lesions the prognosis is not so favorable. If syphilis can be established as the causative factor, the outlook under specific medication is good. Treatment.—Together with rigid diet, Clemen's solution of arsenic is my sheet anchor.—Potter. Diet: A stereotyped diet should not be prescribed; orthodox diet is a pretense. The starch of cereals is more productive of glycosuria than that of potatoes. Begin with strict diet, and add carbohydrates as experimental observation warrants. If sugar disappears, we may allow experimentally a potato and milk. Light wine may be used cautiously.—Robert Saundby. Diet must be changed according to age; the very young will not stand a strict hydrocarbon diet.—A. Jacobi. Considerable liberty in diet is safe in old people.—Lindsay. If the urea decreases considerably, eggs and meat must be supplied. —Robin. To prevent sugar from getting into the urine, keep it from the intestines by stopping carbohydrates for a time.—Pavy. diabetes mellitus. 219 Allowed. (a) Dishes. Meats of every kind, beef, veal, mutton, game, fowl, brain, pancreas, calves' feet, calves' head (soup), smoked meat, tongue, ham, sausage, tripe, kidneys, all fish, oysters, clams, snails, caviar, sardines, anchovies, crabs, lobsters, calves'- feet jelly, butter, cheese, fat, bacon, eggs in any form. Soups. Bouillon, beef tea, egg soup, turtle and mock-turtle soup. Vegetables. All green vegetables, e.g., spinach, lettuce, endive, cabbage, sauerkraut, asparagus stalks, cress, arti- choke, radishes, string beans; mushrooms, nuts, almonds. In moderate quantity, cauliflower, asparagus tops, straw- berries, currants, sour apples, American compote. (b) Liquids. Water, soda water, simple acidulous water (Gieshubler, Apollinaris); tea, coffee (without sugar or milk); Bordeaux wines; light Austrian, Hungarian, and Moselle wines. In moderate quantity, cream, brandy, whiskey, rum, lem- onade and milk of almonds (not sweetened), Pilsener bitter beer. Forbidden. (a) Dishes. Liver, flour of any kind (bread, rolls, zwieback, in small quantity according to the physician's instructions), sugar, molasses, honey, potatoes, rice, sago, hominy, beans, beets, peas, tomatoes, carrots, celery, parsnips, chestnuts, and all sweet fruits, whether uncooked or as compote. (b) Liquids. Milk, champagne, beer, cider, sweet-fruit wines, liqueurs, fruit essences, ice creams, cocoa, chocolate.— Seegen. American store cheese is a valuable food stuff in the pre- glycosuric stage.—Stern. Encourage temperate eating and cut down the diet list.— Murdock. 220 THE PRACTITIONER'S MANUAL. The diet should be strictly antidiabetic, with just so much starchy food as the patient will be found to tolerate in any given case, by experiment, the average being about an ounce and one- half of American wheat flour or its equivalent in the twenty- four hours.—R. C. M. Page. Carbohydrates should be administered to the diabetic to prevent the formation of certain toxic bodies and the severe and often fatal nervous and cerebral symptoms which they induce. Sugar must, even more than in health, be allowed, in order to prevent loss of weight and muscular weakness, which may eventuate in one of the natural endings of diabetes, death by asthenia. —E. J. M. Munson. One of the most important points in treatment is to send the patient to an entirely different climate. The use of drugs, when employed as specifics, cannot be too strongly condemned. Unless aimed purely at supporting some organ or function they are more likely to prove injurious than otherwise. Opium holds out no hope of cure. It not only adds to the suffering and dis- comfort, but hastens the progress. Drugs of the antipyrin and salicyl series often cause albuminuria.—C. W. Purdy. Codeine, gr. ss., twice or thrice daily.—Ord. Liquor arsenici hydrochlorici (P. B.), gtt. x., to be given three times daily, with hydrochloric acid and strychnine in the forenoon, and without these additions in the afternoon.—Mur- ray." So long as opium effects a reduction in the amount of sugar, we may safely increase the dose. Glycosurics are singularly tolerant. A combination of liquor opii and acetate of morphine in solution is the best preparation.—Ralfe. Opium, morphine, and codeine all possess the power of check- ing the elimination of sugar in the urine. Of the three, codeine is the best. Begin with one-half a grain, and increase gradu- ally to ten grains twice daily.—F. W. Pavy. diabetes mellitus. 221 In the adult, to check excessive urination and to improve the condition, uranium nitrate, gr. i., gradually increased to gr. xx. t.i.d.—Samuel West. In children, to take the place of sugar: R Saccharini................................................ gr. xlv. Sodii bicarbonatis......................................... 3 ss. Mannita.................................................. § ij. Mucilag. acacia........................................... q.s. M. et ft. tabl. No c. To lessen the quantity of sugar : R Antipyrin................................................... 3 iij. Glycerini................................................... § i. Aqua....................................................... § viij. M. S. Teaspoonful every three hours. —JOSIAS. R Sulphate of strychnine.................................... gr. -^ Arseniate of sodium....................................... gr. ^ Pure codeine............................................... gr. \ Valerianate of quinine.................................... gr. i. Extract of valerian, a sufficient quantity to make one pill. M. S. From one to six of these pills majr be given each day. —Legendre. R Sodii arseniatis ........................................... gr. i. Lithii carbonatis.......................................... 3 i. Codeina..................r............................... gr. iiss. Extracti cinchona (dry).................................. 3 iv. M. Make into thirty cachets. S. One to be taken after breakfast and one after dinner. —Robin. For the dry tongue : R Pilocarpina nitratis.........................................gr. i Spiritus vini diluti.......................................... tti xx. Aqua....................................................... 3 i. M. S. The tongue is to be moistened with five or six drops of this solution four or five times daily. To lessen the thirst : R Infusi cascarilla............................................... O i. S. A wineglassful three or four times daily. —Da Costa. 222 THE PRACTITIONER'S MANUAL. Or— R Ammonii phosphatis, Ammonii carbonatis.....................................aa gr. x. Spiritus ammonia aromatici............................... tti, xxx. Aqua...................................................... 3 i. M. S. Add to this the juice of a fresh lemon and take thrice daily. —Basham. Or— R Tinctura ferri chloridi................................... 3 vi. Acidi nitrohydrochlorici................................ gtt. lxxx. M. S. Twenty drops thrice daily. —Napheys. In thin subjects with faulty assimilation : Ii Acidi arseniosi........................................... gr. iv. Pulveris opii.............................................. gr. viij. Ammonii chloridi......................................... § ss. M. et ft. pil. xxxii. S. One pill thrice daily after meals. —Marcus. In obese persons, and when of hepatic origin : R Aloes Capensis............................................... 3 v. Sodii bicarbonatis............................................ 5 iss. Spiritus lavandula comp..................................... § ss. Aqua destillata..............................................O i. Macera per dies quattuordecim et cola. S. Teaspoonful thrice daily after meals. —Mettauer. R Extracti jambula fluidi..............t........................ 3 i. Liquoris arsenii bromidi...................................... 3 ij. Aqua destillata............................................ad 3 ij. M. S. Half a teaspoonful in water three times a day. — H. G. McCormick. In epileptoid attacks of urcemic nature and in the presence of acetone, antipyrin, gr. x., t.i.d.—Graves. Caution.—In larger dose this drug may irritate the kidneys. The effects of antipyrin are only fleeting.—Mousse. R Lithii carbonatis.......................................... gr. xxx. Sodii arseniatis........................................... gr. i. Extracti gentiana........................................ gr. xv. M. ft. massa et in pil. No. xx. div. S. One pill morning and evening. —VlGIER. DIABETES MELLITUS. 223 Or— R Sodii salicylatis............................................. 3 iij. Liquoris potassii arsenitis................................... 3 b Glycerini.................................................... 1 i- Aqua cinnamomi..........................................ad § iij. M. S. Teaspoonful to a tablespoonful t.i.d. —J. C. Wilson In children with glycosuria, strontium bromide, p. r. n. Also in the obese and gouty. Obese patients who are not gouty do better on sodium phosphate. Levulose may be given as a sweetening agent ad libitum, and to emaciated patients it should be given in doses of one or two drachms after meals or one ounce during the day.—Solis-Cohen. R Antipyrin................................................... 3 iij. Glycerin ................................................... § i. Water...................................................... 1 viij. M S. One or two tablespoonfuls daily. —JOSIAS. A teaspoonful of beer yeast before each meal, continued for a long time.—Boullaud. Brewer''s yeast, in dose of one to three teaspoonfuls, causes diminution in sugar, increase in weight and strength.—Beylot. Clemen''s solution : ^ Potassii carbonatis, Acidi arseniosi.............................................aa 3 i. Aqua destillata.............................................. § x. Boil until clear solution ; when cold add : B Bromi....................................................... 3 ij. Aqua....................................................... § xij. When the color has disappeared it is ready for use. S. One to five drops once or twice daily. Complications.—When complicated with nephritis the least injurious food is milk.—Henry. In gouty and rheumatic subjects, an alkaline course or salol (thirty-grain doses three times daily).—Nicolaier. Caution.—Should not be employed if there is kidney disease or toxic effects develop. 224 the practitioner's manual. In the obstinate constipation of diabetics, glyerin, 3ij.-x., as a rectal injection three or four times a week.—Teschemaciikr. R Glycerini (C. P.)........................................ 3 i- Acidi citrici........................................... gr- *J- ~iv M. S. One-half to one and one-half teaspoonfuls, gradually increased and well diluted, an hour after each meal. Caution. — Watch for intestinal disturbance from the gly- cerin.—Davis. Bromide of arsenic and gold, air baths, warm baths, steam baths, and massage.—Heinrich Stern. Chloride of gold and sodium.—J. A. Robinson. Jambul is the best remedy in diabetes, gr. v.-xxx.—Kazan. R Jambul......................................................... 50 Buckthorn..................................................... ~u Celery........................................................ * Aromatics...................................................... *5 M. Teaspoonful t. i.d. —Wilcox.'8 In diabetic coma, prophylaxis includes the avoidance of constipation, muscular fatigue, nervous shock, exposure to cold, hardships, etc.—Futcher. In the prodromal approach of coma vary the diet. If carbo- hydrates have been taken in excess, reduce them and replace with proteids and fats, and vice versa. Give large quantities of alcohol in divided doses. Relieve constipation, but avoid drastric purgatives.— Von NOORDEN. Large quantities of alkalies have been recommended. Sodium bicarbonate, 3 iss.— 3 ij., as a daily dose, added to Vichy water. When the prodromal dyspnoea first appears: R Sodii chloridi.............................................. 7 gm. Sodii bicarbonatis......................................... 10 gm, Aqua destill. (steriliz.).................................... 1 litre. M. S. Use two litres for intravenous transfusion. —Lepine. diarrhcea. 225 Intravenous injection of three to five per cent solution of carbonate of sodium.—Stadelmann. The amount of alkaline fluid necessary cannot well be ad- ministered by mouth or subcutaneously. Large doses of castor Oil.—SCHMITZ. Diabetic albuminuria, if phosphatic : R Sodii arseniatis.......................................... gr. ss. Potassii iodidi........................ .................. gr. xlviij. Aqua destillata......................................... vi. M. S. Tablespoonful in a small glass of milk half an hour before eating, morning and night. As a tonic : R Extracti cinchona......................................... gr. iss. Quinina sulphatis.......................................... gr, iss. Extracti nucis vomica...................................... gr. * M. ft. pil. No. i. S. One pill at breakfast and at dinner. After a fortnight: R Calcii glycerophosphatis, Magnesii glycerophosphatis...............................aa gr. iss. Extracti nucis vomica...................................... gr. £ M. ft. cht. No. i. S. One at breakfast and dinner daily. —Robin. In gastro-intestinal disturbances a return to a mixed diet may be required. Lactate of strontium acts well at times. It may be combined with— R Acidi gallici.............................................. 0.10-0.15 Pulveris aloes Socotrina.................................. 0.02-0.05 Extracti cinchona (dry).................................. 0.15 M. S. For one pill. Four such in twenty-four hours. —Robin. Diarrhcea. It may be argued that diarrhcea is a symptom and not a dis- ease, but we are not yet prepared to banish the name. The functional disorders covered by it are not at all likely to become confused with diarrhcea as a symptom of the ulcerative proc- esses in tuberculosis and typhoid. 15 226 THE PRACTITIONER'S MANUAL. Differentiation between the various forms of diarrhcea is of importance, since from this symptom alone the etiological diagnosis of the underlying cause may often be made. In catarrhal diarrhcea the passages are of faecal nature plus a small amount of watery fluid, the consistence is soft, the color light, and the form may be in a measure retained. The catarrhal inflammation due to the presence of micro-organisms is the most frequent form encountered in children. In acute diarrhoea there are abdominal uneasiness and grip- ing, and the passages may after a time become almost colorless. In diarrhoea occurring in the summer months, due to in- digestible and irritating food and especially in thoe swhose liver functions are abnormal, the stools present an appearance which has given to this form the name of "bilious diarrhcea." The term dyspeptic diarrhoea has been employed in describ- ing passages in which particles of undigested food are found, and the faeces occur as scybalous masses floating in an excess of watery discharge. There is often much mucus present. When the mucous discharges contain specks of bright colored blood, or at times a small quantity of unmixed blood, hemorrhoids are first of all to be excluded and we must make sure that the case is not one of typhoid with ulceration. Minute tinges of bright blood scattered here and there and any excess of mucus point to a much inflamed large intestine as the source of hemorrhage. Infective diarrhcea presents signs of greater nerve prostration than the frequency of passages would seem to explain. It is probable that most infantile diarrhoeas of summer belong to this class. Chronic diarrhoea when alternating with constipation is in- dicative of chronic enteritis. There is usually a sense of weight in the abdomen and considerable mucus is passed, by itself or more or less intimately mixed with faecal matter. The subjec- tive symptoms in the adult include an irritability of temper as- sociated perhaps with hypochondriasis, and, from the long dura- diarrhcea. 227 tion of the disease the patient becomes worn out, emaciated, and unfit for ordinary occupations. It often exists as one of the symptoms of tuberculosis. Chronic diarrhoea in infants is always due to some fault in feeding, even when the child is breast fed. Nervous diarrhoea is mostly encountered in neurasthenic or in hysterical or otherwise nervously affected individuals. It is an admitted clinical fact that sudden fright as well as various strong emotions may cause an immediate attack of diarrhcea. The influence of the nervous system is seen too in the acute attacks which occur in subjects of tabes. Nervous diarrhcea in teething children is to be distinguished from ileo-colitis, in which there is much more mucus, and from cholera infantum, in which there is an abundant serous discharge. The character of the stools in nervous diarrhcea is usually watery, and they are free from blood or mucus. If a diarrhoea assumes an intermittent type, particularly in a malarious country, it is well to include quinine with the drugs employed for its cure. Membranous diarrhcea may be of subacute form with severe griping pains, and a looseness of the bowels may alternate with constipation. When there is much mucus, the large intestine is usually involved. In colitis of mild degree the faecal mass may be coated over with a layer of tenacious mucus. Here the evacuations are frequent and characterized by marked tenesmus and the pres- ence of more or less blood with slimy mucus. Colitis is distinguished from the various diarrhoeas by the varying characters of the latter already enumerated, and by the presence of pain along the course of the large intestine. In ulcerative disease of the rectum there will be local pain, and an examination will often make it possible to exclude this as well as hemorrhoids as the source of bleeding. 22s the practitioner's manual. Treatment.—So far as possible the sources of intestinal irri- tation are to be removed. Food may usually be withheld for a time with benefit and without ill consequences. Intestinal irri- gation per rectum, perhaps with the aid of a high-reaching tube (soft-rubber catheter in the case of infants), often gives excellent results. In considering intestinal antiseptics, do not lose sight of the antiseptic and curative properties of normal secretions, which may be increased by such drugs as calomel even in small dose. In diarrhoea not attended tvitli pain : R Hydrargyri cum creta..................... ................ gr. iij. Pepsini puri, Extr. pancreatini........................................aa 3 ss. Bismuthi subnitratis...................................... 3 vi. M. et div. in char No. xii. S. One every two hours. —L. F. Donohoe. For diarrhoea ivith cramps, in the adult: R Tinct. opii deodorata, Spiritus camphora, Spiritus atheris comp.....................................aa 3 ij. Chloroformi purif........................................... 3 i. Acidi carbolici.............................................. gr x. Spiritus vini rect.........................................ad § iij. M. S. One to two teaspoonfuls in wineglassful of water every two hours. —E. J. LORENZE. For vomiting, in the course of intestinal affections : R Menthol................................................... 0.5 gm. Cognac................................................... 40 " Tinct. of opium........................................... 10 " M. S. Take twenty drops in water several times daily. —Pick. R Olei ricini................................................ tti, xxiv. Spiritus chloroformi....................................... 3 iss Sol. morphina hydrochloratis (l£)......................... 3 i, Pulveris acacia........................................... - iiss Syrupi................................................... = ss. Aqua.................................................ad 3 iv M. S. A small teaspoonful every hour and a half till the bowels are quieted. —David Young. diarrhoea. 229 T, Olei ricini................................................. 3 ij Pulveris acacia............................................ 3 b Tinct. opii................................................. ^l viij. Syrupi..................................................... 3 ij Aqua carui..........................................q.s. ad § ij. M. S. Tablespoonful for a child six years old. —Thomas Hillier. R Olei terebinthina............................................ 3 ij- Liquoris potassa............................................ 3 iv. Mucilag. acacia, Syrupi papaveris, Syrupi aurantii florum...................................aa f i. Aqua camphora.........................................ad § viij. M. S. Tablespoonful every four hours. —R. P. White. R Acidi tannici................................................ 3iv. Tinct. opii.................................................. ^l xl. Glycerini ................................................... 3 ss. Aqua mentha piperita....................................ad § iv M. S. Tablespoonful in half an ounce of water every four hours. —Charles Murchison. R Acidi lactici............................................. 3 iiss. -iij. Syrupi.................................................. 1 vi. Aqua................................................... % vij. M. S. Half a tumblerful to be taken between each meal. —Georges Hay em. In acute or obstinate chronic forms : R Acidi sulphurici aromatici................................. 3 iss. Tinct. opii deodorata....................................... 3 b Strychnina sulphatis........................................ gr. ss. Spiritus lavandula comp.................................... § ss. Aqua camphora.....................................q.s. ad § vi. M. S One teaspoonful for an adult every four hours. —Murray. In tuberculous enteritis: R Pulveris Doveri.............................................. 3 iiss. Pulveris creta comp., Pulveris calumba.........................................aa, 3 v. M. et div. in cht. No. Ix. S. Two or three each day. —LlEGOIS. Choleraic diarrhcea : R Tinct. opii....................................................... 4 Spiritus mentha piperita, Spiritus atheris comp..........................................aa 8 M. S. Twenty drops four or five times a day. —ROSAHUSKY. 2^0 THE practitioner's manual. Or— R Tinct. opii, Tinct. capsici, Spiritus camphora..................................aa 3 iij.-J-^Lxij. Chloroformi.......................................... 3 i.-p-Tqiv. Alcoholis............................................ad § i j. M. S. Teaspoonful the dose. —Squibb. For a child of tiro years : R Acidi sulphurici aromatici................................. gtt. xl. Morphina' sulphatis........................................ gr. ss. Elixir simplicis............................................ § i. Aqua pura......................................... .q.s. ad 3 iv M. S. The dose a teaspoonful. — Wm. Pepper. For an infant : R Papaina pura.............................................. gr. ix. Acidi lactici............................................... 3 ss. Syrupi simplicis............................................ 3 iss. Aqua destillata........................................... § v. Tinct. vanilla............................................ q, s. M. S. Coffeespoonful after each nursing. —TOUSSA1NT. In summer diarrhoea : by Benzonaphtholi, Bismuthi salicylatis, Pulveris Doveri..........................................aa gr. v. M. S. To be given every two, three, or four hours to a child two years old. —S. Solis-Cohen. To disinfect the intestine, a solution in castor oil is best, be- cause evacuation of the intestine and antisepsis go together. R ALphanaphtholi............................................ gr. xlv. Chloroformi............................................... tq, v. Olei mentha piperita................................... tti^ ij. Olei ricini..............................................ad 3 iij. M. S. One tablespoonful for a dose. —Maximowitsch. Carbolic acid.—J. B. White. Intestinal antiseptics.—Holt. High washings, and milk with the casein removed by adding essence of pepsin, white of egg being used to take its place.— Dillon Brown. diarrhcea. 231 Withdraw all food for twelve to twenty-four hours and give only sterilized water, or, in fermental diarrhcea, barley water.— 0. T. Osborne. In acute gastro-intestinal catarrh, with nausea, vomiting, and pains accompanying diarrhoea: R Extr. hamatoxyli...........................................3 ij. Acidi sulphurici aromatici.................................. 3 ij. Tinct. opii camphorata....................................... % iij M. S. Teaspoonful every three hours or less often if bowels do not move frequently. In both acute and chronic cases: R Sodii phosphatis................................... gr. xv.-xxx. Give in hot water. —Upshur. To quiet the restlessness in subacute or chronic forms: R Sulfonal.................................................... gr. ss. Sodii bromidi............................................. gr. ij. Spiritus mentha piperita.................................. gtt. x. Aqua camphora........................................... 3 b M. S. Dose to be repeated every two or three hours. —Wells. In chronic gastric catarrh associated with excessive secre- tion of mucus, lavage to stimulate the gastric glands.—Joseph. Summer Diarrhcea of Children.—Eliminate all decomposing food by cathartics, lavage, and irrigation of the colon. Drugs are secondary to prevention and management.—Rardin. To correct acidity and expel contents of canal, magnesii sulphas, 3i., at dose before meals.—S. Patterson. Starvation will cure many cases. White of egg and water or broths furnish a favorite diet.—Koplik. Chronic Diarrhcea of Infants.—Large irrigations of warm boric-acid solution every day or every second day. A pressure of from one to three feet is sufficient and the fluid should enter the colon slowly. The child lies on the back with a cushion 232 the practitioner's manual under the left hip, so that the caecum may be low, to favor the entrance of the solution.—Dauchez. Acute, Subacute, and Chronic Enteritis it/ Children.—Tanni- gen, 0.2 to 0.5, three times daily to infants under one year; and 0.5 to 1 in older children. It is given in water, milk, or soup.—Drews. In many diseases of the infantile intestine the three prin- ciples of truest antiseptic treatment— 1. Thorough asepsis and cleanliness; 2. Free drainage: 3. Freedom from irritation, and perfect rest— summarize the indications which should guide us.—L. Svmes. Summer Diarrhoea.—Healthy bile is the great physiologi- cal intestinal antiseptic. The one agent which will secure flushing from the pylorus downward is calomel, gr. |-^, in the beginning of treatment, combined with bicarbonate of sodium. Spiced poidi ice is a homely remedy of decided utility.— How to Make a Spiced Poidtice.—Mix one teaspoonful each of mustard, ginger, black pepper, cinnamon, cloves, nutmeg, and allspice in a dry bowl. Unless this is done the mustard will lump when hot water is added. Add boiling water, little by little, with constant stirring, until the mass is of the consis- tence of soft putty. Too much water will cause the poultice to run through the meshes of the cloth; too little leaves the poul- tice so dry that it fails to hold together and the spices soon separate and rattle out. After thorough mixing put the poul- tice, steaming hot, into the middle of a thin handkerchief or similar square piece of cloth, and spread out the fragrant masn to about the size of your open hand; fold over it one side of the cloth, then the other side, and finally the two ends. It may be left in place all night without danger of blistering. Cold or lukewarm water fails utterly to bring out the peculiar anodyne quality.—G. D. Hersey. DIARRHtEA. 2oo After castor oil or calomel: R Salicylate of phenyl......................................... 3 i. Salicylate of bismuth..................................... 3 ii] Oil of gaultheria............... . ..........................m xij, Chalk mixture.....................................to make 3 iij. M S 3 ij. every two hours. Opium may be added if there is much pain. —Griffith. After exposure to extreme heat: R Pulveris Doveri ......................................... gr. b Hydrargyri cum creta.................................... gr. i. Pulveris rhei ........................................... gr i.-ij- M. S. Three or four times daily. —LlEGOIS. Or— R Bismuthi subnitratis....... .............................. 3 ss. Tinct. opii................................................. gtt. xx. Syrupi ipecacuanha, Syrupi rhei aromatici..................................aa, 3 iv. Listerini.................................................. § ss. Mistura creta......................................,......§ i. M. S Teaspoonful once in three or four hours for a child ten or twelve months old. —Roberts. In infants who begin to vomit withdraw milk and give a few drops of brandy in sterilized water. At end of twelve hours or longer begin giving fresh beef juice, panopepton, or albumen water.-—Wells. For a child of ten or twelve months : R Bismuthi salicylatis........................................ 3 i. Pulv. ipecacuanha et opii................................... gr. x. Pulv. aromatici........................................... 3i. M ft. chart. No. xii. S. One every three or four hours. Or— When stools are "jelly-like": R Hydrargyri chloridi corrosivi........................... gr. | Liq. potassii arsenitis................................... gtt. xxxij. Syrupi rhei, Syrupi rubi .........................................aa 3 ij Listerini.......................................q.s. ad § ij M. S. Fifteen to twenty drops every one or two hours. 234 THE PRACTITIOJfER's MANUAL. Infectious Diarrhcea in Infants.—Stop the food supply. Re- move the products of imperfect digestion from the intestinal tract by irrigation, continued until the water returns free from admixture of faecal matter. Inject solution of twenty grains of tannic acid in a pint or more of sterilized water, and have it re- tained in the bowel about an hour. When vomiting persists the stomach should be washed out also. To neutralize the toxins calomel in one-tenth-grain doses hourly for the first twenty-four hours is recommended. First among antipyretics is the cooled bath. When watery discharges continue after the irrigation, hypodermics of T^ gr. of morphine and ¥^ gr. of atropine can be given. Stimulants are indicated in the severe cases, and whiskey is the best that can be given. After the urgent symptoms have subsided the child can be nourished with the white of an egg stirred in cold water or the mixture recom- mended by Jacobi: Five ounces of barley water, the white of one egg, one or two teaspoonfuls of brandy or whiskey, some salt and sugar. A teaspoonful every five or ten minutes as indicated. No milk should be given for several days.—Mc- Clanahan. Infantile diarrhcea: R Bismuthi subgallici.................. Sodii bicarbonatis................... Creta preparata.................... Creosoti ,............................ Syrupi cinnamomi.................. Aqua destillata...................... M. S. Teaspoonful after each movement Or boiled water cooled to suitable temperature in small quantities every hour or as thirst demands, all food being ex- cluded for from eight to twenty-four hours.—Watu. ........aa gr. xxx .......... gr i. J. Lewis Smith. ....... 3 b ....... gr- v. ....... 3 ss. ....... gtt. v. ....... 3 ss. q.s. ad 3 iv. —Griffin. Or— R Bismuthi subnitratis, Creta precipitata....... Pulveris opii............., M Divide into ten powders. DIA ^ J —R. Donelson. dysentery, tropical. 261 To remove the acrid and offensive character of the stools, carbo ligni.—Nathaniel Chapman. Local.—■ R Creasote (purified).......................................... tti xv. Laudanum.................................................. gtt. x. Milk or bouillon............................................ 3 v. Boiled water................................................ 5 v i. M. S. Inject after a preliminary boric or salicylic lavage. —Testeirn. For persistent ulcers : R Argenti nitratis........................................... gr. v.-x. Aqua destill.............................................. O i. M. S. Use as an irrigation. Ulcers i)i the Rectum.—After irrigating with water, apply strong silver solution or pure nitric acid, and irrigate afterward with salt or soda solution.—W. W. Johnston. Dysentery, Tropical. In recent times this form has come to be spoken of as amoebic dysentery, since the amoeba coli is constantly present. The stools are more copious but less numerous, and tenesmus is not so marked. Diagnosis.—A gradual or abrupt onset of a mild or severe diarrhcea, with or without fever, with frequent and copious yel- lowish-gray fluid stools, containing mucus and perhaps blood, and the ever-present amoebae coli, are the chief characteristics of tropical dysentery. Differentiation.—Finding an abundance of amoebae in the dejections by means of the microscope renders the diagnosis of this form comparatively easy. Treatment. — Warm injections of quinine in strength of 1 to 5,000, 1 to 2,500, and 1 to 1,000.—Osler. 202 the practitioner's manual. Dyspepsia, Acute. Acute gastric catarrh, or acute dyspepsia may be of mild or severe type. Nausea, regurgitation of tasteless or acrid fluid, bad taste in the mouth, vomiting, epigastric pain, decided thirst, and usually constipation are the predominating symptoms. Diagnosis.—If the stomach symptoms follow immediately upon taking food, especially of indigestible or irritating nature, the true cause is naturally suggested. If, however, this source of irritation is not present, one may suspect in children especially the beginning of one of the acute exanthemata. Differentiation.'—Typhoid fever may begin with much the same train of symptoms, but the characteristic range of tem- perature, the diazo reaction, or other test will soon confirm or disprove the suspicion. Prognosis.—The duration is about two weeks unless com- plicated with duodenitis or gastro-enteritis. Repeated attacks may result in chronic catarrhal gastritis or chronic dyspepsia. Dyspepsia, Chronic. , Chronic catarrhal gastritis has a more gradual onset than the acute form, the symptoms being at first transient and later on more persistent. The appetite is perverted, with craving for particular dishes, and excesses at table are indulged in despite subsequent discomfort. There is often nausea before and vomiting after eating. Eructations of gas and regurgita- tions of bitter or acrid fluid into the mouth are frequent. Food produces a sense of weight or tension in the epigastrium and at times acute pain. The evacuations may contain undigested particles. The tongue is coated, the taste unnatural, the breath offensive. Differentiation from nervous dyspepsia is made by the dyspepsia, chronic. 263 absence of other neuroses and by a more or less constant rela- tionship between the taking of food and the production of symp- toms. The quantity and quality of food do not here seem to play an important role. In chronic gastric catarrh the symp- toms are constant, and if the gastric secretions are examined a diminished acidity and an excess of mucus are noted. Ulcer of the stomach is eliminated by the absence of a cir- cumscribed painful spot, haematemesis or melena, and the lesser intensity of the pain. Dilatation of the stomach is excluded by washing out the organ with the stomach-tube several hours after food has been taken and examining the contents for undigested particles. In cancer an excess of lactic acid is usually present and a tumor may perhaps be palpated in explanation of a coexisting cachexia. In every case of persistent dyspepsia, careful examination of urine should be made.—Loomis. If two hours after a test breakfast (tea, coffee, milk—not over a pint of fluids—sugar, one or two rolls, or bread without butter), there is a sense of heat in the stomach, with burning and acidity, it indicates hyperacid dyspepsia. Gas, weight, fulness show hypoacid dyspepsia. Epigastric pain coming on at the end of a quarter of an hour and gradually increasing indicates a probable gastro-duodenal irritation.—■ DU.IARDIN BEAUMETZ. Treatment.—Before attempting any therapeutic measures we should decide whether there is present an exaggerated, an inefficient, or a perverted function, and the source of the digestive disturbance should be sought out. For acid dyspepsia (fermentative) : R Sodii chloridi............................................... 3 ss. Sodi i bicarbonatis........................................... 1 b Sodii sulphatis.............................................. 3 iiss. M. et ft. chart. S. Small teaspoonful in one pint of hot water an hour be- fore meals. Regulate amount of salts according to bowels—one or two free movements daily being desired. —H. B. Whitney. 264 the practitioner s manual. In chronic dyspepsia, due to atony and dilatation of the stomach in children five to ten years old, the following treatment is to be continued for ten days, then omitted for the same period and repeated. It is contraindicated in severe pain of the stomach with accompanying great nervous irritability : R Pulv. nucis vomica........................................... 0.01 Sodii bicarbonatis, Magnesia calcinata........................................aa, 0.2 Pepsini....................................................... 0.1 M. S. For one powder to be taken before meals, morning and evening. —COMBY. Hyperchlorhydria: R Betanaphthol................................................ gr. v. Ess. zingib.................................................. 3 b 01. cajuput................................................. gtt. i. S. To be taken in a small quantity of water, followed by larger draught. Full doses of alkalies to be given at height of digestion.— D. D. Stewart. Two Essential Points in the Treatment of Dyspepsia.—First. In the treatment of all forms of indigestion, be it gastric or intestinal, a sterile diet must be insisted upon. This means ab- solutely sterile, or at least the attempt to make it so, and admits of no distinction between harmless and harmful micro-organ- isms. Bread made with yeast, as ordinarily eaten, must be con- sidered a germ bearer, and butter also, even the choicest brands. It is the assumption that certain germs are harmless in the intestinal tract which is the cause of failure to relieve many dyspeptics. The physician should look at this matter from the standpoint of the surgeon and make no distinction as to the kinds of germs. Micro-organisms are of no aid to digestion. On the contrary, they may derange and inhibit the process just as much as they do the healing of a wound. Second. Limit or forbid entirely the ingestion of the organic acids in food or drink. We must remember that digestion is essentially an alkaline process. Even the acidity of the gastric dyspepsia, chronic. 265 contents is only temporary and must not go beyond narrow limits. It is proven that gastric digestion is not a life-sustaining necessity. It is necessary to a healthy and normal condition of the body, however, that the contents of the small intestine be maintained in an alkaline condition, so that peptone can be changed into serum albumin. Nature will neutralize a great amount of free organic acid in the intestine, but the alkali necessary is taken from the blood, and hence that fluid loses its normal alkalinity and a departure from a healthy and normal state at once ensues. The elimination of micro-organisms and organic acids from the alimentary tract in dyspepsia oftentimes stands in the rela- tion of cause and effect, for the micro-organisms themselves are the great producers of many of the organic acids. Diet, then, being the great factor in the treatment of all kinds of dyspepsia, some of the distressing conditions may be relieved by the following medication: For nervo-motor dyspepsia: R Sodium bromide ......................................... § ij. Codeine sulphate.......................................... gr. v.-x. Carmine, C. P........................................... gr. xxx. Water (pure)............................................. 3 iv. M. ft. sol. S. From half to a teaspoonful in hot or cold water, either before or after eating, as deemed best in each case. The carmine is not added for its color. The writer believes that the carminic acid therein has germicidal powers. The fol- lowing should be applied to the skin over the region of the stomach by brisk rubbing with a piece of new red flannel: R Ungt. hydrargyri........................................... 3 b Olei sinapis................................................ gtt. xv. M. S. Use a piece as large as a bean as directed, night and morning. For an intestinal germicide the following seems to meet in- dications most successfully: 266 the practitioner's manual. R Salopian....................................................... 3 i. M. ft. capsulas No. xii. S. One capsule before eating. Take no acids while using. —A. H. Hoy. Diet.—Do not reduce the diet to the level of gastric capabil- ity, but elevate the gastric function to the requirements of normal food. Fruit should usually be freely allowed. The banana is rather a vegetable than a fruit, practically the same as a sweet potato—a mass of raw-starch, some sugar. and often an appreciable dose of nitrite of amyl. It is not digested till the intestine is reached. Whenever the patient is well enough, be guided by his likes and dislikes, appetites and antipathies.—A. L. Benedict. In flatulent indigestion : R Zinci sulphocarbolatis...................................... gr. xij, Pepsini pur., Pancreatis ext...........................................aa, 3 ss. Bismuthi subgallat......................................... 3 ij. M. ft. chart. No. xii. S. One before each meal. In indigestion, with much coating of the tongue, in nasopharyngeal catarrh, and especially in morning vomiting: R Pulv ipecac............................................... gr. viij. Pepsini pur............................................... 3 ss. Pulv. rhei......... ....................................... 3 j Sodii bicarb............................................... 3 iss. Tinct. nucis vomica...................................... 3 iv. Aquam menth. pip......................................ad 3 v i ij M. S. Tablespoonful before meals in half a glass of hot water. —L. F. Donohoe. As a tonic and aid to digestion in atonic and fermentative stomachic indigestion: R Liq. pepsini (Hancock's)..................................... = iv. Acidi phosphorici dil......................................... | ss. Strychnina sulphatis......................................... or. i M. S. Teaspoonful in water three times a day after meals. In the reflex nervous disturbances of stomach derangement, especially palpitation of the heart in so-called nervous dyspepsia: dyspepsia, chronic. 267 R Zinci phosphidi, Sodii et auri chloridi....................................aa gr. iss. Ext. nucis vomica........................................ gr.viiss. M. ft. pil. No. xxx. S. One three times a day after meals. —Upshur. Acute indigestion not relieved by cathartics: R Resorcini..................................................... 3ij. Sodii chloratis............................................... 3 i. Mist, rhei et soda............................................ 3 ij. M. S. A teaspoonful every two or three hours. —Andrew H. Smith, When anorexia predominates : R Tinct. nucis vomica.......................................... 3 i. S. Ten drops three times daily. For the insomnia, chloral hydrate, sulphonal, or trional. Gastritis.—Immediate effect is noted from hydrogen dioxide. B Hydrozone...................................................... 1 Aqua bub, or aqua sterilizat................................... 32 M. S. 1 ii. to 3 iv. of such dilution half an hour before meals. Nascent oxygen favors osmosis.—John Aulde. R Acidi hydrochlor. dil.................................... § ss. Tinct. nucis vomica.................................... 3 ij. Liq. potassii arsenitis................................... gtt. lxxij. Ess. pepsini............................................ 3 ij. Aquam...............................................ad 3 vi. M. S. Two teaspoonfuls in water after meals. Or— R Fellis bovis purificati....................................... gr. i. Ext. pancreatini............................................ gr. i. Ext. colocynthidis comp...................................... gr. \ Quinina muriatis..................'......................... gr. ss. Ext. nucis vomica.......................................... gr. \ Ext. taraxaci................................................ gr. i. M. S. For one tablet. One or two before meals. —Wm. Porter. Flatulent Dyspepsia.-—Use remedies which will increase nervous vigor—nux vomica, strychnine, etc. —Stephen Mackenzie. R Magnesia, Phosphate of lime, Powdered charcoal, Sulphur....................................................aa p. a. M. S. Teaspoonful as required, taken in a little water. 20s the practitioner's manual. Or— R Olei creosoti................................................. tti xij. Spiritus tenuioris........................................... 3 ss. Ammonii benzoatis.......................................... 3 ij. Glycerini.................................................... 3 vi. Infusi carj'ophylli.....................................q.s. ad 3 vi. M. S. Tablespoonful in a glass of water. —Dr. B. W. Richardsox. Or— R Olei cajuputi.................................................. 3 ss. Tinct. lavandula comp....................................... 3 ss. Mucilag. acacia............................................ad § ij. M. S. Dessertspoonful when necessary. —Hartshorne. For the violent spasmodic attacks, with great distention of the stomach and bowels, to which some sufferers from flatulence are liable, the following is nearly always efficacious: R Spir. cajuputi (P. B.) . ....................................... 3 ij. Spir. ammonia aromatici..................................... 3 ij. Spir. chloroformi............................................. 3 ij. M. S. The antispasmodic mixture. One teaspoonful in a glass of water every half-hour or every quarter-hour until relief is obtained. When flatulence is associated with pain after food and coated tongue indicating gastritis, the following prescription should be given: R Potassii bicarb, vel sodii bicarb.......................... 3 ij. Spir. ammonia aromatici............................... 3 iss. Lb], strychnina (P. B.)................................. 3 ss. Spir. cajuputi (P. B.)................................... 3 iss.- 3 ij. Spir. chloroformi....................................... 3 i. Infusi calumba vel gentianaco.......................... 1 vi. M. ft. mist. S. A sixth part three times a day between meals. —Stephen Mackenzie. For painful digestion with flatulence : R Sodii bromidi............................................... 4 Pepsini concentrat............................................. 3 Pulv. carbonis ligni...... ..................................... 2 Aqua pur............................................... H Glycerini............................................... 04 M. S. Teaspoonful after each meal. —Lanphear. dyspepsia, chronic. 200 Or— R Sodium bicarbonate....................................... 3 b Tincture of ignatia......................................... gtt. xl. Tincture of senecio (P. B.)................................. I b Syrup of bitter-orange peel................................. 1 i • Alcohol containing ten per cent of chloroform............... 3 ij. Water..................................................... 3 vi. M S. A tablespoonful three times a day. —Wm. Murrell. Or— R Bismuthi subnitratis, Magnesii sulphatis, Creta preparata, Calcii phosphatis.............................................aa 10 M. div. in cachets No. xl. S. One before each meal. —Dujardin-Beaumetz. Dyspepsia with flatulence : R Sodii sulphatis............................................... 3 i. Tinct. nucis vomica.......................................... 3 v. Aqua........................................................ 3 1V- M. S. Teaspoonful t.i.d. after meals. —I. BURNEY YEO. Or— R Bismuthi subnitratis, Sodii bicarbonatis, Pulv. sacchari, Pulv. acacia, Pulv. zingiberis...............................................aa 10 M. S. A tablespoonful, for adults. — W. E. Wheelock. Or— R Magnesia, Calcium phosphite, Powdered charcoal, Sulphur......................................................aa 15 M. S. Teaspoonful to be taken in water when necessary. —Paul Cheron. Or— R Tinct. cardamomi comp...................................... 3 iv. Acidi hydrocyanici diluti.................................... ttl xl. Spiritus ammonia aromatici.................................. ^ l3- Tinct. zingiberis............................................. 3 hj. Spiritus chloroformi.......................................... 3 bJ- Aqua cari.............................................7 per cent albumose, 7.4b per cent salts, and 0.2-1 per cent peptone) added to cow's milk. —Wolf. Antiseptic lavage of the stomach : R Sodii biboratis........................................... 3 ij. Creolini................................................ gr. iv. Aoidi salicylici.......................................... gr. xviij. Thymolis............................................... gr. iv. M. S. Use with a siphon tube after clear-water lavage once a day. —Rosenheim. DYSPEPSIA, CHRONIC. 273 In motor dyspepsia with stasis and acid fermentation, warm-water injections before dinner and supper retained for fifteen to twenty minutes, and after the meal abdominal gym- nastics. —Flessinger. In infants, use a soft tube of 0.5 mm. diameter and attach to its uppper end a rubber tubing 1 m. long with funnel.—Leo. Stomachic tonic when recovering from atonic dyspepsia: R Acidi nitrohydrochlorici..................................... 3 ij. Aqua........................................................ 3 iss. Strychnina sulphatis......................................... gr. i. Misce et adde : Tr. gentiana comp., Tr. cardamomi comp................................aa q.s. ad 3 vi. S. Dessertspoonful in water after meals. —Wood and Fitz. In hyperemesis : R Cocaina hydrochloratis.................................... gr. iss. Antipyrin................................................. gr. xvi. Aqua destill.............................................. 3 iv. M. S. Teaspoonful every half-hour until relieved. --LUTANT. When vomiting is due to excitability of the mucous mem- brane : R Tinct. aconiti............................................. gr. xxx. Bismuthi subnitratis...................................... 3 iij M. ft. chart. No. x. S. One powder every half-hour. —Hare. In dyspeptic vertigo : 1$ Acidi nitrici.............................................. 3 i. Acidi muriatici.......................................... 3 i-Tfi,xl. Aqua camphora......................................... 1 viij. M. S. Shake. Take one tablespoonful in one-half cup of water thirty min- utes before each meal. —W. K. Harris. Dyspepsia and vomiting in tuberculous subjects : R Prepared chalk, Calcined magnesia.......................................aa. gr. iij. Manganese dioxide......................................... gr. iss. Powdered belladonna....................................... gr. T\f% M. S. For one dose, to be taken after eating. If there is severe pain, fifteen one-hundredths of a grain of powdered opium may be added.—Barth. is 274 the practitioner's manual. Dyspepsia, Nervous. Here the many subjective symptoms occurring during diges- tion cannot be referred to any alterations in the stomach which can be demonstrated. Leube classes under this form all cases showing dyspeptic symptoms in which after a test dinner hydro- chloric acid was found and the stomach was shown to be empty seven hours after the meal. There is an absence of organic lesion of the stomach. Diagnosis.—The appetite is usually decreased but is capri- cious. The tongue is usually clean. Soon after eating there are slight gastric pain, frequent belching, and disagreeable sensa- tions. w7ith a sense of drowsiness or irresistible desire to sleep so long as food remains in the stomach. Once the stomach is empty, the patient experiences a slight dizziness and is frequently depressed with hypochondriacal feelings and anxiety over trivial matters. Fulness and occasionally pain are felt in the abdo- men from flatulency. The gastric juice may be found normal but a diminished acidity is frequent. Headache, insomnia, pain in the back, seminal emissions, loss of energy, and palpita- tion upon slight exertion are frequently present. Diagnosis is confirmed by the presence of neurasthenic symp- toms and the absence of organic lesions. While easily digested food does not benefit the condition, indigestible substances often aggravate it. The complaints on the part of the patient are many and varied, and out of all proportion to the results of physical examination. Differentiation from ulcer and cancer is made by the ab- sence of any of the characteristic features of these affections; chronic dyspepsia has a constancy in its symptoms and these are aggravated by errors of diet. Einhorn says that a characteristic feature of neurasthenia gastrica is the suddenness of changes in the patient's condition. He may feel entirely well for a few days and then be again wholly disabled. dyspepsia, nervous. 275 Prognosis is more favorable in emotional than in other nervous dyspepsias. Treatment.—The entire nervous system must be strength- ened. The direct means to this end are hydrotherapeutical measures of a mild nature, such as: (1) The cold pack and luke- warm sitz baths; (2) massage of the entire body with special massage of the abdomen ; (3) electricity; (4) abundance of sleep and rest. The bromides are of great importance. R Ammonii bromidi, Sodii bromidi.............................................aa 1 gm. M. ft. chart. No. xx. S. One twice daily in milk or water. —Einhorn. R Sodii bicarbonatis...................................... 3 jjj Acidi hydrochlorici dil................................. gtt. xlviij. Tinct. Valeriana.................. z \ .................... ^ *• Syrupi zingiberis....................................... ; j\ M. S. Teaspoonful three times a day in water. —Carpenter. R Sodii bromidi................................................ ? i_ Pepsini saccharati, Pulv. carbo. ligni..........................................aa 3 iij. Aqua........................................................ ^ jVi M. S. Teaspoonful after each meal. For nervous hyperacidity of the stomach : R Strontii bromidi (pure)....................................... 3 iij. Aqua mentha piperita....................................... 3 Xv. M. S. Teaspoonful twice daily in milk at mealtime. —Einhorn. In gastralgia, hyperazsthesia,- and hyperchlorhydria : R Methylene blue...................................... 0.10-0.20 cgm. S. For three capsules. To be taken daily. —Berthier. Neurasthenia gastrica: K Ferri bromidi (P. G.), Quinina hydrobromatis.......................................aa 4 Extr. et pulv. rad. rhei........................................q.s. M. et ft. pil. No. cxx. S. Two t.i.d. — Maximowitsch. Emotional Dyspepsia after Shock.— Avoid cold food. Small doses of opium and belladonna. Cognac. Direct treatment to the mental condition.—Rosenbach. 270 THE PRACTITIONER'S MANUAL. Nervous Dyspepsia.—Failure of treatment is often due to failure of absorption of remedies employed because of the ropy mucus, which should be first washed out. Postprandial pains: R Animal charcoal, Magnesia, Ginger. M. For one tablet. S. To be chewed, dry, every half-hour. —Baruch. Moderate pain may be relieved by hot milk or malted milk. Severer paroxysms by saturated aqueous solution of chloroform. Or cocaine, gr. ss. Caution.-—This dose not to be exceeded—and to be given with great caution. Pain several hours after eating : R Bismuthi salicylatis, Magnesia calcinata, Sodii bicarbonatis......................................aa gr. v.-x. M. S. At dose. Severe Forms with Dilatation.—Wash out the stomach with gastric siphon.—H. M. Lyman. Eclampsia, Puerperal. The prodromal symptoms of an attack of eclampsia include distress at the epigastrium, visual disturbances, and frontal or temporal headache of greater or less severity. The attack is convulsive, with a short tonic and a longer clonic stage, followed by unconsciousness of greater or lesser degree. A state ap- proaching that of coma may succeed, or there may be numerous repetitions of the convulsive seizure. The latter may occur dur- ing, before, or after labor. The pre-eclamptic stage shows rapid heart action, diminished excretions, gastro-intestinal de- rangements, and other evidences of toxaemia. There may be sudden complete or partial loss of sight. Just before or during the attack the albumin, while abundant, has ECLAMPSIA, PUERPERAL. Zt I the peculiarity of being wholly soluble or almost so in the pres- ence of a small amount of acetic acid. In the premonitory period the albumin may be almost wholly of this nature.—Bar, Meun, and Mercier. Differentiation.—General convulsions during the puer- perium may be due to epilepsy or hysteria. The previous his- tory of former attacks will aid in diagnosing epilepsy. An epi- leptic attack—which is of rare occurrence during labor—does not as a rule recur at short intervals, as does eclampsia. In the rare cases of hysterical attacks during labor, total loss of conscious- ness practically never occurs. If, during the attack, the pupil reacts to light, then neither epilepsy nor eclampsia exists. Deep coma in parturient women depends almost always upon eclamp- sia. A large amount of albumin in the urine speaks for eclampsia.—Max Runge. Prognosis varies greatly with the time the symptoms come on. Remedies which are effectual in post-partum eclampsia are often useless in that occurring toward the end of pregnancy. The greater the quantity of urine passed the better the prog- nosis. The higher the temperature the worse the prognosis.— Tucker. Treatment.—This is either preventive or curative. Rational treatment is out of the question so long as the pathology is un- known. Large doses of morphine subcutaneously seem to be the best.—Veit. Caution.—In threatened eclampsia morphine is positively contraindicated. —Upshur. Prophylaxis includes frequent examination of the urine for evidences of albuminuria, and a restricted and often exclusive milk diet if albumin is discovered. This is a perfectly preventable disease, since it always gives signs of its approach, for several days, at least, if not for weeks before the attack.—E. P. Davis. To prevent the occurrence of convulsions, care in diet, avoid- 27S the practitioner's manual. ing an overloaded stomach; frequent administration of saline cathartics, lithia water, and other diuretics to stimulate the kidneys. Prevent toxaemia by exclusive milk diet. In the attack, the free administration of chloroform and prompt bleeding. Active cathartics if there is constipation. Prompt delivery; the first indication in a severe case being to terminate labor. In the asthenic form, with full bounding pulse of 120 to 140 beats, congestion of the face, powerful muscular contraction, tincture of veratrum viride, tti, x.-xv., hypodermatically. If no marked result, give in addition 10 minims after half an hour. Caution.—In the asthenic form five minims is sufficient. To lessen arterial blood pressure, lower temperature, and cause diaphoresis, guaiacol, gtt. xl.-l. Gently rub into the abdomen. —Appleby. Eclampsia occurring before labor may often be benefited by hypodermic injections of morphine (gr. +-i) and also of vera- trum viride (6 to 20 drops of the tincture).—Parvin. Large doses of nitroglycerin, veratrum viride, and free catharsis, avoiding morphine.—A. Flint, Jr. Norwood's tincture of veratrum viride in large dose (ten to twenty minims), preferably by hypodermic ' injection. The initial dose can be safely followed, in from thirty minutes to an hour, if necessary, by a dose of from five to eight minims.— Bauer. After each attack chloral per rectum. R Chloral........................................................ 10 Syr. mucil. acacia............................................. 150 S. One tenth (15 gm.) per rectum. Tx, —WlNCKEL. If prostration and nausea are produced by veratrum, opium, diffusible stimulants, or morphine subcutaneously.—Thayer. When the symptoms first show themselves, hot baths and narcosis. If the eclampsia precede parturition, premature labor ECLAMPSIA, puerperal. 279 is induced either by the introduction of bougies or by the use of the colpeurynter.—Schreiber. The speedy evacuation of the uterus constitutes the most im- portant means of treating eclampsia.—Mangiagalli. Attend to the convulsions, and leave the labor to take care of itself.—Gooch. Especially no kind of obstetric manipulation is required for the safety of the mother.—Schroeder. Begin, if the patient is strong and vigorous, and if cyanosis is present, by a bleeding of from 200 to 300 gm.; then give chloral, and give milk by the mouth. Combat the attacks themselves by inhalations of chloroform, and favor diuresis by subcutaneous injections of salt solution. If the woman is delicate, the cyanosis is not very marked, the attacks are not very frequent, chloral alone should be given. Wait until the labor occurs spontaneously, and allow it to end without intervention whenever this is possible. If labor comes on spontaneously but does not end, because the uterine contractions are too feeble or too slow, end the labor by the application of the forceps or by a version, followed by ex- traction, if the child is living, or by a cephalotripsy, basiotripsy, or cranioclasy, if the child is dead. Before intervention, wait until there is complete dilata- tion, or at least a dilatability of the cervix, in order that the operation may be done without danger; that is to say, without violence, and consequently without danger for the mother. Reserve induced labor for a few exceptional cases. Reject, absolutely reject, the Caesarean operation and ac- couchement force as current methods.—Charpentier. Adopt the course which seems least likely to prove a source of irritation to the mother. Thus, if the fits seem evidently in- duced and kept up by the pressure of the foetus, and the head be within reach, the forceps may be resorted to. But if, on the other hand, there be reason to think' that the operation neces- 2S0 THE PRACTITIONER'S MANUAL. sary to complete delivery is likely per se to prove a greater source of irritation than leaving the case to nature, then we should not interfere.—Tyler Smith. Rupture the membranes and empty the uterus as soon as possible without resorting to violence or adding to the nervous irritability of the woman.—McLane. Hypodermic of morphine followed with five or ten minims of tincture of veratrum viride by same method.—Page. Nitroglycerin, one-one-hundredth grain every hour. To diminish toxicity of blood, saline injections in almost unlimited quantities (six and one-half pints in twenty-eight hours).—Sole. Caution.—Use with care when the kidneys are themselves affected. Venesection, in purely neurotic cases.—Crampton. Care should be taken to select the proper case for venesec- tion, and it will be specially indicated when there is marked evidence of great cerebral congestion and vascular tension, such as a livid face, a full, bounding pulse, and strong pulsation in the carotids. —Playfair. Also useful in other forms. — Williams. We have not yet sufficient data from which to draw conclu- sions.—Yeit. Chloroform anaesthesia to control the convulsions; if not promptly effective, the uterus must be speedily emptied. Rapid dilatation, first with steel dilators, if need be, then with the hand, followed by the forceps. Veratrum viride is uncertain, dangerous, and deceptive.—W. Warren Potter. Experience seems to justify the statement that no convul- sions will occur while the patient is sufficiently under the influ- ence of veratrum to hold the pulse below sixty. Empty the uterus too soon rather than too late.—Jewett. Chloroform inhalations are of benefit, but tend to promote fatty degeneration of the heart.—S. S. Jones. embolism and thrombosis. 2*1 In the post-eclamptic stupor magnesium sulphate in con- centrated solution, or Villacabras wrater introduced by means of a long rectal tube high up in the descending colon. As a diuretic and anti-eclamptic, glonoin cannot be overestimated and only veratrum viride is second to it in value. —J. Clifton Edgar. Embolism and Thrombosis, In embolism the symptoms are of sudden occurrence and vary with the particular artery which has been obstructed. If it is the middle meningeal artery which has become occluded by an embolus, we have hemiplegia or monoplegia and aphasia. If it is the pulmonary artery, cough, dyspnoea, and hemorrhage will occur with great suddenness. The diagnosis is here aided by the knowledge of preceding right-side dilatation of the heart and mitral regurgitation. If a terminal artery in an ex- tremity or internal organ becomes occluded, necrosis, gangrene, softening of a given area (brain), or engorgement of the part may occur. Differentiation.—Thrombosis is suggested if there be several attacks in quick succession, little or no rise in tempera- ture, the resulting symptoms coming on slowly. Embolism is suggested if the heart shows an affection such as is likely to result in embolus. In thrombosis there may be a history of vertigo, headache, loss of memory with stupor just before the symptoms referable to sudden closing of the blood-vessel. In thrombosis of atheroma, facial paralysis may come on first and that of the arm and leg only some hours later. In cerebral embolus the subject is younger than in apoplexy, the pulse is more rapid and feeble, aphasia is more common, hemiplegia is more likely to be only partial, complete loss of consciousness is not so common, and improvement is often fol- lowed by relapse. 282 the practitioner's manual. For thrombosis of the cerebral sinuses giving symptoms of general cerebral compression from abscess, see works on surgery. Functional monoplegia may closely simulate cerebral embo- lism. Sudden and complete recovery proves the nature of the paralysis. Cerebral Embolism.—At any age with heart disease or after childbirth. Sudden onset with no loss of consciousness or slight condition of mental confusion or rapid return of consciousness. Improvement occurs within twenty-four hours to a marked de- gree, but symptoms return in three or four days and are perma- nent. Either monoplegia, hemiplegia, or aphasia. Cerebral Thrombosis.—At any age, but chiefly in syphilitic persons and in middle-aged men. Premonitions usually occur. Slower onset without coma, but dulness of mind. The diagnosis between cerebral hemorrhage, thrombosis, and embolism is never positive.—M. Allen Starr. Prognosis.—Sudden death not infrequently follows the blocking of one of the coronary arteries.—Osler. Recovery may be so complete as to leave scarcely a trace, but unless no injury has been done to brain substance it can never be sudden. Care should be taken that a thrombus does not give rise to emboli. The part should be kept in perfect rest until absorption of the thrombus takes place. Avoid massage above all, for by its use detachments of emboli are favored. Embolism and thrombosis of the brain : R Potassii iodidi.............................................. 3viij. Liq. potassii arsenitis....................................... 3 ss. Aqua..............................................q.s. ad § ij. M. S. 3 i. t.i.d. after meals. —R. C. M. Page.28 In thrombus of the vulva during pregnancy, cold applications. During labor intervention is called for only in case of spon- emphysema, chronic. 2*8 taneous rupture of the sac. Terminate labor quickly. Turn out clots and pack. After delivery open only if necessary; lavage, antiseptics.— Charpentier. Emphysema, Chronic. In all chronic emphysema of the lungs, with the exception of the senile form, in which it is flattened, the chest is barrel- shaped with rounded back, and there is often a network of dilated blood-vessels opposite the juncture of the diaphragm with the thoracic walls. The tricuspid often becomes insuffi- cient, leading to general dropsy. Expiration is greatly prolonged and accompanied with loud whistling rhonchi, and nocturnal paroxsyms of dyspnoea may make the distinction from asthma necessary. Percussion gives a drum-like, hollow resonance. Prognosis.—The patient may live almost as long as he otherwise would, but recovery from the condition is practically out of the question. Treatment.—In emphysema of bronchial origin, mineral waters. In arthritic subjects, mixed carbonated waters. In association with catarrhal asthma, waters containing sulphur or soda, alone or in combination with metallic sulphides.— Cazeaux. In emphysema of lungs alone, or complicating bronchial asthma, breathing into rarefied air is promptly effective, curing the latter form. As seen in so many cases after a paroxysm of bronchial asthma, the emphysematous condition remains be- hind and is very difficult to manage by any other means.—S. 0. L. Potter. R Essence of turpentine...................................... 4-5 gm. Peppermint water......................................... 120 " Sugar, Powdered gum acacia..................................aa 4 " M. S. Dessertspoonful every two or three hours. 2*4 the practitioner's manual. Emphysema, Vesicular. Vicarious enlargement of the alveolar spaces occurs in the lung previously altered by disease (pneumonia, pleuritis, atelec- tasis). Vesicular emphysema comes on gradually but ends in a slow chronic process associated with bronchitis and often with asthma. Expiratory dyspnoea is the chief symptom. Differentiation is to be made in the early stages by diffi- cult breathing following exertion alone. Later the signs are overshadowed by those of the accompanying bronchitis or asthma. There is a prolonged and usually weak expiratory sound. The lower border of the lung is as a rule one to two inter- costal spaces lower than normal. On the right side we often hear the hvperresonant note down to the lower border of the seventh or eighth rib and on the left side to the fifth or sixth rib, so that the heart dulness is diminished and at times absent. —Strumpell. Treatment.— R Extr. quebracho................................................ 5 Aqua fontis................................................... 180 Syrupi althaa................................................. 20 M. S. Tablespoonful every three hours. —Neusser. R Potassii iodidi............................................. 3 i. Extr. digitalis fld.......................................... TTLxxiv. Extr. convallaria fld...................................... 3 ss. Syrupi aurantii florum..................................... § ij. Aqua..................................................q.s. ad 3 vi. S. Tablespoonful every four hours. The emphysema is favorably affected by an out-of-door life in a suitable climate; by abstinence from alcohol, tobacco, sugars, and starches, and by methodical inhalations of com- pressed air.-—Delafield. emphysema, vesicular. 2*5 For the dropsy : R Pulv. digitalis............................................. 3 s^-i- Aqua...................................................... ' V1- M. For an infusion. § ss. t.i.d. —Niemeyer. When associated with chronic bronchitis and loss of appetite : R Potassii chloratis............................................ " *ss- Tinct. belladonna.......................................... 3 iss. Syr. pruni virginiana, Tinct. cinchona compos..................................aa ~ ij. M. S. 3 ii. four times daily. —Da Costa. For the paroxysmal cough : R Tinct. lobelia................................................ 3 ij. Spt. atheris sulph............................................ 3 iij. Tinct. conii.................................................. 3 ij • Mist, amygdala............................................ad § vi. M. S. 1 ss. every three hours. —Charteris. R Potassii iodidi.......................................... gr. xxxvi. Ammonii carbonatis.................................... 3 b Tinct. scilla, Tinct. hyoscyami.....................................aa § ss. Aq. camphora.......................................... § v. M. S. = ss. t.i.d. —Greenhow. Arsenical cigarette : R Potassii arsenitis........................................ gr. xv. Aqua destillata........................................ 3" i. Unsized white paper is thoroughly moistened with this solu- tion, dried, and cut into twenty equal parts, and each part rolled into a cigarette. Two or three of these are smoked daily.— Roberts Bartholow. Tabacum smoked, relieves the bronchial spasm. — Chambers. 2*0 THE PRACTITIONER'S MANUAL. Empyema. The physical signs of pus in the pleural cavity are the same as those given by pleurisy with effusion. The temperature goes higher (10o°); chills and profuse sweats may occur; and there is a history of preceding disease (pleurisy, pneumonia, phthisis, etc.). In children there may be oedema of the chest wall, and the network of subcutaneous veins may be very distinct. The breath sounds may be loud and tubular over a purulent effusion of considerable size.—Osler. Fremitus produced by whispering voice is not transmitted to the hand placed upon the chest as in simple serous effusion.— Bacelle. Indican in the urine and albumosuria and usually leucocy- tosis are present. Most pleurisies in children are purulent.— Gerhardt. Differentiation.—Aspiration must often be resorted to in order to distinguish from serous effusion; from a chronic form of pneumonia in infancy. If during pneumonia in children a pinched, anxious expression is assumed, suspicion should be aroused and the needle used. In that following pneumonia the upper line of dulness does not vary with change of position and the "Ellis line" of simple serous effusion is not present.— Babcock. The dislocation of the heart and the displacement of the liver are more marked in empyema than in sero-fibrinous pleurisy. Subpleural abscess simulates empyema so as to be habitually taken for it. Microscopic examination of the aspirated pus alone will decide the question.—Bushnell. Pulsating empyema is distinguished from thoracic aneurism by being on the left side, extensive dulness at the base, pulsation influenced by pressure and respiration. Prognosis.—The prognosis is more favorable in children encephalitis. 2*7 than in adults; in those operated on early than in those operated on later. It is unfavorable after septic poisoning has begun, and when the empyema is caused by the rupture of an abscess into the pleural cavity.—Delafield. Most children get well after simple incision and drainage. —Brothers. Prognosis is modified by the special causative agent. If the pneumococcus is alone present, a rapid recovery is to be looked for. Streptococci give rise to a more severe affection than staphylococci. A sterile exudate suggests tuberculosis. —Osler. Treatment.—Open in the fifth space of the midaxillary line. Irrigate only when fetid. Before the age of twenty-three it is unnecessary to resect the ribs. Freeze the skin with chlor-ethyl spray for the incision. In double general effusion operate first on the left side: local anaesthesia.—Cautley. The regular procedure is to feel for the first rib below the angle of the scapula, to cut down on this rib and remove it up to its cartilage, to put in a large drainage tube, sew up the wound, and dress with bichloride. The dressings are to be changed as seldom as possible, the chest is not to be washed out, and the drainage tube should be removed at the end of the fourth week. —Delafield. Encephalitis. In the acute hemorrhagic form, stupor suddenly develops after a period in which headache, dizziness, and general malaise have been the chief complaints. Coma supervenes and respira- tion is rapid, the pulse and temperature increase, and the pupils become fixed. Diagnosis.—Sudden stupor after a day or two of vertigo and headache points to numerous minute hemorrhages, while 2** the practitioner's manual. persistent headache and signs of brain pressure coming on a week or two after injury point to a suppurative form (brain abscess). (See p. 1.) Prognosis.—Death usually occurs within forty-eight Injurs; still recovery may take place with impairment of function. Treatment.—In sthenic cases blood-letting and free use of calomel.—Oppenheim. In brain abscess, trephining. (See works on surger}7.) Acute hemorrhagic encephalitis may occur in adults, either as a primary acute disease or secondary to other acute diseases, especially influenza. In these cases there is a sudden develop- ment of headache, unconsciousness, hemiplegia, high fever, and death. Mild curable cases of acute encephalitis also seem to occur in adults. The hemiplegia of infants (hemiplegia spastica infantilis) de- pends in most cases upon an acute encephalitis.—Strumpfll. In encephalitis following contusion, we should treat the in- flammation precisely as we would in other regions of the body, always remembering that in the brain, by reason of the bony case in which it is retained, it is impossible for an exudation or hemorrhage to find its way to the surface without surgical as- sistance. —Keen. Enteritis, Acute Catarrhal. The chief distinction between enteritis and diarrhcea is that in the former the cause persists, while in the latter it does not. Enteritis implies the presence of inflammation. It may exist without diarrhcea, but this is the exception and very frequent passages are to be expected. Diagnosis.—The dejections may contain undigested food, are colorless in the absence of bile, grass green when bile passes rapidly through the canal, and occasionally they contain blood. The passages vary from watery to mush-like consistence. Ab- ENTERITIS, acute catarrhal. 289 dominal pain is of spasmodic character, referred to the lower abdomen for the most part. In infectious forms and in high grades of inflammation there are fever and perhaps chills followed by perspiration and more or less marked symptoms of collapse. Differentiation.—From colitis, by the dejections being more watery, while in the latter they contain more mucus and are more homogeneous and show faecal flakes or scybala. Colitis gives the greater amount of abdominal pain, while in enteritis vomiting is a more frequent symptom. If indican is found in the urine it points to enteritis rather than to colitis. If the mucus be blood-stained, the large intestine is more likely to be the source. Tenesmus points rather to proctitis or inflam- mation of the rectum. Chronic enteritis has the presence of mucus as a more constant symptom, and here too we may have a pseudo-membranous form if the discharge contains shreds or casts or an ulcerative form may exist. Treatment.— In infants, intestinal washing with child lying first on one side and then on the other. If diarrhoea is fetid, calomel, one grain. In convalescence, absolute diet of boiled milk, soupspoonful every hour.—Grancher. After washing the bowels : R Bismuthi subcarbonat.................................... 3 i.- 3 ij. Spir. myristica.......................................... ttj, xx. Spir. vini gallici......................................... 3 iij. Listerine................................................. § ss. Mistura creta.............................'........q.s. ad § ij. M. S. Teaspoonful every three hours until relieved. Or— R Bismuthi subnitrat........................................... 3 i. Syr. rhei..................................................... 3 ij. Listerine..................................................... 3 vi. Mist, creta................................................... § i. M. S. A teaspoonful every three hours to a child a year old. 19 290 ^ the practitioner's manual. Or— R Bismuthi subnitratis......................................... 3 ij. Salol......................................................... 3 ss. Tinct. opii camphorata, Tinct. catechu comp........................................aa 3 ij. Mucil. acacia................................................ § i. Syr. simplicis........................................q.s. ad § iv. M. S Teaspoonful every three hours. Or— R Liquor potassii arsenitis....................................... 3 ss. Tinct. opii deodorata......................................... 3 i. Tinct. calumba............................................... § iv. M. S. 3 ij. every two or three hours. —Martin. In children, the milk should be scalded and not boiled. Barley water (1 to 32) exerts an astringent action. If there are feverish vomiting and frequent stools, substitute one raw egg in eight ounces of water. Light chicken broth. Brandy and water in ten-drop doses six or eight times daity. Lavage, using a soft rubber (No. 11 or 12) catheter and fountain syringe.— E. P. Davis. R Resorcin...................................................... 5 Bismuthi salicylatis, Tannigen...................................................aa 15 Sacchar. alb., Sodii carbonatis.............................................aa 7.5 M. et ft. pulv. S. A small even teaspoonful every two hours. In acutely inflamed intestinal segment: R Chloral hydrat............................................. 3.0-5.0 Tannic acid.................................................... 1.5 Lime water..................................................ad 500 M. One-quarter to one-third of this quantity is to be mixed with twelve ounces of warm water or thin starch water, and of this five or six ounces or more may be injected into the bowel, and should be retained as long as possible.—Ewald. In severe pain, leeches to the anus. Poultice over the belly. Enemata with laudanum.—Paul. enteritis, chronic catarrhal. 291 Enteritis, Chronic Catarrhal. Chronic intestinal catarrh, mucous colitis, or chronic diar- rhoea is characterized by six or eight loose passages with or without pain occurring in twenty-four hours; the diarrhcea alternating with periods of constipation. The mucus may be either intermingled with faecal masses or may permeate or coat over the scybala. Adult patients are apt to be irritable or de- pressed, even to the point of hypochondriasis, while children are emaciated and weak. If blood and pus are more or less con- stantly present or if tissue fragments occur, it is indicative of the ulcerative form. An examination with the speculum, may reveal ulceration as high as the sigmoid flexure. In mucous colitis, considered as a functional neurosis, Dr. W. Mendelson makes neurasthenia, mucous passages, and ab- dominal pain the three cardinal symptoms. It is usually mis- taken for an inflammatory or ulcerative condition. Prognosis for recovery is bad. While recovery may take place in favorable cases, the disease extends over months and even years. In the last-mentioned form it depends upon the class of neurasthenics to which the patient belongs. Treatment.—Flax-seed injections, opium, and castor-oil.— Delafield. When neurasthenia is primary, rest cure; daily irrigation of the bowels at 100° F., a quart or two of water being re- tained for ten or twenty minutes. The fewer drugs the better. —Mendelson. R Hydrargyri chloridi mitis Tinct. rhei, Tinct. cinchona.......... M. S. 3 i. twice a day. In duodenitis and ileitis the dietetic plan of treatment is most important. Avoid fats and starches. ...................... gr. b ...................aa § i. —Sir Astley Cooper. 292 THE PRACTITIONER'S MANUAL. In colitis, irrigation. When membranous-like masses are expelled, remove depress- ing influences. Change of climate, electricity ; nutritious diet. —Johnston. When involving the small intestine almost exclusively, uti- lize the stomach for digestion. Keep the intestinal tract clean by frequent and thorough opening. Albuminous food, meat diet —scraped steaks, slightly cooked meat balls, with strong beef tea as a gravy. Salad without dressing, dry toast or crackers. One or two cupfuls of hot water before each meal. Persevere with this diet for several months, and very gradually return to mixed food.—N. S. Davis, Jr. Chronic diarrhoea of many months' or even of several years' duration may be sometimes cured by strict confinement to bed and a diet of boiled milk and albumen water.—Osler. Enteritis, Membranous. A form of diarrhcea in which the dejections contain much mucus may resemble a membrane, which is discharged often after the passage of faeces. There is pain before and at the time of discharge. The latter may resemble shreds or tapeworm-like fragments, or, larger masses may be passed, which simulate casts of the lower bowel. Ascarides may complicate the affection.—Snow. The cases are almost invariably seen in nervous or hysterical women or in men with neurasthenia. It occurs occasionally in children.—Osler. The disease belongs to middle life, and is more common in women than in men.—Delafield. Treatment.—Treat the affection of which the condition is symptomatic. —Tyson. If constipation exists, emulsion of almond oil and turpentine, or castor oil and turpentine.—Carpenter. entero-colitis, acute. 293 For the abdominal pains of muco-membranous enteritis : R Menthol...................................... gr. iij. Alcohol...................................... sufficient to dissolve. Simple syrup................................. 3 vi. Water....................................... § iij. M. S. Teaspoonful. —Mathieu. Infantile muco-membranous enteritis: R Sodii bicarbonatis, Magnesia calcinata...............................aa 0.25 cgm. Pulv. nucis vomica................................. 0.01-0.02 cgm. —COMBY. The most useful drugs are the alkalies, the mineral acids, small doses of castor oil, ipecac, and sometimes small doses of opium. There is also sometimes an advantage in the use of large enemata of cold water and of massage of the abdomen.— Delafield. Or— R Olei terebinthina............................................. 3 i. Olei amygdala express........................................ | ss. Tinct. opii.................................................... 3 ij. Muc. acacia.................................................. 3 v. Aqua laurocerasi.............................................. § ss. M. S. 3 b every three, four, or six hours. —Bartholow. In the chronic form, tannigen, gr. iii.-viii. per diem. For an infant gr. iss.—Kunkler. Freedom from care and worry is sometimes almost essential to the cure. In the majority of cases the condition does not yield to treatment.—Crouch. Entero-Colitis, Acute. This is found especially in the heated term, affecting teeth- ing children or those between the ages of six and eighteen months. It may set in at any season of the year, and is the form of enteritis most common as a secondary complication in the specific fevers of childhood.—Osler. 294 the practitioner's manual. Diagnosis.—The abdomen is enlarged and tender. The passages are small, mucoid, and sometimes bloody, and may number from twenty to thirty in the twenty-four hours. Though at first painless, the stools may subsequently be attended with considerable discomfort. Emaciation is very rapid. The fever may reach 101° F. Differentiation.—From cholera infantum, by the vomiting being much less prominent, by the fever being habitually lower, and by the absence of colliquative diarrhoea and collapse. From dyspeptic diarrhcea, by the greater severity of the symptoms. Prognosis is more favorable than in cholera infantum. A given instance may be protracted for from four to six weeks and may then end in recovery or in death. Extreme cases with convulsions as an early manifestation may run a rapidly fatal course. The prognosis depends very greatly on the ability to secure adequate hygiene and nourishment. Treatment.—Dietetic treatment is important and similar to that indicated in the chapter on dyspeptic diarrhoea. If there be much decomposition, with foul and offensive stools, the albuminous foods are to be withheld and carbohy- drates given. If there be acid fermentation, with sour but not fetid stools, an albuminous diet is indicated.—Escherich. Withhold milk, and feed the child, for the time at least, on egg albumen, broths, and beef juices. The whites of two or three eggs in a pint of water, with a teaspoonful of brandy and a little salt, make an excellent egg albumen.—Osler. Injections with borax, 3i. to O i., or dilute nitrate of silver. —Osler. No milk for a few days. Give the following instead: R Barley......................................................... 3 i. Water........................................................ O i. Boil for 10-15 minutes until O ss., strain and add a little salt, the white of an egg, a teaspoonful of brandy, and a pinch of sugar. —Jacobi. Anodynes to relieve suffering. enuresis. 295 The colon may be flushed with a one-per-cent. cold salt solu- tion.—Tyson. In young children irrigation of the bowels, especially if the colon is largely involved. Bismuth and calomel internally. The routine use of opium and astringents is deprecated.— Clernow. In infancy, proper feeding, removal of irritants. Tannigen, gr. i. Repeat every few hours as required. This drug has the advantage of being insoluble in the stomach.—M. A. Clark. Enuresis. Here we must consider the incontinence of urine as it occurs in childhood and as it affects the adult under varying condi- tions. At all ages of life we have to distinguish between incon- tinence per se as a neurosis and as a symptom of various dis- orders, among which are to be enumerated stone in the bladder, cystitis, genital defects and disease, relaxation of the sphinc- ters, tabes, prolapsus uteri, and a great variety of others. An etiological diagnosis of the particular form of incontinence should so far as possible be made. When habitual and fol- lowed by morning headache, epilepsy may be suspected. Diagnosis.—Nocturnal incontinence in a subject of mouth respiration may be due to the presence of adenoid growths in the nasopharynx. The presence of stone detected by the pas- sage of a searcher will reveal the cause more often in the adult than in the child and open the way to cure. Elongated and ad- herent prepuce is a most fruitful source of irritation in enuresis by day as well as by night, and many patients will be relieved by stripping the prepuce from the glans or by circumcision. The presence of ascarides may be found as the irritating cause, and chronic anaemia is a frequent condition causing reflex irri- tability. In the adult female, according to Boursier, it is one of the 296 the practitioner's manual. earliest symptoms of prolapsus uteri. The loss of urine occurs only when the patient is in the upright position, and it may or may not be attended with pain. The dribbling disappears, however, upon the patient's assuming the recumbent posture. Existing as a neurosis, we have a sudden loss of urine from reflex contraction without dribbling. The exact cause of nocturnal incontinence or bed-wetting in children cannot always be determined. When enuresis diurua coexists, it is evident that loss of control, due simply to the sleeping state, cannot be claimed. If such causes as diabetes, bacteriuria, intestinal worms, local irritation from adherent pre- puce, vulvo-vaginitis, or other genital defect or disease can be found and remedied, the cure is simplified. The following varieties are recognized : Enuresis atonica— enuresis from debility; continua—incontinence of urine both day and night; diurna—incontinence of urine by day; irritata —enuresis from irritability; mechanica—enuresis from mechani- cal causes; nocturna—nocturnal enuresis; paralytica—enu- resis associated with paralysis of bladder; and spastica—enu- resis due to spasm of bladder.—Foster. Prognosis.—The condition may persist during several years or at times during the whole period of childhood, occasionally extending into adult life. When seen after puberty some organic cause must be looked for. Examination of the urine may lead to the discovery of diabetes. A combined diurnal and nocturnal form gives the worst prognosis. Treatment.—If an etiological diagnosis has been made, measures looking toward the removal of the cause will natur- ally be in order. Success frequently depends upon finding as a source of reflex irritation a narrow meatus, adhesions about the vulva, prepuce, or clitoris, ascarides, adenoids in the naso- pharynx, etc. When nocturnal only and without discoverable cause, un- stimulating diet; little fluid, especially in the evening; as per- enuresis. 297 feet hygiene as possible; instruction to the mother to awaken the child at a stated hour and place it upon a vessel to urinate. This is also to be repeated in the early morning. Moral influ- ence should be exerted upon the child's mind and its pride ap- pealed to, if of suitable age, since the will power is capable oftentimes of exerting a decided restraining influence. In a number of instances I have had success in using the following modification of a formula originally proposed by Kelaiditis, especially in the purely nervous form : ^ Cupri sulphat. ammoniat................................... gr. vi. Liquor ammonia........................................... gtt. x. Aqua destil................................................. 3 i. M. S. From one to six drops (according to age) in water morning and night. I have also seen cures affected while the patient was taking: R Ext. rhois aromat. fld.....................................gtt. v.-x. every four hours in water, gradually increased to double the dose. Belladonna is usually well borne by children and in gradually increasing doses has at times given excellent results. R Ext. rhois aromatica fld..................................... 3 iiss. Ext. ergota fld.............................................. § ss. Ext. belladonna fld.......................................... 3 ss. Strychnina sulphat.......................................... gr. \ Syr. aurantii corticis......................................ad 3 iv. M. S. Teaspoonful four times daily. The quantity of belladonna may be increased, and if this fails after a fair trial increasing doses of atropine may be used. R Neutral sulphate of atropine in two-per-cent sol............. 3 iss. Muriate of strychnine in one-per-cent sol................. .. gtt. iv. Syrup of bitter almonds.................................... 3 viss. M. S. From five to sixty drops every evening on going to bed. Commence with five drops (¥\r gr.), and increase by five drops in water every fourth evening until thirty drops per diem are administered. —Macalister. The cold shower bath or the cold douche each night before the patient retires. In nervous, delicate children, one dash of 298 the practitioner's manual. cold water over the shoulders is sufficient. Friction of the sur- face should usually follow the douche. In obstinate cases we may use the ice bag to the spine or apply electricity.—Prender- gast. Tincture of belladonna, § i.a S. gtt. vi. at eight in the eve- ning, and increase every evening by one drop, until it flushes- the face, after which decrease one drop, and continue till relieved. Then diminish dose two drops every week.—S. E. Woody. For an adult: R Tinct. ferri chloridi, Tinct. nucis vomica........................................aa § ss. Tinct. cantharidis............................................ 3 vi. Syr. simplicis................................................ § ij. Aqua.................................................q. s. ad § vi. M. S. 3 b t.i.d. —HOLLISTER. For middle-aged and old women : R Tinct. cantharidis............................................ nDj. Tinct. hyoscyami............................................. v\y. Aqua destillata............................. ................ 3 x. Fiat haustus. Repeat four times daily. —Gregory. For a child: R Strychnina................................................ gr. i. Pulv. cantharidis.......................................... gr. ij. Morphina sulphatis.....................,.................. gr. iss. Ferri pulv....................................,............. 3 i. M. et ft. pil. No. xl. S. One thrice daily. —S. D. Gross. Or— R Extr. jaborandi fld., Extr. belladonna fld........................................aa 3 i. Extr. tritici repentis fld....................................... § ss. Extr. ergota fld., Extr. rhois aromatica......................................aa, § i. Aqua........................................................ | ss. M. S. 3 b thrice daily. —S. W. Armitage. Incontinence Accompanying Chorea. — Quinine sulphate, gr. v. at a dose, to be gradually increased.—Potts. enuresis. 299 Vigorous spanking applied to the nates works well in a large percentage of cases if the full pyschical effect is obtained.— Sanger Brown. Minute doses of atropine up to the physiological effect (Wat- son method) give good results.—H. E. Tuley. One largo dose in the evening, to be gradually increased every four or five days, is a better plan.—Coutts. Massage applied to the neck of the bladder through the rec- tum daily for from five to eight minutes at a time. In bacteriuria, washing out of bladder. In incompetency of the sphincter : B Extr. ergota aq............................................. gr. ss. Extr. nucis vomica......................................... gr. i Bromides at night.—Bartholow. Diminish proteid food.—Cobb. Faradic electricity, especially when there is weakness of muscles at bladder neck. Medium-sized round anode over bladder region. Cathode within urethra. Such current as patient will bear for two to three minutes. One seance may cure. —Koester. Raise the edge of the bed before retiring, diminish fluids, and give belladonna and strychnine internally.—Heubner. Oil of mullein, gtt. xv., t.i.d.—Laws. Raise the pelvis during sleep to an angle of 130°-140° with the vertebral column.—Stumpf. When of psychic origin, attach a weight of from 50 to 100 gm. to the wrist (cordon antisomnambulique), since it is prac- tically a somnambulism of the bladder.—Fiorani. Lycopodium is said to have a selective sedative action on the vesical mucous membrane. It may succeed when bella- donna fails. Tincture of lycopodium, gtt. xx. Give three times a day, gradually increased to a teaspoonful. 300 the practitioner's manual. When micturition occurs upon waking or when waking is imminent, potassium bromide acts well.—Coutts. In girls and women systematic dilatation of the urethra. —Sanger. Epilepsy. If a paroxysm of epilepsy seizure is observed and the habitual confusion following the attack is noted, very little questioning or search for hereditary taint will be required to establish a work- ing diagnosis. When a patient presents himself with a history of having fallen suddenly and an eye witness states that there were at first an agonizing cry, marked pallor of the face, convul- sions, biting of the tongue, frothing at the mouth, possibly in- voluntary evacuations, and that stupor followed the attack, it is fair to go upon the assumption that the latter was epileptic in nature. Diagnosis.—It is claimed by Mairet and Vires that the urine before the attack is hypertoxic and that after the attack it is hypotoxic. The hypotoxicity remaining during the intervals is thought to constitute a permanent stigma in all forms of epi- lepsy. It has also been stated that preceding the attack an epileptic is gloomy, as contradistinguished from the hysteric, whose condition is described as expansive. A sense of pre- cordial anxiety or oppressed feeling is usually described, and almost all epileptics have a peripheral aura of one kind or another. Cranial irregularities and scars upon the scalp, malforma- tions within the nose, astigmatism, or disease of the ear, are to be sought for as possible causes of a reflex epileptic seizure. True epilepsy developing after the thirty-fifth year of age is practically unknown, and either reflex irritation, cerebral dis- ease, or a toxaemic cause is to be sought for. It is well always to be suspicious of epilepsy developing in epilepsy. 301 the adult, for in a majority of such cases the convulsions are due to a local lesion.—Osler. Stigmata of degeneration are morphologic, functional, or psychic. Asymmetrical facial and cranial development, irreg- ular dental formation, retarded puberty, menstrual irregulari- ties, digestive abnormalities, and mental deficiency are to be numbered among the signs. Epileptic attacks are to be looked for during dentition, about the time of puberty, and after the sixtieth year of age. Paroxysms may sometimes be established as of reflex origin by the discovery of retained milk teeth, the presence of intes- tinal worms, or adhesions of the prepuce. Between the attacks the epileptic is irritable, shows loss of memory and other evidences of degeneration. Many epileptics are syphilitic and the history and signs of this disease must be sought for and the disease treated. It is not uncommon for a violent and dangerous mania to possess the subject im- mediately following the attack. Genuine syphilitic epilepsy often assumes the form of Jack- sonian epilepsy.—Collins. Differentiation.—Paroxysms due to disease of the nervous system usually have attacks beginning in one set of muscles, such as those of one limb, or on one side of the face, as in Jack- sonian epilepsy; still it is well to remember that partial aphasia and monoplegias may succeed true epileptic seizures. In alcoholic epilepsy the subject, while in the status epilep- ticus, obeys external influences at once and in a mechanical manner. In hysteria the aura is lacking, and in the fall no injury occurs. The convulsion is tonic and the thumb is not flexed under the index. Hysteria with epileptoid attacks is more difficult to dis- tinguish, since certain subjects of idiopathic epilepsy have hys- terical manifestations as a sequel of their attacks. Hysterics 302 the practitioner's manual. present a certain irregularity and aimlessness of movement in their convulsion, with more rigidity of a tetanic character than is seen in epilepsy and there is more emotional disturbance. Partial epilepsy due to a tumor shows a marked increase of urea and phosphates in the urine during the attack. In hys- terical epilepsy urea and phosphates are excreted in diminished amount during the attack.—Gilles de la Tourette. Apparent cause.... Warning.......... Onset............. Scream............ Convulsion........ Biting............. Micturition........ Defecation........ Talking........... Duration.......... Restraint necessary Termination....... Epileptic Seizure. None..................... Any, but especially unilat- eral or epigastric aura. Always sudden............ At onset.................. Rigidity, followed by " jerking," rarely rigidity alone. Tongue................... Frequent................. Occasional................ Never..................... Few minutes.............. To prevent accident....... Spontaneous .............. Hysteroid Seizure. Emotion. Palpitation, malaise, chok- ing, bilateral foot aura. Often gradual. During course. Rigidity or "struggling," throwing about of limbs or head, arching of back. Lips, hands, or other people and things. Never. Never. Frequent. More than ten minutes, often much longer. To control violence. Spontaneous or induced (water, etc.). -GOWERS. Epileptic convulsions which occur in general paralysis of the insane may be recognized by the accompanying mental disturb- ances. Eclampsia is excluded by the absence of albuminuria, but the presence of the latter does not aid us, since nearly half the instances of epilepsy show albumin after the attack.— Voisin. Prognosis.—(See epileptiform hysteria.) While the patient is constantly in danger of great injury from his sudden fall or from asphyxia, death may also take place by sudden stoppage of the heart beat or by heart rupture. The prognosis depends upon the intensity of the attack and the length of time the epi- leptic condition has existed. Epilepsy of early infancy may be recovered from and even in the adult spontaneous cure has oc- EPILEPSY. 303 curred. Amelioration is frequent, especially under bromide-of- potassium treatment. It is said that while in this country only one per cent, of recoveries is noted, in Germany under the village system (which has recently been introduced here at the Craig settlement) five or six per cent, of recoveries takes place, while more than one-half of those admitted are decidedly improved. This may be given to-day in the words of Hippocrates: " The prognosis in epilepsy is unfavorable when the disease is congeni- tal, and when it endures to manhood, and when it occurs in a grown person without any previous cause. . . . The cure may be attempted in young persons, but not in old."—Osler. Treatment.—Salts of bromine constitute the drug treat- ment of epilepsy. I have never been able to satisfy myself that a mixture of the bromides possesses any particular advantage over the indi- vidual salts.—Joseph Collins. The medical far outbalances the surgical treatment in re- sults obtained. First of all exclude such causative factors as intestinal worms, onanism, alcoholism, etc. In administering bromides, which in one form or another constitute the most approved remedy, dilute well and give so that the greater quantity has been taken about three hours be- fore the time of habitual attack. The quantity may be grad- ually increased for the first few weeks. In epilepsy, especially that associated with psychical disorders, duboisine sulphate, y^-g- of a grain increased to -fa of a grain, diminishes the number and intensity of attacks and gives most favorable results.—Cividali AND GlANELLI. Epilepsy from chloro-anoemia: R Protoxalate of iron............................................ 0.20 Magnesia...................................................... 0.10 M. Two such powders daily just before eating. B Acidi hydrochlorici............................................ 1 Aqua destillata............................................... 120 M. S. Teaspoonful in a little water after meals. TT —Hayem. 304 the practitioner's manual. To control the frequency of convulsions : R Infus. adonis vernalis fol. ( 3 ss. -i. : § vi.)............... § vi. Potassii bromidi........................................ 3 ij- — iij. Codeina................................................ gr. ij. — iij. M. S. One to two teaspoonfuls in water four times daily. —De Bechterew. Or- R Antipyrin.................................................. 3 b Ammonii bromidi......................................... 3 iiiss. Strontii bromidi............................................ 3 b Liq. potassi i arsenitis....................................... TU xl. Ext. solani Carolinensis.................................... 3 xss. Aqua...............................................q.s. ad 3 vi. M. S. A dessertspoonful or more twice daily. Borax is not to be compared to the bromides in efficacy for most cases and in large dose has the disadvantages of producing abuminuria, dryness of the skin, and eczema-like eruptions with dryness and loss of hair. In giving borax begin with eight to fifteen grains, daily. If the attacks are not influenced by the time a daily dose of 120 grains has been reached, no benefit is to be obtained.—Mairet. Bromides should be continued after apparent cure. Fre- quent baths may prevent skin complications.—Fere. Senile epilepsy due to cerebral circulatory disturbances origi- nating in heart or blood-vessel disease does not improve under the bromides but usually under small doses of digitalis.— Naunyn. Reflex epilepsy can often be completely cured or markedly benefited by the relief of eye strain. Epilepsy should not be treated with drugs until a very careful and intelligent search has been made for all reflex causes.—Ambrose L. Ranney. To Prevent the Spasm.—If the attack is preceded by a warn- ing an attempt may be made to ward off the fit by giving some sudden shock—placing the feet at once in hot water; giving inhalations of ammonia or nitrite of amyl; or shutting off the circulation for a time in one extremity. f epilepsy. 305 In irritable patients as well as in those who suffer from depression, when bromides alone do not give results add: R Opii........................................................ gr. xv. Ft. pil. No. xxx. S. One three times daily and increase by one pill each day until a daily dose of 30 pills or 15 gr. is taken. After this stop opium and give mixed bromides. Repeat at intervals of two or three months. Skilled nursing and careful attendance are essential.—Flechsig. To abort an attack: R Nitroglycerin.............................................. gr. ^ Aqua destil................................................ TTI x. M. S. Inject hypodermatically. In putrefactive fermentations, intestinal antiseptics and laxatives.—J. Allison Hodges. Nitroglycerin, gr. -g-1^, given at shorter intervals than the bromides. When toleration becomes established it should be stopped for one or two weeks.—Spitzka. Nitroglycerin, gr. yA-g-, given eight times daily controls the restlessness and temper as well as the motor phenomena.—J. G. Kiernan. ]$ Bromide of potassium.................................... 100 parts. Tincture of calabar bean.................................. 35 " Water...................................................470 " Give 3 iv. increased to 3 vi. and finally to § i. daily. —POULET. Bromide of potassium may be given in daily dose reaching as much as twenty grams. Bromism may be prevented by: R Potassii bromidi............................................... 3 S8. Beta naphthol................................................. gi, Sodii salicylatis............................................... t>ss. for each dose, which is considered curative as well as preven- tive.—Fere. The addition of arsenious acid, gr. ^-, tends to prevent eruptions. —Keller. 20 306 the practitioner's manual. Strontium bromide is less likely to produce acne, but it has less effect upon the convulsions.—Wood. Bromides have been abandoned as unnecessarily severe at the Buffalo State Hospital. Their good effect is merely tem- porary. Milk diet, exercise, immediate relief of symptoms of constipation and rest to the digestive organs constitute the ap- proved method.—Percy Bryant. In auto-intoxication the regulation of the diet, frequent drinking of hot water, occasional flushing of the large intestine, the use of intestinal antiseptics, are all indicated. Tincture of simulo, 3 Ii.—3iii. t.i.d., deserves trial.—Frederick Peterson. In petit mat, to transform into grand mal and improve men- tal and moral sphere, convulsives—picrotoxin, belladonna.— Pierret. As an adjuvant: R Zinci oxidi............................................... 0.10 cgm. Pulv. Valeriana.......................................... 0.10 " Pulv. belladonna......................................... 0.01 " Sapon. medic............................................. q. s. M. S. To make one pill. Take four daily. R Ammonii bromidi............................................. 3 vi. Antipyrin.................................................... 3 b Liquor, potassii arsenitis...................................... 3 i- Aqua mentha piperita....................................... § vi. M. S. 3 ss. in water night and morning. —Wood. In status epilepticus, chloral hydrate, gr. xl.-lxxx. Caution.—While chloral is a powerful sedative upon the whole vascular system and especially upon the heart, it cannot but be productive of great harm in very large doses. The following is used at the Craig Colony, after which few seizures are noted: R Tinct. opii deodorata......................................tUv. Potassii bromidi.......................................... gr. xxv. Chloral hydrat............................................ gr. xx. Liquor morphina sulphatis (U. S.)........................ 3 i. M. S. One dose ; repeat in two hours if necessary. —L. Pierce Clark. EPILEPSY. 307 When not contraindicated by cardiac weakness, to produce sleep, hyoscine hydrobromate, gr. yfg- - -^. —Trowbridge and Mayberry. R Potassii bromidi............................................. 1 ss. Tinct. belladonna............................................ 3 iij. Tinct. simulo...........................................q.s. ad § iv. M. S. 3 b t.i.d. p.c. in water. —Peterson. R Potassii bromidi, Sodii bromidi, Ammonii bromidi, Potassii iodidi, Potassii bicarbonatis..................................aa 3 ij. Tinct. digitalis...............___....................... 3 ij - — 3 iv. Liq. potassii arsenitis................................... 3 ij- Infus. calumba...................................q. s. ad §" xij. S. Half a tablespoonful after dinner, supper, and at bedtime. —J. W. Fowler. When iron produces cerebral congestion, medullary glyceride. R Potassii bromidi............................................. § ij. Ammonii bromidi........................................... § i. Ammonii carbonatis....................................... gr. xl. Aqua..............................•......................... 1 xiv. M. S. 3 i. t.i.d. with three on retiring. —Carpenter. R Sodii bromidi, Potassii bromidi, Ammonii bromidi.........................................aa 3 iij. Potassii iodidi, Ammonii iodidi..........................................aa 3 iss. Ammonii carbonatis........................................ 3 i. Tinct. calumba..............................................§ iss. Aqua................................................q.s. ad § viij. Dissolve and mix. Dose, 3 iss. before meals, and 3 iij. at bedtime. —Brown-Sequard. R Strychnina sulphatis......................................... gr. i. Extr. ergota fld.....„___,.................................. = iss. Liq. potassii arsenitis....................................... 3 ij. Sodii bromidi...........................„.................... ? iss. Tinct. digitalis.............................................. 3 iij. Aqua mentha piperita................................q.s. ad § iv. M. S. 3 i. in a half-tumblerful of water before eating. —Hamilton. 308 THE PRACTITIONER'S MANUAL. When associated with irregular heart action : R Zinci valerianatis........................................... gr. iij. Extr. belladonna........................................... gr. \ Pulv. digitalis............... .............................. gr- i M. S. For one pill. Take thrice daily. —Da Costa. Diet.—Indigestion is of ten the starting-point of a paroxysm. Epileptics should eat moderately, slowly, and only at regular intervals, avoiding indigestible articles and should see to it that the bowels act freely once a day. Limit nitrogenous foods. Most epileptics do best on a diet which is chiefly vegetable. —Merson. The colony system embraces the features par excellence for the moral treatment of the epileptic: Proper food, regular habits, exercise, etc., and withdrawal from baneful household influences.—Spratllng. Trephining and removal of diseased tissue give some good results, but seem more especially applicable to traumatisms re- ceived within a few months of the epileptic manifestations. If trauma has set up changes of an irritative nature which can be localized, the only treatment is to excise with all possible speed. Nothing is to be gained by subjecting other forms to operation. After apparent cure keep up moderate doses of bromides for two or three years.—Collins. Epilepsy, Cardiac. The form of functional heart disturbance in which the pulse becomes exceedingly slow, dropping to ten beats or less a minute, with pallor followed by lividity and perhaps subnormal tempera- ture, is to be distinguished from bradycardia due to nervous dis- turbances, to cardiac disease, or to toxaemia. In the form in which the face is mottled, deep purple, or covered with ecchy- motic spots, the heart beat being excited, the diagnosis is not epilepsy, cardiac. 309 difficult, because of the absence in epilepsy of these pronounced symptoms and the fact of loss of consciousness, while in cardiac epilepsy the convulsion is not severe. Bradycardia, like tachy- cardia, may show even on post-mortem examination no cause for the unusual heart action. It is, however, probable that there exist certain changes in the cardiac ganglia to account for the marked slowness of heart action. Respiration may be di- minished and present a Cheyne-Stokes character. Differentiation is to be made from the effects of drugs, poisons, and such diseased states as are known to result in diminished heart beat. Prognosis is unfavorable for those instances associated with actual disease of the heart, blood-vessels, or brain. Recovery may follow after the heart beat has fallen to four per minute. Treatment.—In the presence of cardiac weakness the avoid- ance of all unusual efforts should be insisted upon. An impor- tant factor to be borne in mind is the condition of pseudo-death which may occur in essential bradycardia, from which the patient arouses after a time as the heart regains its activity, even when powerful drugs have been unavailing to restore its action or bring back signs of life. R Tinct. strophanthi............................................. | ss. S. Two to ten minims every two to three hours. Caution.—This is to be administered with great care. When pneumogastric irritation causes slowness of the heart beat: R Atrophia sulphatis........................................... gr. J2 Aqua....................................................... q.s. S. Inject subcutaneously, especially when dizziness and syncope are present. —Cardarelli. 310 THE PRACTITIONER'S MANUAL. Erysipelas. Erysipelas, as a rule, presents little difficulty in diagnosis. Following a rigor or a distinct chilliness, headache, general malaise, coated tongue and constipation, an erythematous red- ness appears in the neighborhood of a wound, or upon the face near the inner angle of the eyelid, or upon the nose or cheek, which, within a few hours, or a day, extends at the periphery, and the horny epidermis begins to rise in bullous formations. Erysipelas of the throat or of internal location is, on the contrary, recognized with the greatest difficulty and usually can be sur- mised only by the history of exposure to infection or possibly by the subsequent development of external manifestations of the same process. Erysipelas of the newborn has its most frequent site of origin at or near the umbilical wound, or starts, as I have seen it a number of times, from infection of a circumcision wound when this ritual procedure has been carried out among uncleanly surroundings or when the cut surface has not been properly protected. In young children any lesion of a delicate surface, and especially the lesions of varicella, furnish a favor- able starting-point for the erysipelatous process. I have ob- served a number of cases originating in the pustules of ecthyma and in the lesions of vaccination. Accompanying redness and infiltration of the skin, there are restlessness and disturbances of the digestion. The erythe- matous patch creeps with more or less rapidity, until the whole trunk, the limb, or the body becomes, little by little, invaded. Differentiation.—The presence of fever and other grave symptoms exclude erythema, eczema rubrum, and wandering oedema, which are the affections most likely to be mistaken for it. There is a condition following vaccination, spreading out over the arm and shoulder, attended with local heat, tenderness, and swelling, with limited extension into the surrounding parts, erysipelas. 311 similar to that seen in erysipelas, which I have called pseudo- erysipelas. It has seemed to me to be due to a mixed infection at the time of vaccination rather than to a subsequent infection of the wound. It is attended with fever and great restlessness. Prognosis.—An attack of uncomplicated erysipelas will terminate of itself usually within a fortnight. Relapses are, however, common, and some patients may have either yearly recurrences for several years at about the same season, or, in rare instances, an attack may come on at each menstrual epoch for a time. Chronic nasal catarrh, fistulous openings, nasopharyngeal diseases, etc., seem to predispose to recurrences and repeated attacks. In the newborn, erysipelas of the umbilical or other region is almost always fatal unless the process can be hedged in and cut short by prompt and radical measures. Treatment.—My chief reliance in the treatment of ery- sipelas at all stages and in all localities has been in ichthyol applied as an ointment of ten per cent, or stronger as a lotion, or, more especially, as an exclusive dressing made with flexible collodion and applied so as to cover the patch and an area of healthy skin beyond. In erysipelas of the nose or cheeks a fifty - per-cent aqueous solution of ichthyol is to be thoroughly applied to the mucous membrane of the nostrils, by means of a swab. This solution, recently recommended by Dr. Klotz, I have found to furnish an excellent means of applying ichthyol to the skin surface in this as in many other skin diseases. I have also believed that good results have followed in chil- dren as well as in adults the application of a tight adhesive band about the extremity, the trunk, or the head. It is applied about an inch beyond the border of the patch with sufficient pressure to impede circulation in the superficial lymphatics of the skin. This naturally can be better carried out when there 312 THE practitioner's manual. is a bony surface over which to make pressure. The Kraske method of criss-cross scarification has not, in my hands, given such results as would lead me to practise it in preference to the above method. It is, however, so highly spoken of by some that it may be given a trial. I prefer to make the incisions only in the sound skin and to cover them with a one to one-thousand solution of bichloride of mercury. R Ammonii sulphoichthyolat........................................ 1 Collodii flexil.................................................... 2 M. S. Paint on as required. R Ichthyol, Vaseline.....................................................aa 50 M. S. Apply and cover with antiseptic gauze. R Ichthyol, Water........................................................aa 50 M. S. Paint on and let dry. Renew several times daily going beyond borders of patch. R Creolin......................................................... 1 Iodoform....................................................... 4 Lanolin..........................................................10 M. —J. Koch. For internal use in adults: R Quinina sulphatis............................................ 3 ss. Tinct. ferri chloridi........................................... 3 ij. Aqua destillata........................................q.s. ad § ij. M. S. Teaspoonful in water every two hours. A paint much used at the City Hospital: R Tinct. benzoini composita..................................... § ij. Collodii flexil................................................. I i. Glycerini..................................................... 31. M. S. For local use. In erysipelas of the trunk region in which the inflammation is not deep seated and there is not much tension: R Hydrargyri chloridi corrosivi.................................. 1 Aqua destillata............................................... 5,000 M. S. To be applied by means of hot cloths to the wound and to raw surfaces. This may be still further diluted and used where there is erysipelas. 313 much tension and the surface has been denuded by bullous formation. T$ Acidi phenici........................................... 0.50 cgm. Alcohol................................................. gtt. xxv. Spiritus terebinthina.................................... 15 gm. Tinct. iodi.............................................. gtt. xx. Glycerini................................................ 15 gm. M. S. For local application. —ROTHE. Burrow's liquid as employed by Billroth: R Aluminis................................................ . 5 gm. Plumbi acetatis............................................ 25 " Aqua destillata........................................... 500 " M. S. Applied locally. Burrow's own formula: R Plumbi acetatis cryst........................................... 100 Aqua destillata................................................ 300 1$ Aluminis..................................................... 66 Sodii sulphatis................................................. 12 Aqua destillata............................................... 500 Mix the two lotions cold and let stand two days at a temper- ature of 10° C. Filter without washing the precipitate. This can be applied to extensive raw surfaces without danger of in- ducing lead poisoning. In weak and anaemic states, or when there is depression: 1$ Tinct. ferri chloridi...................,....................... § ij. S. Fifteen minims poured into one or two gelatin capsules at time of taking, to be followed by a copious draught of water. —E. F. Smith. Or, where capsules cannot be taken, ten to twenty minims in an excess of water or through a glass tube. Streptococcus antitoxin serum, q.s. Inject 10 to 20 c.c, followed in twenty-four hours by a smaller dose.—Marmorek. Caution. —Unfavorable results and even death have been attributed to the serum. R Gutta percha, Chloroformi.............................................aa 25 gm. Ichthyol.................................................... 25 " S. Paint on a thick layer extending beyond the margin of patch. —Juhel-Renoy. 314 the practitioner's manual. R Tannic acid, Camphor...............................................aa 4 parts. Spirit of ether............................................ 30 " To be applied hourly for four or five times. Or— R Ether, Camphor...................................... =.............aa 100 M. S. Apply. Or— R Acidi carbolici............................................. 3 ss. Tinct. iodi, Alcoholis...............................................aa ni xxx. Olei terebinthina.......................................... 3 b Glycerini................................................ 3 iss. M. The lesions are to be painted with this liniment every two hours and covered with aseptic tarlatan. R Plumbi carbonatis, Olei oliva...................................................aaq.s. To make a thick paint. S. Brush over inflamed parts every two or foui hours. —Baruch. Or— R Ext. jaborandi fld............................................. ^ i. Tinct. opii, Glycerini ..................................................aa § ss. M. S. Paint parts. —Claybough. R Acidi salicylici................................................ 3 ij. Make twelve compressed tablets. S. Two three times in twenty-four hours. Caution.—Not to be used when dyspnoea or cerebral mani- festations and not to be too long continued.—Hallopeau. As a tonic in all forms : R Sol. quinina sulphatis (gr. xv. in "% i.) ........................ § ij. Tinct. ferri chloridi........................................... 3 iv. Spt. chloroformi.............................................. 3 vi. Glycerini...............................................q.s. ad 3 iv. M. S. 3 i. every four to eight hours. —Carpenter. R Potassii permanganatis...................................... gr. vi. Aqua destillata....... .,,.................................. 3 vi. M. S. § ss. t.i.d. (Keep in glass-stoppered bottle.) —Bartholow. erythromelalgia. 315 For an infant one month old: R Tinct. ferri chloridi........................................... 3 ss. Acidi acetici diluti........................................... 3 ss. Liquor ammonii acetatis...................................... 3 b Syrupi....................................................... § ss. Aqua.................................................q.s. ad § iij. M. S. 3 b every three hours. —Meigs and Pepper. External applications: R Acidi carbolici............................................. 3 b Acidi oleici................................................ § b-ij. M. S. Apply at frequent intervals around (not over) the erysipelas area. —A. Jacobi. Caution.—Guard against carbolic poisoning. The first evi- dence is a pink stain on the napkin from urine, after exposure to the air for half an hour. Oleum linum, plumbum album. Mix in proper proportion to make a thin paste to be spread over the patch. In infants, especially that starting from the umbilical region: 1$ Hydrargyri bichloridi................................... 0.05 cgm. Calcii sulphatis.......................................... 10 gm. Vaselini................................................. 40 gm. M. S. For local use. —C. Paul. Give fluid extract of jaborandi, at first a dose sufficient to produce a pronounced sweat; subsequently every four hours sufficient to maintain gentle diaphoresis.—Packard. Caution.—This should be given very cautiously or not at all to children. Erythromelalgia. This condition, characterized by non-inflammatory pain and redness, usually limited to one extremity, showing hyperalgesia and increased local temperature, the symptoms increasing in hot weather, and when the limb hangs down, is presumably a manifestation of spinal or cerebral disease. It has been ob- 316 the practitioner's manual. served several times in hysterical subjects and has recently been considered by Pospeloff as a symptom of syringomyelia. It is at times associated with Raynaud's disease, and in its absence the diagnosis may be confounded with the latter, espe- cially in the second stage, when a local erythema develops. It occurs mostly in the feet, but also in the hands, while both may be affected simultaneously. It usually begins in the ball of the foot, heel, and great toe, extending to the great toe and dorsum. Differentiation is made by the mode of onset and the fact that erythromelalgia never goes on to gangrene.—Collins. Myxoedema is simulated in some of the features of particular cases, but the fact that as soon as the horizontal position is re- assumed the objective symptoms disappear wholly or in part distinguishes the condition. It is scarcely, however, to be con- founded with any other painful condition. For further differentiation, see "Symmetrical Gangrene." The two affections may at times be associated. Prognosis.—Mild cases may recover under favorable condi- tions, severe ones under treatment, while others go from bad to worse. Treatment.—A section of nerve has been excised with some benefit (musculo-cutaneous, ulnar). Massage has been recom- mended. Improvement may follow rest, cold applications, general tonic treatment. Warm or cold baths, electricity, and antipyrin.—Strumpell. Fever, Ephemeral. Febricula, or simple continued fever, occurring especially in children and lasting from one to twelve days, sometimes ter- minating at the end of twenty-four hours, is distinguished by an absence of lesion or source of irritation which can be determined. A febrile paroxysm lasting for twenty-four hours and disap- pearing completely is spoken of as ephemeral fever. If it per- fever, ephemeral. 317 sists for three, four, or more days without local affection, it is referred to as febricula.—Osler. Diagnosis is chiefly by exclusion. There is an elevation of temperature with rapid rise, which continues for an indefinite time and subsides with the occurrence of free perspiration. On the supposition that auto-intoxication or undiscoverable source of irritation exists, it has been at times called irritative fever and, when functional digestive derangement has been thought to be the cause, gastric fever. Some instances have been attributed to dentition. There is frequence of pulse, restlessness, lassitude, lack of appetite, headache, and a moderate degree of fever. Differentiation.—Catarrhal fever in children has a higher range of temperature, is epidemic in character, and of longer duration. Fellow fever in children in the tropics is to be diag- nosticated with difficulty from simple continued fevers. Prognosis is always good for speedy recovery, often by the fourth day. Treatment.—A basic formula for all febrile conditions: R Spiritus atheris............................................. 3 ss. Potassii acetatis.............................................. 3 ij. Spiritus Mindereri, Aqua camphora...........................................aa § iij. Syr. simplicis................................................ 3 ij. M. S. For adults, a tablespoonful, for children a teaspoonful every two hours. Tincture of ferric chloride may be added in scarlatina, diph- theria, and erysipelas. The reaction of spirits of Mindererus should always be slightly acid in order to make a beautiful mixture when iron is added.—J. A. Larrabee. The following powder, called by me "The Compound Anti- pyretic Powder," furnishes a safe and reliable means of reduc- ing temperature in fever without inducing collapse. R Antifebrin.................................................. gr. 3. Antipyrin, Phenacetin...............................................aa gr. ij. M. S. To be given hourly until the temperature is reduced. —L. Weber. 318 the practitioner's manual. For a child, when no etiological factor is discoverable: R Tinct. aconiti............................................. gtt. v. Potassii bromidi............................................ 3 ss. Spt. atheris nitrosi......................................... 3 ij. Mist, potassii citratis....................................... § ij. M. S. Teaspoonful every three hours. Or— R Tinct. aconiti............................................... ^l -fV Tinct. belladonna........................................... Tq, ^ Tinct. bryonia.............................................. ^ ih> Chocolate........................................q.s. for one tablet M. One every half-hour for six doses ; and then one every two to three hours, as necessary. R Phenacetin, Salol......................................................aa gr. i. For a dose. Repeat frequently until an effect is manifested. —J. M. Da Costa. When headache is troublesome and for a general sedative influence upon the nervous system, phenacetin in frequent small doses is the safest and most pleasant modern antipyretic. —C. Birnie. Fever, Exanthematic. In no class of cases is the professional man less likely to be excused for erroneous diagnosis than in the exanthemata, and still there are difficulties arising in the differentiation of measles from scarlet fever, German measles, and various skin affections, which at times most closely simulate it, and which tax the diag- nostic skill of the physician to the utmost. After an eruption is once fully established, the nurse, the mother, and especially the grandmother, feel no need of the physician's opinion. It is, however, in the very onset or in the prodromal days, when the child may be "sleeping for the measles," or may be "breeding" one of the other eruptive diseases, that the physician is expected to predict what course the disease is to take. There are certain signs and indications, which, taken collec- tively or even singly, may aid us in early diagnosis and which fever, exanthematic. o±y will surely help us in differentiating the affections from one another. There are, however, certain erythemata giving mor- billiform appearances which are being constantly added to by the introduction of new remedies. Thus, no sooner have we differ- entiated the roseola-like eruption due to iodoform than we find much the same produced by antipyrin. And scarcely have we differentiated the measles-like erythema due to some bacillary affection, like diphtheria, than a new series of observations are made upon quite similar eruptions, the result of antitoxin injec- tions. There is one point in differentiation between these proc- esses, and that is the fine dotted specks upon the hard palate present in measles and absent in the erythemas, and, as Dr. Koplik has recently pointed out, fine pearly points upon the buccal surface of the lips and between the lines of the gums are characteristic in the early stages before the eruption comes out. All of the exanthemata may have prodromal rashes of scarlati- nal form, rubeola form, or erysipelatous appearance. In measles it may occasionally resemble miliaria rubra with minute vesicles surrounded by a pink areola. According to Robet, the erythema appears about the second day of invasion. The following tabulated statement was presented in a recent lecture by Professor Rotch, of Boston: Incubation ... Prodromata... Efflorescence . Variola. 12 days. 3 days. Macules. Papules. Vesicles. Pustules. Large crusts. Larynx. Lungs. Varicella. 17 days. A few hours Vesicles. Small crusts I:;;:;:;;;: Measles. 10 days. 3 days. Papules. Rubella. 21 days. A few hours Papules. Scarlet Fever. 4 days. 2 days. Erythema. Lamellar. Kidney. Ear. Heart. Desquamation Complications and sequela. Furfuraceous. Ear. Lung. Tuberculosis. For further differentiation between these eruptive fevers and for treatment, see under the various headings. 320 the practitioner's manual. Fever, Glandular. This acute infectious disease, confined almost wholly to chil- dren, was first described as Drusenfleber by Pfeiffer in 1 ssj>. A preferable designation would seem to me to be lymph-node fever. The cause has not been definitely determined, but would seem to be an auto-intoxication from the intestinal canal. I am indebted to Dr. J. P. West, of Bellaire, Ohio, who has observed the affection most extensively in this country, for the following description. Diagnosis.—The disease usually begins suddenly, although there may have been an ill-defined malaise for from one to three days. With the onset there is headache, muscular sore- ness, marked prostration, high temperature, and often nausea. In from twelve to thirty-six hours after the beginning of well- defined symptoms there will be seen an elongated smooth swell- ing on one side of the neck near the sterno-mastoid muscle. Palpation will show this to consist of a chain of swollen lymph nodes. Twenty-four to forty-eight hours later the same will be noticed on the other side. The enlargement of the nodes increases slowly for from four to seven days, remains stationary for a brief space, when it begins to subside and disappears en- tirely in from two to three weeks. The swelling usually begins on the left side (probably owing to the proximity to the thoracic duct), is usually larger on the side first affected, may be con- fined to one side, and does not begin on the two sides at the same time. The nodes are painful and tender, and the head is held in a constrained position. Enlargment to a slighter ex- tent is commonly felt in the postcervical, axillary, inguinal, and mesenteric lymph nodes, and symptoms point to the in- volvement of the retropharyngeal, retrotracheal, and bronchial nodes. In the majority of cases the liver and spleen are also FEVER, GLANDULAR. 321 enlarged. The temperature remains continuously high; the tongue is coated; there is depression, anorexia, pain in the abdo- men, and constipation. The skin is dusky, but shows no erup- tion. There is some redness of the fauces in the minority of cases and rarely a severe angina. No other local process. After from four to seven days there is a diarrhcea with discharges of greenish mucus, fall of temperature, and general improvement. Marked ansemia and weakness continue for a number of days. Milder cases, lasting for a shorter time, are usually accom- panied by diarrhoea. Williams believes that the poison enters by way of the pharynx or tonsil, but aside from a slight redness the throat presents no signs. Differentiation.—Parotitis of irregular form is excluded by absence of salivary-gland involvement and swelling of spleen and liver, which never occurs in mumps; from scarlet fever and rotheln by lack of eruption. Prognosis.—The affection is usually mild, the glands re- suming their normal size after a fortnight. Pronounced anse- mia and weakness may persist for a variable time in some cases. Hemorrhagic nephritis is a possible complication. Treatment.—For the severe pains in the neck apply com- pressed lint spread with extract of belladonna and glycerin. Or, lint soaked in laudanum, one part, and water, four parts. R Salicin................................................... 3 ss.- 3 i. Ft. cht. No. xii. S. One every four hours. —Chas. W. Chapman. Small doses of calomel at the outset. To relieve the pain and general malaise, salophen. During convalescence, iron, and for local use belladonna ointment made with lanolin.—A. E. Roussel. For the obstinate constipation often present, calomel, gr. i-£, in tablet triturate, twice or more times daily, followed by a saline. 21 322 the practitioner's manual. For the succeeding iceakness and anaemia : R Ferri peptonati (Merck).................................... gr. xlv. Elixir calisaya............................................ 1 ij. M. S. 3 i. after each meal. For the hacking cough which may persist : R Ext. hyoscyami................................... Sacchari albi...................................... For eight powders. S. One twice daily. Fever, Hay. The onset is attended with paroxysms of sneezing, irritation of the Schneiderian membrane, smarting about the inner can- thus of each eye, somewhat similar to that of a beginning coryza, and, after a period varying from a few hours to a day or two, coryza actually begins. There is a history of the affec- tion recurring each year at the same period. There is more of a pricking sensation and irritation about the mucous membrane of the nose than in ordinary catarrhal affections. If bronchitis develops it usually is attended with a greater amount of dysp- noea and with it attacks simulating asthma. Soreness of the throat, pain in the eyeballs, lachrymation, and neuralgic pains over the brows are not infrequently accompaniments. The picture as a whole is not to be mistaken for other conditions. Treatment.—Change of residence, if possible, before the known date of annual recurrence, is the only positive prophy- laxis or cure. Make sure that the nasal passages are free from irritating obstruction. After a course of Carlsbad salts and spraying the nostrils with Carlsbad water, douche the mucous membrane with a strong solution of nitrate of silver and, as an after-treat- ment, apply: R Mentholi................................................... 3 gm. Resorcini................................................... 3 " Spt. vini diluti............................................. 14 " M. —MtJLLER. 0.04 2 FEVER, HAY. 323 (I.) Control neurotic habit. R Zinci phosphidi.......................................... gr. viij. Ext. belladonna.......................................... gr. x. M. div. in pil. No. xl. S. One pill t.i.d. Commence about three, or four weeks before hay-fever period and continue until it ends: R Zinci phosphidi.......................................... gr. vijj Acidi arseniosi...........................................gr. i. M. div. in pil. No. xl. One pill t.i.d. (II.) Correct any deviation of nasal septum, hypertrophic rhinitis, or remove polypi. (III.) Atomized solution of cocaine for the acute exacerba- tion.— Lefferts. R Eucalyptus oil.......................................... z j Glycerin............................................ z \ Tincture opium.............................................. 3 j-s Distilled water...........................................up to = vi. Use with atomizer three times daily. Or— R Liq. potassii arsenitis, Extr. nucis vomica fl., Extr. cinchona fl. (detannated)...........................aa 3 vi. Alcoholis............................................. z j j-: Syr. aurantii..........................................qs. ad 3 ^i. M. S. One to two teaspoonfuls, taken three times daily, with or after meals. —Hall. Cycling has been said to mitigate greatly the symptoms of hay fever by relieving the eye irritation and keeping off the paroxysms of sneezing. In the asthmatic stage, terpin hydrate, gr. xv.-xx.__H. J. LOEBINGER. In a lithaemic subject, forbid strawberries, tomatoes, and an excess of white potatoes, and give phosphate of sodium.—H. A. Arnold, B Camphor-menthol......................... 13 Lanolin.........................••'..'.".'."!^'!!"!!!!!!!!!""] 100 M. S. Use as a spray to check sneezing and arrest profuse watery discharge. —S. S. Bishop. 324 THE PRACTITIONER'S MANUAL. It is said that fifteen-grain doses of salicylic acid may ward off an attack. It is also said that equal parts of laudanum and spirits of camphor painted over the nasal mucous membrane are of benefit. At the onset, acid phosphate, 3 i.— 3 ii-, in a glass of water at bedtime and on awakening in the morning, then a three- days' course of salicylate of sodium. In very obstinate cases : R Morphina..................................................gr. -| Atropina................................................... gr. ^ Repeat in one or two hours if hydrorrhcea and sneezing are not relieved.—Bishop. R Mentholis.................................................. gr. xx. Olei amygdala dulcis...................................... 3 ij. Acidi carbolici............................................. TTLx. Cocaina hydrochloratis................................... gr. vi. Ung. zinci oxidi........................................... § ss. S. Apply thoroughly to the nostrils on cotton attached to a toothpick. —Frederick G. Smith. R Zinci valerianatis........................................... gr. i. Pil. asafcetida co........................................... gr. ij. M. ft. pil. No. 1. S. Two or three times a day. —McKenzie. R Cocaine, Menthol......................................................aa0.5 Boric acid, Powdered acacia.............................................aa 5 S. Use as a snnff. Or— R Camphor.................................................... gr. x. Boric acid................................................... 3 i. S. Use as a snuff. First, I cleanse the nasal mucous membrane with an alka- line solution. I then apply to the sensitive areas, by means of cotton pledgets, an eight-per-cent cocaine-phenate solution, keeping this in contact with the parts for at least ten minutes, followed by a spray of a solution of the same strength. The result was diminution of the hyperaesthesia, lessened congestion. fever, hay. 325 and relief of the constant coryza and sneezing that are so annoy- ing in these cases. The treatment failed to benefit the cases in which there was marked hypertrophy. I then removed the thickened membrane, and the result was a partial relief. In cases characterized by reflex asthmatic symptoms an eight-per- cent spray of cocaine was used with most marked effect.—Kyle. R Chloroformi, Acidi carbolici, Camphora............................................aa aq. part. M. S. Inhale. —Fairman. R Tinct. aconiti radicis........................................ 3 iss. Glycerini................................................... 3 iiss. M. S. Apply to the nose. —Ringer. R Camphora................................................... 3 v. Ether, sulphurici............................................. q. s. Dissolve to the consistence of cream, and add : Ammonii carbonatis......................................... 3 iv. Pulv. opii................................................... 3 i. M. S. Apply. Keep tightly corked. —George M. Beard. 1$ Quinina sulphatis.......................................... gr. vi. Aqua camphora............................................ § vi. Sodii chloridi............................................... 3 ss. Aqua....................................................... 5 iv. M. S. Use in an atomizer or snuff from the hand. —R. P. Lincoln. R Belladonna fol............................................ gr. ix. Hyoscyami fob, Stramonii fol...........................................aa gr. ivss. Phellandrii aquatici fol................................... gr. iss. Opii ■ • • •,................................................. gr. i Make two cigarettes by rolling in paper. Only two to be used during an attack. —Morrill Wyman. R Chloralis, Pulv. camphora........................................aa gr. xvi. Acidi carbolici........................................... 3 i. Morphina............................... ................ gr. xij. Acidi oleici............................................... gr. vij. Olei ricini................................................. 3 vij. M. Rub well together to make a lotion. Apply by means of a little ivory or hard-wood plug to the interior of the nostril. —Horace Dobell. 326 THE PRACTITIONER'S MANUAL. R Hydrarg. chloridi corrosivi..........................,..... gr. \ Quinina hydrochloratis.................................... 3 b Acidi carbolici ........................................... gtt. xx. Glycerini................................................ad § i. M. S. Apply by means of camel's-hair brush. —Sir Andrew Clark. R Potassii iodidi................................................ 3 i. Liq. potassii arsenitis......................................... 3 b Aqua........................................................§ iv. M. S. Teaspoonful every four or six hours. R Tinct. iodi.................................................. 3 b Acidi carbolici............................................. gtt. x. Aqua destillata............................................ 1 iv. M. S. Apply locally with a postnasal syringe. —Roberts Bartholow. For the hydrorrhoea, cinchonidine, gr. xx., daily. R Sodii bisulphatis......................................... 1 part. Aqua destillata......................................... 500 parts. M. To be used as a lotion for nasal passages. Or the exhibition of a wash of— R Acidi acetici............................................... "rq ij. Resorcini.................................................. gr. iss. Sodii chloridi.............................................. gr. iv. Aqua destillata............................................ § i. For inhalation: R Menthol................................................... gr. viij. Chloroform............................................... tti, v. Benzol.................................................... ttj, xx. Oil of cassia............................................... HI iij. Light carb. of magnes..................................... gr. xx. Water..................................................ad 1 i. M. S. A teaspoonful is poured into a pint of hot water at a temperature of 140° F., and the vapor is slowly inhaled for ten minutes. — Wm. Murrell. Fever, Hectic. This is a form of febrile manifestation present in several con- ditions, attended with more or less prolonged suppuration. Diagnosis.—The intermissions, which are usually periodic in character, are rather distinctive, remission and exacerbation oc- FEVER, MALARIAL. 327 curring daily, sometimes twice in twenty-four hours. More or less profuse sweating makes a part of each paroxysm. If it has been at all prolonged, loss of weight is an important diagnostic feature. It is the usual accompaniment of advanced phthisis. A typical hectic fever means a pyogenic intoxication. Treatment.—From a physiological and therapeutical stand- point the drugs most immediately indicated are strychnine and atropine. When hyperpyrexia is insignificant, but the chill, sweat, and prostration are the prominent features : ~S, Strychnina sulphatis......................................... gr. i Atropina sulphatis.......................................... gr. -fa Extr. gentian................................................ q.s. M. etft. pilulas No. xii. S. One t.i.d. When all the symptoms are present: 1$ Strychnina sulphatis........................................ gr. $ Atropina sulphatis.......................................... gr. ^ Antifebrin................................................... 3 i. M. etft. capsulas No. xii. aut oblat. S. One t.i.d. orp.r.n. When the sweating-stage is absent, but the temperature and prostration predominate: B Strychnina sulphatis..................................... gr. ■£• Phenacetin........................................... ... 3 ij. Caffeioa citratis......................................... gr. xxiv. M. etft. oblat. No. xi. S. One wafer t.i.d. autp.r.n. —H. S. Stark. Fever, Malarial. Malarial fevers when they present their characteristic regu- larity of recurrence, conforming to one of the well-known types, occasion little difficulty in diagnosis. This is especially true if the location is one known to be in a decidedly malarial district. When, however, symptoms of chill and fever present an irreg- ular intermittent course, neither coming up on each day, as in quotidian, nor every other day, as in tertian, nor presenting any 328 the practitioner's manual. other regularity of interval, doubt may arise. It is to be re- membered, however, that well-recognized double tertian pre- sents paroxysms in different portions of each day, but here the hours upon alternate days correspond with each other. In a general way, it may be said that the nearer the paroxysms are to each other the longer is the duration of the fever. After the first week the patient shows signs of anaemia. The Diagnosis may be confirmed in one of two ways: either by an examination of the blood, which will disclose the malarial parasite or plasmodium, or by the less positive therapeutic test of administering quinine. The distinct onset, as in adults, with chills, is never observed in infants under two years of age. Physicians practising in malarial districts frequently see chills in infants, which is contrary to our experience.—Proben. A convulsion may take the place of a chill in infants, and if repeated for several days with a distinct periodicity a clew to our diagnosis may be thus given.—Proben. The parasites are present in all forms of the disease, and constitute a diagnostic criterion of unfailing accuracy in uncin- chonized subjects. The diagnosis of the malarial fevers can be made with certainty by the blood examination. An intermit- tent fever which resists quinine is not of malarial origin. There are three well-known varieties: 1. The tertian organ- ism, which matures in forty-eight hours and produces quotidian paroxysms if two crops are present, tertian if only one. This is the parasite of common, simple, intermittent malarial fever of the spring and autumn. 2. The quartan parasite, which has a cycle of development of seventy-two hours, and if only one crop is present gives the regular quartan intermittent; if two or more crops are present, the paroxysms might occur every day or every other day. The quartan type is rare north of the Chesapeake Bay. 3. The parasite of irregular malarial fever —the remittent, continuous, and pernicious types. This variety of organism is smaller, less readily recognized, not so abundant PLATE I. ir&tpr X) &$ v •*,'.. t 10 0& 11 The Parasite of Tertian Fever. PLATE II. v^y a 10 vixpi 11 12 13 14 15- O [ • *0~r< €®1 The Parasite of Quartan Fever, representing the segmentation following the various phases of development. Reproduced by permission from Reports.. Johns Hopkins Hospital. PLATE III. 10 ixy: M 13 14 1* 16 Appearances in ^Estivo-Autumnal Fever, showing various forms of intracorpuscular organisms. PLATE IV. Flagellate Organisms. PLATE V. ^ Figs. 1 and 2.—Cresent Forms. Fig. 3.—An Ovoid Body. Reproduced by permission from Reports, Johns Hopkins Hospital. fever, malarial. 329 in the peripheral circulation, and in pernicious forms might select curious sites, as the brain or mucosa of the intestines. It is further characterized by the development of crescents—a fact of greatest moment in diagnosis.—Osler. Microscopic Diagnosis of the Three Species of Parasites. Tertian. Quartan. ^Estivo-autumnal. Large size. Smaller size. Smallest size. Pale, but pigment very ac- Pigment coarser, abun- Less pigment. tive. dant. 12-80 segments. 6-12 segments. Generations overlap. Abundant flagella. Often ring shaped. Spores, largely in spleen Spores in blood every- Spores in spleen and mar- and marrow. where. row. Form crescents. Active amoeboid motion. Less active. Less active. Red discs large and pale. Small and pigmented. Shrivelled and " brassy." —Wm. L. Thompson. Differentiation.—In malaria the fever is intermittent from the start; not so in other fevers. In hectic fever of phthisis with its succeeding sweats there is a close resemblance to intermittent fever in which the chill has been overlooked or possibly omitted. Suitable tests upon either side of the question will dispel doubt. Septicaemia and pyaemia or suppuration may all be ushered in with chill, fever, and sweat, and for a brief period lead into error. Likewise hepatic disease and gall stones may present symp- toms which might be referred to a malarial origin. In chill and fever following the use of instruments in the urethra we have this history to point to the origin, while in so-called nervous chill there is less elevation of temperature. To examine for the Plasmodium a small drop of blood, freshly drawn by pricking the lobule of the ear and placed upon a thor- oughly clean slide and covered with an equally clean cover glass, is examined at once by the aid of an oil-immersion lens. The protozoon in its various stages of development and varying forms dispels the doubt which may have surrounded any obscure 330 the practitioner's manual. case. Fix the specimen by placing in equal parts of absolute alcohol and ether for at least two to three hours. As a staining-fluid: R Methyl blue (concent, sol.).................................. 1 part Ale. sol. eosin (one per cent)................................ 2 parts The haemoglobin of the red corpuscle is stained red, the eosinophile cells a deep strawberry red, and the ordinary leu- cocytes and malarial parasites blue.—Kilroy. The autumnal fevers of the Southern Atlantic States, recently studied by Bedford Brown and others, have often been con- founded with typhoid. This fever prevails annually from July until October, or until the temperature falls to 32°. The pro- longed form differs widely from the acute by having a much more gradual rise of temperature, and when the adynamic stage is reached it may mark as high as 106°. There is also a pre- monitory stage in which the general health and mental activity decline. An Easy Method.—The straight edge of a half-inch strip of note paper is to be drawn through the drop of blood. The edge is then quickly drawn across the clean cover glass held at nearly right angles, before the blood has had time to dry. Mount dry by gumming to the slide with strips of thin paper.—MacLeod. Crescents are found only in the aestivo-autumnal forms.— Edwards. There are also neuralgic pains in the limbs, back, and head, often mistaken for muscular rheumatism. The temperature curve in some cases of prolonged malarial fever resembles so closely that of typhoid that other signs have to be relied upon. The importance of microscopic examination is well illustrated by Dr. W. W. Eussell, in speaking of this mode of differentia- tion from surgical fevers. An instance is related of a patient who presented herself to the surgeon, complaining of pain in the lower abdomen with chills and fever. Examination revealed a mild pelvic peritonitis, for which the tubes and ovaries were at fever, malarial. 331 once removed. The patient, however, continued to have her chills and fever; the latter reaching 107° and being attended with collapse. The blood was now examined, as it should have been before operation, and the Plasmodium was found in abun- dance. Quinine would have cured the symptoms and preserved the adnexa. For one reason or another the parasite is not to be found in every instance of supposed malaria and enlargement of the spleen, and other symptoms will have to serve as the basis of diagnosis. In children the remittent type is that usually mistaken for typhoid, but it is the tertian, according to J. Lewis Smith, which usually predominates after the eighteenth month of life. The chill is usually absent, but it may be replaced by a convulsion. If this is repeated several times with a distinct periodicity, it points rather strongly to a malarial origin. Splenic enlarge- ment, which is rather frequent in infancy, is more often due to other causes than to malaria. These include rachitis and syphilis. Before making the diagnosis of surgical fever after operation, be sure that malaria is excluded by an examination of the blood. —W. W. Eussell. From septicaemia, by the period of fever extending over about twelve hours in malaria, while in septic conditions it varies from six to twenty. Further points are the absence of haema- tozoa, resistance to quinine, and presence of leucocytosis. Ma- laria post partum is very often septicaemia, and I rarely see a case of abscess of the liver which has not been drenched with quinine.—Osler. In typhoid the onset is much slower than in remittent, there is much more malaise, chills are not so frequent, and the fever goes up by irregularly progressive steps, not reaching the high point seen in malarial fever by the second or third day (perhaps 106° F.). Herpes is rare in typhoid, though common in malaria, and in the latter rose-colored spots do not occur; tympanites is 332 the practitioner's manual. absent. By the end of the first week VVidal's test may confirm typhoid or blood examination show plasmodia. Having these two tests at our command, no case should remain long in doubt. Typho-Maiaria.—Typhoid resembling malaria or presenting its features may be due to the ongrafting of fever of septic origin. Neglected cases of true malaria infection may, in rare instances, fail to yield at once to quinine, and lead to the sus- picion of a typhoid element; but such cases are not and cannot be called typho-malarial fever, and a failure to resort to micro- scopic examination of the blood does not sanction a misnomer. —Gordon. In nervous chill fever is absent, as in gall-stone colic, and the initial chill following the passage of a catheter.—Osler. Prognosis.—Fatal cases are common in our Southern States and in tropical climes. In the North the prognosis is good. Prophylaxis.—For those residing or travelling in malarious districts, pure water. Quinine, gr. v., in solution may be taken daily over prolonged periods. For a brief stay this dose may be increased.—Thin. To be given after the paroxysms have been arrested : R Tinct. iodi, Tinct. ferri chloridi, Tinct. sanguinariaa...................................aa equal parts M. S. Gtt. xiii.-xv. after each meal. —Carpenter. In obstinate forms: R Ferri ferrocyanidi, Pulv. guaiaci resina?........................................aa 3 i. M. et ft. chart. No. xii. S. One powder thrice daily. —Ellis. For rectal injection : R Quininae bisulphatis........................................ gr. xv. Acidi sulphurici diluti..................................... q.s. Aquae.............................................. q.s. ad § ij. M. S. Inject. Warburg's Tincture.—The following formula of this famous tincture, as given by Dr. Warburg himself, contains: fever, malarial. 333 Socotrine aloes, 12 oz.; rhubarb, angelica seeds, confect. Damocratis, of each 4 oz.; elecampane, saffron, fennel, prepared chalk, 2 oz.; gentian root, zedoary root, cubebs, myrrh, cam- phor, larch boletus, of each 1 oz. Digest the above in 500 fluid oz. of proof spirit in a water bath for twelve hours, then express and add quinine sulphate, 10 oz. The mixture is replaced in the water bath until all the quinine is dissolved, then cooled and filtered. Or, a simpler form: Socotrine aloes, 5 troy oz.; zedoary root, 5 troy oz.; cam- phor, 2 drachms; angelica seeds, 2 drachms; saffron, 3 drachms; quinine sulphate, 3 troy oz.—288 grs.; proof spirit, 9 pints. Macerate seven days; strain, press, and filter. R Quininae sulphatis..........................................gr. x. Capsici pulv............................................... gr. iij. Opii pulv.................................................. gr. i. M. S. One dose. —Alonzo Clark. In autumnal fevers, to obtain the full antidotal effect of quinine we must saturate the system promptly. To avert the adynamic stage, twenty to thirty grains of quinine in divided doses three times daily. In case of insomnia, a hypodermic of morphine and atropine. —Bedford Brow7n. R Quininae sulphatis.........................................gr. xiv. Ferri et potassii tartratis................................... gr. cv. Aquaa destillatae........................................... z jij. Liq. potassii arsenitis.....................................tti, xxiv. M. S. 3 b from one to three times daily. Or, in graver forms: R Quininae muriatici.........................................gr. XV- Sodii chloridi.............................................. gr. i8S< Aquae destillatae............................................. 3 iiss M. S. Use one-half the above quantity as an intravenous injection. —Barcelli. 334 the practitioner's manual. Or— R Quininae sulphatis........................................... gr. x. Acidi sulphurici diluti......................................m, x. Syr. aurantii................................................ 3 ij. Aquae.....................................................ad 3 i. This amount three times a day. —FOTHERGILL. Or— R Hydrarg. chloridi mitis, Pulv. ipecacuanhas et opii...............................aa gr. iv. Quininae sulphatis......... .............................. gr. xvi. For four pills. Two to be given at bedtime and two the following morning. —Claiborne. For malarial and also uric-acid conditions : R Quininae sulphatis, Hydrarg. cum creta.....................................aa gr. xvi. M. et ft. capsulas viii. S. Two capsules each night at bedtime, followed by two drachms of epsom salts in a glass of hot water before breakfast. —H. P. Loomis. In gastric catarrh or the gastro-hepatic symptoms of lithae- mia, precede the specific treatment of malaria by a short course of broken doses of calomel, and it may be necessary to give quinine by suppository or subcutaneously.—Daland. In malarial cachexia, in addition to eight grains of quinine in capsule on an empty stomach morning and evening: R Liquor, arsenici chloridi................................... gtt. v. Tinct. ferri chloridi....................................... gtt. xx. Elixir, Aquae............................................aa q.s. ad 3 i. M. To be taken three times a day, after meals. —Da Costa. If the heart is feeble or arrhythmic : R Digitalin (cryst.).............................................. 1 Aquae.......................................................... 1000 M. S. Gtt. xv., to be followed by oxymel of squill and salts of potassium. —VlDAL. In hepatic involvement: R Strychninae arseniatis..................................... 0.30 gm. Sterilized vehicle...................................q.s. ad 100 c.c. M. S. Inject every other day. FEVER, MALARIAL. 335 Each syringeful contains three milligrams of the arseniate. R Quininae lactatis........................................... 20 gm. Antipyrin................................................. 20 gm. Aseptic vehicle......................................q.s. ad 100 c.c. M. S. Inject also every second day. Each syringeful contains 20 cgm. quinine salts and 20 cgm. antipyrin. Also a daily cold douche.—Roussel. In anasarca of malarial origin : R Compound spirit of juniper................................... O i. Sulphate of iron.............................................. 3 ij. Acetate of potassium.......................................... 3 ss. Fluid extract of digitalis...................................... 3 ij. Syrup of squill................................................ | ss. Dose, a tablespoonful three times a day. In severe cases the patient is to drink also a cold infusion of elder root.—Mullone. In children: ~Bf Ext. helianthi annui ale. (sunflower).......................... gr. \ S. In the twenty-four hours. This gives satisfactory results.—Moncorvo. Or— R Quininae sulphatis........................................gr. xxiv. Acidi sulphurici diluti................................... gtt. xxx. Syr. zingiberis, Syrupi, Aquae..................................................aa I i. M. S. 3 b three or four times daily, according to the age. —Meigs and Pepper. Or— R Tinct. eucalypti globuli, Alcoholis...................................................aa 3 ij. Quininae hydrochloratis...................................... 3 gs Quinoidinae.................................... ~.-x Acidi hydrochlorici....................sufficient to make a solution. Dose, from 20 to 40 drops five times a day. —Zuckermann. In malaria in infants, when malnutrition progresses in 336 the practitioner's manual. spite of continued small doses of quinine and perhaps of diluted hydrochloric acid: R Liq. potassii arsenitis.......................................... 3 ss. Tinct. ferri malat........................................... 3 ij. M. S. Five drops three times daily for a child of three years, and increase one drop per diem until forty drops are taken in twenty-four hours. The dose is then to be diminished drop by drop. Caution.—Arsenic is contraindicated when there is gastric complication. Change of locality is then demanded.—Feucht- wanger. Disguise the taste of quinine by combining with chocolate. For hypodermic injection : R Quininae hydrochloratis.................................... 1 part. Aquae destillatae.......................................... 4 parts. M. With proper precautions the injections are not followed by abscesses. Or, quinine may be given in enema; the quantity of solution should not exceed one ounce.—Binz. When improvement has not occurred under quinine and arsenic, methylene blue, 0.25 cgm., three times daily. To reduce temperature, external application of creosote and guaiacol (ni xv.). When quinine cannot be given by the mouth: R Quininae sulphatis.......................................... gr. xv. Acidi hydrochlorici.....................sufficient to make soluble. Aquae dest.................................................. 3 i. M. S. Inject twenty minims into the cellular tissue of back or forearm, followed by gentle rubbing to aid in diffusion. —Benson. Caidion.—This quantity of acid might cause inflammatory reaction. When quinine treatment has not succeeded: R Tannin.................................................... 4 gm. Sweetened water.......................................... 150 " Give one-quarter part every two hours, fasting, but with abundance of fluid between the doses. On the third and sixth days two doses are given. —Alix. fever, malarial. 337 Or— R^ Quinine muriate............ .............................gr. xlv. Antipyrin................................................ gr. xxx. Distilled water........................................... 3 iss. M. Boil the water in a clean test tube, and add the ingredients ; filter while hot through sterile paper. S. Inject from fifteen to thirty drops, and repeat if necessary. —E. J. K.EMPF. Or— IJ Olei terebinthinae.............................................. 3 i. Syrupi........................................................ 5 > j. M. Add four ounces of water while stirring, let cool, strain, and give in teaspoonful doses. —Brodnax. To cleanse the chylopoietic system: R Podophyllin................................................. gr. i. Leptandrin.................................................. gr. ij. Iridin...................................................... gr. i. Ext. nuc. vom............................................. gr. i. Capsici...................................................... gr. i. M. ft. pil. xl. S. One or two three times a day. —Kempf. In giving quinine give enough. Sixty grains daily or ten every four hours will arrest an attack in seventy-two hours or less. Thirty grains daily in three-grain doses will prolong it to five or six days. Ten grains every eight hours will have more effect on the germs than two grains every hour, and will not make the patient so nervous. In swamp regions the dose for a child between the ages of one day and eight years is five grains.—Bedford Brown. Ear buzzing may be controlled to a large extent by simul- taneous use of small doses of atropine.—Aubert. In malarial hcematuria, prevent by giving quinine in re- quisite amount at the proper time. When the kidneys are not acting well it is very hazardous not to administer quinine.—Sears. Keep the bowels open with calomel followed by salts, use hot mustard baths, and administer the following combinations in alternation every three hours: 22 33S the practitioner's .manual. R Spirit, terebinthina?......................................... 3 ij Acidi carbolbi............................................ Ki". \. Potassii chloratis............................................ 3 iij. Spirit, lavandnlae comp...................................... 3 ij. A caciae gum................................................ 3 iij. Aquae menthae piperita?...............................q.s. ad § iv. —J. E. Long. Or— R Sodii byposulpbit.............................................. 3 b Give in water. Repeat every two hours until thorough purgation, then con- tinue in smaller doses. Quinine not only fails to arrest, but ag- gravates every symptom and adds to the mortality.—Meek. Or— R Quininae sulphatis............................................ 3 i- Tinct. ferri chloridi........................................... 3 v. Liq. acidi arseniosi........................................... 3 iss. Potassii chloratis........................... ............... 3 b Syr. zingiberis.........................................q.s. ad 3 iv. M. S Teaspoonful in water thrice daily, after meals. —Guice. In bilious remittent malarial infection, rectal injections of carbolic acid. • Hypodermics of quinine. For the profound nervous depression: R Sodium arseniate........................................... gr. iij. Strychnine sulphate........................................ gr. iss. Distilled boiled water....................................... 3 xss- M. S. Teaspoonful as required. —Pepper. Simple intermittent in adidts : R Massae hydrargyri.......................................... gr. x. Ext. hyoscyani i............................................ gr. v. Quininae sulphatis.......................................... gr. xx. M. ft. pil. No. x. S. One every hour during the afternoon, to be followed by salines in the morning. —E. J. Kempf. In pernicious malaria, a very fatal form, supposed to be due to greater intensity of action of the parasite, or, what is more likely, to greater susceptibility, quinine hypodermatically. FEVER, miliary. oo.) To check recurrent paroxysms: R Pil. ferri carbonatis................................... Ac. arseniosi......................................... Quininae sulphatis.................................... M. ft. capsulas No. xx. S. One capsule three times a daj Or— R Quininae sulphatis............. Liq. potassii arsenitis.......... Tinct. ferri muriatici.......... Syrup, zingiberis............... Aquae destill................... M. S. Dessertspoonful after meals Fever, Miliary. Sweating-fever occurs in epidemics, in which the attack be- gins with lassitude and distress in the region of the stomach, followed in from twelve hours to several days by profuse perspi- ration, debility, restlessness, and occasionally muscular cramps and delirium. On or about the fourth day, an eruption appears as the symptoms abate. This consists of a measles-like erythema occurring in crescentic patches, or it may resemble more a scar- latin if orm rash. Diagnosis.—The diagnostic feature, however, is the occur- rence of miliary papules changing into vesicles, which rupture and discharge and are followed by desquamation. The vesicles are so minute that at first they can be felt better than seen, until later on, when they increase in size and the contents be- come turbid. The vesicles appear usually first upon the chest and neck, subsequently invading the trunk and extremities. Convalescence beginning about the tenth day is usually pro- longed and accompanied by anaemia. Prognosis for mild cases is good, while in epidemics of severe type the mortality may be high (33 per cent). Treatment.—For the sweating, atropine sulphate, gr. y^, by the mouth or hypodermatically. For the precordial distress, anodynes. 3 b gr. i ....... 3 ss. ....... 3 iss. ....... I ss. ....... 3 iss. q.s. ad 1 iv. 340 the practitioner's manual. Fever, Relapsing. This epidemic affection has a period of fever of from five to seven days' duration; then comes an intermission of a week fol- lowed by a relapse lasting three days. During the incubation, which may occupy as much as eight days of lassitude and tran- sient pains, the diagnosis is not suggested except at times of epi- demic prevalence. The incubation includes one or more chills, frontal headache with dizziness, pains in the back and extremi- ties, and prostration, in the presence of a temperature which may reach 106° on the first or second day. The face is flushed, the tongue is coated, the bowels are constipated; nausea and vomit- ing may also be present. While the crisis usually occurs upon the fifth, sixth, or seventh day, it may be as late as the tenth, when the temperature, previously as high as perhaps 10S°5 falls at once to normal or to a subnormal point. All the symptoms subside in a strikingly abrupt manner, their disappearance often being attended with sweating. In the relapse the temperature may go even higher than before. Diagnosis.—The spirilla of Obermeier are constantly present in the blood during the parox}7sm. These are slender, wavy spirals, measuring from 16m to 40a, staining with Loffler's blue (alcoholic solution of methyl blue, 30 c.c. ; 1-10,000 solution of caustic potash, 100 c.c.) or other aniline colors. This serves to distinguish the affection from typhus, since both diseases develop under similar conditions of faulty hygiene. Relapsing fever has, however, no peculiar eruption and the sensorium is rarely much disturbed, the patient being but slightly affected with stupor. Differentiation.—In yellow fever temperature is lower, pulse slower, jaundice more marked, and the eye has a "fiery appearance." Remittent fever shows a regular remission; there are no pains in the muscles and joints as in relapsing. It has no re- lapses and no crisis. fever, simple continued. 341 In dengue, the remission occurs on the third or fourth day; the joints are swollen, and the glands enlarged and tender. An eruption also appears in the relapse. Typhoid is excluded by finding spirilla in the blood. The course of the first paroxysm may closely resemble a short typhoid. Exanthemata resembling roseola, purpura haemorrhagica, urticaria, herpes, measles, and scarlatina were observed in eight per cent of Loewenthal's cases. A parenchymatous glossitis has been observed as a rare com- plication in a case ending fatally. Prognosis.—Mortality ranges from four to eighteen per cent. Treatment.—To relieve muscular pains, antifebrin, phena- cetin. or antipyrin. As a roborant, quinine. It will, however, not prevent the relapse.—Tyson. Or, opium hypodermically or by the mouth. For the wakefulness, chloral, trional, sulphonal. For the fever, cold baths. For collapse, alcohol, strychnine, digitalis.—Wood and Fitz.s Fever, Simple Continued. In the protracted form of simple continued fever the ther- mometer records a point sometimes as high as 103° F. There is a slight morning remission and evening rise. In the so-called thermic fever of Southern States there is much nervous excite- ment and also sleeplessness. It lasts from two to six weeks, and sometimes longer. Diagnosis is chiefly by exclusion, since there are no charac- teristic symptoms. Differentiation.—The chief distinction is to be made from typhoid fever in its irregular form by the absence of eruption and of most of the typical symptoms of typhoid; when the spleen is enlarged and the resemblance to typhoid is otherwise close, the Widal test or the element of time will settle the point. 342 THE PRACTITIONER'S MANUAL. From malarial fever by the absence of the plasmodium and of any decided intermission, and by the fact that antiperiodics are without effect. It is furthermore to be distinguished from lithsemia in its febrile state. From influenza by its not occur- ring in epidemic form, and by the fact that more than one person in a family is rarely affected. Catarrhal symptoms, if any, are very slight and there are no deep-seated pains. Prognosis.—Fatal cases occur, as a rule, only when the fever is due to some definite infection. Treatment.—The treatment of prolonged simple continued fever is purely symptomatic. Quinine has no effect and ordi- nary antipyretics here only a temporary influence.—Da Costa. Antipyretics may be given to relieve headache, but they may prove harmful if given in large dose with the view of reducing temperature.—Birnie. Fever, Typhoid. It is only during the first week of enteric fever that the diagnosis presents difficulties. The same chilliness, mental sluggishness, and muscular weakness, are complained of as occur in other febrile conditions. It is only when the temperature goes a little higher each night, nose-bleed occurs, and the spleen can be made out to be enlarged that the diagnosis is established with any degree of positiveness. This can always be ventured with greater confidence if it is known that the disease is prevalent in the neighborhood. Diagnosis.—In the first week the fever is the only constant indication, and this may be attended with evidences of bron- chitis tending rather to mislead. Persistent frontal headache, if present, should be a cause for suspicion. Tenderness in the right iliac fossa is a sign of much value, especially when attend- ed with prostration and loss of appetite out of proportion to the febrile signs. The expression is dull or apathetic. The fever, typhoid. 343 tongue is covered with a thick white or creamy fur, which sub- sequently becomes more of a yellowish-brown, and the breath has a peculiar mouse-like odor. While the tendency to diar- rhcea is quite constant it is not wholly so, and when accom- panied by distention from gases, and a distinct gurgling-sound and sensation beneath the fingers occur upon pressing firmly in the right iliac region, the strongest suspicions are aroused. The discharges are best described by the familiar terrn of "pea- soup" stools. Movement of the bowels is not painful. The temperature in a mild case is more apt to be below than above 103°. In the second week of a mild attack it goes slightly above 104°, being higher each evening and down again in the morning. When the eruption is present it is strikingly char- acteristic, and is usually sufficient to decide the question or con firm a doubtful diagnosis. The lesions consist in isolated, slightly elevated, rounded or oval-formed papules, varying in size from 1 to 4 mm. The color is distinctive in being of a rosy or pink hue. If traction is made upon the skin alongside of a lesion, the color momentarily disappears. There are successive crops, the duration of each papule being four days at the most, and it may be followed by faint pigmentation. The eruption is rarely present before the end of the first or beginning of the second week. Enlargement of the spleen comes.earlier. Per- cussion over the lefthypochondrium may give a palm-sized area of dulness. Dr. Baruch says that resistance of the rectal tem- perature to a bath with friction, at 75° for fifteen minutes, is almost a sure test for typhoid fever. If a bath gradually cooled from 90° to 75° fails to reduce the rectal temperature two degrees in one-half hour, the diagnosis of typhoid fever is almost certain. Eisner's culture test is based on the fact that the Eberth bacil- lus alone grows upon the medium (potato-gelatin to which one per cent of iodide of potassium is added). This, as well as Pfeiffer's serum test, is open to objection as a working method. The Widal test accomplishes much more satisfactory clinical 344 THE PRACTITIONER'S MANUAL. results. It is of clinical value, although certain chemical agents produce like results. The test is based upon the theory that the blood of typhoid subjects contains some substance incompatible with the life of the bacillus typhosus when brought into contact with it. This is said to appear in the blood in from four to seven days after the onset of clinical symptoms. The bacilli group themselves into clusters and their active movements be- come arrested. Dried blood may be utilized in the test; a drop is sufficient. No special apparatus is required. The move- ments of the bacilli can be seen with an eighth objective. A recent broth-culture can be obtained from a bacteriologic labora- tory. The simplest way of testing is to prick the finger pulp and suck 3 c.c. of the patient's blood into a hsemocytometer tube (\ c.c. will suffice). Blow out and allow to clot. Add the serum to 10 c.c. of bouillon cultivation of Eberth's bacillus. In about twenty minutes the microscope will show the characteristic aggregation of the microbes if typhoid fever be present.— Widal. Caution.—In order to avoid mistaking a normal agglutina- tive reaction for the typhoidal, a dilution should be used such as is not known ever to give a reaction with non-typhoid blood. The negative result of a preliminary test with equal parts of serum and culture suffices to exclude typhoid. If positive, a low dilution (1 in 10) may be used.'—Wm. H. Welch. The serum diagnosis, as first applied by Widal, is by no means a positive one. The serum reaction is not a specific one, and it has certain limitations which might lead to false conclu- sions. The culture should be of high and known degree of virulence and the bacillus actively motile. One should dilute in the proportion of 1 to 10; higher dilutions do not show any special advantages. The absence of a reaction does not exclude the diagnosis of typhoid fever. Much the same results are given by the dried and the fluid serum. The serum is first procured fever, typhoid. 34.J by cantharides blister. An expert bacteriologist is required to make the test.— Guekard. Absence of agglutinations excludes the diagnosis of typhoid. Complete and permanent agglutination does not with certainty signify typhoid, since the reaction may take place when the ty- phoid has already run its course.—Gerloczy. In children a mild form of fever with perhaps slight cough is often typhoid without characteristic clinical symptoms. It may last not over nine days or for several weeks. Quinine does not affect it favorably.—J. L. Smith. It is rare under two years of age. The remittent secondary stage is absent in over fifty per cent, but relapses are frequent. Constipation is more common than diarrhoea. Tenderness is rarely marked. Hemorrhage is very rare. The eruption usually comes out earlier than in the adult. Capillary bronchitis is present in forty per cent and may mask abdominal symptoms. Meningeal symptoms are not infrequent. Albuminuria is common, but serious renal complications are rare.—J. L. Morse. Rose spots are present in sixty-six per cent. Tympanites is nearly always present to a slight degree and also gurgling. Tu- berculous meningitis is excluded by the regular breathing and pulse, unsymmetrical or abnormal pupils, stupor rather than de- lirium, and convulsive movements. Pneumonia develops more rapidly. Simple diarrhoea and enteritis are not accompanied by fever. In typhoid the stools are painless and not green. Measles and typhus have larger spots, and variola likewise has the eruption by the fourth instead of the eighth day. — W. L. Stowell. Differentiation.—The rather characteristic range of tem- perature, especially when taken along with the rosy papules, nose bleed, diarrhoea, and dulness of expression will leave no doubt concerning cases at all typical. Those which simulate 340 the practitioner's manual. malarial fever, especially as it occurs in subtropical regions, those which simulate cerebro-spinal meningitis, or those which suggest pneumonia or generalized tuberculosis as well as con- cealed suppuration, spoken of by Tyson, will be distinguished if the various tests now at our command are carefully applied. Typhus fever shows no abdominal symptoms and the eruption which occurs is macular, larger, of duskier hue, and subse- quently becomes petechial. Certain instances of appendicitis simulate typhoid, but the local symptoms and abdominal tender- ness are all much more acute. In meningitis the patient, in- stead of being apathetic, its restless and irritable; vomiting also occurs and the temperature varies within a wider range. Among other conditions which at times simulate typhoid and are mistaken for it are to be included lumbricosis, trichinosis, uraemia, salpingitis, influenza, gastritis, ptomain poisoning, appendicitis, and genital-tract infections. If intestinal fermentation and the choleras are excluded, in- dican in the urine is said to be almost as diagnostic as Ehrlich's test. To test for indican, mix the urine with an equal amount of strong hydrochloric acid. Add drop by drop a 1 in 20 solution of chlorinated soda. A green color indicates its presence; an excess gives a blue color, especially in the presence of, chloroform. The "diazo" reaction in the urine is quite constant from the second to the seventh day. Its intensity is said to vary with the severity of the case. Malarial fevers, gastro-enteritis, and gas- tric fever may be excluded by it, but its occurrence in many other affections prevents its being of positive diagnostic value, though it is of differential and prognostic worth. In using Ehrlich's diazo test, the following solutions, freshly prepared, are employed: (a) Hydrochloric acid, 5 ; water, 95; sulphanilic acid to satu- ration. (b) Sodium nitrite, 0.5 per cent. fever, typhoid. 347 Mix forty parts of (a) with one part of (b) in a test tube; then add an equal amount of urine and shake the contents thor- oughly. Then allow a quantity of ammonia water to run down the side of the test tube from a pipette, until a layer is formed. If the aromatic compounds upon which this test depends are present, a brilliant garnet ring is formed at the junction of the layers. If the tube is then shaken violently, a beautiful rose- colored froth appears. Modification of Test.—If instead of the 1 to 40 solution 1 part (b) to 100 parts (a) is used, the mixed reds and yellows mostly disappear. The reaction remains distinct for typhoid, septicaemia and advanced malignant disease, but pulmonary tuberculosis and pneumonia are excluded. In doubtful or negative cases the surface foam after shaking is yellow, while if the reaction be present it is a delicate pink or rose red.—Chas. L. Greene. The diazo reaction is found in typhoid pneumonia, measles, miliary tuberculosis, sepsis, and severe cases of phthisis. It is absent in meningitis.—Klemperer. Prognosis.—-Mortality varies according to the plan of treat- ment. Under the expectant method it is about fifteen per cent. while under systematic cold bathing it has been reduced to about seven per cent. In children under three years of age the prognosis is very grave; at four years it is not so serious, and at five years or over it is nearly always favorable. The mortality has been reduced at least five per cent by the introduction into hospitals of the cool bath.—Juhel-Renoy. Elderly and obese subjects make prognosis correspondingly grave, while renal complication renders a fatal outcome almost sure. The higher and more continuous the fever, the more pro- fuse the diarrhcea, the greater the tympanitic distention of the abdomen, and the more marked the cerebral symptoms, the worse the prognosis.—Delafield. 348 the practitioner's manual. Treatment.—From the beginning, insist that the mouth, tongue, and gums be kept clean.—Delafield. Perfect rest of both body and mind. Plenty of cool water, no alcohol, in young, vigorous subjects. For headache, cold compresses.—Upshur. Brand Method.—Whenever the rectal temperature reaches 39° C. a full bath is given at the temperature of the room (i\:j°- 70° F.), and in heated seasons cooled down to this point by ice. The duration is of about fifteen minutes, during which the sub- ject is systematically rubbed by several attendants and if able rubs himself. In very high temperatures the time may be pro- longed to twenty or twenty-one minutes. When begun very early the patient ma}', if he prefers, step from the bed into the tub; otherwise the naked body, with a towel over the loins, is carefully lifted and deposited in the tub alongside. The head rests upon an air cushion and the forehead is covered with a wet compress. Patients with very high temperatures and nervous symptoms may have cold affusions to the head. The bed is ar- ranged with a rubber sheet covered with a blanket, and this with a linen sheet, which is to be snugly tucked around the body and covered with a blanket. After ten or fifteen minutes, the surface may be thoroughly dried and the nightdress re- placed. Milk or broth is now given, after which there is gentle sleep. The time in the tub is shortened if the patient becomes restless and shows too great cyanosis. This has been variously modified by different practitioners. The mortality rate before the introduction of the baths in a series of l,s^S cases was 14.S percent. In 1,902 cases with bathing the mortality was 7.5 per cent.—F. E. Hare. Half an ounce of whiskey fifteen minutes before each bath: cold affusions to the head during the baths: glass of hot milk containing malt extract after the bath.-—W. Gilman Thompson. Don't counteract the good effects of the baths by giving too much whiskev.—Shiler. fever, typhoid. 349 Not to give patients the benefit of this chance is to incur a re- sponsibility to which no surgeon should expose himself.—Nogier. Mild nephritis is not a contraindication.—Tyson. Tubbing is altogether the best treatment for the disease itself and not simply for the temperature reduction.—Delafield. The cold-bath treatment, rigidly enforced, appears to save from six to eight in each century of typhoid patients admitted to the care of hospital physicians. While I enforce the method for its results, I am not enamored of the practice. One equally life sav- ing and less disagreeable to the patient is a desideratum.—Osler. It is urgently demanded, because it helps patients to traverse comfortably the weeks of continuous fever and makes the prog- nosis better.—Northrup. Apply the method in every suspicious case until the diag- nosis can be made, and continue it in such as prove to be ty- phoid.—Baruch. To Disinfect the Intestinal Caned.-—Chlorine water can be safely administered until complete disinfection of the alimentary canal is obtained. Under its use the tongue becomes cleaner, the appetite and digestion improve, fever declines, and the stools lose their offensive odor. The general strength, the intellectual proc- esses, and nervous conditions improve. The disease is short- ened in duration, and usually proceeds to rapid and complete recovery. — Wilcox. Or at the beginning of the disease, give ten grains of calomel on alternate days. Give one grain of carbolic acid and three drops of tincture of iodine, every four hours, during the entire illness.—Augustus Elliott. I can testify to the inefficiency of carbolic acid and iodine and of the ? naphthol.—Osler. Or, sulphocarbolate of zinc, gr. v. Repeat every three or four hours until the temperature falls.—Sangree. Or, boric acid, cgm. 0.50 to 0.75, after a purgative dose of castor oil containing five or six drops of turpentine. 350 the practitioner's .manual. Calomel, gr. T\j -£, every half-hour until six, eight, or ten arc taken. Or, carbolic acid, gr. i., well diluted, every hour. The Woodbridge Method.—On the appearance of the earli- est symptoms: Tablet No. 1. R Podophyllin................................................ gi\ ^g Hydrargyri chloridi mitis.................................. gr. ^ Guaiacol carbonatis......................................... gr. j1,,- Mentholi................................................... gr. r' Eucalyptol.................................................. nj, i. One tablet of the above formula should be given every fifteen minutes during the first twenty-four hours, and larger doses during the second twenty-four hours if found necessary, so that during this and the succeeding twenty-four hours there may be secured five or six full and free evacuations'of the bowels during each of these periods. On the third or fourth day the following treatment should be begun : Tablet No. 2. R Podophyllin................................................ gr. ^ Hydrargyri chloridi mitis.................................. gr. y1^ Guaiacol carbonatis......................................... gr. 4- Metholi.................................................... gr. TV Thymoli.................................................... gr. TV Eucalyptol.................................................. ttj, i. One tablet to be given every hour or two. Tablet No. 3. R Guaiacol carbonatis....................................... gr. iij. Trrymoli.................................................. gr. i. Mentholi................................................. gr. ss. Eucalyptol................................... ............ ni. v. After three days capsule No. 3 is given, one every three hours, between which tablets (mostly) No. 2 are given according to the effect upon the bowels. There have been treated 7,s27 cases with 150 deaths, or 2 per cent., and a duration of a trifle over twelve days. These re- sults prove that typhoid fever can be aborted. FEVER, TYPHOID. 351 They teach that it is amenable to curative treatment in all of its stages, and they go far toward proving that death and protracted illness are wholly unnecessary consequences of the disease. — Woodbridge. Believers in the abortive treatment of typhoid must bear in mind the existence of the abortive form of Liebermeister, and the typhus levis of Griesinger, intelligently to differentiate ty- phoid from the diseases with which it may be confounded.—R. W. Holmes. Modified Woodbridge treatment: R Hydrargyri chloridi mitis.................................... gr. x. Thymoli, Eucalyptoli, Salol......................................................ail 3 b Guaiacol carbonatis............................... ........ 3 ij. M. div. in capsulas No. xx. S. Give one every three hours. —MULHERON, Hydrargyrum chloridum mite, gr. -£%, every fifteen minutes. Alternate with guaiacol, gr. v. If the calomel produces sore mouth, substitute sulphate of magnesium. In mild cases, these drugs may shorten the at- tack, but in severe ones they have no effect. Intestinal anti- sepsis is not of any real value.—Delafield. To reduce temperature, local applications of guaiacol over the right iliac region.—H. G. McCormick. Caution.—Not more than thirty minims are to be rubbed in at once. In high temperature, when heart complications render usual antipyretics dangerous: R Ammonii carbonatis........................................ 3 ij. Acidi salicylici............................................. 3 iiss. Elix. pepsini lactat., Aquae cinnamomi.........................................ml 3 ij. M S. Teaspoonful in a little water every three hours. —H. R. Slack. Caution.—Use only the translucent lump of ammonium carbonate to dissolve in the cinnamon water. 352 THE PRACTITIONER'S MANUAL. Or, guaiacol liquefied by gentle heat and painted over the chest wall, the area being covered with adhesive plaster, brings down the temperature from one to five degrees.—Blaise. Phenacetin, cgm. 0.5(», six times daily. (Two hundred cases treated with three per cent mortality).—Bignami. Nothing equals the cold bath.—J. B. Herrick. Internal balneation, ice-water enemata. Chill may be due to antipyrin or other antipyretics employed. If we give the modern antipyretics in large doses chills will occur, which are due simply to the fact that the tempera- ture has been depressed, and then it rises, and this rise is ac- companied by mild and sometimes by severe chills. Drop your antipyretics and the chills disappear.—Janeway. Cold-Air Treatment.—Patient lies on a tube mattress and is covered by another through which a cooling mixture flows. By means of taps, warm water can be turned on first and the tem- perature lowered to the required degree. The advantages over tubbing are, first, no handling of patient; second, no shock.— J. MbRRAY-GlBBES. To insure mental and physical rest and to lessen nervous exhaustion, morphine sulphate, gr. -^, to be repeated as neces- sary, with whiskey by the mouth or hypodermatically.—C. W. Cutler. Wedgwood treatment: R Liq. ferri perchloridi..................................... th, xx. Liq. hydrargyri perchloridi................................. ir\, xxx. M. S. Every four hours. I regard this as the best treatment for the generality of cases.-—Ewart. Or—Carbonate of Creasote Compound. R Carbonate of creasote........................................ 3 xix. Thymol..................................................... 3 vi. Menthol..................................................... 3 iij. Eucalyptol ,................................................ 3 viss. Alcohol, commercial................. ........q s. ad % viij M. ft. solutio. S. This is stock solution. FEVER, TYPHOID. 353 To make emulsion from the above, in order better to ad- minister it, use R Solution of compound carbonate of creasote................... 3 v. Powdered gum arabic........................................ 3 iss. Pure water................................................... 3 iv. M. S. One teaspoonful every three hours in wineglass of water, to be fob followed by a drink of water. —T. W. Simmons. R Pulv. carbonis ligni...................................... § iij. Iodoformi................................................ gr. Xv. Naphtbalini.............................................. gr. lxxv. Glycerini........................ ....................... = vi. Carnipepton.............................................. z jss M. S. A teaspoonful every two hours in one-third glass of water. —Bouchard. My favorite prescriptions for an adult are: R Thymoli.................................................... 3 ij. Saponis medicinalis........................................... q.s. M. ft. capsular No. xxx. S. One every four hours. Or— R Thymoli, Guaiacol carbonatis........................................aa 3 iss. Saponis medicinalis.......................................... q s M. ft. capsulae No. xxx. S. One every four hours. I combine the guaiacol carbonate, especially when the lungs are involved. I first clear the alimentary tract with calomel, grs. ii.—v., followed by a saline.—Royster. Glycozone, as in cholera infantum.—Aulde. R Salol................................................... 3 j Thymoli..............................................'." gr. xxxvi. Bismuthi subnitratis.................................... ^ H Mucilag. acacire.............................. z j-: Syr. tolutani.................................... zjv M. S. Tablespoonful three times daily. —Alfred Moore. Antiseptic oxygenation : ~Sf Methylene bichloridi............................. ,j Sol. hydrogen, peroxidi (10 vols.)........................... ? i. Acidi hydrochlorici diluti................................. ^ xxx Aquse destillata?...................................q s ad * vi M. S. One-half ounce every three hours in half a tumbler of water. no —B. W. Richardson. 354 the practitioner's manual. R Naphthol (alpha).......................................... gr. iv. Phenacetin................................................ gr. iij. Pulv. rhei.................................................. gr. i. Tinct. cinnamomi.......................................... TR ij. For one tabloid. One or two six times a day. Or— In severe cases : R Naphthol (alpha).......................................... gr. viij. Bismuthi salicylatis....................................... gr. ij. Pulv. rhei................................................. gr. ij. Ext. belladonna-......................................... gr. k Pulv. cinnamomi......................................... gr. iij. In cachet. One four to six times daily. —Maximowitsch. For an adult: R Salol......................................................... 3ij. Thymol..................................................... 3 ij. Tablets of cupric arsenite (aa, cgm. 0.01)..................... No. xx. Papoid....................................................... 3ij. Guaiacol carbonate.......................................... 3 ss. Soap powder................................................. gr. v. M. ft. caps. No. xx. S. One every four hours with milk. —VlKO. Salol, gr. v.-x., every four hours until the urine is tinged; then lessen the dose.—Bramwell. Calomel, gr. 2V Repeat every quarter or half hour for two or three days. Following Dr. Delafield's suggestion, I would discontinue the calomel just as soon as the system has been brought under its influence, and would maintain gentle catharsis by Epsom or other salts or mineral waters, aided by copious draughts of pure water, and would put the patient upon the chlorine-water treat- ment of Burney Yeo, and keep him on that and on liquid diet until convalescence is well established.—R. C. Newton. Cases that run the shortest course with least trouble and least mortality are those in which there has been constipation not treated by calomel or with intestinal antiseptics.—Osler. Keep the bowels thoroughly open and the alimentary canal fever, typhoid. 855 as aseptic as possible. Such good nourishing food as the patient will readily assimilate. Plenty of water by both mouth and rectum. Use the best intestinal antiseptic known. Never give opium, phenacetin, or acetanilid. Give strychnine as indicated. If this plan is followed, you will rarely have a death from typhoid fever.—H. G. McCormick. To relieve the flatulency, a few drops of milk of asafoetida and a few drops of the oil of turpentine well mixed.—Hare. Or, oil of turpentine together with oil of anise.—King. For intestinal hemorrhage : R Benzonaphthol............................................. 5 gm. Salicylate of bismuth...................................... 10 gm. Extract of opium..........................................0.10 cgm. Syr. of rhatany............................................ 30 gm. Syr. of orange flower...................................... 30 gm. Mucilage.................................................. 120 gm. Soupspoonful every half-hour. Lead-and-opium pill by the mouth and small doses of mor- phine hypodermically. Normal salt solution is injected when there is much loss of blood, and favorable results follow its use in most desperate cases. A fatal result may follow in typhoid fever without blood appearing externally, so we must be on our guard.—Osler. Ergotol hypodermically in conjunction with ice-water ene- mata.—H. G. McCormick. Or, subcutaneous saline injections: R Sodii phosphatis....................................... 6 c. c Sodii chloridi...................................... 6cc Aquaa destillatse.......................................... 1,000 c.c. --G FRAUD. Oleum terebinthinae, 3 ss. Serum Treatment.—Serum of immunized horses may be used.—Chantemesse. Or that of sheep.—Borger. To disinfect the faeces as thoroughly as possible: 356 the practitioner's manual. R Hydrargyri chloridi corrosivi.................................. 3 ij. Acidi hydrochlorici diluti.................................... 3 x. Aquae........................................................Ob Or— R Hydrargyri chloridi corrosivi.................................. 3 ij. Potassii permanganatis........................................ 3 ij. Aqua?........................................................ O i. —Delafield. Hygienic and dietetic measures must be mainly depended upon, wTith the free use of water internally and externally. In the average case there is no substitute for milk in some form—■ plain, boiled, peptonized, or with lime or soda; two quarts daily is the minimum. In exceptional cases when exhaustion has been marked, I have given twenty whole eggs or the whites of forty eggs in twenty-four hours.—W. S. Ely. Milk is the best food for typhoid patients. Give two or three quarts in twenty-four hours. Less than two is not enough, over three is too much.-—Delafield. 1. Milk, hot or cold, with or without salt, diluted with lime water, soda water, apollinaris, vichy; peptogenic and peptonized milk; cream and water (i.e., less albumin); milk with white of egg; buttermilk, koumyss, matzoon, milk whey; milk with tea, coffee, cocoa. 2. Soups: Beef, veal, chicken, tomato, potato, oyster, mutton, pea, bean, squash; carefully strained and thickened with rice (powdered), arrowroot, flour, milk or cream, egg, barley. 3. Horlick's food, Mellin's food, malted milk, beef peptone, bovinine, somatose. 4. Beef juice. 5. Gruels: Strained cornmeal, crackers, flour, barley water, toast water, albumin, water with lemon juice. 6. Ice cream. 7. Eggs, soft-boiled or raw; egg-nog. S. Finely minced lean meat, scraped beef. The soft part of raw oysters. Soft crackers with milk or broth. Soft puddings without raisins. Soft toast without crust. Blanc mange, wine jelly, apple sauce, and macaroni.—F. C. Shattuck. To aid stomach digestion, a properly regulated dietary, by- fever, typhoid. 357 drochloric acid, pepsin, and the like, and nux vomica to stim- ulate motor activity. These remedies are antiseptic in their widest acceptation.—H. A. West. Once the diet has been found which agrees with the patient, whether it be milk or other, it is important that it be not changed without grave cause. It can be continued for ten days after cessation of fever.—Samuel West. Defer stimulation until cardiac weakness gives warning of imminent vital exhaustion.—Skinner. When a patient on milk diet is not doing well and tempera- ture goes up, give animal broths (mutton, chicken, beef) in- stead. Hard-boiled eggs grated and given as a sandwich.—Heine- man. In convalescence no solid food should be allowed for a week or ten days after return to normal temperature. My custom has been not to allow solid food until the tem- perature has been normal for ten days.-—Osler. In children : R Guaiacol...................................................... 3 i. Glycerini..................................................... 3 i. Alcoholis..................................................... 3 ij. M. S. One to six drops in whiskey and water every two hours, according to the age of the patient. —KOENIG. Cold sponging with or without alcohol. For restlessness and delirium, Dover's powder. For intes- tinal antisepsis, turpentine or salol. For heart tonic, camphor and strychnine.—Wr. L. Stowell. For headache, restlessness, and irritability, codeine, gr. £, or sulphonal, gr. x.-xx., or bromide of sodium, gr. xx.—Dela- field. To reduce temperature and to induce sleep, lactophenin, gr. iii.-viii.—F. Gordox Morrill. 35S the practitioner's manual. For children: R Beta-napbthol (dissolved in heated oil).................... gr. xxiv. Olei amygdalae dulcis (dissolved in heated oil)............ 3 ss. Olei cassia?............................................... tti, i. Pulv. acacia?............................................. q. s. Glycerini................................................ 3 ss. Aqua?.............................................q.s. ad §iij. M. ft. emulsio. S. One teaspoonful every four hours with milk for a three- year-old child. —E. YlKO. Fever, Typhus. The locality in which typhus fever develops does much to aid us in arriving at a just estimate of the condition. Its bein^ known by the common terms of "ship fever," "camp fever/' "jail fever/' and the like, serves to indicate its great tendency to affect inmates of crowded localities and insalubrious sur- roundings. Diagnosis.—There is at first the same chilliness as in ty- phoid, with headache, prostration, and dizzinesss, but here there is pronounced pain referred to the region of the back and thighs. Instead of passing the first week up and about, as in typhoid, the patient is compelled to seek the recumbent posture. Here, too, the temperature, instead of rising gradually, attains a maximum perhaps of 105° by the end of the second day. The pulse, in a severe case, is feeble and small, though retain- ing a soft quality. There are also redness of the eyes and con- tracted pupils. During the first week of the disease there is venous congestion of the face and conjunctivae. Eruption.—The spots are of irregular size and shape, and are of a dull red or of a bluish, dusky hue, appearing between the fourth and seventh day. They may often be first seen about and in the infra-axillary area before they appear upon the abdomen. Unlike the eruption of typhoid, it does not come out in crops, but may develop purpuric or hemorrhagic features, and may persist as long as ten days. Odor of a musty, pungent character is often present. FEVER, YELLOW. 35'J Differentiation.—From typhoid it is distinguished by the greater severity of the chill, as a rule, as well as of the other early symptoms, along with greater fever, prostration, and earlier development of cerebral symptoms, which are likewise more constant and more severe. Tympanitic distention of the abdo- men does not occur in typhus.—Delafield. In cerebro-spinal fever the head symptoms are more intense and include hyperesthesia and tendency to retraction. There are also convulsions and strabismus, and an uncertain and ir- regular course of symptoms. In pneumonia the pulse is slower, respiration quicker, the eruption is absent, and physical examination decides the ques- tion. In uraemia there is usually some oedema. Prognosis.—In severe epidemics the mortality is as high as from 30 to 35 per cent. Below the age of five and in patients over sixty it reaches the high point of from Oo to 70 per cent. The prognosis can be stated as unfavorable in alcoholics and in those who show early signs of cerebral disturbances, hemorrhagic eruptions, adynamic conditions with muscular tremblings, etc. Treatment.—The bowels should be kept open and alcohol freely given, while all depressants are withheld. In epidemics, when the conditions of the climate are suitable, the cases are best treated in tents in the open air.—Osler. Fresh air is of the greatest importance. Keep the windows open all the time, irrespective of the weather.—Delafield. Fever, Yellow. An early diagnosis of an early case has greater import in this affection than in almost any others here discussed. This, however, is not so easy a matter as it is an important one. There is a chill followed by fever, in which the face is flushed, the conjunctivae are injected, the pulse is full but slow and gaseous, 300 the practitioner's manual. and the temperature ranges from 101° to 109° F. There are headache, severe pains in the back and limbs, dry skin, tongue furred but moist with red margins and usually tremulous, urine scanty, often albuminous, by the third or fourth day even in mild cases, and probably always so in the second stage. If by this time there is a high percentage of albumin and the other symptoms are marked, an almost positive diagnosis may be ventured. Upon the second or third day nausea becomes aggravated and wv black vomit"' characteristic of the affection occurs. The latter in moderate cases resembles coffee grounds and in severe ones a tarry substance. Vomiting may, however, be of a bilious character, or watery, or ma}' be wholly lacking. The stage of decline, following the above symptoms, may oc- cupy from a few hours to two days, to be followed by a stage of febrile reaction. In the second stage or that of depression the temperature may be normal or even subnormal, and the patient may appear so well that if seen first at this time a mis- take is apt to be made. The eye and skin symptoms are at this time, however, rarely absent. Differentiation.—In remittent malarial fever, the chill is longer, the remission earlier, the tongue has a thick yellowish coating, is thicker and more flabby, and above all the plasmo- dium is to be found in the blood. Relapsing fever has its relapse considerably later. The pulse is much more rapid, the jaundice slight and late in devel- oping. Acute yellow atrophy has higher fever and pulse rate, comes on more insidiously with early jaundice, while black vomit is a late manifestation, and the urine contains an abundance of bile. Pernicious and hemorrhagic malarial fevers, besides being distinguished by Laveran's plasmodium, show early remission, lack of albumin aside from that due to blood, while delirium and stupor are common. FEVER, YELLOW. 3(51 Yelloic Fever. Incubation, five to nine days. Duration, three to seven days. One paroxysm terminating in recovery or collapse. Very severe nausea and vomiting ; early epigastric tenderness. Black vomit. Hemorrhages. Tongue clean or slightly coated. Pulse variable, slow at end. Eye injected and humid. Pain above eyes, in back and calves. Rarely delirious, mind generally clear. Urine albuminous, usually suppressed. Convalescence rapid. Muscular prostration slight. Bilious Remitte May extend to months. Nine days or more. Several, with remissions. Not so severe nor so early. Bilious vomiting. None. Heavily coated. Quick \mtil convalescence Natural. Fulness in head. Delirium frequent, mind dull. Not so. Slow. Greater. —Potter. : Dengue, occurring as it does in the same regions as yellow fever and prevailing at the same season, is to be carefully distin- guished. Its first stage is of short duration, while the joint and muscular pains are peculiarly characteristic. The eruption, too, coming out about the third day and ending in desquamation, should suffice for its diagnosis. Prognosis should always be guarded on account of the high death rate. In the intemperate and those of full habit it is correspondingly bad. A favorable result is to be looked for when the temperature during the first two days does not exceed 103.5° F.—Sternberg. Black vomit is an unfavorable though not always a fatal sign. In childhood the death rate is much lower than in ad- vanced years. In certain epidemics there is a mortality of between fifty and eighty per cent for hospital cases and those between the ages of fifty and eighty. Relapse is often fatal. Treatment is chiefly symptomatic. Prophylaxis includes everything understood under strict quarantine and hygiene. At outset: R Quinine, Calomel...................................................aa gr. x. M. S. For one dose. ~ —Carpenter. 302 the practitioner's manual. As an antiseptic and antacid: R Hydrargyri chloridi corrosivi................................ gr. £ Sodii bicarbonatis........................................... gr. cl. Aqua? pura?................................................ O ij. M. S. Three tablespoonfuls every hour given ice cold. —Sternberg. For cerebral congestion, cold to head and mustard plasters to extremities. To mitigate fever, etc., tincture of digitalis, gtt. xxx.-lx., every three or four hours.—Bemiss. To attenuate the severer symptoms, tincture of eucalyptus has been advised in large doses. Or— R Tinct. eucalypti.............................................vt[ xxx. Aqua?...................................................... O ij. M. S. As a frequent enema. For urcemic symptoms, suppression of urine, etc., hot-air baths, digitalis, and cautious use of jaborandi. Cold sponging at frequent intervals. Twenty grains of calomel and twenty-five grains of quinine should be administered at once, followed after an interval by sulphate of magnesium. Mustard plasters should be applied to the entire abdomen, and mustard foot baths given frequently. After the saline has acted give: R Potassii acetatis............................................ 3 i.-ij. Potassii citratis............................................ 3 b Morphinae sulphatis......................................... gr. i. Aqua?....................................................... 1 vi. M. S. A dessertspoonful every three hours. —F. P. PORCHER. To sustain feeble heart in second stage, alcohol, iced cham- pagne. Good quality Rhine wine is retained when all else is rejected.—Blair. For hemorrhage, ergotin hypodermatically. Iron prepara- tions. FEVER, YELLOW. 363 To check tendency to black vomit, tincture of ferric chlo- ride.—Guiteras. For vomiting : R^ Tinct. camphora?, Chloroformi................................................aa I ss. M. S. Two drops repeated as required. Diet.—Liquid food only when fever subsides. Solid food too early favors relapse. In gastric irritability milk and lime water until broths, etc., can be taken. The sheet anchors are free catharsis, diuresis, and diaphore- sis at the beginning, with large doses of quinine hypodermati- cally. After that secure mild catharsis and free diuresis through - out the disease, emesis when the vomit is turning from white to yellow, morphine when necessary to control vomiting or to overcome extreme nervous jactitations, and finally cardiac stim- ulants when indicated, generally from the beginning of the second stage.—J. E. Stubbert. Beta-naphthol, gr. viiss., every hour or two, according to indications, supplemented by a drink, to be taken ad libitum, composed as follows: 1} Sodii benzoatis.......................................... 3 iiss.-iij. Sacchari albi............................................ 3 ij- 3 iv. Aqua? destill............................................O ij. • M. S. To be drunk freely, mixed with an equal quantity of seltzer water, ice cold. —T. S. Dabney. Administer a purgative, then sodium salicylate combined with aconite or antipyrin, followed by quinine, resorting to the chlorine water in the second or third stages and supplementing it with artificial serum in certain cases of anuria.—A. Simeos. 304 THE PRACTITIONER'S MANUAL. Filariasis. The filaria sanguinis hominis, by obstructing the lymph channels, is capable of determining various grades of anaemia, chyluria, and haematuria, as well as elephantiasis of a limb or of the genitals. The variety known as filaria perstans appears to be the causative factor in the "sleeping-sickness" of the west coast of Africa which is characterized by a lethargic state lasting for weeks and months. Diagnosis.—There is no positive clinical diagnostic sign. Filariae can be found only by blood examination. The ordinary form is found in the blood only at night, hence the diagnosis based upon its absence by day would be faulty. Its width is that of a red blood corpuscle, but it is about fifty times as long. After an absence of subjective symptoms, perhaps for years after these nematode worms have infected the system, anaemia and lymphatic tumors, especially in the testicle and cord, show them- selves and elephantiasis may supervene. It is not always pos- sible to detect the presence of the parasite in even marked in- stances of lymph scrotum or elephantiasic enlargement of an extremity. Though a disease of the tropics, it is said to be increasing in and about Charleston, S. C. Prognosis.—The chief danger to life is that the adult worm may fix itself in the heart. Filariae may exist in the blood for years without materially influencing the general health. Treatment.—Metblyene blue, gr. ii., every four hours for five days.—Austin Flint. Thymol, gr. i., every four hours, with subsequent increase of the dose. Chyluria : R Ichthyol.................................................... gr. iij. Ft. pil. No. i. S. From two up to ten such daily. —MONCORVO. FURUNCULOSIS. 365 Guinea-worm disease, due to the filaria dracunculus, sets up a suppurative inflammation in the subcutaneous connective tissue. Its presence can be distinguished beneath the skin by its simulating to the touch a coiled-up string. When about to pierce the surface a vesicle forms, increasing up to 12 or 15 millimetres in diameter attended with itching; or severe suppurative inflammation may affect a larger area of skin. The diagnosis is confirmed if the string-like coil changes its position before inflammatory changes occur. Violent inflammation may follow rupture of the worm in the effort to secure its extraction. Extract gradually by winding about a stick or roll of card- board, twisting a little each day. To kill the worm and its progeny and prevent inflammation: R Tinct. asafcetida?............................................. § b S. Teaspoonful three times a day. —HORTON. Caution.—To be used only in adults and for a limited period. Perchloride of mercury injections (1 to 1,000).—Boyd. A Pravaz syringeful may be injected into the burrow at several different points.—Emily. Compresses of carbolic-acid lotion (1-15).—Roth. Furunculosis. Boils are chiefly to be distinguished from multiple abscesses of the skin, having a non-furuncular origin, by the presence of a central core; and from beginning carbuncle, which is charac- terized by having numerous openings instead of the usual single central opening of the boil. While furuncle is frequently multiple, its lesions being scattered perhaps over various portions of the surface at the same time, the individual lesion does not flatten out and extend at the periphery, as does the carbuncle. 366 the practitioner's manual. The term furunculosis is applied most properly to the condition of recurrent crops of boils in a given subject. Treatment.—To abort the furuncular process : R Liq. ammonia?.......................................... 3 i. -f- ^ xx. Aqua?.................................................. 3 ij. M. S. Teaspoonful in water three times a day. —Randolph. In gouty subjects: R Extr. colchici radicis.......................................gr. iv. Ft. pil. s. a. No. xii. S. One or two three times daily. Spirits of camphor locally.—Brocq. During the formative period, tar water to drink and: R Sulphuris sublim........................................... gr. iss. Pulv. camphora?............................................ gr. i. M. For one capsule. S. Three such to be taken daily. —Robin. R Sodii sulphatis, Sodii bicarbonatis, Potassii sulphatis, Acidi tartarici, Mucilag. acacia?..................................... ........aa 10 M. S. From ten grains to a drachm daily in divided doses, in a wineglass- ful of water or milk. /// diabetics, strict diet and codeine or other drug to reduce sugar output. When habitual: * R Sodii arsenitis............................................... gr. i. Syrupi simplicis............................................. § i. Aqua?.................................................q.s. ad § iv. M. S. Teaspoonful in water twice a day. Apply on compress: R Chloroform............................................... 30 gm. Essence of cloves......................................... 5-10 " Beechwoood creosote ..................................... 1-2 " Camphorated oil.......................................... 50 " —Gourine. Apply carbolic acid to the central point. R Ichthyol....................................................... 3 i. Empl. plumbi................................................. 3 ij. Empl. resina?................................................. 3 i M. S. As a plaster. —Stellwagon. gangrene. 367 Or, unguentum diachylon (Hebra): R Acidi salicylici.......................... Empl. saponis............................ Empl. diachyli.......................... M. S. Spread and apply. Gangrene. While this subject is more appropriately discussed in surgical works, we must here mention senile gangrene of the lower extremities, occurring chiefly in diabetics, and in which surgical measures are usually to be deferred until a line of demarcation is distinct. Amputation should be above the knee (Hutchinson) if the process involves the dorsum and sole. Multiple gangrene of the skin occurs chiefly in hysterical girls and is often mistaken for feigned or artificially pro- duced lesions from the use of acids and irritants. Some mani- festations or stigmata of the hysteric state should be discover- able. Disseminated infectious gangrene in infants and children subjected to'unfavorable hygienic surroundings, and especially after debilitating diseases, may be accompanied by noma. Noma may occur without marked preceding disturbance, as an ulceration about the gum and internal cheek surface with loosening of teeth, foul breath, and subsequent swelling, and dusky or livid redness, extending to the skin surface of the cheek. The hardened, waxy tissues soon show gangrenous changes and perforation may occur before death, which is not an uncommon termination. Pain is not a pronounced symptom. Measles would appear to be a predisposing cause. Gangrene from the use of carbolic acid is reported by Czerny. This occurs from the continued use of moist dressings contain- ing the official three-per-cent solution of the acid applied as an antiseptic for minor wounds of the extremities. 3 iiss. 5 iss. \ i. 36S THE PRACTITIONER S MANUAL. For external use: R Bromi................................................... 3 1- Potassii bromidi......................................... 3 ij. + 3ij. Aqua?.................................................... Iiv- Mix the potassium bromide and water and add the bromine. —J. Lawrence Smith. In infantile disseminated gangrene after varicella, vaccinia, impetigo, and accompanying purpuric manifestations: R Acidi boracici.................................................. 3 Sol. hydrarg. chloridi corrosivi (1-10,000)...................... 100 M. S. Use as wash and in bath. —Caillault. For treatment of noma, see "Stomatitis Gangrenosa." Gangrene, Symmetrical. Raynaud's disease, or local asphyxia of the extremities, occurs symmetrically after exposure to cold. Diagnosis.—The fingers or toes, ears, and tip of the nose become suddenly pale, hard, and numb, and subsequently turn black and gradually separate. At times there is severe pain. Even when the lividity does not result in the actual death of the part, the symmetry and other signs are sufficient to make the diagnosis easy. Nervous phenomena are often noted, and shock may preciptate the attack; numbness and tingling in the fingers may precede the attack for years. It is most frequent in epileptic maniacs. —Wigglesworth. Sharp distinction between syphilitic and non-specific instances and between this affection and one depending on anatomical changes in the arteries (arteritis; endarteritis) cannot always be made. Neurotic gangrene may closely simulate it.—W. Alexander. It may often complicate hysteria.—Osler. Prognosis is serious in the extremes of age. It is better when syphilis is an underlying cause. gastric neuroses. Differentiation.— Local Asphyxia (Raynaud). Sex: four-fifths females. Begins with ischaemia. Affected part becomes bloodless and white. In certain cases there is the deep, dusky congestion of a cyanosed part, with or without gangrene Pain may be absent or acute, and comes and goes ; has no relation to position. May precede local asphyxia. Unaffected by seasons. In many cases all the symptoms can be brought on by cold. Ana?sthesia to touch. Analgesia. Temperature much lowered and un- altered by posture. Gangrene local and limited; likely to j No gangrene ; asymmetrical. be symmetrical. I —D. W. Prentiss. Treatment.—Electrical bath.—Barlow. Glonoin in small oft-repeated doses.—F. P. Henry. Improve the general health of the patient; improve local circulation and nutrition ; relieve the pain.—Charles K. Mills. If a history of syphilis is given, appropriate antisyphilitics. Gastric Neuroses. Gastralgia is one of the important forms of this class, in which the character of the pain is neuralgic and occurs inde- pendently of organic diseases when the stomach is empty. Gas- tralgia as a symptom occurs in carcinoma, ulcer, and the various forms of gastritis. As a functional condition it is present in neurotic females, as an accompaniment of anaemia and neurasthenia. Erythromelalgia (Mitchell). Of twenty-seven cases two were in fe- males. Little or no difference in color, until foot bangs down in upright posture, when it becomes rose red. Arteries throb and parts become of a dusky red or violaceous in tint. Pain usually present; worse when part hangs down or is pressed upon. In bad cases more or less at all times. Worse in summer and from beat. Eased by cold. Sensation of all kind preserved. Hyperalgesia. Temperature greatly above normal. Dependency causes in some cases in- crease of beat, in others lowering of temperature. 370 the practitioner's manual. Diagnosis is often suggested by a general tendency to neu- ralgic pains elsewhere. The pain is sudden, referred to the epigastrium; it becomes sometimes aggravated periodically but almost always when the stomach is wholly or partially empty, and taking food is more apt to give relief than otherwise. Steady pressure with the flat hand may also give ease. In an acute attack the patient is doubled up, the breath comes short and quick, and there may be a sensation of impending dissolution. The face is dull, drawn with pain, and covered with cold perspiration. After lasting for from a few minutes to perhaps an hour or more, vomiiing may give relief, followed by exhaustion and relaxation. Differentiation.—In colic the pain is referred to the region of the umbilicus, and there is frequently spasmodic contraction of abdominal muscles with rapid change of position in the pain. It is also more frequent after meals. From the gastric crisis of tabes by the history of the case, and the fact that the pain often begins in the groin and extends up the sides to the epigastric region. The lightning-like shoot- ing pains are also absent, and in tabes or its preataxic period such attacks bear no relation to the empty state of the stomach. In neurasthenic gastralgia a boring sensation is complained of and the pain radiates over the lower ribs to the median line. In that which has been called by Rosenthal the depressant form, a constant dragging weight or disagreeable feeling of fulness follows the taking of food. The neuralgic form of pain is not so intense. This is to be distinguished from the gastralgia of hysteria and that of or- ganic disease. In the latter there is retarded digestion, while in true gastric neuroses the period of digestion remains normal. In the hysterical form the gastric pain alternates with neural- gias in other parts of the body and other evidences of hysteria are to be discovered. From ulcer or cancer of the stomach the differentiation is (iASTRIC NEUROSES. 371 made by the pain being more diffuse and not brought on or ag- gravated by taking food. Prolonged and attentive study of all the general symptoms, idiosyncrasies, habits, etc., of the patient may be necessary in order to establish the correct diagnosis of gastric neurasthenia. Treatment.—Early morning gastralgia is often relieved by eating a hearty breakfast. This of itself serves to distinguish the pain from that of gastric ulcer and gastritis. Gastralgia of gouty origin, salicylate of colchicine, gr. gV- Or, colchicine, gr. ■£%. In the gastralgia of neurasthenia, rest cure.—S. Weir Mitchell. If due to impotence, phosphorus, gr. T^ in pill form. Nervous Gastralgia.—The best treatment for purely nervous gastralgia—characterized by pain when the stomach is empty, which is immediately relieved by the ingestion of food—con- sists in the internal administration of arsenic. Acidum ar- seniosum, gr. -fa, three times daily between meals for several weeks. A mixed diet is preferable.—Sir James Sawyer. The most generally useful drugs are codeine, chloroform, bismuth salicylate, creosote, cerium oxalate, compound spirits of ether. R Sodii bicarbonat............................................. 3 iss. Tinct. nucis vom............................................n\ xl. Liq. morphina? (gr. ij. to 3 i.).............................. 3 i. Spir. amnion, aromat........................................ 3 iss. Syr. zingiberis.............................................. 3 i. Aqua? mentb pip.....................................q.s. ad ^ viij. M. S. § ss. four times a day. —.1. W. Martin. R Morph. bydrochlorat....................................... gr. iij. (or codeina?............................................... gr. vi.) Cocaina? hydrochlorat...................................... gr. v. Tinct. belladonna?.......................................... 3 i. Aq. amygdala? amara?...................................... 3 v. M. S. Ten to fifteen drops every hour. When pains are very severe, three doses of ten drops each within an hour. 37-! the practitioner's manual. Or— R Codeina? pbospb............................................ gi\ t Bismuthi subnit........................................... gr. v. Sacchari lactis............................................. gr. iij. M. S. A dose, every two hours. —EWALD. Or— R Argenti oxidi................................................ gr. v. Extr. hyoscyami........................................... gr. v. M. ft. pil. No. x. S. One t.i.d. before meals. ■—Bartholow. Or— R Tinct. capsici................................................ 3 ij. Cannabis indha?.............................................. 3 ss. Tinct. opii deod............................................... § i. Spir. chloroformi.............................................. 1 i. Spir. lavandulas........................................q.s. ad 3 *v- M. S. 3 i. every thirty minutes until relieved. —Hare. R Spir. a?tberis comp., Tinct. illh-ii, Tinct. rhei................................................aa 3 gm. Tinct. nuc. vom............................................. 1 gm. M. S. Twenty drops at mealtime. —POTAIN. Caidion.— The use of irritating substances, such as chloro- form and Hoffman's anodyne, always endangers aggravation of the original disease.—Wood and Fitz.9 Liquor potassii arsenitis, gtt. i.-ii., t.i.d. for a considerable period. If vasomotor spasm is suspected from pallor, nitroglycerin, gr. T\^, in solution or recently made tablet, by hypodermic. Or— R Cocaina? muriat................. ........................ gr. ij Antipyrin................................................ 3 iij. Aqua? destil................................................ 1 i. M. S. For hypodermic use. Ten to twenty minims. —Landon B. Edwards. Subcutaneous injection of water over the epigastrium. GASTRITIS, ACUTE. 37/j Spiritus aetheris comp., m x.-xx.; chloroform, gtt. iii. or iv. on sugar; Cocaine, gr. i-|, once or twice daily. Caution.—Should not be given at the same time with amyl nitrite, opium, or bromides. Morphine sulphate, gr. £-£, hypo- dermatically. Gastritis, Acute. Gastritis may result from a variety of local irritants, pro- ducing inflammation of the mucous membrane. These may be toxic, mycotic, mechanical, or chemical. Diagnosis.—The symptoms leading to the diagnosis will, therefore, vary with the etiological cause, which, if known, will be of the greatest diagnostic value. Generally speaking, there are sense of fulness, gastric pain and tenderness, vomiting, perhaps of blood, fever, headache, thirst, anorexia, fulness, eructations, etc. The symptoms of acute catarrhal gastritis will be found under the caption "Dyspepsia." Pseudo-membranous gastritis is a rare form accompanying infectious diseases. In phlegmonous gastritis, which is also rare, the onset is sudden, the pain severe, the fever high, fol- lowed by typhoid symptoms and subsequent collapse. Differentiation from typhoid by the febrile rise and its sub- sequent fall being more abrupt, having less marked remission; by absence of enlarged spleen and occasional presence of " fever sores." The last sign is unreliable (Hemmeter). Prognosis is favorable. Treatment.—If due to an irritant poison, including alcohol, and the stomach contents can be removed by emesis or by lav- age, this should be done before the remedies used are introduced. A saline purge may also be in order. In all instances it is best to withdraw all food except perhaps broths, and small doses of milk and lime water given at frequent intervals. 8v4 the practitioner's manual. In acute alcoholic gastritis, ipecac, gr. v., to be repeated every ten or fifteen minutes until emesis. Counter-irritation over the epigastrium. For the first few days, fluid extract of hydrastis, 3 i. Repeat as necessary. If no early vomiting : R Pulv. ipecac................................................... 1.5 Antimon. et potass, tart....................................... 0.05 M. ft. chart. No. i. S. At one dose or divided. —EWALD. If pain is present: R Codein. phosphat.............................................. 0.05 Extr. belladonna?.............................................. 0.03 01. theobrom................................................. q.s. M. et ft. suppos. No. x. S. One every hour. —Boas. Or— R Codeina?.................................................... gr. vi. Aqua? menth. pip...................................... .... § iss. M. S. 3 i. thrice daily. Evacuate the stomach, then wash with: R Thymol................................................... gr. viij. Boric acid. .. ........................................... § ss. Warm water.............................................. O i. —Hemmeter. In subacute gastritis: R Bismuthi subnit............................................. 3 iij. Sodii bicarb................................................ 3 iij. Guaiacol.................................................... gtt. x. Syr. rhei arom.............................................. 3 ij. Aqua? menth. pip........................................... § iij. M. S. Teaspoonful in hot water. —Tuffs. Gastritis, Chronic Catarrhal. Chronic dyspepsia, so-called, comes on slowly with perversion of appetite, usually bad taste in the mouth, perhaps dryness, nausea, and vomiting either after food is taken, or, especially GASTRITIS, CHRONIC CATARRHAL. o<0 in alcoholics, before breakfast. Acid or acrid regurgitation, belching, precordial distress, a faint feeling before the regular food-taking periods, and a sense of weighty oppression after eat- ing, or at times actual pain may be present. Diagnosis is based upon the greater persistence of the symp- toms of acute indigestion, which are all intensified, plus the dis- covery of an abundance of mucus, decreased motility, and pro- nounced lack of absorptive power. The stomach tube will prove a valuable aid in diagnosis. Siphonage may show absence of hydrochloric acid as early as one hour after taking food, in conjunction with an abundance of mucus. This does not exclude cancer. Differentiation.—Cancer is the most important condition to be eliminated. (For the early signs before a tumor can be felt see chapter under this head.) Ulcer of the stomach is much more likely to have haema- temesis as a symptom. Dilatation of the stomach is to be excluded, mostly by physical signs, since the gastric secretions are quite similar in both conditions. Treatment.—For anorexia : R Stryclinina? sulphatis.......................................... gr. + Acid, hydrochlor. dil................................... 3 [ Elix. gentiana?............................................... ? vj M. S. | ss. in I ij. of water through a tube. —Hemmeter. Hydrochloric acid is often advantageous when combined with small doses of quinine and strychnine. R Quinina? sulphatis........................................ „r xxx Strychnina? sulphatis.................................... gr. ss Acidi muriat. dil......................................... 3 iiss Tinct. cardam. co................................ 3 jjss AqU8e....................................'.'.'.'.'.'.'.'...q.sVad liv. ' Mix and filter. S. 3 i. in water after meals. — Wm. Pepper.23 Lavage.— Sodium bicarbonate, two-per-cent solution, facili- 3c F.—Louis Behkens. Use a pint at first every morning, gradually increasing to two or three quarts ((.»s.6° F.). Glauber's salts, asepsin, or boric acid may be used. — Webster. Bitter tonics in chronic gastritis: » R Tinct. nuc. vomica? ........................................... 3 ij. Resorcin resublim............................................. 3 ij. Tinct. gentian................................................. 3 v. Syr. simplicis......................................... q. s. ad 5 V. M. S. Tablespoonsul every two or three hours. R Tinct. nuc. vomica?........................................... 3 b Decoct, condurango........................................... 3 iy- M. S. Tablespoonful half an hour before meals. — EWALD. To dissolve the mucus and destroy microbes of fermenta- tion, lavage and— b> Hydrozone.................................................... 3 i ■ Aqua? destill.................................................. § iv. M. S. Drink while stomach is empty once daily. The hydrozone may at first produce acrid sensations in the stomach, but as the irritated gastric surface improves in tone under its influence this will pass away and sensitiveness to its action will subside. When necessary the amount of hydrozone may be reduced until the stomach becomes more tolerant to it. —H. T. Webster. In the hyperpeptic form, with abundant secretion without dilatation, prescribe a course of Carlsbad water, unless there be heart disease or phthisis or the subject be feeble or aged. A formula for an artificial Carlsbad, for home use, is the follow- ing: R Sodii sulphat............................................. 2.5-3 gm. Sodii bicarb.............................................. 2-2.5 gm. Sodii chloridi........................................... 1 gm. Aquae destil............................................. 1 litre. Sterilize or consume while fresh. —G. Hatem. gastro-enteritis. 877 Gastro-Enteritis. Intestinal catarrh involving the stomach in infancy is scarcely to be distinguished from cholera infantum. Differentiation.—Xervous disturbances may be so pro- nounced that tuberculous meningitis is thought of. Treatment. — When milk is distasteful and fluids are vom- ited, give somatose by the mouth or rectum, with the addition of a little salt to a solution in milk or water. For children with fever : R Hydrarg. chlor. mit...................................... gr. i.-ij. Sacch. lactis.............................................. q. s. In milk. Or, with addition of beta-naphthol, gr. hi.—Grasset. R Beechwood creosote..........................................rq, iij. Dissolve in alcohol............................................tti, xv. Add mucilage................................................ z jjj M. S. For children a teaspoonful, for adults a tablespoonful, immediately before each meal. —Zaugger. In acute gastro-enteritis of children, bismuth is especially efficacious when combined with Colombo: R Calumba? radicis............................................ \ „m Make an infusion with water.............................. 75 « Filter and add : Bismuth subnitrat.................................... 3 » Syr. aurant. cort. amar..................................... 15 « M. S. Teaspoonful every two hours. —Trabaudt. In entero-colitis of infancy : R Cupri arsenit............ „.. 1 . ................................ s1 ■ ■nnr Aquae...................................................... | iv M. S. Teaspoonful every fifteen minutes. —Larrabee. For acute infectious gastritis in infants : R Cupri arsenitis...................................... ~r _a_ 1 Sacchar. lact............................ , : , ^.j M. div. in chart. No. xvi. S. One powder hourly, and when improvement begins give one powder every two or three hours. —Kruger. 378 the practitioner's manual. Wash out the stomach with a two-per-cent solution of boric acid. R Calomel................................................... gr. •■ Opium..................................................... gr. Ti^ M. S. Give in a spoonful of warm water every two hours till five or six doses are taken. For obstinate vomiting : R Creosote.................................................. gr. f Extr. opii aq............................................. gr. ^c Sugar.................................................... gr. xx. Aqua? foenic.............................................. 3 iiss. Aqua? destil.............................................. 1 i. + 3 ij. M. S. A dessertspoonful for a child of two years every two hours. Older children a tablespoonful. Or, resorcin up to gr. xx. in twenty-four hours. For prof use diarrhcea, bismuth subnitrate or salicylate, gr. v.-viii., with a little opium. In exhaustion, salt solution subcutaneously.—Demme. As intestinal antiseptic, salol, gr. i.-v. Or, naphthalin, gr. i.-ii., in mucilage, milk, or malt extract to an infant of one year, every one, two, or three hours. As an astringent, tannigen, gr. vi.-x.—Moncorvo. In convulsions of gastro-intestinal origin, colic, greenish stools, and vomiting, frictions of chamomile oil to the abdo- men. Injections or lavage to free the intestines. Hypodermo- clysis of normal salt solution.—Nauwelaers. Irrigate the stomach and the bowel with lukewarm water and flush the colon and rectum till the contents flow away clear. Never employ antipyretics, as antipyrin and quinine or other similar drugs, but resort to hydropathic measures, reiving on the warm bath gradually cooled from 90° to 7oc. Duration of bath five minutes, to be repeated every few hours if neces- sary. Place an ice bag on the top of tbe head, following the bath, and place the patient in a cool room, if we cannot have the child immediately removed to cool sea air. Unless it be a nursling, proscribe milk; and if a nursling then discon- glanders. 379 tinue the breast at least one-half day to give the stomach abso- lute rest. Administer beta-naphthol bismuth in doses of five to ten grains to a child of one year every two, three, or four hours, depending on the nature of the case. If vomiting persists and cannot be controlled by medication, resort to rectal feeling, and administer the bismuth in a small suppository, also per rectum, but invariably doubling the dose required per mouth. Warn against the danger of administering alcohol, and any wine or beer. Cold sponging to check the perspiration, with equal parts of alcohol or water, or use bay rum. Where cyanosis and very cold extremities exist, resort to hot mustard baths.—Louis Fischer. Glanders. Farcy or equinia gives symptoms in from a few days to three weeks of the time of inoculation. There is fever with pros- tration, and vague myalgic and articular pains are complained of. Later on severe rigors with profuse sweating and a typhoid condition come on. Diagnosis.—A discharge from the nostrils, at first catarrhal and often purulent, and perhaps bloody and of offensive odor, is the most characteristic manifestation. In the acute form this occurs early; in the chronic, late. Characteristic signs upon the skin surface are in the form of scattered groups of red papules, which soon reach the size of bird shot, changing to a yellow color; later on pustules may develop if the papule first becomes a vesicle, and then the lesions may resemble variola. Subsequently superficial ulceration may occupy the site of these groups, or gangrenous spots may form. The diagnosis is facili- tated by the subject being one who is much engaged with horses, from which animals the disease is contracted. Diagnosis is difficult only when many of the skin and mucous membranes changes are still lacking. In veterinary pratice injections of malleine are resorted to for diagnostic purposes, giving a char- 3H0 the practitioner's manual. acteristic fever curve. In man trial of the same has been made, but as yet with no positive results. Prognosis is serious: the more so the more acute the ini- tial signs. Treatment.—Quinine seems to be the only drug of much value. Efforts must be directed toward maintaining the pa- tient's strength. If the point of inoculation is seen early it should be acted upon with destructive escharotics. As abscesses form they are to be opened; internal antiseptics, iodine, arsenic, strych- nine. Vaccination with culture fluid has been employed only in horses. Antistreptococcic serum (not yet sufficiently experi- mented). No drug yet tried has any marked specific effect on the dis- ease.—Durham. There are no known remedies which have any control over glanders. If the case be seen early, the points of inoculation should be thoroughly destroyed by excision and caustics. — Wood and Fitz." Glycosuria. Besides existing as a permanent symptom of diabetes, gly- cosuria is likewise symptomatic of a variety of affections, which should not readily be confounded with diabetes proper. Certain subjects of gout or other forms of lithaemia, when suffering from obesity of long standing and often subject at the same time to gall stones, as well as many debilitated persons of advanced age, are found to pass sugar either habitually in small quanti- ties, or paroxysmally in perhaps larger amounts. This may go on for years without having any marked influence per se upon the general health. Unless the diet is too rigidly restricted, under a misapprehen- sion of the cause and requirements of the case, the prognosis is GOITRE. 8*1 good so far as the continuance of life goes, although sugar may persist. The one point which makes the condition impor- tant is that it should not be treated as diabetes, but should lead to detection of the underlying cause, to which treatment may more properly be directed. See also " Diabetes." Goitre. Bronchocele or simple goitre ma}T exist in various degrees of development, upon one or both sides, so small as scarcely to direct notice, or of such a size as to cause great inconvenience and deformity. Again, the enlargement may be poststernal and be perceptible only during deglutition. Diagnosis.—Symptoms resulting from pressure upon the vessels and nerves are the same as from any other abnormal growth in this region. Differentiation.—It is distinguished from all other tumors chiefly by the fact that the enlarged thyroid takes an upward motion when the patient swallows. Treatment.—Interstitial injections of iodine. The official tincture is employed. The irritating action of the alcohol and the specific action of the iodine are supposed to concur in the cure. The dose is half a syringeful the first time; afterward a syringeful (cubic centimetreV—Duguet. The above is often uncertain, and generally useless and in tumors of large size slow. Enucleation takes the first rank. Cachexia strumipriva is not to be feared.—Hache. Caution.—Iodine by parenchymatous injection has resulted in many accidental deaths. When iodine treatment has not succeeded glycerin extract of thyroid body, one to one and a half teaspoonfuls (each tea- spoonful representing 30 cgm. of the fresh organ), given dailv. —Cabannes. 3**2 the practitioners manual, R Acidi arseui >si.............................................. gr. ^ Ergotini.................................................... gr. i. Pilula? ferri bromidi (Fr. Cod.) ............................. gr. iv. M. ft. pil. No. i. S. One to be taken three times a day after food. —Ramsay Smith. Parenchymatous injections of iodoform. R Iodoform........................................................ 1 Ether............................................................ 5 Olive oil......................................................... 9 M. S. To inject. Caution.—This must not be exposed to sunlight.—Mosetig. B Iodoform.................................................... 1 part Sulphuric ether, Olive oil.................................................aa 7 parts. M. S. Til, xv.-3 i. by injection. Repeat every two to five days.—Galee. Caution.—Inject slowly, standing behind the patient and pressing the gland back against the spinal column, plunge the needle in deeply, avoiding cutaneous veins. To ascertain if the needle has entered the gland, let the pa- tient swallow; if it has entered, the needle will be carried up- ward and the syringe will take a downward direction.—Kapper. In intractable goitre remove the patient to a region in which the disease is not common. Complete disappearance of the tumor may result.—Dock. Cataphoretic treatment by tincture of iodine, the cup elec- trode being attached to the positive pole and a current of six to eight milliamperes being used. The application is repeated daily. —Hunter M'Guire. Thymus gland has been used to a limited extent with suc- cess. Thymus can be given for a longer time than the thyroid without causing disagreeable symptoms. R Iodi.......................................................... l Potassii iodidi.............,................................... 5 Aq. destil...................................................... 100 M. S. For external application. Caution.— This must not be exposed to sunlight. goitre, exophthalmic. 3s:-5 Goitre, Exophthalmic. The symptom complex to which Graves called attention, likewise called Basedow's disease, consists in excitation of the heart beat, followed by swelling of the thyroid body, pulsation in the arteries of the neck, and protrusion of the globes of the eyes. Besides the rapid heart action, which is an almost constant phenomenon, there may be attacks of palpitation, attended or not with murmurs and exaggeration of the heart sounds. Diagnosis. — While of slow development, a sudden aggrava- tion of all or some of the symptoms leads the patient to consult the physician. Although it is a simple matter to distinguish those instances in which the tripod—goitre, exophthalmos, and rapid heart action—is present, it is not so easy when only one of these symptoms is prominently present. It is possible for a tachycardia, the reason for whose existence for many years has not been understood, to have joined to it later on the characteristic bulging eye and the swelling of the thyroid gland, thus completing the picture. The exophthalmos may be absent in any given case. Among the early signs are especially to be noted a lack of combined action in the eyelids and brow when the globe is sud- denly carried upward, pulsating movement in the lids, and in- complete closure of the palpebral fissure. Photophobia, or double vision, may also be an early sign. The retardation in the movement of the upper lid is called Graefe's sign. The sub- jects are irascible, excitable, melancholic, hysteric, or show a tendency to become epileptic. Choreic movements, associated with a tremor which is said to be rarely absent from the first, and characterized by a rapidity of vibration, are of the greatest diagnostic importance in the absence of hysteria. The myograph shows eight to nine 3S4 the practitioner's manual. oscillations as against five plus in paralysis agitans and seven in poisoning by mercury. Mobius has found that increased moisture of the skin is seldom absent. Vitiligo or bronzing of the integument is also likely to occur. Among other signs more or less constantly found are gastro- intestinal and dyspeptic symptoms, neuralgias, paraesthesias, diminished resistance to galvanic currents, glycosuria, irrita- bility of the bladder, and neurasthenic symptoms. One or more of these may be present in any instance. In children the symp- toms are usually the same except that tremor and Graefe's sign are usually absent. Differentiation.—From simple goitre time alone may be required, but it is so common to find subjects of Graves' disease neurasthenic that, in the absence of signs of neurasthenia, and if palpitation is not a marked feature of the case, it may be set down as one of simple goitre. It must be remembered, how- ever, that an enlarged thyroid may precede other symptoms by a number of years. Guttmann makes the point that double systolic murmur is characteristic of the exophthalmic form. When tachycardia is the only symptom, its distinction from the essential form lies chiefly in the fact that the latter is of paroxysmal nature; the heart beating at a normal rate in the intervals. In some in- stances showing this same form of palpitation, the beat reaching perhaps the very high point of "200 to 250 or more to the minute. it may be necessary to await the development of other symp- toms. Prognosis.—The greater the size of the thyroid and the prominence of the globes, according to Gowers, the less likelihood is there of recover)'. The course is essentially chronic, extending over many years. A few instances ending acutely in recovery or death have been reported. About an equal number of instances terminate respectively goitre, exophthalmic. 385 in death, in more or less complete recovery, and in improve- ment. In children the prognosis is rather favorable. Treatment.—Thymus-gland feeding and glycerin-extract administration have given some favorable results in the ex- perience of Owen, Wood, Cohen, and others. Thymus tabloid, gr. iii., is said to be equal to gr. viii. of the gland. Increase gradually to nine tabloids daily.—C. F. Nammack. Thyroid is indicated in non-cystic goitres and exceptionally is of advantage in special instances of exophthalmic goitre. Caution.—Extreme care is necessary in treating the latter affection.—Lapine. In some instances, under the use of thyroid there is a rapid increase of all the symptoms.—H. L. Winter. For persistent painful heart action : R Tr. aconiti rad., Nitroglycerin! (1 per cent, solution)........................aa tti, i. Ext. cacti grandiflor........................................ Ttj, x. Aqua? dest.............................................q.s. ad 3 i. M. S. This dose to be taken upon rising, at noon, and at bedtime. —James J. Crook. For the tachycardia, digitalis, strophanthus, convallaria; while bromides are useful for their sedative action. Sodium phosphate, gr. xxx.-xl., for daily dose.—Tra- chewski. Glycero-phosphate of sodium, gr. xx., three or four times daily.—M. Allen Starr. The faradic current. Strong currents may be applied di- rectly to the gland.—Putnam. The cure of associated peripheral lesions, as the removal of polypi, intranasal cauterization, the cure of uterine disease, in- testinal atony, chronic constipation, etc., has been followed by disappearance of the symptoms of Basedow's disease. 35 386 the practitioner's manual. To lower vascular excitement : R Pulv. ipecac................................................ gr. vi. Pulv. digitalis.............................................. gr. iv. Ext. opii................................................... gr. ss. M. et ft. pil. No. xii. S. From four to six pills a day. —DlEULAFOY. To lessen nervous excitability, hydrotherapy. Cold hip baths, warm or cold foot baths, and uterine douches are of value in menstrual complications. To calm the palpitations, tincture of veratrum viride, gtt. ii.—v. four times a day, extended over several months.—G. See. For intestinal antisepsis : R Phenol bismuth.............................................. 3 iv. Sodii benzoat., Bismuthi subcarbonat......................................aa 3 ij M. div. in capsulas No. xlviii. S. Two an hour after meals. Such drugs exert a specific control over the vascular and cardiac disturbances, in marked contrast to the inefficiency of cardiac sedatives. When there are dyspnoea and palpitation, tincture of bella- donna, or tincture of aconite, p.r.n., night and morning.—W. H. Thompson. Heart tonics, such as digitalis or strophanthus, do harm, causing headache, dizziness, etc. Thyroidectomy should be resorted to only in extreme cases. —Ralph R. Spencer. Electricity.—Galvanism is superior to farad ism ; weak cur- rents are sufficient, two or three milliamperes; each application should last six minutes; applications should be made two or three times a day. The anode should be placed on the back of the neck, over the seventh cervical vertebra; the cathode should be moved up and down the side of the neck, from the mastoid process along the course of the great nerves. We have in electricity an agent powerful for good in the majority of cases.—Cardew. GOUT. 387 Galvanism to the sympathetic and vagus. The strength of current is regulated according to the tolerance of the patient, the amperage depending entirely upon the sensation of each in- dividual. Caution.—Avoid too strong currents, too long seances, and the faradic current, which overstimulates.—Robert Newman. R Tinct. strophanthi..............................................§ i. S. Gtt. viii.-x. three times daily. It may even be carried as high as twenty or thirty drops by gradual increase of one or two drops daily.—E. D. Ferguson. Antipyrin, gm. 2-3 daily.—Huchard. Unless the patient will abstain from meat and take milk in- stead, little improvement can be expected. The milk, however, should be fermented, as in matzoon or kumyss. A purgative dose of calomel should be given once a week.—W. H. Thompson. General treatment including remedies directed against the ansemia often acts well. Tincture of fucus vesiculosus, gtt. xxx. three times a day, has been recommended. Gout. Gout is either acute and transient, or chronic and persis- tent. It is a disease of adult life (rarely seen in children), affect- ing by preference the smaller joints and one at a time. In acute gout there is evidence of intestinal derangement, portal congestion, and nervous disturbances, with dry and unperspiring skin. Diagnosis.—The seizure is sudden, occurring often at night or in the early morning. The metatarso-phalangeal articulation of the great toe is that most frequently affected. The pain is extreme and the skin over and about the affected region is red, tense, ©edematous, hot, and shining, and pits upon pressure. The symptoms, mostly marked in plethoric individuals, may 388 the practitioner's manual. comprise fever, restlessness, insomnia, and at times a critical perspiration, which may attend a morning remission. The duration of the acute attack is usually brief under ap- propriate medication, but recurrences may be predicted. Des- quamation follows the swelling. Chronic gout applies to the terminal changes occurring in joint structures; the attacks are frequent, pain and fever are much less pronounced, but the ar- ticulations become stiff, enlarged, and at times immovable. When chronic from the start the patient is usually otherwise debilitated. If tophi or deposits about the joints are not present, the diag- nosis hangs upon the history of preceding attacks and charac- teristic changes in the blood and urine. When chalk-like de- posits have taken place they are recognized by their superficial character and by showing a lesser resistance than do the excres- cences of rheumatoid arthritis. Marked flexion of the first pha- lanx of the middle finger is looked upon by Paget as pathog- nomonic. Snppyressed gout, with various symptoms independent of articular pains, etc., is a term used to designate cardiac attacks with dyspnoea, gastric, nephritic, nervous, cutaneous, and pul- monary manifestations in gouty subjects, for which no other cause is to be found. The term visceral gout applies to an affection of the mucous membranes of the intestinal, urinary, and especially the respira- tory tracts. Arterial tension is increased and arterio-sclerosis is frequent. A distinction must be made between declared gout and the con- dition of goutiness. In the latter many forms of muscular pain, stiffness, and tenderness of joints, neurasthenic and neu- ralgic symptoms as well as visceral disorders are to be properly referred to the gouty habit. Irregular forms are more common in America than the typical. —Kinnicutt. gout. 389 Differentiation.—The acute variety must be distinguished from acute rheumatism, which is a disease of youth, affects several joints, chiefly the larger, and is attended with free per- spiration, by the absence of uric acid in the blood and the fact that the salicylates cure the latter while they do not generally benefit gout. Rheumatoid arthritis is more likely to be confounded with chronic articular rheumatism than with gout, the changes being limited to a few of the larger articulations. Still the deformity resulting from the two conditions can be quite similar in appear- ance. The Roentgen rays clearly show in some instances the differ- ence between the splint-like deposits in gout and exostoses at the margins of articular surfaces in arthritis deformans. Dupuytren's contraction may be mistaken for gouty flexion of terminal phalanges without marked gouty signs. It is the rule in gout that the deformities are asymmetrial and unequal on the two sides.—E. Reynolds. Prognosis.—In otherwise healthy individuals of middle age, the prediction may be made that suitable remedies will give prompt relief from acute symptoms and that under suitable re- strictions as to diet and mode of life the danger will be minimum. In those of advanced years and in otherwise debilitated subjects chronic gout is to be looked upon with great apprehension, be- cause of the marked tendency to heart and kidney complica- tions, vascular changes leading to apoplexy, and the intercur- rence of pneumonia, diabetes, etc. Gout is curable, but some of its results are not. Treatment.—In acute attack, opium must be our chief re- liance for the relief of pain. An aperient should be given at once, followed by a saline and a mixture containing alkalies, and colchicum, according to the indications. It is possible to cut short an acute attack by giving drachm doses of wine of colchicum seed until free purgation. 39b the practitioner's manual. Colchicum and alkalies occupy the first place, though the salicylic group of remedies is not without its value.—Ewart. Colchicum is better than salicylates for the Sydenham type of English gout, which is rare in America.—H. C. Wood. Hygienic Measures.—Hygiene is of course important, not only as a prophylactic but in treatment of the prolonged attacks. The alimentary regime is probably the most important of these; still the amount of exercise, of brain work, the patient's dwell- ing, clothing, etc., must all receive careful attention. Diet.—There is no diet for gout; it is diet for the individual. Red meat in some subjects will precipitate an attack, in others it alone will effect a cure. — Wood. A rational mixed diet is best, avoiding excess. Avoid as- paragus.—Luff. Control the diet, enjoin exercise, give natural mineral waters. —Garrod. Avoid sweets, fermented liquors, potatoes, and do not over- tax the digestion with carbohydrates.—L. F. Bishop. Patients do best on azotized and starchy food, but some can- not take the latter.—W. H. Draper. Thin beefsteak free from fat, boiled in water. The whites of two to four poached eggs. A thin slice of oven-toasted bread with each meal. No fluids at meals. No alcohol.—W. Arm- strong. Breakfast.—A selection may be made from the following articles of diet: Porridge and milk, fresh fish, fat bacon, eggs, tea infused for three minutes and then strained from the leaves. Lunch and Dinner.—Whiting, sole, turbot, and plaice. Meat should be taken at only one meal, and then in moderate quantity. Two vegetables and in abundant quantities. Stewed fruits or baked apples every day. One tablespoonful of whiskey, freely di- luted with an aerated water, may be taken at lunch and dinner. Exercise up to a point short of fatigue and discomfort should be taken. Cycling is an excellent exercise for the gouty, GOUT. 391 since it furnishes good muscular movement in the open air with- out the gouty joints having to bear the weight of the body. If there be any cure it is exercise. Keep it within the point of causing exhaustion, gradually increasing. Bicycle exercise. —H. C. Wood. For acute gout, the indications for colchicum are fever, tender- ness, decided sweating, increased thirst, very concentrated urine, accelerated breathing, and overaction of the heart.—Schulz. In inveterate forms, free purgation. Then in cupful dose two or three litres of water at 3s°—ts° C., pure or acidulated with lemon juice (half a litre before each meal). Hydrotherapy both internal and external, as well as mas- sage and electricity, will all have their fields of usefulness in particular instances. A weekly Turkish bath is an agreeable and most successful method for sweating out hereditary taint. Salt bath each morning followed by brisk friction with bath towel. In subjects of chronic lead poisoning, hot and vapor baths. (Sulphur baths here contraindicated.) Potassium or sodium iodide if tolerated. In chronic goutiness or in the intervals of acute attack, the most important measure is the use of mineral baths, with massage applied directly to the joint affected with a low grade of in- flammation.—C. C. Ransom. R Hydrarg. chloridi mitis, Aloes, Ipecacuanha? pulv., Ext. colchici rad.............................................aa 3 i M. Divide into sixty pills. S. One three times daily. ,T_ —White. Or— R Ext. colchici radicis, Ext. aloes, Pulv. ipecac, Hydrarg. chlor. mitis......................................aa gr. i. Ext. nucis vomica?........................................... gr. £ For one pill. One every three or four hours until purgation ensues. —A. L. Loomis. 392 the practitioner's manual. Or— R Vini colchici sem............................................. § ss. Potass, iodidi................................................ 3 ij. Liq. potassa?................................................. § iss. Tr. zingiberis............................................... 1 ij. M. S. 3 i. twice daily in warm water. —Hodgson. Or— R Lithii benzoatis.............................................. 3ij. Aqua? cinnamomi........................................... § iiss. M. S. 3 b in a wineglass of water every four hours. —Jaccoud. In acute form : R Vini colchici sem............................................ 3 iij. Spt. amnion, aromat......................................... 3 xiij. M. S. 3 i. every three hours. —Bartholow. In gouty diathesis with symptoms of nephritis : R Extract of stigmata of maize.............................. 3 iss. Benzoate of sodium, Carbonate of lithium....................................aa gr. xlv. Oil of unise................................................ gtt. iij. Divide into sixty pills. S. One t.i.d. before meals for twenty days in each month. —Huchard. R Colchicine.................................................. gr. -^ Quinina? muriat............................................ gr. iij. Morphina? muriat........................................... gr. i For one pill. S. One pill every four or six hours. —Woodbury. R Tr. stramonii............................................. 4 parts. Tr. colchici sem........................................... 6 " Tr. guaiaci............................................... 60 " M. S. Teaspoonful three times a day in milk. —Gayle. Colchicine-methyl salicylate, 0.20 gm., in capsule, p.r.n.— Tobias. The best formula is: R Tinct. colch. sem............................................... 1 Alcohol......................................................... 10 M. S. Twenty to forty drops during the day. —SCHULTZ. gout. Tincture of colchicum in m v.-xv. at dose will give good re- sults. Caution.—Avoid when heart's action is exceptionally feeble. —Garrod. In robust fidl-bodied men : R Vini colchici.................... ........................... 3 i. Potass iodidi............................................... gr- x- M. S. For a dose ; to be repeated three times daily until brisk purgation. —MURRELL. Or— R Ext. digitalis............................................ gr. iiiss. Quinina? hydrobrom..................................... gr. xxvij. Colchici sem............................................. gr. viij. M. ft. pil. No. xii. S. One morning and night. —Becquerel. Or— R Magnesii sulph............................................. 3 ij. Potass, bicarb.............................................. gr. xv. Tr. colchici sem............................................ v\ x. Infus. buchu.............................................. § i. Ft. haustus. S. To be taken every four or six hours, followed by a large draught of water, not too cold. --FOTHERGILL. In chronic: R Lithii citratis, Magnes. carb...............................................aa 3 i. M. div. in cht. No. vi. S. One twice daily. Local : R Lithii carb. vel citrat......................................... 3v. Aq. dest...................................................... § xx M. S. Apply by means of lint, especially when skin is unbroken —Garrod. Or— R Veratriua?.........................................._..... ^ j Adipis........................................... z j M. S. Apply to painful joint at onset. (hint ion.—Do not use if skin is broken.—Turnbull. Or— R Sodii bicarb., 394 THE practitioner's manual. Apply on absorbent cotton and cover with oil silk or retain with bandage.—Wood. Or, lint soaked in a strong solution of nitrate of potassium, carbonate of sodium, or iodide of potassium often gives speedy relief. Petroleum is much used in Russia as a local application. R Salicylic acid............................................ gr. lxxv. Alcohol (90 per cent)..................................... I i. Oil of hyoscyamus, Castor oil..............................................aa § ij. Essence of wintergreen...................................v\ xx. Apply as a saturated compress over the painful part morning and night.-—Dettinger. Half an ounce of iodide of potasium dissolved in half a pint of rectified spirit (methylated spirit is used in hospital practice); then one ounce of soap liniment is added, and, finally, one-half drachm each of oil of cajuput and oil of cloves. A piece of lint soaked in this mixture is wrapped around the affected part, covered with protective dressing, and kept in place by a ban- dage. The inflammation usually subsides in from twelve to twenty-four hours.—Murrell. Or— R Ess. terebinthina?............................................... 15 Alcoholis camphorati, Tinct. saponis................................................aa 4o Tinct. cantharidis............................................... 4 Ft. linimentum. S. For external use. —RlBEIRO. Hot dry air, ranging as high as 320° F. or higher, for forty to sixty minutes, applied by means of a cylinder, in gout as well as in various chronic lithsemic conditions.—A. Graham Reede. Or by means of the Tallman-Sheffield apparatus. In gouty affections of heart, digitalis and strophanthus are preferred to all other heart tonics. Caution.—Use salicylates, colchicum, and potassium salts with caution. GOUT. 395 Lithium salts are best avoided because of their irritating ac- tion on the alimentary canal. Opium as little as possible. Do not attempt to call forth an attack by baths, for fear of unfavorable action on heart.—Schott. Furuucuii in the Gouty.—Gouty people are often attacked by successive crops of boils. Treat such cases by the internal administration of colchicum. Locally, apply strong tincture of camphor.—Brocq. Gout of the intestines is often indistinguishable from typhli- tis. Colic, enteralgia, and enteritis are often of gouty nature. Sodium salicylate, gr. xv., every three or four hours, along with alkaline salts of sodium or potassium.—Haig. Gastralgia in the gouty : T$ Chloroform water............................................. 3 ij. Syrup of orange............................................... § b Simple syrup.................................................. 3 b M. S. A dessertspoonful every fifteen minutes until the pain is relieved. —Dujardin-Beaumetz. Visceral gout, without articular symptoms within twenty- four hours, is to be treated at once with colchicum and the joints usually affected are to be blistered.—Jaccoud. Tophi, being in all respects the equivalent of foreign bodies, may be removed as such by means of surgical procedure (curet- tage) in the interval of attacks. As a prophylactic : 1$ Acidi lactici................................................... 3 x. Aqua?................................................. ....... 3 x. M. S. Half to one teaspoonful each morning with two, three, or four glasses of water. Continue for three weeks, stop for a week or two, and begin again, keeping up treatment for months and even years.—Be- renger-Feraud. To avert recurrence, or when in the attack there is little 396 the practitioner's manual. fever, tinct. guaiaci ammon. in dose of teaspoonful for an in- definite time, as it is harmless.—Sir A. B. Garrod. Or— R Guaiaci...................................................... gr. x. Mellis....................................................... 3 b M. ft. confect. S. 3 i.-ij. immediately after each meal. —MURRELL. We may almost always prevent the painful attacks in chronic gout and dissolve the deposits of biurates in the joints by com- bining the use of lycetol with proper regime. This drug has the uric-acid solvent properties of piperazin joined to the diuretic action of tartaric acid.—Henley. Haemophilia. The hereditary predisposition to bleed upon the occurrence of slight trauma, and also spontaneously, shows signs, as a rule, before the second year of life. It may declare itself simply as a tendency to the production of ecchymotic spots upon the skin, by a tendency to hemorrhages of mucous membranes, or by in- ternal hemorrhages and the occurrence of joint affections. Painful inflammation of the knee, elbow, ankle, or shoulder especially may result in deformity. Diagnosis.—hemorrhage without cause, especially when a family history of " bleeders" can be obtained, makes the diag- nosis easy. The members of a family thus affected are usually those of the male sex, the disease being transmitted through the females to their own male offspring; while they themselves escape. Males are more subject than females in the proportion of 11 to 1. Prognosis.—Out of one hundred and fifty-two boy bsemo- philics eighty-one died before the seventh year.—Grandidier. Treatment.—Glycerin extract of red bone marrow. HEMOPHILIA. 397 R Acidi gallici.............................................. 3 ss. Acidi sulphurici diluti....................................... tti, xl. Tinct. opii deodorati ........................................ tt[ xx. Infus. digitalis.............................................. 1 ij. M. S. Two teaspoonfuls every three hours. —Roberts Bartholow^ When much blood is being lost inject around the seat of bleeding, at from three to six different points, a hot saturated solution of tannic acid. Also for general hemostatic effect, strychnine, gr. -^q, hypo- dermatically.—H. C. Howard. As a prophylactic before surgical operation chloride of lime to render the blood more coagulable; camphor and turpentine to increase the white corpuscles.—Treves. R Calcii chloridi................................................. 40 Aqua? destil.................................................... 100 Teaspoonful in a glass of water. —Wright. Intravenous injections of hot saline solutions, employing a nozzle of glass or hard rubber, such as undertakers use in em- balming. This can be attached to the tube of any fountain syringe. In renal hcemophilia, absolute rest in bed. Ice bag over the kidney region. Sodium sulphate, gr. i., every hour, and— R Hydrastin.-e hydrocblor...................................... gr. iv. Ergotol..................................................... z ss Tr. opii deodor............................................. 3 ss Glycerin.................................................... ? j Aqua? menth. pip.....................................q.s. ad § ijj M. S. Teaspoonful every four hours. Subsequently liq. ferri mangan-pepton, 3 i., in milk twice daily. — W. J. Robinson. Inject upon the bleeding wound a few grams of fresh blood, immediately after it has been taken by a Pravaz syringe from the vein of a healthy subject. This coagulates in a few minutes and the hemorrhage, after the application of a light bandage, ceases permanently.—Bienwald. 398 THE PRACTITIONER'S MANUAL. Pack a bleeding cavit}r with gauze soaked in perchloride of iron and give calcium chloride in dose of 1.30 gm. every four hours.—Clifford Perry. In bleeding gums, purpura, and metrorrhagia, thyroid ex- tract seems to exercise an influence on the plasticity of the blood.—Dejace. Hemothorax. The accumulation of pure blood in the pleural cavity is rare excepting as the result of injury or rupture of an aneurism or blood-vessel. Diagnosis is made by the acute anaemia, which accom- panies the signs of fluid in the chest. Bloody sputa may point to the lungs as the source of the hemorrhage. Prognosis.—If the patient survive the injury and no com- plication ensue, absorption may be expected. Treatment.—Keep the patienb at absolute rest and apply the cold-water coil or cracked ice in a bag to the chest. Mor- phine hypodermatically in sufficient dose to prevent coughing. If subsequently the amount of fluid interferes with respiration, enough may be drawn off by aspiration to give the required ease. Haemorrhoids. Piles are usually described according to their implication of the external or internal portion of the lower gut. The internal are those which originate in and are covered over with mucous membrane; the external those which habitually protrude. Diagnosis should always be based on inspection. Differentiation.—Painful, itching, and hemorrhagic dis- orders in the anal region are all too apt to be called piles, and very often erroneously. JNot only are pruritus ani, prolapsus, fissure, fistula, warty and even malignant growths, as well as HAEMORRHOIDS. 399 hemorrhages from various causes, often regarded as piles for a long time by the patient, but they are not infrequently so re- garded too by the careless physician. In pruritus there is an absence of tumor and of hemor- rhage. Prolapsus presents a cone-shaped protrusion of velvet-like appearance occupying the whole circumference, while haemor- rhoids occupy, with firm or hard masses, but one segment. Inspection will reveal the nature of venereal or other warty growth, while in malignant tumor firm nodules are to be discov- ered in the rectal wall, and, if they have begun to ulcerate, little diffir-ulty in diagnosis will remain. Polypi, if present, are found as pear-shaped, smooth, rather soft tumors attached by a long pedicle. In fissure, upon distending the sphincter, under anaesthesia if necessary, the painful ulceration which has produced the severe symptoms will be disclosed. Prognosis.—Many instances will prove unsatisfactory as to recurrences unless radical operative measures are resorted to. Treatment.—Everything depends upon an acurate diagnosis of the exact condition; whether the piles are external or in- ternal, inflamed, itching, strangulated, or bleeding, etc. In non-protruding painful piles, cold water by injection will often give greater relief than any other local application. In protruding non-bleed"nig piles : R Plumbi acetat.......................... Pulv. opii.............................. Bals. Peru............................. Vaseline.............................. When very painful, hot-water applications. Then— R^ Cocaina?................................................ gr. Ext. opii.................................................. gr. Ext. belladonna?.......................................... gr. Lanolini.................................................. § i. M. S. Apply after washing. Then return mass gr. xx. gr. xv. 3 b 400 the practitioner's manual. And, as a suppository at bedtime : R Iodoform................................................... gr. iv. Morph. sulph............................................. gr. £ M. ft. sup. No. i. For itching of surrounding parts : R Ichthyol....................................................... 3 i. Vaseline....................................................... | i, —Mathews. Or— R Calomel................................................,....... 3 i. Cerat. simp...................................... ............. | i. M. ft. ung. Or— R Pulv. galla?.................................................. 3 i. Pulv. camphora?............................................. 3i. Pulv. opii.................................................. gr. x. Ung. stramonii.............................................. § i. M. S. Apply twice daily. Or— R Ext. stramonii, Acidi tannici...........................................aa gr. ss. Liq. plumbi subacetat..................................... gtt. ij. Plumbi carb................................................ gr. i. Creosoti.................................................... gtt. ss. 01. theobroma?.............................................. q.s. M. ft. supposit. Or— R Morph. sulph............................................... gr. iij. Cocaina? hydrocbl.......................................... gr. vi. Extr. sol. bellad............................................ gr. iij. Vaselini.............................................q.s. ad 3 iv. M. S. Apply. —J. V. Beceljere. For bleeding haemorrhoids: R Ferri subsulph.............................................. gr. iij. Plumb, acetat.................................0............. gr. i. Mass. hydrarg.............................................. gr. ss. 01. theobrom............................................... q.s. Ft. suppos. i. Introduce one morning and evening. —HORWITZ. HEMORRHOIDS. 401 B Camphorated lanoline........................................ § i4. Castor oil.................................................... 3 iiss. White precipitate of mercury................................. 3 i£. Conium hydrobromate........................................ 3 ss. —MONTN. B Lanolin...................................................... | iv. Petrolatum................................................... § iij. Glycerin..................................................... § ij. Distilled ext. hamamelis...................................... | i. Tannin..................................................... 3 ss. Powd. opium............................................... 3 ss. M. S. Apply locally. —Fenner. Or— R Ext. hyoscyami................................................ 3 ij Pulv. saponis................................................. 3 h Plumbi acetatis.............................................. 3 { Glyceriti amyli................................................ z{, M. S. Use externally morning and night. Or— B Calomel................................................... 3 ss Morphine muriate......................................... gr. iiss. Bismuth subnitrate...................................... 3 vi Vaseline........................•....................... 3 vj Glycerin............................................... 3 [i Apply. —Allingham. Or— R Acidi gallici................................................ gr x Extract, opii.......................................... ~r jv Extract, belladonna?................................... „r v Unguent. simplicis...................................... 3 jv M. S. Apply locally night and morning. —Hare. For the radical cure of hemorrhoidal tumors: 1. Weak Solution. B Potassii iodidi............................................gr xxx Iodi....... "'..." r,i____................................................... ^r- "J- 402 the practitioner s manual. 2. Strong Solution. R Potassii iodidi............................................. g1'• xlv- Iodi....................................................... gr- xv Glycerini................................................. I1- M. Solution No. 1 or No. 2 is ordered according to the suscepti- bility of the patient. The method of treatment is as follows: The patient first takes a warm sitz bath. Then he dips pledgets of cotton in the iodine solution and applies them to the hemor- rhoidal tumors. This should be repeated every hour, or at longer intervals.—Preissmann. R Ext. hamamelidis fld......................................... 1 •• Ext. Hydrastis fld., Tinct. benzoini comp.......................................aa 5 ss. Tinct. belladonna?............................................ 3 i. 01. oliva? carbolizat. (five per cent carbolic acid)........q.s. ad § iij. M. S. Apply frequently. —L. H. Adler, Jr. Sitz bath and washing with water at 120° to 130° F. In- sert into anus cottton tampon wet with two-per-cent cocaine be- fore and after stool. Dilate with Trelat's two-bladed speculum. Extirpate only as a last resort.—Reclus. In internal haemorrhoids, particularly associated with some- what frequent movement of the bowels: R Liq. ferri pernitratis.......................................... 3 iv. Liq. potass, arsenitis.......................................... 3 ij- Aqua?...............................................■ • -q-s- ad Iiv- M. S. Shake and take through a glass tube a teaspoonful in a wineglass of water after each meal. —A. Vander Veer. Radical cure : irrigate bowel with salicylic solution. Intro- duce— R Cocainse.................................................. gr. ij. Morphina?................................................ gr. i -i 01. theobroma?............................................ ij._v. Confect. rosa?.............................................. q.s. Divide into twenty pills. S. One thrice daily after meals. —William A. Hammond. In the congestive form : B Pil. hydrarg.............................................. gr. xxiv. Ferri sulph. exsiccati..................................... gr. xij. Pulv. opii................................................ gr. iss. Extr. gentiana?................................ „.......... gr. xxiv. M. et ft. pil. No. xxiv. S. One or two before bedtime. —Seymour. Or— B Resina? podophylli.......................................... gr. ij. Extr. colocynth comp..................................... gr. xij. Extr. nuc. vom............................................ gr. iij. Ferri sulph. exsic.......................................... gr. xij. M etft. pil. No. xii. S. One at bedtime. —Pepper. HEADACHES. 409 Or— R Ferri sulphat............................................gr. xxxij. Magnes. sulphat......................................... 3 x. Acid, sulphur, dil.................................•...... 3 ij- Tinct. cardamom, comp................................. § ij. Syrupi, Aqua? pimenta?.......................................aa 1 i. M. S. 3 ib in water twice a day. — Wright. In the plethoric form, the hot foot bath is often of signal service. To abort a bilious or dyspeptic headache : B Pilula? hydrargyri, Pilula? rhei composita?....................................aa gr. iv. Extracti hyoscyami......................................... gr. ij. Divide into two pills. S. To be taken at night. —Henry G. Wright. In the goidy : R Potassii carbonat........................................... 3 iss. Amnion, carbonat........................................... gr. xl. Tinct. serpentaria?........................................... § ss. Aqua? camphora?............................................ § iiiss. M. S. 1 i. to be added to water and lemon juice (aa § ss.). To be taken while effervescing, twice or thrice daily. —Wright. In the nervous: R Acid, nitromuriat. dil..................................... 3 ij. Strychn ina?............................................... gr. ^-ss. Spiritus chloroformi....................................... 3 vi. Tinct. zingiberis.......................................... 3 iij Aquam.................................................a(j § ijj M. S. 3 b in water t.i.d. —Tanner. Urcemic headache : B Potass, citrat................................................. 3 ,, Spir. juniperis................................................ 3 vj Spir. aether, nitr.............................................. 3 H Inf. scoparii......................................... 3 vj M. S. A wineglassful t.i.d. —Day. 410 THE PRACTITIONER'S MANUAL. Prodromal to cerebral syphilis : R Hydrarg. chloridi mitis..................................... gr. iss. Olei oliva? sterilizat......................................... q.s. S. As an injection every ten days. R Potassii iodidi........................................... 3 i.- 3 iss. Daily for a, woman ; double for a man. Neurasthenia after syphilis, bromides, hot baths, massage, change of climate. To prevent recurrence, every function must be maintained as nearly as may be in normal working-order. Especially is it necessary to secure daily free action of the intestines. Causes for recurrent migraine are to be sought in all the organs of the head—eyes, nose, throat, etc. Eye strain is to be especially watched for and corrected. Heart Diseases. Acute Endc >ca rditis. In the presence of acute rheumatism, the heart should be examined again and again with the utmost care, since endocardial changes may occur without marked subjective symptoms. Pericardial oppression, dyspnoea, palpitation, and increased temperature, not accounted for by outward signs of rheumatic exacerbation, should direct attention to the heart valves. Diagnosis.—Even in the discovery of a murmur we are not always justified in deciding that endocarditis is present, since the murmur may be of ha?mic or functional nature; conversely, physical signs may be absent where endocarditis exists. The presence of severe and debilitating affections other than rheu- matic, such as typhoid, scarlatina, diphtheria, and the like, make the diagnosis of endocarditis probable. In suspected ulcerative endocarditis take the temperature several times daily; the thermometer is of as much use as the stethoscope. The temperature rises and falls.—Lauder-Brunton. HEART DISEASES. 411 Differentiation.—From simple endocarditis are to be differ- entiated those cardio-respiratory murmurs caused by a quick inspiration, occurring coincidentally with the heart beat. This is readily accomplished by noting that the respiratory murmur disappears when the patient holds his breath. Malignant endocarditis may simulate by its symptoms of toxaemia, acute tuberculosis, typhoid or malarial fever. These may be excluded by? the more gradual onset in typhoid and tuberculosis and by the temperature range, while an examina- tion of the blood will exclude malaria as a cause. Endocarditis in the Aged.—In old people a recrudescence in an acute or subacute form of old chronic valvular lesions is by no means an uncommon thing. Febrile endocarditis in the aged may arise primarily from an attack of acute articular rheuma- tism, or may result from some other form of infection, but these are tbe exceptions, as it is almost always engrafted on an old valvular lesion.—W. M. Gibson. Gonorrhceal endocarditis may be regarded as a malignant form. The cocci have been demonstrated in the blood of the living, and in the thrombi post mortem. Treatment. Prophylaxis.—As soon as the heart sounds in acute articular rheumatism begin to grow muffled, or a bruit is detected, give in addition to the salicylate, iodide of potassium, 0.60 cgm. three times daily; also apply flying blis- ters over the apex and along the course of the fourth, fifth, and sixth intercostal nerves. Keep the patient in bed for a long time, and give a light milk diet.—Caton. R Pulv. opii................................................. gr. ij. Hydrarg. chlor. mitis ..................................... gr. xvi. M. etft. chart. No. viii. S. On ■ powder t.i.d. —BUDD. To reduce heart's action : B Tioct. viratri viridis........................................... | ss. S. Gtt. v. —Hazard. 412 THE PRACTITIONER'S MANUAL. Locally: R Tinct. iodi......... ..................................... 3 iij. Spir. chloroformi......................................... 3 i. Tinct. aconit. rad......................................... gtt. xxv. M. S. Apply with a brush twice daily —Keating and Edwards. After active signs have abated, rest hbr some days, and agents which lower blood pressure within heart and vessels.—Fother- GILL. * Poultices are of great benefit and give decided relief.—Da Costa. To reduce high temperature, Leiter's coils applied to thorax or abdomen.—Tyson. In the cardiac complications of the acute infectious diseases, and during the acute stage of an endocarditis, the application of an ice bag to the precordium is of great service. While acting as an antiphlogistic, it at the same time relieves palpitation, di- minishes pain, and slows the heart's action. Orrhotherapy has been employed for the cure of malignant endocarditis, antistreptococcic serum being used. Chronic Endocarditis. When congenital, the right side and the tricuspid valve espe- cially is affected, while the acquired form affects the left side by preference. The mitral is mostly involved in early life, while in late life it is the aortic which is generally diseased. Physical signs reveal the condition, often before symptoms present themselves. The signs of endocarditis include a blowing-sound, excited action of the heart, slight if any increase of the area of dulness, and strong impulse. Sounds, normal or more distinct, except at the site where the murmur is heard.—Da Costa. Diagnosis.—Cardiac dropsy, especially about the ankles, disappearing during rest in bed is one of the earliest manifesta- tions. heart diseases. 413 Emboli carried into the circulation may cause sudden death; or when lodged in the brain produce hemiplegia; or carried to the spleen produce splenitis; or to the kidneys, necrosis; or into the extremities, causing gangrene. Symptoms may, therefore, be most varied, remaining latent if compensation of the heart wall be maintained ; otherwise signs of dilatation occur. Prognosis is good if the compensation is maintained. In children a fatal termination is looked for earlier, while in the aged the condition may exist for many years so long as the gen- eral nutrition is kept up. A fatal result follows implication of the valves on the right side sooner than of those of the left, cya- nosis and dropsy being more readily produced. When several valves are affected the prognosis is more unfavorable. Were it not for the permanent changes in the valves and the danger from embolism, the outlook would be favorable. Aside from this is the danger of the simple form becoming septic and leaving the heart much more seriously damaged should recovery take place. Valvular Diseases. Aortic insufficiency is relatively infrequent, and is the most serious valvular lesion; sudden death is the usual result. Diagnosis.—The murmur is heard most distinctly in the second right intercostal space, is diastolic, and is transmitted down the left margin of the sternum. Signs of hypertrophy and dilatation are always present and cor boviuum is frequent. The Corrigan or water-hammer pulse, with visible pulsation in the peripheral arteries, is an almost constant symptom. Pain is a symptom accompanying lesions at the aortic orifice, but is rarely found in mitral affection.—Not n nag el. Treatment.—In valvular disease in which digitalis has failed to restore compensation the Nauheim baths may prove remarkably beneficial. In aortic regurgitation digitalis is not always beneficial. 414 the practitioner's manual. Good results are secured at Nauheim in lack of compensation from both aortic and mitral disease, separately or combined.— Rives. Caution.—In aortic regurgitation digitalis is a dangerous medicine. Exercise should be abstained from while taking digitalis, since it counteracts its influence.—English. Aortic stenosis is a quite frequent lesion, though not so common as insufficiency. Diagnosis.—A systolic murmur at the midsternum, oppo- site the third interspace, transmitted upward and to the right into the vessels, is not pathognomonic; a similar murmur but less harsh, occurs with the thickening of the valves and in lwcmic conditions. Prognosis.—The lesion is often well borne for a long time. A moderate amount of hypertrophy of the left ventricle will usually maintain compensation. Liability to sudden death from overdistention of the left ventricle is ever present.—J. K. Crook. Treatment.—The only excuse for prescribing digitalis is to give vigor to the muscle of the heart when the tendency to dilatation is announced. Unload the congestion of the liver and spleen by calomel and salines, and strengthen the heart by saline baths and resistance exercises.—Heineman. Mitral insufficiency is the most common valvular lesion, and gives the most promising prognosis. Diagnosis.—A systolic murmur, loudest at the apex, trans- mitted to the axilla, and heard at the back. Heart enlarged transversely. When in a case of mitral disease we have had overfilling of the pulmonary veins, and consequently increased tension in the pulmonary artery and augmented loudness in the click of its valvules, disappearance of this accentuation of the second sound over the pulmonary artery indicates great failure on the part heart diseases. 41o of the right ventricle. Feebleness or absence of aortic or mitral murmurs, previously present, suggests failing ventricular con- traction on the left side. Treatment.—Only in relative and functional insufficiency is a complete cure possible in valvular disease; treatment prolongs life. Absolute rest in bed until hypertrophy has occurred ; then begin exercise. The patient should stop and rest as soon as pal- pitation and shortness of breath occur. The diet should contain a preponderance of proteids; alcohol, coffee, and tea sparingly and diluted. Caution.—Never give digitalis in large amount unless the patient remains in bed until the desired effect is produced and the drug has been stopped. To excite kidney action : R Hydrarg. chl. mitis........................................... 3 ss. Ft. cht. No. x. S. One, two or three times daily. —Liebermeister. For the mitred disease : R Zinci sulphat............................................. gr. i.-iij. Camphora?............................................... gr. i. Ext. hyoscyam i.......................................... gr. ij. M. ft. pil. S. Take t.i.d. —Barlow. In mitral regurgitation with anaemia: R Pulv. scilla?................................................. gr. x. Pulv. ferri, Pulv. digitalis (English), Quin. sulphat............................................a,a 3 i. M. etft. pil. No. xx. S. One pill t. i.d. —Bartholow. To produce diuresis and diminish anasarca, morphine.— Hervouet. In the congestive and dropsical complications of advanced disease: R Pulv. digitalis.............................................. gr. i. Pulv. scilla?................................................. gr. i. Pil. hydrargyri............................................. gr. i. M. ft. pil. One to be taken thrice daily between meals. —Sir James Sawyer. 410 the practitioner's MANUAL. Mitral stenosis is often borne for a number of years and liability to sudden death is not great. Diagnosis.—A presystolic murmur, heard above and a little to the inner side of the apex beat and transmitted downward and to the left. A rough, grating, well-defined fremitus or thrill, best felt in the fourth or fifth interspace within the nipple line, is pathogno- monic.—Osler. Compensatory hypertrophy and dilatation of the right heart may produce bulging of the chest wall in children. Non-compensation produces venous stasis in the pulmonary circulation. Bronchitis is common. Treatment.—In the stenoses, until hypertrophy of the sec- tion of the heart concerned has taken place, all great demands upon it which the heart is not able to meet at once should be carefully avoided. —Liebermeister. Aortic regurgitation with mitral stenosis : R Tinct. stropbanthi, Tinct. nucis vomica?, Tinct. digitalis............................................aa p. a?. M. S. Gtt. xx.-xxx. t.i.d. —W. H. Thompson. Tricuspid Stenosis.—As a diagnostic sign of this condition we have a pulsation of the liver, which James MacKensie desig- nates the auricular type. It is the hepatic pulse and not the venous pulse that is looked upon as distinctive. In congenital defects and dilatation without valvular disease. resistance gymnastics, carried out by an experienced nurse under physician's orders.—Saundby. Heart Disease in Children. General Diagnosis.—In the young irritability of temper is often referable to valvular affections and should lead to exami- nation of the heart. heart diseases. 417 In anaemic and nervous children irregular heart action is frequent. The rhythm may be disturbed by disorders of diges- tion. Differentiation.—In cardiac irregularity, tuberculous men- ingitis must be excluded. General Prognosis.—-In order to prognosticate in the car- diac affections of children we must inquire: 1. If the cardiac disease was caused by a single attack of rheumatic fever, how long it is since the attack, and what has been the health in the interval? 2. If there have been two or more rheumatic attacks, at what intervals have they occurred? 3. The family history. 4. What is the condition of the patient as regards general nutrition? o. Is there good compensation, or commencing or even advanced failure? 6. If there is heart failure, is it recent, or only a stage farther on the downward course? The condi- tion of the heart, lungs, liver, and kidneys will help materially in answering this question. 7. If there is oedema of the ankles. Frequent recurrence of rheumatism at short intervals is a bad sign. A subject of aortic regurgitation cannot expect length of days. Fatal failure may occur at any time.—Chapman. In dilatation with secondary hypertrophy the prognosis is good, if ordinary precautions are taken. Treatment.— In organic valvular disease in children, nux vomica gradually and cautiously. I prefer, however, for a child of eight years, if digitalis fails: B Tinctura? ferri chloridi........................................ 3 ij Syrupi ananassa? sativa? (pineapple)...........................^ v. One teaspoonful every three hours, alternating with : B Spir. a?ther. nitrosi............................................ z ss Spir. Mindereri................................................ | jv One teaspoonful every three hours. —J. Lewis Smith. In heart failure in children, occurring in acute febrile dis- ease: 27 41S the practitioner's manual B Caffeina?, Sodii benzoatis.........................................aa 1.(5 Tinct. aurant. cort........................................ gtt. xx. Aqua? destill., Syr. simplicis............................................aa 50 M. S. Tablespoonful for a dose. —Bruneau. Heart Disease in Pregnancy. Parturition may be the determining factor in producing a dangerous condition of cardiac weakness. Death from heart failure occurs with the greatest frequency during the week suc- ceeding labor. When symptoms of heart failure are noted as early as the third or fourth month, emptying the uterus is justifiable. Free bleeding during the third stage of labor has a most useful effect. The application of leeches over the liver or heart when, dur- ing the puerperium, blueness of the face and lips, dyspnoea, and pulmonary troubles tell a tale of an overdistended and failing right ventricle. Of all drugs strychnine and nitrite of amyl are the most useful.—Handfield-Jones. In syncope, inclination of the head downward and back- ward, transfusion of blood, subcutaneous injection of a solution of common salt, electrization of the phrenic nerve, and artificial respiration when respiration also is affected.—Bobrof. Treatment of Chronic Endocarditis in General. /. Hygiene and Exercise.—Eesistance gymnastics, or Dr. Schott's system, consists of slow movements made by the patient and resisted by the operator, short intervals being allowed for rest. The exertion should be small, and the patient should be loosely clothed and told to breathe quietly. This matter of quiet breathing is quite important. It must be watched and controlled by the operator. The resistance should not be of such a kind heart diseases. 4l<) as to prevent the patient from feeling master of the situation. The operator must not grasp or in any wise constrict the limb, but oppose by the hand held flat. The following rules are laid down : 1. Each movement is to be performed slowly and evenly; that is, at a uniform rate. 2. No movement is to be repeated twice in succession in the same limb or group of muscles, 3. Each single or combined movement is to be followed by an in- terval of rest. 4. The movements are not allowed to accelerate the patient's breathing, and the operator must watch the faco for the slightest indications of (a) dilatation of the alae nasi; (b) drawing of the corners of the mouth; (c) duskiness or pallor of the cheeks and lips; (d) yawning; (e) sweating; and (/) palpi- tation. 5. The appearance of any of these signs should be the signal for immediately interrupting the movements in process of execution, and for either supporting the limb which is being moved or allowing it to subside into a state of rest. 6. The pa- tient must be directed to breathe regularly and uninterruptedly, and should he find any difficulty in doing so or for some reason show a tendency to hold his breath, he must be instructed to continue counting in a whisper during the progress of each movement. 7. No limb or portion of the patient's body is to be so constricted as to check the flow of blood.—Sir T. Grainger Stewart The movements are as follows: 1. Arms extended in front of body on a level with shoulder, hands meeting; arms carried out until in line, and brought back to original position. 2. Arms hanging at sides, palms forward; arm flexed at elbow until tips of fingers touch shoulder, back to original position; one arm only moved at a time. 3. Arms down, palms forward ; arms carried outward and upward until thumbs meet over head; back to original position. 4. Hands in front of abdomen, fingers flexed so that second phalanges touch those of opposite hand; arms raised until hands rest on top of head; back to original position. 5. Arms down, palms against thighs; arms raised in 4.50 the practitioner's manual. parallel planes as high as possible; back to original position. (b Trunk flexed on hips; return to original position. 7. Trunk rotated to left, to right; return to original position. 8. Trunk flexed laterally, lb As No. 1, but fists clenched. 10. As No. 2, but fists clenched. 11. Arms down, palms against thighs; each in turn raised forward and upward until arm is alongside of ear, then turned outward, and arm descends backward. l'J. Arms down, palms to thighs; both together moved backward in parallel planes as far as possible without bending the trunk forward. 13. Thighs in turn flexed on trunk, opposite hand resting on chair. 14. Lower extremities in turn extended fully, and bent on trunk forward and backward to extreme limits of movement, opposite liand resting on chair. 15. Legs in turn flexed on thigh, both hands on chair, lb. Feet together; lower extremities in turn abducted as far as possible, and brought back to original position, opposite hand resting on chair. 17. The arms, extended horizontally outward, are rotated from the shoulder-joint to the extreme limits forward and backward. 18. The hands in turn are extended and flexed on the forearm to extreme limits, and brought back in line with arm. 19. The feet in turn are flexed and extended to extreme limits, and then brought back to their natural position. Indications, generally speaking, are all circulatory dis- turbances, all diseases of the heart with or without valvular disease, and particularly with loss of compensation, angina pec- toris (bath should always be first employed), and congenital cardiac disease. Ordinary complications, such as oedema, ana- sarca, hydrothorax, hydropericardium, and moderate chronic renal congestion, do not contraindicate the above treatment. In patients incapable of walking and climbing, as in Oertel's method. Contraindications are found in arterial sclerosis in advanced stages; in the presence of many complications, pulmonary in- farction, etc.; marked weakness, aneurism of the aorta of heart diseases. 421 second or third degree; acute and chronic nephritis.—H. N. Heineman. The Oertel system consists essentially in requiring the patient to take daily walks up hills or mountains of different steepness, the distance graduated according to the requirements of the individual patient. Mental occupation is valuable. All forms of exercise are contraindicated during loss of com- pensation, with a feeble heart laboring to maintain equilibrium. Rest in bed is then essential. II Cardiac Remedies.—Compensation is a relative term: compensation in the face of work and license generally; com- pensation without strain of muscle or tax of mind; compensa- tion with rest of body and mind insured. If failure has oc- curred, as is usually the case when treatment is called for, get at the cause which is at work. Overwork, insufficient exercise, underfeeding, overfeeding, cardiac poisons, mental distress or strain, ansemia from hemorrhage, insanitary life and work, uterine complications, affections of the lungs taxing the right heart, affections of the vessels taxing the left heart, including Bright's disease—these are examples of the varieties of causes at work in cardiac failure which must be searched out and treated, each in its own proper way.—J. M. Bruce. In overdistention of the cardiac cavities removal of blood will give great relief. Leeches may be applied, cupping-glasses may be used, or a three-inch blister applied over the ensiform cartilage to'obtain a copious flow of serum. Next to abstraction of blood is a pifrgative dose of calomel followed by sulphate of sodium. Considerably limit the inges- tion of fluids. Keep the patient sitting up for several nights; oedema of the lower extremities is thereby induced; withdraw the serum by puncture. Lastly phlebotomy.—James Little. Digitalis is the most frequently useful drug. Caffeine is a cardiac tonic ranking next to digitalis and stro- 422 THE PRACTITIONKIbS MANUAL. phanthus, but is liable to produce restlessness, nervousness, and wakefulness. The bromides often relieve cardiac distress, but are depress- ing. Arsenic is a heart tonic. NiWoglycerin is very effective in overcoming obstruction in the arterioles; dose, gr. T-lF increased to gr. -^ or more. Amyl nitrite acts more quickly, but the result is not so per- manent. It is anodyne. Sparteine sulphate in doses of two or three grains is useful as an alternate stimulant. The more frequent and the more irregular in force and rhythm is the heart beat, the more confidently can we prescribe digitalis. The drug is injured by being kept for days in aqueous solu- tion. Mix the dose of tincture with water or spirits at the time of giving. It slows the heart action by prolonging the diastole. When it fails to bring about an increase in the force of the contractions give strophanthus. Digitalis is in general a far more useful drug. Stop giving as soon as it has produced the desired effect, namely, slowing and steadying of the heart beat. An occasional dose may be given to maintain the effect. When chronic inflammatory changes are still going on in the valves, iodide of potassium appears to aid the action of cardiac tonics.—Stewart. In gouty affections digitalis and strophanthus are to be pre- ferred to all other cardiac tonics. Caution.—Avoid overexertion; stimulants (light Rhine wines are the least harmful). Salicylates, antipyrin, and anti- febrin require caution. Lithium salts irritate the alimentary canal and potassium salts should be very cautiously used, owing to their toxic action on the heart, and opium as little as possible. Unfavorable action upon the heart may be exercised in try- ing to call forth the attack of gout by baths.—Schott. HEART DISEASES. 423 In strychnine we have an ideal cardiac stimulant, which not only acts upon the circulation, but upon respiration, digestion, and assimilation as well. It is especially indicated in the weak heart of pneumonia and febrile processes, given hypodermati- cally in 3V to TV grain doses, repeated until some sign of the drug is manifested. It is also useful to relieve the alarming symptoms which occur in surgical anaesthesia, in the cardiac weakness often associated with neurasthenia, and in that due to depressed nerve force. Strophanthus is of great value as a car- diac sedative in that form of tachycardia so common in exoph- thalmic goitre. These two drugs will retain their supremacy because of their influence over the vital centres in the medulla. to which the various systems of the body look for support and encouragement.—Krauss. Caution.—Strophanthus is not suitable for prolonged use and may cause extreme cardiac "distress." After a period of rest it may again prove useful.—Little. Strophanthus is a heart poison and not a heart tonic. Even small doses in a weakened heart are said to interfere with nutri- tion.—Balfour. Calomel.—Dr. Maldaresco has reported very favorable re- sults from a course of calomel, followed by the iodide of potas- sium. He first gives one and one-half grains every two hours for six doses daily, and keeps this up for two or three days, when the dose may be increased to two or three grains for a few days longer, before the iodide is begun. To reduce arterial tension, chloral is of great use in con- nection with nitroglycerin.—Kinnicutt. In high arterial pressure, when nitroglycerin is contraindi- cated : B Chloral, Bromide of sodium............... Syrup of lactucarium............. Water................. .......... M. S. Teaspoonful every four hours. .....aa 3 ij. ....... !i- q.s. ad | iij 424 THE PRACTITIONER'S MANUAL. In Low Tension.—For the relief of passive congestion aiul to establish compensation, the pulse being of low tension, the cali- bre of the blood-vessels should be contracted by vasoconstric- tors, of which the most reliable is "ergotole." For the regu- lating of the rate of cardiac contraction, drugs which have little or no effect upon the size of the blood-vessels should be used— strophanthus or sparteine, caffeine or cactus. — Wilcox. Atropine is indicated in irritation of the pneumogastric, slow pulse, dizziness, convulsions, snycope. Hypodermic injection, one-half to two milligrams.—Cardarelli. A tonic dosimetric granule : R Morphine................................................... gr. Tl3 Strychnine.................................................. gr. xfj Atropine.................................................. gr. ^h Caffeine.................................................... gr. ^T May be used hypodermatically.—Edw. C. Mann. As an analgesic in the more or less permanent pains of vas- cular cardiopathies: R Tinct. piscidiae erythrina?................................... 60 gm. Tinct. verat. virid., Ext. aconiti rad. ale......................................aa 15 " M. S. Thirty drops morning and night. —LlEGEOIS. In the intense pain of mitral disease, morphine, gr. T\r to \, hypodermatically. In imperfect compensation, as little food as possible should be taken, to decrease heart work.—Hirschfield. In threatened cardiac debility, any excess of alcohol, even habitual slight excess, is to be strongly deprecated. In debility following influenza, diphtheria, and other exhausting disease, whiskey may be of use in doses of from two drachms to an ounce, not exceeding four ounces in twenty-four hours, always taken with food or mixed with milk.—Sir T. G. Stewart. Alcohol often fails to support the heart and is apt to add hepatic engorgement to cardiac weakness.—Little. heart diseases. 42-j In emergencies use strophanthus, since it acts more quickly than digitalis.—T. G. S. In cardiac debility, as in tuberculosis and in fatty heart, dehydration and mountain climbing.—Oertel. To relieve nocturnal breathlessness, place the patient in a chair and apply a large light hot poultice to the chest. Give a little hot wine and water. If these means fail, morphine hypodermatically. Or— R Morphina? sulphat.......................................... gr. iv. Chloral.................................................... gr. ij. Liq. atropina? sulphat. (P. B.).............................. ^l xij. Aqua? camphora?....................................q. s. ad 3 iv. The chloral is added merely to make the solution keep; it renders the injection slightly painful. Ten minims contain morphine sulphate, gr. \, and atropine sulphate, gr. -^\-^\ but eight minims is a suitable dose for a first injection.—James Little. For dyspnoea, Hoffman's any done or paraldehyde in drachm doses; or, better, chloralamide, gr. xxx. For anasarca : B Diuretin (Knoll)......................................... 1 gm. Pulv. digit, fol........................................... 0.10 cgm. Sacch. alb.................................. ............ 0.30 cgm. For one powder. Three such daily. —ElCHHORST. Diuretic pill: B Scilla? pulv., Digitalis pulv., Caffeina? citratis........................................aa gr. xxx. Hydrarg. chlor. mitis..................................... gr. v. M. et ft. pil. No. xxx. S. One pill thrice daily, after meals. Or— B Theobromine............................................... gr. x. Powdered digitalis...................................... .. gr. i. Camphor................................................... gr- ij. Calomel..................................................... gr. i. S. In a capsule. Four to be taken daily. 421 i THE PRACTITIONERS MANUAL. R Calomel, Scilla? pulv., Digitalis pulv.............................................aa gr. i. For one pill. S. One every four hours. —FOTH KIN JILL. Or, blue pill, gr. iii., three times daily, to be gradually dimin- ished. Or, in grave cases of dropsy, theobromine, gr. 45 to 75, daily for three days.—Germain See. Caution.—Never attempt to remove the dropsy by hot-air baths or pilocarpine.—Loomis. For dropsy, full doses of digitalis every three hours and then every two. Omit solid food and reduce liquids to a minimum. The association of nitroglycerin (gr. to^-tV) with digitalis is important. For irregularity of heart action, palpitation, and pain, bel- ladonna plaster over the heart region; nitroglycerin.—Tyson. Stimulants and opium in sufficient quantities to relieve the marked depression of the early period.—A. L. Loomis. For Palpitation of the Heart.-—The various diseases that are accompanied by palpitation—incipient acute aortitis, acute endo- carditis, acute pericarditis, adhesions of the pericardium, and mitral stenosis or insufficiency—are benefited by digitalis or its substitutes. I give the following formula: B Quinine hydrobromate.................................... 3 i. Powdered digitalis........................................ gr. xxx. Extract of convallaria..................................... gr. xxx Divide into forty pills : two to four to be taken daily. —Huchard. To relieve the palpitation and nervousness of functional heart disease, cactus grandiflorus, in a tincture made by macer- ating four ounces of fresh stems in a pint of strong alcohol for a month, seems to act chiefly on the accelerators and sympathetic ganglia, shortening the diastole and stimulating the special vasomotor svstem. — Watson. heart diseases. 427 Belladonna Piaster applied over the heart is one of the best remedies we have. An ice bag over the precordium gives excellent results. Irritable heart : B Chlorahmid.................................................. 3 iv. Tinct. belladonna?............................................ 3 ij Elixir simplic..........................................q.s. ad § iv. M. S. Teaspoonful three times daily, between meals and at bedtime. —Egbert. In cardialgia of hysteria and neurasthenia, tr. piscidiae eryth., gtt. xx. For a daily amount.—Liegeois. In heart failure, the most essential thing is rest. Bleed- ing in great venous congestion of mitral stenosis.—Sharkey. When threatened, hot water bag over the heart region. Nauheim baths or artificial imitations should be tried and passive exercises used when there is grave debility of the heart, restive exercises when there is greater vigor, and Oertel's method (graduated hill climbing) when the heart has sufficiently recovered.—Sir T. G. Stewart. Caution.—Do not use the Schott method indiscriminately. Rest and heart tonics are the best means.—Bramwell. Unsystematic exercises are heart weakening, systematic exercises heart strengthening.—Schott. The most suitable cases for the Schott treatment are those of enfeebled heart, with or without marked dilatation, and with or without organic valvular lesion.—Lancet Commission. In heart failure from chloroform, rapid impulses (up to one hundred and twenty a minute) are given by the surgeon's left hand over the heart region as he stands on the patient's left and steadies the right chest wall with his left hand. Stimulants may be demanded, and the best are alcohol, cam- phor, strong coffee with rum or cognac, and hypodermic injec- tions of camphorated oil or ether.—Liebermeister. 42S THE PRACTITIONERS MANUAL. Formula for wine of coca : R Coca leaves............................................... Cognac................................................... Sherry wine.............................................. Hungarian wine.......................................... Macerate for several days and add seven grains of citric acid mixture to stand for several days and then filter. In the aged, tinct. digitalis, tti x., at bedtime, twice each week for three months.—James Little. Whenever the bicuspid valves have lost their ability to close the auriculo-ventricular orifice, and the cavity of the right ven- tricle is distended, while the muscular walls have lost compen- satory power, with pulsating, enormously distended, over- charged jugulars, with pronounced epigastric pulsations and a soft, blowing, distinctly marked murmur over the right heart, when other means fail, venesection often gives relief, tem- porarily at least.—B. Robinson. III. Diet in Cardiac Disease.—The question of proper diet depends upon the condition of the heart: when compensation is disturbed, the venous engorgement of the viscera disturbs digestion. In general employ nutritious food, easy of assimilation, and use small quantities repeated at fequent intervals. To be especially recommended are predigested beef, or beef and bread; peptonized milk, milk with Vichy or lime water; kumyss, matzoon, egg albumen with water, whey, light broths of different kinds, meat jellies, curds, beef juice. Limit the amount of liquids taken at and even between meals. All spirit- uous liquids should be avoided, save when the habit of life ad- mits of a small quantity of diluted light wine (light Moselle or claret). Aerated waters should be used with care and no cold fluids of any kind taken. As to solid food, the avoidance of excess of starches, sugars, and fat is urgent, but to recommend the suppression of carbohydrates is to leave the system in a 5 iij- Iiss. O iss. Svb Allow this heart, acute dilatation. 429 materially weakened condition, and without its main source of muscular energy.—H. N. Heineman. Increase nitrogenous and decrease carbohydrates. Mixed diet. Liberal potations in lithaemia, but not with the meals. When practical substitute aromatic spirits of ammonia for alcohol. Prohibit tobacco and usually coffee and tea.—Satter- thwaite. Avoid overdistention by flatulence. Avoid starches and sugars, and give food often but in small quantities.—W. G. Thompson. In Senile Heart. — 1. There must never be less than five hours between each meal. 2. No solid food is ever to be taken between meals. 3. All those with weak hearts should have their principal meal in the middle of the day. 4. All those with weak hearts should have their meals as dry as possible.— Balfour. Heart, Acute Dilatation. Acute dilatation of the heart may arise from overexertion, as in wrestling, boating, bicycling, violent effort, and the like, or from overindulgence in alcoholics. Diagnosis.—There are usually oedema, pallor, and shortness of breath, following violent pain in the heart region; at the time of undue strain a murmur may be heard, but usually in the tumultuous heart beating none is detected. Percussion. the position of the apex beat, and viewing the heart through the fluoroscope show the enlargement. The extent of the apical stroke as shown by direct vision with the Roentgen rays is of value in the diagnosis of dilatation of the left ven- tricle.—Abrams. Radiography.—Affix an almost straight wire, extending from the third to the sixth rib at a proper distance from the left sternal border. Using as a generator either a powerful static machine or an 430 the practitioner's manual. induction coil of at least S" spark, you let your machine work so as to produce the strongest ,c-rays at your command, when you may see only the scapula, the ribs, the left part of the spine, or the sternum, not to forget—plainest of all—your wire in front. Having familiarized yourself with your landscape, you now very gradually reduce the brightness of the ,r-rays— in the case of a static machine by reducing the speed—and you will observe the shadow of the heart, extending within or out- side your wire. Sometimes you can see a thinner and larger shadow superimposed on a smaller and thicker one, the former representing the heart in diastole and the latter the same in systole. Differentiation.—The disappearance of the murmur after a time is incompatible with rupture of a valve. Prognosis.—The heart may return to natural size, but recov- ery is slow. Arteriosclerosis may result and lead to "fibroid heart."— Handford. Treatment.—Rest, warmth. R Spir. a?th. comp........................................... m xl.-c. Aq. camphora? vel aq. menth. pip......................... | i. At a dose every three hours. In extreme lividity, venesection, not less than six nor over ten ounces being withdrawn.—Duckworth. To produce catharsis : R Mist, senna? comp. (P. B.).................................... 1 iss. Tinct. jalapa? (P. P.)......................................... 3 i. For hepatic enlargement and dropsy : R Pil. hydrarg................................................. gr. ij. Pulv. digitalis, Pulv. scilla?...............................................aa gr. i. Brandy or gin, 5 ii.— 3 iii. in twenty-four hours. For dyspnoea and insomnia, morphine. heart, chronic hypertrophy and dilatation. 431 As a diuretic : B Lemonade..................................................... Ob Cream of tartar................................................ 3 b Diet.—Easily digested, nutritious food. For most cases digitalis is best; when not under constant observation, strychnine. Caution.— In aortic reflex digitalis must be guardedly used. — Dvce Duckworth. /// idiopathic enlargement of the heart, the Schott treat- ment, by baths and gymnastics, seems specially serviceable before compensation has become irretrievably lost.—Babcock. When much dilatation obtains, with cardiac arrhythmia, gen- eral dropsy, and pulmonary oedema, the infusion of digitalis in ounce doses four times daily should be administered for two or three days; then the permanent dose of a half-grain of the powder may be given thrice daily with benefit for a long time. — W. H. Thompson. In acute degeneration of the right cavities, in a heart yet undegenerated, venesection relieves the overstrain.-—B. Robin- son. It is best to choose the median or median basilic vein. Heart, Chronic Hypertrophy and Dilatation. The term dilatation should be reserved for enlargement of the cavity of the heart with associated degeneration of the heart walls. In hypertrophic dilatation the walls are not degenerated. —Ad ami. Differentiation.— In hypertrophy the first sound is loud and booming in character, greatly intensified, and accompanied by a heaving impulse against the chest walls. It may or may not be accompanied by a murmur. The intercostal spaces are widened, the apex is displaced downward, and its impulse against the chest wall is localized and distinctly visible. In dilatation the character of the first sound is totally differ- 432 the practitioner's manual. ent. It is short and valvular, and somewhat resembles the second sound. The impidse is diffused, covers a large space, and the apex of maximum intensity may not be found, or it may be seen but cannot be felt. The pulse in hypertrophy is regular and full. If arterial sclerosis is present, then the pulse is greatly modified. The pulse of dilatation is weak, irregular, and generally rapid. The Prognosis in hypertrophy is generally good, while in dilatation it is quite the reverse, and as the dilatation increases the prognosis becomes more and more grave. Cardiac hyper- trophy is associated with arterial sclerosis and accompanied by the pulse of arterial degeneration. Enlargement of the heart is a common complication of chronic renal disease.—W. H. McEnroe. Treatment.— For irregular heart action : B Pulv. digitalis............................................. gr. x. Pulv. colchici sem....................................... gr. xx. Sodii bicarb.............................................. gr. xxx. M. et ft. pil. No. xx. S. Take one three or four times daily. —BOWDITCH. In simple enlargement: B Tr. digitalis.................................................. § iss. Ext. ergot, fld................................................ % iij. M. S. 3 i. thrice daily. —Bartholow. The Schott treatment is of especial value in simple dilatation without valvular disease.—Greene. In excessive hypertrophy of sedentary individuals after a life of active exercise aconite acts well. Next to aconite as a sedative comes gelsemium and then veratrum viride.—Hare. In dilatation : R Pulv. digitalis............................................... gr. v. Ext. belladonna?............................................. gr. i. Ferri reducti................................................ 3 ij- M. For xx. pills. S. One t.i.d. heart, fatty. 433 In dropsy caused by dilatation : R Tr. digitalis..................................................§ ss. S. Gtt. x. t.i.d. —Da Costa. In dropsy from cardiac disease : R Pulv. digitalis...........................................gr. i.-iss. Pulv. scilla?.............................................. gr. i. Hydrarg. cum creta, vel pil. hydrargyri.................. gr. i.-iij. M. ft. pil. No. i. S. One pill t.i.d. —Baillie. In hypertrophy with dyspnoea, ascites, oedema, and grave disturbance of the circulation : B Hydrarg. chlor. mit........................................ 1.5 gm. Pulv. sacch. alb............................................ q. s. M. ft. chart. No. xv. S. One every two hours, or six daily for two or three days ; after this one or two powders a day. Subsequently give potassium iodide.—Maldaresco. In the abstract, digitalis is applicable to any cardiopathic state in which dynamic failure of the cardiac muscle is present, without any reference to the primary cause from which such failure is developed. It is not only useless but harmful in the heart irregularities following influenza.—Sansom. In aged persons, who present signs of dilatation with degen- eration of the ventricular walls, with shortness of breath and dropsy, when digitalis and strophanthus have ceased to be of benefit, caffeine deserves to rank next as a cardiac tonic.— Little. Heart, Fatty. Diagnosis.—There is no certain sign of this condition. Gen- eral state of patient, condition of heart sounds, rhythm (irregu- larity of pulse is the rule), etc., aid in diagnosis. Differentiation.—Fatty degeneration cannot be differen- tiated clinically from fatty deposit. Prognosis depends on degree, and the condition of patient. 434 the practitioner's manual. Treatment.— R Sodii arsenat............................................... gr. ^ Potass, iodidi............................................... gr. f Pulv. nucis vom............................................ gr. % Pulv. rhei.................................................. gr. f Ext. dulcamara?............................................ gr. iss. M. et ft. pil. No. i. S. One pill daily. —A. Robin. R Extracti cimicifuga? fld., Syr. acacia?................................................aa 1 ss. Aqua? amygdala? amara?...................................... § iij. M. S. 3 b every three hours. —Ellis. In fatty heart, dilatation of cavities, and mitral regurgitation with anaemia: R Ferri reducti................................................ 3 b Pulv. digitalis fol. (Eng.)................................... 3i. Quinina? sulphatis........................................... 3b Pulv. scilla?................................................. gr. x. M. ft. massa et in pil. No. xx. div. S. A pill three or four times daily. —Bartholow. Heat Exhaustion. There is here a moderate degree of weakness occurring in those who have been under excessive bodily strain during periods of great heat or in overheated quarters. Diagnosis.—There are at first dizziness or at times loss of sight, profuse cold perspiration, and marked pallor, with loss of consciousness, which is partial or complete. The bodily tem- perature is decreased below the normal, even to 95° F.—H. C. Wood. Differentiation.'—The extreme adynamia with feeble pulse and subnormal temperature distinguishes the condition from sunstroke in which the unconsciousness is often profound and the temperature extreme. The distinction from heart failure or the syncope of concealed hemorrhage is made by the greater fall in the bodily tempera- ture in heat exhaustion. hydatid disease. 435 Prognosis. —Recovery is the rule. Treatment differs decidedly from that of heat stroke. While digitalis and strychnine may be given with benefit, as indicated under the latter condition, cold baths are naturally con- traindicated, and in their place heat is to be applied with friction of the body, the application of hot water, warm baths, etc. Stimulants may be administered by the mouth or by injection. Cold cloths may be applied to the head and hot cloths to the feet. Restore the temperature and give alcohol and diffusible stimulants hypodermatically if necessary. (See also "Sun- stroke.") Hydatid Disease. The echinococcus or larva of a taenia occurring in the dog tribe may affect the lungs, peritoneum, liver, kidneys, and other tissues of the human body. The urst symptom may not arise until after a cyst, result- ing from embryo invasion, has attained such a size as to pro- duce signs of pressure. Diagnosis.—Tumors due to this cause are painless, unat- tended with disturbances of nutrition, and are of habitually slow growth. The employment of an aspirator to draw off the fluid which contains scolices or hooklets confirms the diagnosis. The fluid in which these bodies float, while free from albumin, con- tains sugar and succinic acid. Rupture of a cyst, or leakage into the tissues at time of as- pirating, may cause fever and an urticarial eruption, or may produce dyspnoea and collapse. Differentiation.—A. large hydatid of the back starting from the spinal column, which had been looked upon as a sarcoma by several observers, was successfully operated upon recently by my friend, Dr. Samuel Lloyd. Hydatid of the liver gives a circumscribed tumor, which is at times to be distinguished from amyloid degeneration and from 436 the practitioner's manual. cancer only by the use of the aspirating needle, and from cirrhosis with enlargement by the absence of persistent jaundice. Subphrenic abscess may be simulated by suppurating hydatid, both in its symptomatology and physical signs. The discovery of characteristic elements in the drawn-off fluid naturally ex- cludes all other growths, both cystic and solid, which occur in this region. Hydrothorax is almost absolutely counterfeited by hydatids of the pleural cavity. Tuberculosis is simulated by echinococcus of the lungs, especially in the upper lobe, even to the occurrence of haemop- tysis. The absence of bacilli differentiates while their presence does not exclude echinococcus, since the two conditions may coexist. Treatment.—Cure may result from aspiration, particularly when the cyst is so situated that it can be removed; operation usually proves successful. Hydrocephalus, Acute Idiopathic. When of benign character it is usually a meningitis serosa interna, following a meningitis serosa externa. Diagnosis.—Its recognition is possible with certainty only after noting the results of evacuation of the cerebro-spinal fluid. Differentiation.—From purulent meningitis or brain ab- scess, tuberculous meningitis, and tumor by sudden total and permanent disappearance of symptoms after operative evacua- tion of cerebro-spinal fluid. Prognosis.—Recovery may take place spontaneously. Treatment.—Evacuation of cerebro-spinal fluid.—Boen- ninghaus. ' HYDROCEPHALUS. 437 Hydrocephalus. When enlargement of the head does not begin until some time afterbirth, there is partial or absolute dulling of the mental faculties. When the child is some months of age the increase of fluid, taking the place of brain tissue, stunts the mental de- velopment. If, however, the progress is a slow one the child may show intelligence in many directions but will belong in the class of idiots. Acute hydrocephalus is a concomitant of men- ingitis. (For the more rare acute idiopathic form see page 436.) Diagnosis.—Chronic hydrocephalus has its chief objective characteristic in the disproportion between the enlargement of the cranium and the smallness of the face. The fontanelles bulge and the sutures are separated. Differentiation.—In rhachitis the shape of the head is square. If the anterior fontanelle is prominent it is only tem- porarily so, and there are evidences of rachitis in other portions of the bony structure. In leontiasis ossea the enlargement is due to a thickening of the bones themselves. In acromegaly the hands and feet are likewise enlarged. In cephalic hypertrophy the enlargement is at the back of the head and there is no exophthalmos. Treatment.—To relieve pressure symptoms in acute hydro- cephalus, tap the vertebral canal (see "Tuberculous meningitis"). —Quincke. In chronic hydrocephalus, tapping the canal is a safer pro- cedure than tapping the ventricle.—Caille. In tapping through the open anterior fontanelle, keep to one side .of the middle line to avoid the superior longitudinal sinus. If much fluid is removed, follow by pressure on the skull. 438 THE PRACTITIONER'S MANUAL. Hydronephrosis. Cystic tumor of the kidney or a state of distention of the pelvis by urine or non-purulent fluid may be so large as to make the tumor the most prominent symptom. This is fluctuating, and there is usually an inverse ratio between its size and the amount of urine passed. It may attack both kidneys coinci- dentally or in succession. Diagnosis.—The pathognomonic sign of fluid tumor of the kidney pelvis is the fact that it decreases in size after a copious discharge through the bladder. Differentiation.—The absence of fever as well as the urine's freedom from pus shows the case to be not one of pyo- nephrosis. From hydatid cysts it is distinguished by the ab- sence of fremitus and the further fact that the tumor does not move with respiration, as does the hydatid. As between kidney tumor and ovarian cysts, the fact that the tumor lies behind the colon points to kidney origin. The colon may be inflated to make this diagnostic point possible. Punc- turing the cyst will give valuable aid only in recent cases, since older kidney cysts contain a fluid which has the same general characteristics as that of an ovarian cyst. Intermittent hydro- nephrosis gives a tumor in the region of the kidney,, attended with pain, nausea, vomiting, and scanty urine. Here, too, the tumor decreases as the urinary flow becomes abundant. Pyonephrosis is diagnosticated when evidences of pus are found. Hydrothorax. Diagnosis.—The diagnosis from pleurisy with effusion is made by the affection existing on both sides, in the absence of fever, and being accompanied by general anasarca. Differentiation.—Pyothorax can be distinguished from HYSTERIA. 439 non-purulent accumulation by the aspirating needle alone. Peptones are found in the urine in other conditions as well. Treatment is to be directed toward the disease of which this is a symptom, while aspiration may be resorted to for temporary relief. Hypersemia of the Brain. Cerebral hyperaemia, as the term is usually employed, is almost synonymous with asthenia or exhaustion of the brain from overwork. Diagnosis.—Headache attended with ruddy hue of the face, pulsating carotids, vertigo, mental confusion, and somnolence or sleeplessness are the prominent symptoms. Differentiation.—In chronic emphysema, cardiac disease, mediastinal tumor, etc., the same symptoms are present from circulatory disturbance and the retention of carbonic-acid gas. Apoplexy is simulated when the symptoms come on sud- denly and are followed by unconsciousness. Extreme congestion of the brain, as after violent emotion, may be followed by the rupture of a vessel. Treatment.—When apoplexy is simulated, bleeding from the arm. Leeches behind the ears. Cupping to nucha, purging. The free use of lithia water. Hysteria. Either succeeding a feeling such as of a ball passing up from the stomach into the throat, or without any preceding symptom of note, the subject, usually of the female sex, becomes sud- denly agitated, has violent muscular contractions, or may fall in a seizure somewhat closely resembling that of epilepsy. Diagnosis.—In the milder forms there is a succession of al- ternate sobbing and laughing, and this may be succeeded by a 440 the practitioner's manual. state of apparent insensibility, in which the patient lies motion- less for hours and perhaps eveia for days or weeks. In the preconvulsive period there may be an aura. Con- sciousness and memory are intact in this period, while in the convulsive they are abolished. An almost constant sign both in hysteria with depression and in hysteria with erethism is said to be complete or partial abolition or marked diminution in the reflex excitation of certain points, such as the external auditory canal, the nasal fossa, lower lid, and skin of forehead, when tickled with a hair or other delicate substance. Hysterical contractures and palsies are especially observed in convalescence from acute and chronic disease in childhood. Spasms of screaming alternate with spasms of crying or laugh- ing, and jactitation of the extremities occurs.—Jolly. Differentiation.—Severe attacks are to be distinguished from epilepsy, and this is done by noting that, in hysteria, the unconsciousness is only partial or apparent and comes on gradually. The face, instead of being deathly pale, is flushed or dusky. The tongue is not bitten and there is no frothing at the mouth. The paroxysms last longer, the movements are irregular, and made as though with some purpose. The attack rarely occurs at night, while the epileptic seizure is frequent at this time. At the onset of the fit sounds if made at all are prolonged and not like the quick cry which accompanies the fall in true epilepsy. In coming out of the attack the hysteric is depressed, while the epileptic is dull and either has headache or is inclined to sleep. The distinction between true and feigned hysteria is often quite a difficult matter. Besides the typical attack we may have various phases of hysterical disease, such as hysterical fever, in which the temper- ature goes to unusual heights, 112° F.—A. A. Smith. All human-body temperatures above 117° F. are instantly incompatible with life.—W. G. Thompson. hysteria. 441 Extraordinary emotionalism is the first thing that strikes us in the hysterical (males equally with females).—Max Nordau. Perityphlitis may be so closely mimicked by hysteria as al- most to lead to operation. Absence of fever is suspicious. In traumatic hysteria the symptoms do not as a rule come on at once, but, as it were, after a period of incubation. They are not on this account to be looked upon as feigned. Prognosis.—Almost all forms are amenable to proper treat- ment. The predisposition may have to be combated for many years. Treatment.—To break up or prevent an attack and in hys- terical coma, apomorphine, gr. yV/, trypodermatically. B Acid, arsenosi............................................. gr. ss. Ferri sulphat., Ext. sumbul..............................................aa gr. xx. Asafcetida?................................................. gr. xl. M. ft. pil. No. xx. S. One t.i.d. p.c. —GOODELL. Hysterical Aphonia.—Introduce a sound into the larynx far enough to produce spasm. Then have the patient repeat a few letters, count, and articulate simple words. When rebellious, treat by electrization of the larynx, massage, tongue traction, psychical measures.—Boulay. Ethyl-chloride spray to the nucha until a spot of the size of a silver dollar is frozen.—Kebbell. Hysterical haemoptysis in men is not at all influenced by ergot, ice, astringents, etc. Treat the neurosis. Good results follow hypnotism.—Laurent. Hysterical dysphagia simulating stricture or confounded with oesophageal spasm, with pain, constriction, and sensation of foreign body, is relieved by the frequent passage of an olive- tipped bougie. The electric sound should be avoided.—A. Coolidge, Jr. Hysterical gastralgia, giving exquisite sensitiveness over 442 the practitioner's manual. the stomach, is to be confounded only with that of severe acute gastric catarrh.—Sticker. In young girls ivith "laughing hysterics"': R Tinct. opii deod............................................. 3 iss. Tinct. castorei (Fr. Cod.)..................................... 3 iiss. Tinct. valerian, ammon., Spir. a?ther comp.........................................aa 3 vi. M. S. 3 i. every two hours in water. —Gerhard. For excitability and various forms of distress occurring at night in persons between the ages of fifteen and twenty-five years: R Extr. valerian, fld............................................ § ij. Extr. Scutellaria? fld.......................................... § iss. Extr. hyoscyam i fld.......................................... 3 iv. Amnion, bromidi............................................. 3 v. M. S. 3 i. diluted with sweetened water early in the morning, at teatime, and at bedtime. —Davis." In hysterical spasm of the diaphragm simulating chorea, try hypnotic suggestion.—Berdach. For the relief of the vasomotor instability resultant in the various emotional states, zinc and other valerianates are often useful. Against this condition, and the erotism, camphor monobromate is frequently beneficial. To secure slumber, the non-existence of which should first be ascertained, trional, phenacetin, and sulphonal, rather than chloral or morphine, should be used. For the relief of the pseudo-anginas, glonoin or strychnine is of value. In the convulsions of grave hysteria, the hypo- dermic administration of apomorphine will often prove bene- ficial, or glonoin, or the inhalation of amyl nitrite may prove equally valuable. Hysterical aphonia and deafness have frequently been removed by amyl nitrite.—Geo. F. Butler. INFLUENZA. 443 Hystero-Epilepsy. It is only in the typical instances that one differentiates readily this condition from true epilepsy. The attack occurs in the night or early morning; the patient suddenly falling with a cry, followed by loss of consciousness, urination, and biting of the tongue. After an attack there are stupidity and fatigue. The discov- ery of stigmata of sensibility of a permanent character is of much value, but while they may be absent, it must be remem- bered that epileptics occasionally show disordered sensation. When hysterical symptoms, such as the globus hystericus and areas of hypersesthesia, have preceded the attack, they throw light upon its nature. The attack is usually longer than that of true epilepsy and the relaxation of convulsive spasms is gradual. If contorted motions and cataleptic postures succeed the paroxysms, the hysterical nature is most strikingly suggested, especially if delirium and hallucinations persist after the return of consciousness. Treatment.—To cut short an attack, duboisine sulphate, gr. yjfo (Albertoni); gr. 2I0 (Belmondo); gr. -fa (Samuely). Influenza. In grippe the onset is sudden and ushered in with chill, some- times with delirium or marked nervous symptoms. There are pronounced weakness and intense pains in the back and extrem- ities. The symptoms in the many varieties described vary with the type present. One must depend chiefly upon the presence of the disease in its epidemic form to distinguish mild attacks from ordinary catarrhal affections, and upon the preponderance of typhoidal, muscular, nervous, cardiac, or gastro-intestinal symptoms to give it the proper classification. In the pulmo- nary form there are high fever, vomiting, headache, occasionally 444 the practitioner s manual. nose-bleed, and decided prostration. Extreme nervous prostra- tion is not unusual. The varied symptoms at the onset in in- fancy (including febrile, gastro-intestinal, nervous, and thoracic) make the diagnosis quite difficult. The initial temperature is very high but tends to fall quickly. Differentiation.—Influenza differs from simple catarrhal affections in that the fever, malaise, and general symptoms which precede the local manifestations are out of all propor- tion to the extent of the latter. Miliary tuberculosis, typhoid fever, and meningitis may be simulated, especially in infancy. The rash, beginning upon the neck on the second day, brightest on the uncovered parts, in association with "straw- berry tongue," may simulate scarlet fever. In deceptive cases draw a drop of blood from the finger into a tube, plug with cotton, and lay aside for twenty-four hours. It will now show a culture of diplo- and strepto-bacilli char- acteristic of grippe, extremely motile, and easily visible with a 600 diameter microscope.—Coronado. Prognosis depends upon the age and previous condition of the subject, the freedom from complications, and the care exercised during and after the attack. It is more serious in the extremes of age. The majority of cases ending fatally are those in which the patient unduly exposes himself. One attack does not confer immunity. In some instances it would appear to predispose to others. Treatment.—To abort, hydrarg. chl. mit., 0.10 cgm. twice daily, in first or second day of attack. If fever does not sub- side, wet packs to the thorax.—Freudenthal. To reduce the fever and bring about free perspiration : R Antipyrin................................................ gr. xv. Pilocarpina? hydrochlor.................................. gr. ss. Tinct. aconiti............................................ gtt. viij. Aqua?.................................................... 1 iss. M. S. One tablespoonful followed by a general hot bath or a fool bath of ten minutes' duration ; the patient being covered warmly in bed. influenza. 445 One dessertspoonful of hot toddy, repeated in twenty minutes if sweating has not occurred.—Wood and Fitz.8 In the gastro-intestinal forms, very restricted diet (boiled milk), counter-irrita'tioii over the abdomen (spice plaster, see page 232). R Sodii sulphitis............................................___3 jv. Aqua?........................................................ | vi_ M. S. A teaspoonful in as much water every two hours till all pain is relieved and the patient is well. —MONELL. When there is intolerance for quinine, bichloride of mercury in minimum dose.—Francis. Creosote, fifteen to seventy-five minims daily.—Iselin. Or— B Spir. camphorae........................................... ? 88 01. caryophylli........................................... m xxx Chloroformi................................................ 3 iij Tr. opii deod............................................... 3 ij Tr. capsici.............................................. 3 ij M. S. Gtt. xxx.-xl. in water every hour or two. —Wood and Fitz.9 In profound adynamia, musk, gr. v.; hypodermic injection of brandy, ether, or strychnine. To spray the nasopharynx: B Camphor, ^entho1.................................................aagr.xx. Acid carbol. purified.................................. 3 ss Albolene........ z • .............................................. r IV. M. S. Several times daily. Stimulating tonics, bland nutrients, rest, and if possible change to a warm climate. In the pneumonia of influenza or in gastro-intestinal forms with feeble, small, and rapid pulse: 446 THE PRACTITIONER'S MANUAL. Give early a single massive dose, and no more medicine for five or six days. Or, twenty drops daily for two days. When miliary tuberculosis or typhoid is simulated, the above acts in differentiation by causing defervescence, which will not occur in either of the named conditions. If the pulse is not brought down and the condition ameliorated, there is reason to believe that an error in diagnosis has been committed. —GlNGEOT AND DEGUY. In bradycardia the effects of digitalin may be less certain, but it seems not to be contraindicated. To relieve painful inflammation of the larynx and bronchi and many other symptoms: R Pulv. Doveri, Quin. sulph...........................................aa gr. ij.-iv. Pulv. hyoscyam. fol..................................... gr. \ M. ft. pil. sen cachet No. i. S. One or two daily. —LlEGOIS. For the severe neuralgic and muscular pains, headache, etc.: R Caffeina? citratis.......................................... gr. viij. Acetanilid, Lactopeptone..........................................aa 3 i. M. et div. in chart. No. viii. S. One every three hours. —L. F. Donohoe. When cdtended with mental and pjhysical depression : R Spirits of camphor, Compound tincture of lavender.............................aa 3 ij. Spirits of chloroform......................................... 3 i. Mucilage of tragacanth... ................................... § i. Distilled water.............................................. § iij. M. S. Tablespoonful every four hours. —Devereux. In nervous disturbances of the heart, sodium sulpho-car- bolate, gr. xx.-xxx. every two, three, or four hours, according to the severity; liquid diet; alcohol cautiously; brandy in dessertspoonful doses every three or four hours; phenacetin or antipyrin unless profuse perspiration or signs of nervous prostra- tion contraindicate it.—Sansom. INFLUENZA. 447 R Quinina? sulph..........................................• • • • 3 i. Pulv. digitalis, Pulv. scilla?..............................................aa gr. xx. Extr. opii.................................................. gr. v. Extr. glycyrrhiza?........................................... q.s. M. et ft. pil. No. xxx. S. Take a pill four times daily. __p R Potass, nit.................................................. 3 b Spir. a?ther. nit.............................................. 3 iv. Liq. ammon. acet........................................... 3 iss. Aqua?.................................................q.s. ad 3 vi. M. S. | ss. with 3 i. of water every four hours. Take for four days and follow with quinine as a tonic. - Morell Mackenzie. To allay the cough: B Ammon. muriat............................................. 3 iss. Morph. sulphat.............................................. gr. ij. Tinct. sanguinaria?, Syr. ipecac................................................aa 3 ss. Syr. glycyrrhiza?............................................ § i. Aqua?....................................................... 1 ij. M- s- 3idoses- -Carpenter. In the febrile form : R Sulphate of quinine, Extract of cinchona.....................................aa gr. xxx. Extract of aconite root.................................... gr. iss. M. Make a mass, and from it twenty pills. S. Take three pills twice daily In pronounced catarrhal and inflammatory symptoms : B Dover's powder, Powdered squill, Sulphate of quinine.....................................aa gr. xxx. M. For twenty powders. S. Four or five to be taken daily. In vomiting and much epigastric pain : B Bicarbonate of sodium, Calcined magnesia, Salicylate of bismuth.....................................aa gr. v. M. For one powder. S. Three to five powders daily. —Huchard. In an uncomplicated case : B Pilocarpina? hydrochloratis.................................. gr. ss. Morphina? .sulphatis......................................... gr. $ Aq«se...................................................... z iij. M. S. 3 i. every fifteen minutes till diaphoresis. Follow this treatment with quinine.—H. C. Wood. ■#* 448 THE PRACTITIONER'S MANUAL. When muscular symptoms are pronounced : B Sodii benzoatis.......................................... 3 ij. Salol..................................................... 3 i. Phenacetin.............................................. gr. xxxvi. M. ft. chart. No. xii. S. One every four hours. In infancy : B Phenacetin................................................. gr. iss. Pepsin..................................................... gr. ij. Calomel.................................................... gr. -fa. To be given every two or three hours to a child of two years. I consider phenacetin the safest and best remedy.—B. M. Smith. When the neuralgic element predominates, quinine hydro- bromate, 0.25 cgm., every four hours. Or, salophen, gr. v.-vi. as a daily dose (gr. ss. in a delicate subject, at first every two or three hours).—Drews. In succeeding multiple neuritis, absolute rest, anodynes, codeine, cinchonidine salicylate. Blisters when pain is in super- ficial nerves. Watch heart and respiration, keep up nutrition. In later stages potassium iodide and mercuric chloride in small doses.—Allyn. Insanity. It is the general practitioner who usually must make the early diagnosis of mental unbalance, or by discovering evidences of impending mental defect institute means of averting such disaster. The majority of patients suffer from depressional forms and are amenable to home treatment. Diagnosis.—The history of antecedent taint is not always obtainable, but patients will often acknowledge family neurotic tendencies. There is usually a ntate of unrest, nervousness under exami- nation; the complexion in those already insane or about to be- come so is rarely clear. Inactivity of the thumbs in writing, drawing, saluting, and the like is, according to Burton Ward, INSANITY. 449 an infallible symptom, even when the subject speaks and acts rationally. Delusions in mental disease may be divided into the follow- ing: Delusions of satisfaction, of grandeur, of riches. Delusions of humility, despair, ruin, culpability. Delusions of persecution. Hypochondriacal delusions. Religious delusions. Erotic delusions. Delusions of bodily transformation.—Ball and Ritti. Differentiation. — We must distinguish first between true insanity and congenital mental defect; the temporary mental symptoms of various constitutional diseases, the effects of cer- tain drugs, alcohol, etc.; and secondly, between the different forms of insanity itself. Of the latter we have mania, melan- cholia, dementia, general paresis, and paranoia. Prognosis.—With correct management from the start, nearly all cases of insanity unattended by paralysis or physical decay may be cured.—Savage. Treatment.—Thyroid feeding gives good results in many instances. Among other ill effects sexual excitement leading to mastur- bation has been noted during the use of this drug. Transient albuminuria occurs in ten per cent of those treated. It would seem especially applicable in a form of mental dis- turbance occurring at the climacteric, with depression, anxiety, morbid fears, but without delusions or insomnia.—Starr. No case should be allowed to become incurable without a trial of this method.—Clouston. Caution.—It is not unattended with danger . . . and may influence the future mental powers of the subject.—Berkeley. In gouty subjects colchicum or other measures directed against the diathesis may cure the insanity. 29 450 the practitioner's manual. Moral treatment with constant skilled attendance is effica- cious but expensive. In meningeal insanity (acute mania, maniacal epilepsy) as a cerebral depressant, scopolamine, gr. -%%-$. Inject. Mental depression in diseases of the pelvic organs : R Strych. sulph............................................... gr. -fa Quinina? sulph............................................. gr. iss. Ext. hyoscyami............................................gr. iss. Ferri reducti............................................... gr. i. M. For one pill. S. One pill three times a day. —Tally. Acute Dementia. The term stupor with dementia seems less appropriate for a certain class of young patients, who, although motionless, stand- ing perhaps for hours in cataleptoid attitudes, or sitting without a word the whole day through, are quite capable of shouting remonstrances and resisting vigorously when attempts are made to dress, bathe, and feed them. Diagnosis.—History of nerve defect, heredity, and mental or physical shock, weak heart action, with cold and blue extremi- ties, are aids. Menstruation ceases in young girls. Differentiation.—From melancholia by the facts that flesh is not lost; sleep is undisturbed; the shortness of the period of depression; lack of suicidal tendencies. From chronic dementia by the suddenness of symptoms after fright, illness, etc. Prognosis.—The more acute the whole process, the better the chance of ending favorably. That secondary to mania, melan- choly, epilepsy, and apoplexy gives unfavorable prognosis. In institutions many succumb to phthisis. Treatment can be carried out at home under constant per- sonal supervision. Prevent masturbation, supply abundant warmth, exercise, shower baths, massage, electricity, stimu- lants. insanity. 451 Acute Mania. Almost invariably there is an early stage of depression, just as in melancholia we habitually find excitation among the early manifestations. Diagnosis.—Rambling in confused conversation; inability to keep up a sustained train of lucid thought; exaggerated ideas; evasive answers; moral changes; abnormal ideas and acts which are justified by the subject; perhaps delusions; rapid and unnaturally brilliant but varying talk. Subsequently abusive, violent, filthy in talk and habits; de- structive, delusions, hallucinations. The evanescent character of the facial expression is marked; its variability and abrupt transition are characteristic. At one moment sorrow, distraction, anger, or fear may be depicted, to be superseded with lightning rapidity by an expression of intense joy and laughter, of contentment or of bravado. The particular emotion expressed is always strongly depicted. The patients are frequently very loquacious, and prone to mimicry and grim- aces. The eyes are bright, the pupils vacillating, the conjunc- tivae often injected. Differentiation.—In acute delirium fever is always present; the patient is often in a stuporous or semicomatose condition, and reacts but slightly or not at all to external stimuli; in acute mania there is sleeplessness, the patient is active and "wide awake." From melancholia by the mind and memory being clear in the latter and judgment good on matters not connected with self. In meningitis there is intolerance to light, the pupils are contracted, and the temperature may be elevated. Prognosis.—In acute delirious mania, if the patient lives, he will almost certainly recover. In the first attack almost all get well. 452 the practitioner's manual. If hereditary, chronic mania or dementia follows.—Bland- ford. Treatment.—Remove to an institution, if possible in the country, where outside exercise and supervision are a possibility. Mechanical restraint and overdosing with drugs are both harm- ful. R Sulphonal.................................................. gr. xv, Sodii bicarb................................................ gr. iv. M. S. One dose. Repeat up to three times daily. In rebellious instances give up to seventy-five grains daily. —Kadt. In violent and abusive patients, give hyoscine, gr. x\^.— Weatherly. Or, continuously during the acute stage, hyoscine, gr. tfW-tot three or four times daily.—Galbraith. Or, duboisine, gr. yf^-^ hypodermatically.—Massant. Gr. -gig..—Gubler. In wild delirium, daturine, gr. ^hs-■£■$, hypodermatically, or hyoscine hydrobromate, gr. T|¥. R Tinct. cannabis indica?......................................... 3 b Potass, bromidi................................................ 3 i, Aqua?.........................................................q.s. M. S. At dose three times daily. As hypnotic, paraldehyde, 3 ss.- 3 i. To quiet muscular activity, coniine, tti ss.-tti iii. Inject hypodermatically.—Ringer. To quiet excitement, ext. ergotae fid., 3ss.-3i.—Crichton Browne. Or, tinct. gelsemii, til xv.-xx. at dose.—Potter. After confinement, ext. cimicifugae racemosse fld., gtt. xx.-xxx. t.i.d. In violence not otherwise restrained, apomorphine, gr. TV,, hypodermatically while subject is held. This produces vomit- insanity. 453 ing and relaxation of muscles. Anaesthesia, morphine, cold douche to head, and hot bath to body.—Hare.33 Melancholia. This form of insanity may be acute or chronic. A gradual onset may be one of the features pointing almost equally to neurasthenia with depression and insomnia. Diagnosis.—The predominant symptom is one of gloomy despondency accompanied by apathy, lack of desire or inclina- tion beyond that connected with an absorbing introspection. In the severer forms, instead of the quiet dejection, there will be moaning with anguish depicted upon every feature and bodily movement indicative of intense psychical suffering. Here, contrary to what is found in the milder forms, delusions occur after a time and possibly also hallucinations, preserving, "how- ever, the type of melancholic depression. The general health suffers and there is progressive loss of strength and weight. Defective assimilation is a characteristic feature. The delusions follow some particular form either of a*religious or other nature. There is frequently pericardial anguish in the early morning or tendency to suicidal attempt, which seems to be more frequent at this period of day. The facial expression is usually characteristic; the com- plexion is pale, often sallow; the muscles, especially those of the lower half of the face, are flaccid; the angles of the mouth droop, giving the face a longer appearance than ordinary. The forehead is wrinkled, the head bowed forward, the eyes have a distant look. Somatic stigmata, such as facial asymmetry, are usually absent; when present the prognosis is more serious. The facial expression varies; anxiety, sadness, despair, gloom, distrust, fear, indifference, or inertia may be depicted. A facial expression of anxiety, restless worry, or jealousy is often one of the first objective signs.—James Shaw. 454 the practitioner's manual. Prognosis depends upon the mildness or severity of the form, the personal antecedents, and the possibility of keeping up nutrition. A large percentage of patients is susceptible of cure. Recurrences have to be anticipated. Treatment.—In home treatment secure absolute control over the patient's personal and domestic life. Have a nurse or at- tendant constantly present, preferably one with special training. Isolate. In debilitated patients secure partial enforced rest by having them remain abed, until ten, eleven, or twelve o'clock. Diet must be nutritious, and if necessary enforced by means of stomach or rectal tube, the former introduced through the nos- tril. Relieve insomnia, visceral derangements, and psychic pain with appropriate drugs. For the relief of pyschical pains, ext. opii aq., gr. -§--i, three or four times daily.—W. B. Pritchard. Deep injections of ether into the buttock.—Shepherd. In motor or excited melancholia, tr. opii deodorat., ttixv.- xx., gradually increased until nixl. or nilx. are given three times a day.—Nuckolls. R Moschi optimi................................................ 3 iij. Tinct. castorei (Fr. Cod.)................................... § iss. Syr. zingiberis................................................ § i. Aqua? destill..........................................q.s. ad § vi. M. S. 3 ii- t.i.d. —E. J. Clark. R Camphora?, Extr. hyoscyami................................... .. .aa gr. xlv. M. et ft. pil. No. xl. S. Two pills t.i.d. —Gooch. In extreme sensory irritability, rest in bed, isolation, food rich in fats.—Rayner. Thyroid feeding has given some good results.—B. W. Stone. Insanity in women, due to mental worry or moral shock: R Tr. cannab. ind ... S. Three times daily. TTI X. INSANITY. 455 This is almost a specific, and is of great value as well in mania. —Suckling. Opium is the most generally useful of all drugs in insanity. It has a direct influence on the mind, antithetical to the painful emotional state of melancholia and to the persecutory delusions of monomania.—Spitzka. Strict attention must be paid to digestion and the atonic state of the bowels so frequently encountered. For the indigestion : B Bismuthi subgallat....................................... gr. v.-x. Or— B Salol..................................................... gr. ij.-v. When the bowels have become regular and the digestion is good, see that large amounts of nourishing food are taken. For sleeplessness, hyoscine, gr. yut> often does good service. A glass of dry wine or eggnog will often dispose the pa- tient to sleep.—H. E. Alliston. B Sol. auri et arsenii bromidi................................... tti, x. S. Inject three times daily. In suicidal form give gold; in the aged give arsenic. B Liq. potass, arsenit... ....................................tti, ij. Tinct. opii................................................ni. iij.-v. To be given three times daily. —Bartholow. Paranoia. By this general term are understood certain chronic forms of insanity, primary in origin, in which a systematized delusion dominates the subject. The erotic, inventive, reformatory, and religious are some of the types met with. The course is chronic. Volition is little or not at all impaired. The emotional faculties are preserved, but delusions pervade the whole personality. In the progressive stages there is an ever- widening deviation from the normal type. At first the subject 456 THE PRACTITIONER'S MANUAL. may appear only somewhat unbalanced, but delusions of perse- cution are soon apt to show themselves. The paranoiac may be perfectly rational and appear sane until his hobby is brought out. The facial expression varies with the kind of delusion. Granted the truth of the delusion or delusions, the facial reac- tion is normal.—James Shaw. Differentiation.—The ambitious or expansive paranoiac converses and argues rationally and in a systematized way, but from false premises, while in the subject of acute mania the delusions are less fixed and are not supported by rational argu- ment. In the former the delusion is of gradual growth, while in the latter it is usually abrupt and expansive. In paretic dementia there is a general weakness of the men- tal faculties associated with tremor, the delusion is variable, the thoughts are rambling, disconnected, and usually supported by incongruous argument. Treatment.—The time to institute treatment is in the early stages or in youth, when the subject is simply regarded as "peculiar." Early training and education, regular habits, with aid in thinking along proper lines, may do much to counteract the inherent mental defect. When hallucinations are developing and delusions are likely to follow, prevent the subject, if possible, from secluding him- self and nursing his morbid fancies. When self-control is lost and he becomes the victim of systematized delusions, little can be done except to place him under strict control.—Henry M. Hurd. The paranoiac is generally allowed to remain at home, al- though he is often the most dangerous of all the insane. He should be guarded. In mild cases moral treatment to divert from purposes of revenge for fancied injuries may suffice.—B. W. Stone. As paranoiacs are keenly alive to all that transpires around INSOMNIA. 457 them, are very sensitive as a general thing, and have good memories, residence in an asylum is not always advisable and may, in some cases, even prejudice the chances of recovery.— James Shaw. Insomnia. Diagnosis is usually accepted from the statements of the patient seeking advice. The physician's duty is to decide whether the sleeplessness is functional or symptomatic of some other condition, and, if so, of what. Treatment.—Drug treatment must put the patient in a position to go to sleep in a natural way and not put him to sleep. It should effect a lowering of intracranial pressure.-— Beaumetz. In confirmed insomnia, trional, gr. xv.-xx. each night.— Browne. Caution.—Prolonged administration should be interrupted at intervals for several days to avoid cumulative toxic effect. In primary insomnia, and in the sleeplessness of lunatic and alcoholic patients suffering from serious cardiac disease, trional, gr. v.-xv., repeated p.r.n.—Bakofen. B Narceina?................................................. gr. viij. Confect. rosa?............................................. gr. xv. M. et ft. pil. No. xxiv. S. One to three pills at bedtime. —Laborde. When pain is not an element: B Chloral..................................................... gr. Xx. Ammonium bromide....................................... gr. xx. Fl. extr. mix vom.......................................... gtt. x. Fl. extr. belladonna........................................ gtt. ij. M. S. To be taken at once and repeated in an hour or two if needed. —Adolphus. In nervous insomnia: B Formamidate of chloral.................................... 10 gm. Tincture of ginger......................................... 10 " Distilled peppermint water................................. 150 " M. S. A dessertspoonful at night. —Boas. 458 the practitioner's manual. In intense motor excitation, duboisine, gr. -r£"Tr_Ts> hypo- dermatically. —Skuridin. In the inability to fall asleep, trional is indicated; if the patient awakens in the early morning sulphonal does better. Insomnia from overexcitement: B Sulfonal.................................................... gr. xv. Or— B Trional.................................................... gr. xij. Sodii bicarb............................................... gr. x. M. S. Just before the evening meal. Avoid mental work at night, exciting diet, and overheated quarters. To induce natural sleep, hygienic living throughout the day: supper about 6 p.m.; rest until 7; a walk in the open air, a spin on the bicycle, a ride on horseback, or quiet employment within doors; not more than one cigar; at 8:30 the bath, fol- lowed by rubbing; at 8:45 milk and crackers, and at nine o'clock to bed. Rise about six, take a cold sponge bath; five or ten minutes' walk; breakfast about seven." That following alcoholic excesses : B Chloral., Potass, bromidi.........................................aa § iv. Extr. cannabis ind., Extr. hyoscyami........................................... gr. xvi. Chloroformi.............................................. 3 ij. Aqua? bullientis....................................q.s. ad O ij. M. Dissolve the cannabis in the chloroform and add the chloral. Pour the boiling water on this and add the bromide and the hyoscyamus. When cold filter. Dose : Dessertspoonful to tablespoonful. —E. C. Hooved. When opium cannot be borne : B Tr. hyoscyami................................................ § ij. S. 3b-iv. —Campbell. B Amylene hydrate (P. G.)................................... gr. xc. Morph ine hydrochlorate.................................... gr. £ Extract of licorice.......................................... 3 iiss. Distilled water............................................. 3 xxv. M. S. Half on retiring. INSOMNIA. 459 Or— B Amylene hydrate........................................... gr. Ix. Morphiue hydrochlorate.................................... gr. i Mucilage of acacia......................................... 3 vi. Water..................................................... 3 xiiss. M. S. As an enema. —Fischer. B Paraldehyde................................................. 3 ij. Glycerin.................................................... 3 ss' Syrup...................................................... § i- Sweet spirits of nitre....................................... 3 x. Oil of anise or of orange..................................... gtt. xx. M. S. Tablespoonful every half-hour until sleep, or until six have been taken. —A. A. Rawson. When the skin is hot and dry : B Tinct. aconiti...............................................tti, xvi. Aqua?....................................................... § ij. S. 3 i. every fifteen minutes. —Anstie. In the eruptive fevers in childhood, tuberculous meningitis, pernicious malaria with cerebral excitement, trional, gr. vi.-xv. in the twenty-four hours. Children show a particular tolerance and it is prompt in action.—H. D. Chapin. In neurasthenia, strychnine and digitalis are often effective. —C. K. Clarke. In overworked students, strychnine or hot coffee. Magnesium Dulphate is an ancient but trusty ally. As a last resort, chloral- amide, but without the patient knowing what drug he is taking. —Donald MacAlister. In the insane, chloral is the surest sleep producer. Paral- dehyde at times acts well. Secure sufficient out-door exercise and supply suitable diet.—J. Y. A. Campbell. B Chloral...................................................... gr. x. Sulphonal................................................... gr. x. Phenacetin.................................................. gr. v. M. S. For one dose. —Edwin Rayner. 401) the practitioner's manual. If the patient be gouty, sodium phosphate, sodium salicylate, piperazin, or uricedin. In kidney disease with contracted blood-vessels, nitrites. In ancemia, iron in organic preparation.—R. W. Wilcox. To break a pernicious habit of sleeplessness, trional in initial dose of gr. xx.-xxiv., subsequently reduced to gr. xv.—J. A. Browne. Intestinal Obstruction. Obstruction is not always differentiated with ease from colic due to other cause, or, having been established, it is not always easy to say what the nature of the obstruction is, whether due to bands, stricture, tumor, foreign body, faeces, hernia, twists, or invaginations. The pain is paroxysmal, soon followed by vomiting, tympanites, and prostration from shock, while all at- tempts to move the bowels are in vain. Diagnosis.—In obstruction of the small intestine there is usually an increased amount of indican in the urine and dysuria is apt to be present. If the obstruction is in the large intestine, the indican is not increased.—Williams. Differentiation.—Strangulated hernia is the important condition to be excluded by examination, since the symptoms are practically identical. Enteritis is excluded by the collapse and comparative free- dom from fever. The vomiting in shock is reflex and never very serious. If rupture of the intestine has occurred, it becomes persistent and intractable. Faecal impaction is distinguished from intussusception, vol- vulus, cancer, stricture, and other causes of obstruction by rectal examination, which discloses the hard mass of fasces even when diarrhcea has recently been present. The faecal tumor may be found in the right iliac fossa extending to the outer half of Poupart's ligament. This may be soft and yielding, and pres- intestinal obstruction. 461 sure may cause pain. When in the hepatic flexure, it must be distinguished from an enlarged liver. When in the transverse or descending colon it is to be distinguished from tumor of the stomach, spleen, pancreas, and kidney, and it is said that the faecal tumor has even been mistaken for a pregnant uterus. Treatment.—Taxis by inversion of the patient, forcible shaking, pushing of the intestines from side to side, and the administration of large enemata while the patient is inverted, all under chloroform narcosis.—Jonathan Hutchinson. Gentle massage when the abdominal walls are not tense, or repeated enemata cautiously given.—Reid. For fcecal retention : B Fresh ox gall.................................................. § ij. Olive oil..................................................... O ss. Warm and inject each night, securing its retention as long as possible. After the rectum is free, high injection (under continuous pressure not exceeding two pounds to the inch) of hot water containing boric acid. A half-gallon should be introduced.— Sir Andrew Clarke. Caution.—Serious damage to the peritoneal coat may result from too great a pressure. The water bag held two or three feet above the abdomen should suffice. Make an infusion of 250 gms. of coffee in 12 cups of boiling water. Give one cupful every fifteen minutes until eight have been taken and then every half-hour.—Guerin. In obstruction of bowels, apply over the abdomen lint smeared with ext. belladonna and vaseline, p.ae.—Wm. Murray.27 In impacted faeces in a child, a large positive-pole electrode is placed upon the abdomen. The negative pole, four and one- balf inches long, is introduced into the rectum, into which a pint of a salt solution has been previously injected. The current is gradually raised to twenty milliamperes.—Mingour and Bergonie. 462 the practitioner's manual. Intussusception. Invagination of the bowel, in which an upper segment passes within one lower down, produces a tumor varying in size from a swelling scarcely to be made out upon palpation up to one over a foot in length. Diagnosis.—A history of violent muscular effort, severe paroxysmal coughing, or even overloading the stomach just be- fore the attack of sudden colic often helps materially in the diagnosis. The latter is facilitated by the presence of tumor, and active peristalsis confined to a limited area points to an obstruction having occurred lower down. Pain relieved by firm pressure over the tumor favors this diagnosis. Collapse may soon follow other symptoms, including faecal vomiting. Obstruction in the large intestine is more apt to be an intus- susception than volvulus, which is a less common affection. In- tussusception occurs mostly in children, one portion of the bowel being invaginated into the lumen of another portion. It is most common in the lower segment of the ileum or in the caecum. The symptoms are those of intestinal obstruction, but unless the invaginated part projects through the rectum, as at times it does, or a gangrenous loop of intestine is thrown off with the dejections, an accurate diagnosis is difficult. Hiccough is a prominent s}rmptom. Differentiation from acute peritonitis may necessitate an exploratory laparotomy. The occurrence of a discharge of bloody mucus with tenesmus is a sign of great diagnostic value. If, on exploration per rectum, the end of the invaginated gut can be felt, it lends valuable confirmatory evidence. The presence of a tumor as above noted, before it has been masked by suc- ceeding peritonitis, is one of the most important differential aids. Distending the rectum with fluid or air by means of a long nozzle, the patient being in the knee-elbow -position or on intestinal obstruction. 463 the side, may verify the provisional diagnosis and at the same time the physician may be thus carrying out one of the most successful modes of treating intestinal intussusception. The age of the patient gives material aid, since volvulus occurs between the ages of forty and sixty years, as a rule, and gall-stone occlusion also after the fortieth year. Prognosis.—Infantile intussusception left to itself is fatal in ninety-eight per cent of the cases.—Wiggin. Radical operation gives a mortality percentage of seventy- two. Early operation gives the best prognosis.—Treves. Treatment.—When the attempt to distend the bowel as above mentioned has not succeeded, abdominal incision must be entertained, and not more than three days should be allowed to pass before the surgeon's aid is sought. Withhold food. Give opiates. Mechanical disinvagination by introducing into the gut hydrogen gas or filtered air after washing out the bowel with high enemata. Attempts at reduction by the injection of water into the bowel should be resorted to before operation. Or— B Tabaci......................................................... 3 b Aqua? bullientis............................................... O i. Macera per sextum hora? partem, et cola. S. Inject one-quarter or one-half, and repeat in half an hour, if necessary, carefully watching its effects. The mechanical method is uncertain in results, may produce false impression of success, and delays operative measures. When lavage by ordinary methods fails, anaesthetize the patient and support in the inverted position. By means of a rectal tip introduce water under pressure into the gut, alternating with forcible kneading.—Pynchon. Caution.—Too great pressure of water may cause rup- ture. In chronic intussusception as in acute, temporizing without good reason and postponing operative measures is bad practice. —Rydygier. 464 the practitioner's manual. Inflation does not appear to be safer than injection, and neither is advisable as a prelude to laparotomy.—Mortimer. When the obstruction has existed several days and the pa- tient is weak, do not give chloroform. Freeze the skin with ethyl chloride and make a small artificial anus. The obstruction may be dealt with afterward.—J. Crawford Renton. The after-treatment in laparotomy in very young children is very important and skilful nursing has much to do in bringing to a successful issue.—Clubbe. Inject a pint and a half of tepid saline solution under a pres- sure of three feet. If this is not successful, resort at once to laparotomy.—Wiggin. Pass a soft-rubber tube as high up in the colon as possible, fasten the outer end of the tube over the nozzle of a carbonic- acid siphon, and allow as much of the gas-charged water to enter as will.—Dawbarn. R Sodii bicarbonatis..................................... gr. xl. - 3 b Aqua?.................................................. 1 vi. Solve et fiat enema. S. Inject. Follow immediately with : R Acidi tartarici pulv................................ gr. xxxv.-xlvij. Aqua?............................................ § iv. Solve et fiat enema. S. Inject. The effervescence will cause the bowels suddenly to distend. —Bartholow. Acute intussusception is in reality a form of strangulated hernia, and the subacute is frequently an irreducible hernia. Enemata are far from being devoid of danger. An enema should be slowly introduced under anaesthesia and in the Sims position. In collapse small doses of morphine, stimulants under the skin.—Wiggin. Or, inflate the bowel through the rectum, even when the intestinal ulcer. 465 apex of the intussuscepted gut has protruded through the anus. —Wilkinson. In tympanites, if relief fails to follow cathartics, posture, enemata, and rectal tube, then coeliotomy and incision of bowel should be undertaken without delay.—Porter. Volvulus. Twists in the bowel, usually upon its mesenteric axis, impli- cate the large intestine and usually that portion near the sig-. moid flexure or caecal region. In a small percentage only is the small intestine the seat of twisting or knotting. It rarely occurs under forty years of age. Diagnosis.—Pain, as in other forms of acute obstruction, is an early and lasting symptom. At first it is referred to the umbilicus; later, to the seat of the obstruction. Vomiting oc- curs early, if the twist be in the small intestine; late, if it be in the large intestine. Faecal vomiting is a late symptom when the volvulus is in the sigmoid flexure. An absolute diagnosis can be made only by exploration. Prognosis.—This is the most rapidly fatal form of obstruc- tion. Treatment.—Palliative measures are of no avail. As soon as diagnosis has been made, operation is immediately demanded. Intestinal Ulcer. Ulcer of Duodenum.—It is especially in youth and in the presence of anaemia that we look for symptoms of duodenal ulceration. They are the same as those of indigestion or dys- pepsia of the intestine. This affection seems to be peculiarly frequent after severe burns of the skin surface. Differentiation from gastric ulcer is often difficult, as many of the same features are common to both. The pain, in typical instances, is more localized at the tip of 80 466 the practitioner's manual. the xiphoid cartilage. Vomiting or passing blood tends rather to exclude functional disorders. Perforation is apt to be con- founded with occlusion or appendicitis. Prognosis.—Six per cent of gastric and duodenal ulcers are said to end in perforation followed by rapid death. Treatment.—The same as in gastric and typhoid ulcer. In perforating ulcer of the duodenum, sudden epigastric pain, nausea, faintness, anxious expression, and other symptoms quite similar to those of gastric ulcer occur, especially in those ad- dicted to alcohol. Surgical treatment may result favorably.—Dunn. Acute perforating ulcer of the jejunum seems to be analo- gous in many respects to stomach ulcer and calls for much the same plan of treatment. Jaundice. Icterus interests us chiefly as it occurs in infancy, since, in the adult, it is symptomatic of a variety of affections depending upon definite disease processes elsewhere described. It occurs as a physiological state in the early days of life, passing away without treatment after brief delay, and without affecting the general health. When, as sometimes happens, it is present in subjects of hereditary lues, symptoms of hepatitis may be made out. It is also not uncommon in infants who present, post mortem, changes or malformations in the bile ducts, or who have cardiac lesions or persistence of the foramen ovale, or it occurs as a symptom of acute infectious diseases. The jaundice ac- companying congenital malformations appears a few days after birth, and is so intense that all tissues and fluids, including the urine, are bile-stained, and a fatal result commonly ensues in spite of treatment. If the icterus be due to an infectious or toxic cause, other manifestations pointing in this direction will usually be present. In the adult cholelithiasis must not be ex- JAUNDICE. 467 eluded from the diagnosis because of the absence of jaundice. It is possible for an impacted stone to exist in a duct so dilated that bile escapes alongside, and, as every one knows who has made or seen any number of autopsies, the gall bladder may be filled to its utmost capacity with calculi in subjects who had presented during life, so far as the history could be gathered, no yellowing of the skin. Catarrhal jaundice is usually seen after an attack of indi- gestion. While most common in the young, it may occur at any age and is especially frequent in malaria, in some forms of chronic heart or kidney disease, and may occur after exposure to dampness. There may be a true icterus in the newborn due to liver derangement. Obstructive jaundice occurs in stenosis from malignant dis- ease, occlusion from gall stone, conditions of fibrosis, or inflam- matory thickenings about the common bile duct. Treatment.—Physiologic, benign, and self-limited jaundice of the newborn requires no treatment. In that due to congeni- tal malformation of the bile ducts, or to congenital heart lesions, treatment is of no avail. When depending upon specific hepa- titis, therapy is to be directed to the original disease. In simple catarrhal icterus, intestinal lavage, intestinal antisepsis. In catarrhal icterus in a child : B Pulv. digital., Pulv. scilla?.............................................aa gr. vi. Potass, nitrat............................................. gr. xij. Pulv. aromat.............................................. 3 b M. et ft. chart. No. xii. S. One once or twice daily. For the pruritus of persistent icterus, massage and vapor baths, open-air life, gymnastics, diuretics, and, if the bladder is overdistended, puncture and evacuation.—Dujardin-Beaumetz. In simple catarrhal jaundice, a five weeks' course of Hathorne 468 the practitioner's manual. spring of Saratoga or a course of Carlsbad waters, with alka- line waters between meals (Vichy, Vals). To stimulate the descent of a stone, irrigate the large bowel with cold water.—Tyson. In severe icterus, calomel, gr. \, morning and night.— Hanot. For a child of five years : R Ammon. chlor................................................ 3 iss. Elix. simp................................................... 3" iij. M. S. 3 b in water t.i.d. after meals. —Powell. R Sodii phosphat................................................ § ss. Div. in partes vi. S. One before meals. —Bartholow. In the catarrhal form : R Fellis bovis pur.............................................. 3 i. Mangani sulph. exsic....................................... 3 ij. Resina? podophylli........................................... gr. v. M. et ft. pil. No. xx. S. One t.i.d. —Da Costa. R Potassii acetatis.......................................... § iij. Tinct. nucis vomica?..................................... Til xlviij. Glycerini, Syr. rubi idsei..................................aa q.s. ad § vi. M. S. 3 ii. in tumblerful of water four times daily. —Hugo Engel. R Hydrarg. chlor. mit........................................ gr. iij. Pulv. opii.................................................. gr. ij Bismuthi subnitr........................................... 3iiss. M. et fiant chart. No. vi. S. One every three hours. —William Pepper. B Aloes socotrina?, Cambogia?, Hydrarg. chlor. mit......................................aa gr. xv. Syrupi..................................................... q.s. Divide into ten pills. S. One or two a week to keep bowels soluble. —A. Gubler. jaundice, acute infectious. 469 Jaundice, Acute Infectious. Febrile icterus, or Weil's disease, seen mostly in butchers and brewers, especially after exposure to the cold of ice houses and beer vaults, begins with chill and fever reaching 105° F., falling gradually between the fifth and tenth day to normal. Recur- rences with milder symptoms of a shorter duration are noted in about one-quarter of those affected. There is mild jaundice almost from the start, lasting somewhat beyond the deferves- cence. The pulse falls when the skin becomes yellow, perhaps to a normal point. The liver and spleen are enlarged. The skin shows an erythema and at times a herpes about the end of the first week, and more rarely ecchymoses may occur. Diagnosis is made easy by the characteristic range of tem- perature associated with the symptoms of jaundice, especially in epidemic prevalence. Jaundice comes on quickly after a chill, fever, headache, vomiting, and pain in the stomach region. The vomited matter may be black, and hemorrhages into the skin and mucous mem- branes may occur. The urine may be suppressed after showing a large percentage of albumin, and coma may follow upon de- lirium or stupor. Differentiation.—From acute yellow atrophy of the liver, by the history of occupation and exposure, and by the fact that the liver is not decreased in size while the jaundice is more in- tense. Y"ellow fever is excluded by the history of the onset in the absence of epidemic prevalence of that disease. Typhoid fever has a less sudden onset with prodromata and characteristic eruption, while here there is a much shorter course and remissions are characteristic. The diagnosis from simple catarrhal jaundice is often one of great difficulty. Prognosis.—Death occasionally occurs early and in severe epidemics the mortality may reach twenty-five per cent. 470 the practitioner's manual. The prognosis is generally good.—Walter B. James. Treatment.—In the early stages: R Hydrarg. chor. mitis.................................... gr. iij.-vi. Ft. pulv. No. xii. S. One three times daily. Alkaline waters, intestinal irrigation, milk diet.—James. Kidney, Abscess. In suppurative nephritis chills recurring with irregularity and fever of continued type are among the symptoms. Diagnosis.—If an injury has occurred and signs of localized suppurative inflammation follow, abscess may be suspected. If the abscess ruptures into the pelvis of the kidney, an abundant pyuria makes its appearance and blood is often present in the urine. There may be suppression. Idiopathic abscesses are confined to one kidney; the symptoms begin gradually ; besides repeated chills and irregular fever, there is anaemia, emaciation, and frequently nausea and vomiting.—Francis Delafield. Suppurative pyelonephritis is always secondary and the re- sult of some infection. If, following sounding, catheterization, or gonorrhoea, or associated with hypertrophy of the prostate, long-standing stricture, or chronic cystitis, repeated chills occur, with high fever, profuse sweating, and a general septic state, this condition should be suspected. Differentiation.—From tuberculosis of the kidney, by the history, the negative microscopical and bacteriological examina- tion of the sediment, and the absence of pulmonary or bone tuberculosis. More important is the question whether one or both kidneys are affected. Pre-existing suppuration in the bladder or urethra nearly always affects both kidneys. In about twenty per cent of seventy-one collected cases of well-defined acute suppurative pyelonephritis, the lesion was unilateral.—Weir. Catheterization of the ureters enables us to collect the urine from the kidneys separately. kidney, amyloid degeneration. 471 Prognosis.—In the true "surgical kidney" it is bad. In- volvement of one kidney only, and absence of purulent cystitis, hypertrophied prostate, stricture, etc., make the prognosis more favorable. Treatment.—In acute septic infection following sounding and operations on the genito-urinary tract, give quinine. In "surgical kidney" give methylene blue, 0.1 gm. in cap- sule with nutmeg, three or four times a day. In idiopathic and solitary abscess perform nephrotomy, and drain as in ordinary abscess. Exploratory nephrotomy of one or both sides is justifiable in acute septic infection of the kidney, with the hope of relieving acute interstitial invasion or perhaps of finding a larger focus of suppuration. If double nephrotomy shows that but one kidney is affected, nephrectomy may be indicated.—Weir. Kidney, Amyloid Degeneration. Amyloid infiltration may complicate chronic interstitial or chronic parenchymatous nephritis and the symptoms will depend largely upon the primary disease. Diagnosis.—The general symptoms are much the same as in amyloid changes in other organs. The liver and spleen are here likewise apt to be enlarged and a coexisting diarrhcea makes the presence of amyloid changes highly probable, espe- cially if the urine is rich in albumin while showing but little sediment, and there is some suppurative process going on else- where in the body. The urine is generally increased in amount and of low spe- cific gravity; casts are abundant, especially of the fatty variety; the "waxy" (hyaline) cast is not distinctive. 472 the practitioner's manual. Kidney, Hydatids of. We may or may not have tumor. There is one-sided fluc- tuation, sensation of thrill, and the urine may show vesicles which have passed. The tumor if present is tense and usually painless, even on pressure. Differentiation from hydronephrosis cannot be made except by presence of vesicles, exploratory puncture, or incision. Treatment.—Incision and evacuation of cysts. Kidney, Movable. Aside from any surgical interest that a loose, displaced, or floating kidney may have, it interests us here by reason of its comparative frequency in women, subjects of tabes, and in neu- rasthenics. Diagnosis.—Polyuria and gastro-intestinal symptoms are not infrequent. Pain may be referred to the area of distribu- tion of the spinal nerves. Physical examination gives greater aid in diagnosis than do the symptoms. Differentiation.—The fact that displacement on the right side is more frequent makes differentiation from distended gall bladder necessary, especially as jaundice may be present in both conditions. A retroflexed bladder, in the case* of a downwardly displaced liver, may closely simulate the outline of a kidney. Both are movable, the former always in the arc of a circle, and it is more readily mapped out than is the kidney. If distended with calculi, it also feels harder. The kidney may be felt behind the bladder tumor.—Morris. (See "Abdominal Tumors" for further differentiation.) Prognosis.—It may produce hydronephrosis, induce gall stones, dilatation of the stomach, neurasthenia, or death by tor- sion of the vessels and ureter. Mild cases often cause no symp- toms, exist without the patient's knowledge, and require no treatment. kidney, tuberculosis of. 473 Treatment.—Mechanical support for the abdomen and con- tained viscera. For complete cure surgical procedures are required. Kidney, Tuberculosis of. When existing as a primary or local condition early detec- tion is of vast importance. Diagnosis.—Early signs are often referred to the bladder. Fever, associated with dull aching pain, tenderness over one kidney region, frequent micturition without other discoverable cause, urine being acid and containing albumin and subse- quently pus, blood, detritus, epithelium, and renal cells, may lead one to watch for tumor. If, in the sediment of the urine collected by means of the ureteral catheter, tubercle bacilli are found, a positive diagnosis can be made. Bacilli are scanty and not readily distinguished from smegma bacilli. Differentiation.—From stone in the kidney pelvis by ab- sence of characteristic colic; the two are often asssociated. It is important to ascertain whether both kidneys are af- fected ; this may be determined with some accuracy by testing the permeability of the kidneys with methylene blue, ureteral catheterization, and microscopical and bacteriological examina- tion of the collected urine. Prognosis. —Fatal ending for most instances in from a few months to three years. Recovery without operation is rare. Proximate mortality with operation, twenty-eight to thirty per cent. In primary tuberculosis of one kidney and no involvement of the bladder, nephrectomy gives good results. Treatment.—In early stages corrosive sublimate in small doses. Morphine for pain. Calcium chloride and remedies as in phthisis. Urotropin, tuberculin.—Harrison. 474 the practitioner's manual. Operative treatment should be limited to cases in which the strength of the patient is sufficient to resist the immediate effects of the operation, and in which either the renal disease is pri- mary, or, if secondary, the primary disease is not far advanced. —Senn.37 Kidney, Tumors of. Congenital: f Round-celled. Fibro-sarcoma. Striped myosarcoma. Adeno-sarcoma. Dermoid cysts. Adult origin : Cavernous tumors. Sarcoma. ( Cystic. Adenoma j ^^ Carcinoma (a) of kidney Sarcoma < j Cystic. (Tubular. ^Epithelioma. (b) of pelvis lcono.d_ —Paul. Diagnosis.—The presence of lymphadenoma, pain, tender- ness, haematuria, and possibly of sarcomatous or carcinoma- tous cells or tissue in the urine, when malignant disease of the bladder can be excluded by the cystoscope, is suggestive, espe- cially if the tumor can be felt. Prognosis.—Good if diagnosis is made early, rendering radi- cal operation possible. Treatment. —Nephrectomy. (For other kidney diseases see under "Nephritis.") LARYNGISMUS STRIDULUS. 475 Laryngismus Stridulus. Laryngismus stridulus in children produces a spasmodic ces- sation of respiration and congestion of the face. There is a struggle for breath, and as the spasm relaxes inspiration takes place with a characteristic crowing-sound. There is neither cough, nor fever, nor markedly altered voice. Attacks usually occur at night. Differentiation.—The low temperature practically excludes laryngitis. In the adult a severe attack excites the gravest apprehension, not only on the part of the patient but upon that of the friends as well. The face is cyanosed, the body bent forward, and the patient struggles in his efforts for breath. In hysterical spasm the inspiration is stridulous, while the expiration is free. Prognosis.—Usually good. Sudden death has been re- ported. In measles a spasmodic croupy laryngitis may occur early during the time of eruption or during convalescence, closely simulating this condition. Treatment.—For an adult, inhalations of chloroform, ether, or nitrite of amyl. In children, rickets being the chief etiological factor, it is important to give the child proper diet and put it under anti- rachitic treatment. In spasmodic epileptiform seizures, bromide of potassium, gr. x., repeated as required. B Potassii citratis.......................................... 3 i. Syr. ipecacuanha?......................................... 3 ij. Tinct. opii deodorati..................................... gtt. xij. Syr. simplicis............................................. 3 ij. Aqua?..................................................... I iss. M. S. Teaspoonful every two hours for a child of two years. —Meigs and Pepper. 476 the practitioner's manual, For a child of four or five years : R Potassii bromidi.........................................---- 3 i. Aqua? destillata?............................................. 3 ij. M. S. To be given in divided doses during the day and continued in the same or larger dose for five to eight days. —Huchard. R Antimonii sulphurati (Kermes mineral)................ 0.05 cgm. Tinct. aconiti, Tinct. belladonna?..................................aa 5 gtt. Syr. aurantii florum................................... 30 gm. Aqua? sambuci...............................q.s. ad 120 gm. M. S. Teaspoonful to a dessertspoonful every half-hour. As an emetic, hydrarg. subsulphas flav., gr. iii.-v. Safer and better than tartar emetic. Wet pack to the neck.—Bar- tholow. B Potassii bromidi, Sodii bromidi.........................................aa. 3 b Chloralis.................... ........................... gr. xlviij. Syr. simplicis.......................................... 1 b Aqua? cinnamomi................................q.s. ad 3* iij. M. S. 3 i. every half-hour. —Powell. To arrest an impending attack : B Chloral.................................................. gr. v.-xv. Syr. simplicis, Aqua? destillata?.......................................aa. 3 ss. M. S. One dose. —Bartholow. In rickety, cachectic children : R Quinina? sulphatis.......................................... gr. vi. Acidi sulphurici diluti...................................... iU vi. Tinct. aurantii, Syr. zingiberis...........................................iia 3 ij. Aqua? destillata?............................................ 3* iij. M. S. 3 b t.i.d. —Oke. Or— R Phosphor i................................................... gr. y1^ Olei amygdala? dulcis........................................ 3 i j. Acacia?...................................................... 3 iij. Aqua? destillata?.......................................q.s. ad "% iv. M. S. Teaspoonful twice a day. LARYNGITIS, ACUTE CATARRHAL. 477 Or— B Mo3chi.................................................. 0.20 cgm. Syrupi.................................................. 25 gm. Aqua? tilia?............................................. 60 gm. M. S. Teaspoonful four or six times a day. Laryngitis, Acute Catarrhal. A cough with hoarseness, "loss of voice," pain on swallow- ing, perhaps spontaneous, and either a dryness or sense of con- striction in the throat, are the features on which a diagnosis is based. While the character of the voice is almost sufficient, the laryngoscope should be used in confirmation. Differentiation.—From the chronic form by duration, lesser degree of pain, etc. From the tuberculous by absence of lung signs and ulcera- tion. From syphilitic by lack of evidence of infection. From laryngismus stridulus, by lack of crowing inspiration. From diphtheria by absence of membrane and less-marked fever. From spasmodic asthma and bronchitis by absence of cough. From aneurism by lesser degree of pain. From oedema of the larynx; paralysis of laryngeal muscles; hysterical aphonia. (See under these headings.) Treatment.—Inhalation of hot steam, medicated or not, by means of a rubber tube attached to the spout of a tea-kettle or by means of an inhalation apparatus. In children, hot moist sponges to the throat. B Tinct. aconiti ............................................... gtt. i. S. In water every fifteen minutes. In simple laryngitis, the best sedative is a flow of non-irri- tating bronchial mucus, to encourage which apomorphine, gr. sV, in a freshly compounded acidulated mixture, is advised every three hours.—T. Hubbard. The best drug sedative is codeine sulphate, gr. 478 the practitioner's manual. Or, pilocarpine, gr. y-^ in tablet form every hour, for three or four doses. Hot mustard foot baths and hot drinks. As a spray : B Olei santali............................................ gtt. iv. -vi. Olei picis............................................... gtt. i.-iij. Albolene............................................... § i. M. In beginning attacks in singers, etc., dilute nitric acid, gtt. v.-x. in water or on a lump of sugar.—Kyle. B Tinct. ferri chloridi.......................................... 3 ij. Potassii chloratis............................................. 3 ij. Potassii bromidi ............................................. 3 iij. Extr. glycyrrhiza?. . .......................................... 3 b Aqua? destillata?......................................q.s. ad ^ vi. M. S. A dessertspoonful in water every three or four hours. Gargle and swallow. —Carl Seiler. The use of astringents is attended with the best of results. B Liq. ferri persulphatis.................................... gtt. v.-x. Aqua? destillata?......................................... § i. M. S Use in atomizer. —Daily. In children, in connection with acute rhinitis: B Cocaina? muriat........................................ gr. ij.-v. Aqua?.................................................... tti xv. Ft. solut. et adde : Glyceriti acidi tannici................................... 3 i. Olei petrolati......................................... ad § i. M. S. Apply by nasal atomizer every two or three hours. —Bosworth. Before making application cleanse nasal passages with Dobell's solution (see page 200). For persistent and distressing cough in a child of seven years : B Acidi hydrocyanici diluti.................................. TU ij. Codeina?................................................... gr. iss. Ammonii muriatici........................................ gr. xvi. Aqua? laurocerasi...................................q. s. ad 1 ij. M. S. A teaspoonful every two hours as needed. laryngitis, chronic. 479 After a calomel purge give: B Tinct. aconiti......................................... TU xij.-xxiv. Sodii bromidi......................................... 3 ij. Syr. lactucarii.......................................'. § b Aqua?..........................................q.s. ad § iij. M. S. 3 ii. every four hours. —Hare. R Potassii chloratis, Potassii bromidi, Pulv. extr. glycyrrhiza?.....................................aa 3 i. Tinct. ferri chloridi........................................... 3 ss. Sacchar. albi.................................................. q.s. M. ft. trochisci No. xx. S. One every three or foar hours. —Seller. Laryngitis, Chronic. We have here a variety of forms due to a variety of causes. In a general way it may be said that there is complaint of a sense of constriction, but no difficulty in swallowing. From a constant desire to "clear the throat" coughing is frequent, but the expectoration scanty. White, stringy, boiled-starch-like mucus is coughed up. There is a considerable amount of hack- ing, hoarseness, and hypersemia of the mucous membrane, as seen by laryngoscopic examination. The voice is harsh, rough, or almost lost. Differentiation.—From the acute, by history of its having followed the latter and the evidences of chronic inflammation. Tuberculous and syphilitic laryngitis are excluded by absence of history and of characteristic ulceration, excoriations being more commonly present in the catarrhal form. From paralysis of the cords, ulcerative changes, tumors, and exudations, by means of the laryngoscope, chronic subglottic laryngitis is distinguished by a bulging immediately below the edge of the cords, as an evenly rounded tumefaction. Dys- phagia when present is indicative of the tuberculous form.— Da Costa. Prognosis for total and permanent recovery in adults is not 480 the practitioner's manual. brilliant, excepting for the rarer instances in which treatment can be rigorously carried out. There are frequent exacerba- tions of acute laryngitis. Treatment should be directed to any underlying systemic defect. Relief may depend upon the cure of nasal defects causing mouth breathing, or the removal of the patient from unwhole- some and dusty surroundings and occupations. Restore the passages above to a healthy condition by curing hypertrophic rhinitis, chronic nasopharyngeal catarrh, etc. Alcohol should be interdicted. Mild astringents are far more efficient than the stronger ones. R Argenti nitratis......................................gr. x. to \ i. (This is usually sufficient.) Or— R Zinci sulphatis....................................gr. v.-xx. to § i. Or— R Zinci chloridi.................................... gr. ij.-vi. to § i. Or— R Cupri sulphatis...................................gr. iij.-x. to § i. —Bosworth. As a sedative inhalation : R Tinct. benzoini comp........................................... § iv. Chloroformi.................................................. 3 ss. M. S. Teaspoonful in a pint of water at 140° F. —Carpenter. In singers and public speakers, as perfect rest of voice as possible. Anodyne expectorants without syrups, iron tonics, faradic electricity, mountain air.—Seller. laryngitis, tuberculous. 481 Laryngitis, Tuberculous. The most frequent sites are the ventricular bands and the vocal cords, the right side being most often affected. It may be primary, or secondary to pulmonary tuberculosis. The growth is slow and the course chronic. The symptoms are hoarseness, dyspnoea, and very frequently dysphagia. Lesions assume two forms: 1. Granular infiltration with con- gestion and oedema, undergoing later a caseous degeneration. 2. Ulceration—ulcers shallow, superficial, with jagged edges, and gray, smooth base.—Cheval-Rousseaux. Differentiation.—The growths cannot be distinguished clinically from fibroma, papilloma, or sarcoma. — Payson Clarke. Microscopic examination of the sputa or scrapings makes early diagnosis possible. Prognosis.—Treatment offers relief and prolongs life, but seldom cures. Pulmonary complication. Treatment.—-General treatment is imperative. Hygiene and mountain air. Medicinal.—Guaiacol carbonate and creosote are useful. Local.—Atomization, inhalation, insufflation, injections, and pigments are the local measures. The application of lactic acid or sulphoricinate of phenol gives gratifying results. Or, parachlorphenol in five to twenty per cent solution in glycerin. Enzymol is a most valuable auxiliary to lactic acid and the curette.—Gleitsmann. Produce anaesthesia with a ten-per-cent cocaine solution and apply: R Acidi phenici............................................ 1-5 gm. Acidi lactici............................................. 2-15 " Glycerini neutr........................................... 20 " First in weak then in full strength. — Botey. 31 482 the practitioner's manual. For the dysphagia: R. Cocaina? hydrochloratis................................... gr. iv. Morphina? hydrochloratis................................. gr. iss. Antipyrini............................................... gr. xxx. Aqua? destillata?, Aqua? laurocerasi.......................................aa § i. S. Apply by means of atomizer during the day. Injections of menthol in olive oil.—Rosenberg. Tracheal injections of creosote or guaiacol in olive oil, two per cent. Dose, three grams increased to twenty.—R. Botey. Surgical.—Incision, curettage, submucous injections, elec- trolysis, galvano-cautery, laryngotomy, laryngectomy, trache- otomy, and intubation comprise the surgical procedures.— Gleitsmann. If the infiltration does not yield to local medication, resort to curettage. Contraindications for curettage are advanced pulmonary disease, disseminated tuberculosis of larynx, and extensive in- filtration producing stenosis. For the latter tracheotomy or laryngectomy may be indicated.—Gleitsmann. (See also under "Tuberculosis.") Laryngitis, Syphilitic. This may be: 1. Primary; seat of initial lesion; rare. 2. Secondary; erythema, mucous patch, or ulcer. 3. Tertiary; gummata or ulcers. 4. Hereditary; resembles tertiary form; uncommon. Differentiation.—Secondary syphilitic laryngitis gives no characteristic appearance; it must depend on other evidences of disease, history, and result of treatment. Treatment. — Antisyphilitic. R Hydrargyri chloridi corrosivi............................ gr. i. Potassii iodidi.......................................... 3 ij.- 3 iv. Syr. sarsaparilla? comp................................... § iss. Aqua?............................................q.s. ad § iij. M. S. 3 b twice daily after meals. —Stevens. LEPRA. 483 Larynx, (Edema of. Decided swelling may occur independently, as a complication of grave systemic disease or of laryngitis or other throat affec- tion. Symptoms of stenosis come on rapidly. Phthisical and syphilitic patients are frequently affected. There is a feel- ing of painful fulness in the throat and a peculiar barking cough. Symptoms are those of asphyxia—rapidly increasing dysp- noea, cyanosis, delirium, coma, and death. It is also called acute oedema of the glottis. Treatment.—Ice rarely does good; a solution (five per cent) of cocaine sometimes relieves mild cases. If this fail, scarify at once, making deep incisions. Intu- bation may be attempted; lastly, tracheotomy.—Lefferts. Scarification of the swelling, mustard plaster, or fly blister to the throat; bleeding, leeching, cupping; atmosphere sur- charged with moisture. B Aluminis....... Aqua?........... S. Use in atomizer Caution.—Silver solutions are too apt to increase spasms. To prevent recurrence, constitutional treatment directed against the particular organ at fault. When associated with perichondritis, ichthyol in aqueous solution to the mucous membrane and externally. B Ichthyol, Lanoline....................................... aa ? i Apply to the throat externally. —Kyle. gr. xv.-xx. \ b 484 the practitioner's manual. Lepra. Leprosy is not difficult of diagnostication when fully devel- oped, and especially in its tubercular form with recurrent erup- tions of bullae, tubercles, and diffuse plaques, leaving pigment stains behind, muscular atrophy, thickened ulnar nerve, per- forating ulcer, and leonine face with loss of expression. In any doubtful case the lepra bacillus may be sought. Diagnosis.—It is, however, in the anaesthetic or macular form, and especially in the earlier stages, that greatest diffi- culty is encountered. The first intimation may be the fact that the subject has received a burn without experiencing pain. This form may begin as a bullous eruption, perhaps limited to one or more fingers, and gradually spreading until both hands are involved and the bullae are succeeded by rounded ulcers. The characteristic anaesthesia extends up the arm, giv- ing areas in which the reaction to pain, heat, cold, etc., is abol- ished. Erythematous spots or macular patches of brownish pigmentation develop. Mixed forms may present serpiginous pigmented patches upon the body along with tuberous nodules above the brows and in the lobe of the ear. Bone disease of the hands can be determined by the a?-rays, resorption of the distal phalanges being made out. Since years may intervene between the infection and first signs, a very early diagnosis is scarcely ever possible. Almost the earliest sign is the occur- rence of erythematous spots, especially on exposed parts. In the anaesthetic variety the spots extend at the periphery and clear up in the centre. Differentiation.—From other forms of pigmentation by the presence of anaesthesia. From syphilis by a lack of history of infection and of earlier signs; by the difference in color of the lesions and the course. Syphilitic lesions tend more to roundness of contour, and to the formation of rounded groups and crescentic and LEPRA. 485 serpiginous patches. There is no initial lesion corresponding to the chancre. If an excised portion of skin shows no bacilli and there are no anaesthetic areas, doubt may still exist. The thera- peutic test by mercury is not conclusive, since many lepers do extremely well on this treatment. The erythematous blotches are distinguished from measles, drug eruptions, and the like, by their persistence. From morphcea by the absence of the violaceous areola sur- rounding the patches. From mycosis fungoides by the more rare development of fungating masses or tumors in lepra and the more rapidly fatal course of mycosis. From syringomyelia by resecting in an anaesthetic zone a superficial cutaneous nerve. If lepra is present the bacillus will be found. In a number of instances of supposed Morvan's dis- ease Hansen's bacillus has been discovered by different observ- ers. Other affections for which lepra in its later stages has been mistaken are scleroderma, arthritis deformans, muscular atrophy, and hysterical contractures. From lichen planus, by the subjective symptoms, which are not found in the latter, and by the absence of itching. From pemphigus, by the ulceration that often follows the bullae in lepra. From skin tuberculosis, by the bacilli, which are much more abundant than in the latter and more readily stained. A Simple Method of Examination for the Bacilli.—A cover glass is smeared with a drop of the serum obtained by scraping one of the suspected leprosy nodules. This is stained with car- bol fuchsin and decolorized with sulphuric acid and methylene blue (Gabbett's fluid), and examined under the microscope in the ordinary way.—Johnston and Jamieson. Prognosis.—Few instances of recovery under drug treat- ment have been recorded, and in some of those that have been reported recurrence has subsequently been noted. Under change 486 the practitioner's manual. of climate many patients do extremely well for years. The average of life after the first symptoms are noted is about eight to ten years. Treatment.—Orrhotherapy.—The Carrasquilla serum cure, leper serum passed through the horse, is employed by hypoder- matic injection. There is no reaction until after the third or fourth injection. Then feelings of cold and rigors are noted. Under this treat- ment sensation returns in anaesthetic areas, the health improves, ulcerations cicatrize rapidly.—Juan de Dios Carrasquilla. Another serum is made by injecting the juice of freshly re- moved lepra nodules into animals and drawing off their blood when they have fully returned to health. This injected into lepers gives a reaction after six hours, and results in various signs of improvement after a course of from three months to a year (sixty cases, six cures, lasting a year to date of report).—Laverde. Antivenomous serum (Calmette), in experimental stage.— Isadore Dyer. Locally : R Bismuth oxyiodogallate........................................ 10 Vaseline....................................................... 100 M. S. Use as an inunction with massage over the whole body. To inject into leproma : R Aristol........................................................ 5 Glycerin........................................................ 35 Aqua? destillata?................................................. 10 —FORNARA. For lesions upon the face : R Ichthyol.................................................... 3 ss. Acidi salicylici........................................... gr. x. Tinct. benzoini............................................. gtt. xx. Ung. zinci oxidi..............................■.............. § i. M. ft. ung. leptomeningitis. 487 Or— B Europhen....................................................... °-5 Olei amygdala? dulcis........................................... 10 Filter, sterilize, and inject one cubic centimetre. B Airol............................................................ 5 Vaseline............................................•........... *5 M. S. Apply. Or— B Airol............................................................ 5 Glycerin........................................................ 35 Aqua?........................................................... 10 M. S. Inject hypodermatically. B Europhen...................................................... 5 Olei oliva?...................................................... bOO S. Use by energetic and prolonged friction in slight extent of surface lesion. In internal lepra the above sterilized and filtered, by subcu- taneous injection.—Goldschmidt. Or— B Olei chaulmoogra?.............................................. 3 b Petrolati....................................................... % ij- M. S. Apply in conjunction with the oil internally. —Cottle. B Potassii permanganatis...................................... 1-2 Aqua?....................................................... 1.000 Use warm as a wash and local dressing. —Carrasquilla. Leptomeningitis. Inflammation involving the pia mater and arachnoid will be referred to under the various forms of meningitis and acute peri-encephalitis. The acute variety is distinguished by pain along the spine, coming on after a chill and growing rapidly worse, attended with radiations toward the extremities and about the body (girdle sensation). Spasm of the muscles of the back may produce simply rigidity or opisthotonos. Other muscles of the body may be the seat of rigidity, painful cramps, or spasmodic contractions; when the spasm affects the sphinc- ters, retention of urine and obstipation result. 488 the practitioner's manual. Differentiation.—In chronic meningitis, while the back pain is increased by motion, the spasmodic element is lacking, though slight muscular twitchings may occur. Prognosis.—Slow recovery may take place, or death may be due to apnoea, or the condition may pass into a chronic form. Though complete paralysis scarcely ever follows, there is a gradual increase in the weariness of limb and a peculiar heavy sensation. Treatment.—Rest in cool, darkened room. Cool drinks, cool applications to the shaven head. In robust subjects, wet cups to back of neck or phlebotomy. —Collins. In chronic spinal form, thermal-spring course; mild cold- water cure; internally, potassium iodide. If recovery follows, it is probable that we had in reality to do with neurasthenia or hysteria.—Bruns and Windscheid. (See "Pseudo-Meningitis.") Leukaemia, Two varieties of leukaemia are recognized : a lieno-medullary and a lymphatic. It is very rare. Diagnosis.—Characteristic of the spleno-myelogenous or first variety is the fact that myelocytes are the most abundant of the white corpuscles. In the lymphatic the greatest percen- tage is furnished by the mononuclear cells. Red corpuscles are decreased in number and the haemoglobin is lessened in amount. Instead of there being 1 white to 500 or 1,000 red corpuscles, there is perhaps 1 to every 3. There is in the first an involvement of the long bones, as indicated by tenderness; in the second an implication of greater or lesser extent of the lymph nodes throughout the body. In both the spleen is enlarged ; at times greatly so. Cabot35 calls at- tention to the variation in size of the myelocytes, the occurrence of intermediate cells, and the large number of nucleated red cells. leukaemia. 489 The onset is gradual, with increasing weakness and occasion- al pains in the region of the spleen. Anaemia with its accom- panying symptoms comes on later and increases as the spleen enlarges. Lymphatic enlargements in the neck, axillae, and groins, otherwise unexplained, may point to the lymphatic form of leucocythaemia, or, as Kneis claims, eye changes, such as hem- orrhage into the lid or conjunctiva, may be the initial sign of an acute attack. Temperature is sometimes increased up to 103° F. Differentiation.—Hyperleucocytosis gives an increase in the number of white cells, but it is of temporary duration, while here the increase is permanent. The various anaemias are to be distinguished. (See table on page 27.) Hodgkin's disease would seem to be closely related, by the fact that there is said to be an occasional transformation of the latter into the splenic form. Prognosis.—Usually regarded as a fatal disease, the final stage of cachexia being reached within a year or more. Cure has been reported from the prolonged use of oxygen inhalations. Treatment.—Arsenic seems to have but little effect unless pushed to its full limit. Inhalations of oxygen, four litres being used daily in one instance. The patient was discharged cured after two months, the spleen being of normal size.—Koster. B Acidi arsenosi................................. Pil. ferri carbonatis, Quinidina? sulphatis.......................... M. ft. pil. No. xl. S. Two pills three times a day Bone Marroiu.—Twelve ribs of sheep were carefully scraped and chopped into small fragments, then rubbed up in a mortar with one pound of glycerin. This was allowed to macerate for ......• • • gr. i. .......aa 3 i. —Da Costa. 490 the practitioner's manual. three or four days, being kept in a refrigerator during that time. It was then strained through gauze, and the resultant liquid given in teaspoonful doses three times a day.—John S. Billings, Jr. Arsenic is of more benefit than bone marrow, but the latter may be given when there is idiosyncrasy against arsenic. B Liq. potassii arsenitis.....................................TTI x.-xv. —Handford. It is said that splenectomy has been resorted to with favor- able result, but death from hemorrhage is an almost certain outcome of this procedure. Lightning Stroke, Electric Stroke. This is not necessarily fatal. There may be simply shock, burning of the surface, etc., or suspended animation. In the first class there is weakened heart beat, respiration is slow and sighing, and the surface may show evidences of discoloration; in the second, no evidence of life may be present. Respiration may cease, while the heart continues to act feebly; in such cases the face and lips are livid, the pupils dilated, and the cor- neal reflex may be absent. Treatment may prove successful if artificial respiration is kept up—just as in the case of supposed death from drowning— for an hour or even two hours after breathing has seemed to stop. Warmth to the surface. Stimulants hypodermatically. ' Liver, Abscess of. Suppurative hepatitis may be of traumatic or infectious origin. The first pronounced evidence of its existence may be a discharge of pus through some round-about channel. Diagnosis.—There is progressive loss of weight and strength and often marked lassitude and depression are noted; pain of liver, abscess of. 491 constant character is present over the liver, especially if suppu- ration approaches the surface, when it may be acute, or the pain may be referred to some distant part, as to the right shoulder. There may be a dry cough and dyspnoea when the pressure is up- ward. The temperature may be so slightly elevated as to escape notice, and is apt to be erratic. When fever is accompanied by recurrent chills and sweating, pointing to a focus of suppuration, the liver should come in for a large share of attention in the at- tempt to locate the pus. The only trustworthy aid to positive diagnostication is ex- ploratory aspiration. Even here a negative diagnosis is not warranted unless several attempts have been made, since either the abscess cavity may not have been reached, or the purulent contents may be too thick to be drawn off through the needle, or other elements of doubt may exist. The point of puncture is in the seventh intercostal space in the axillary line upon the right side. Enlargement may be made out, with bulging of the right hypochondrium and perhaps fluctuation, if the amount of pus is sufficiently large. History of dysentery, with pain, tenderness, and enlarge- ment of the liver, hectic, sweats and rigors, right-side posture, erratic temperature, progressive emaciation, and gastric disturb- ances are among the most constant symptoms. Profound, de- pression and lassitude are out of proportion to the gravity of the disease and appear early, and insomnia may be an enduring symptom. Restlessness, headache, and irritability of temper are present in some cases.—George Ben Johnston. In hot climates the fact that dysentery has preceded the symptoms aids in the diagnosis of "tropical abscess." Tropical abscess may run its entire course without producing any sub- jective symptoms indicative of liver disease, a sudden lethal ter- mination resulting from rupture into some neighboring organ or cavity. 492 the practitioner's manual. Differentiation.—Typhoid fever is at times suggested by the attending fever showing evening exacerbations; here the Widal reaction aids us. Localized peritonitis may be simulated by a certain crepita- tion on palpation. Empyema is excluded by the position of the retracted lung high up along the spine; still, abscess has been taken for em- pyema. Gall stones are excluded by the lesser degree of pain and jaundice present. Hydatids are unattended with fever or other symptoms until the cyst has attained considerable size. Malaria may be simulated in those instances presenting symptoms of chill, fever, and sweating at more or less regular intervals; but in malaria the recurrences are more typical and the spleen is more greatly enlarged, while by the use of quinine it maybe excluded, as well as by the absence of the plasmodium. Prognosis.—Recovery is the exception unless surgical means are instituted or a favorable direction is taken by the pus when it discharges spontaneously, as into the stomach, colon, or lung. The duration is from six to eight weeks. Small tropical ab- scesses may exist for years in a quiescent form and then undergo enlargement and burst.—Fayrer. Or, they may be absorbed or partially absorbed, and become encapsulated.—Maclean. Treatment.—Medicinal treatment is of little avail. When pus is located a free opening must be made in the most dependent part. If protective adhesions have not formed, protect the peri- toneal cavity before opening the abscess. In acute hepatitis (before suppuration): R Pulv. ipecac................................................... 3 b Mucil. acac................................................... q- s. M. ft. pil. No. iv. S. At a dose, and repeat every six hours. —Maclean. liver, acute yellow atrophy. 493 Absolute rest, light diet, relieve bowels by mercurial purge. To evacuate hepatic abscess, the trocar is preferable to in- cision.—J. Kingston Fowler. No method is successful which fails completely to evacuate the abscess and allow free drainage. Puncture with the trocar is unsurgical, but an aspirator needle may be used to locate the cavity with accuracy.—Johnston. Rupture into the peritoneum calls for prompt flushing of the peritoneal cavity.—Hulke. Ammonium chloride is a specific in tropical abscess of the liver. As much as twenty grains may be given three or four times a day. — William Stuart. Liver, Acute Yellow Atrophy." After a period of symptoms referable to the stomach, slight jaundice, fever, and diminished liver dulness are noted. It occurs in the adult, chiefly in women. Severe vomiting, perhaps hemorrhagic, is attended with intense headache, muscular and arthritic pains, convulsions, and possibly delirium and coma. The temperature is not high until just before death, when it may be 104° F. Diagnosis.—The condition is extremely rare in this country.. Diminished size of the liver with jaundice, epistaxis, marked restlessness, nervousness, and possibly convulsions, point to this condition. In alcoholics the liver area may not be diminished, and especially if hypertrophic cirrhosis has existed crystals of leucin and tyrosin may be found in the urine. The progress of the disease is rapid. Differentiation.—In phosphorus poisoning the symptoms are very similar, but the liver is enlarged instead of being de- creased in size. There is more vomiting and the nervous ele- ment is less pronounced. 494 the practitioner's manual. In parenchymatous hepatitis the jaundice is due to obstruc- tion, and the disease pursues a much slower course. In yellow fever there are severe backache, injected eyes, more fever, and less nervous excitation. Prognosis.—Death follows the advent of the more severe symptoms within a few days, milder symptoms having extended over a period of a week or more. Treatment is symptomatic. Liver, Amyloid. Amyloid degeneration is a condition accompanying cachectic states, chronic nephritis, rachitis, carcinoma, leukaemia, pseudo- leukaemia, and the like. There are emaciation, anasarca, and various signs of debility, often accompanied by diarrhcea. Al- bumin is present in the urine, which is of low specific gravity. Liver dulness may embrace an area extending from the crest of the ilium as high as the third rib. There is no tenderness on pressure. Diagnosis.—When the liver has reached such a size as to cause subjective sensations of fulness or even weight in the right side, and the symptoms above mentioned suggest this con- dition, the diagnosis is warranted, especially if suppuration of long duration has been a feature of the case. The lower edge of the liver is rounded, firm, and smooth, except in the presence of cirrhosis and syphilis, when the surface as well as the edges of the liver may be irregular. Differentiation.—This must be made from other enlarge- ments, such as those due to hydatids, to passive congestion, and to fatty liver. Prognosis.—Death usually occurs within six months after ex- cessive enlargement of the organ renders the diagnosis possible. Treatment is directed to the suppurative or other disease upon which the condition depends. LIVER, cancer of. 495 Liver, Cancer of. We must here include sarcoma as well as carcinoma. Diagnosis is more difficult in the absence of enlargement, but is facilitated by the history of primary cancer having existed elsewhere. If there has been progressive hypertrophy, and es- pecially if cachexia exists, it is less difficult. Three varieties of primary cancer of the liver with cirrhosis may be recognized. In the first the duration is short, from four to six months; there is some ascites; no jaundice; spleen normal or a little enlarged; abnormal development of subcutaneous abdominal veins; one lobe (generally the right) of the liver enlarged and carcinoma- tous, the other atrophied and cirrhotic. The second variety, which is much rarer, is characterized by a diminution in the size of the liver. In the third variety, which is the most com- mon, the ascites is generally hemorrhagic, jaundice slight (or marked), spleen generally a little enlarged, and the liver usually much enlarged and presenting an irregular nodulated surface. —Pennato. Differentiation.—The symptoms are more severe than in fatty or amyloid liver, and the presence of jaundice excludes the latter. Abscess has its chill, fever, and sweat, while hyda- tid disease presents a liver of nodular surface, which is softer and not attended with such prompt wasting of the body. In doubtful cases the aspirating needle may be resorted to. The nodular liver of gummy syphilis associated with amyloid changes usually has a specific history as a guide; the gum- mata are larger and softer than cancer nodules, they are of slower development, and disappear under antisyphilitics. The development of ascites in any instance of prolonged jaundice in which the liver is not markedly enlarged rather favors the diagnosis of cancer. Here often a history pointing to alcoholism on the one hand, or to primary cancer on the other, or a family history of cancer must be relied upon. Sarcoma is almost in- 496 the practitioner's manual. variably secondary; often to disseminated, melanotic sarcoma of the skin. The diagnosis depends largely upon the history of the primary disease. Liver tumor is distinguished from that of the stomach, colon, etc., by its complete dulness on percussion, while the latter gives a dull tympanitic note. The former, too, changes its position in respiration much more than the latter. Prognosis in both forms is bad. Death occurs within eigh- teen months, often much earlier. Treatment.—No hope can be held out from any known therapeutic resource. Keep down the pain with morphine and relieve the gastro-intestinal complications. Liver, Cirrhosis. Chronic interstitial hepatitis gives no distinctive early signs. If there is a history of alcoholism and ascites has developed, this form of hepatitis is to be suspected. Diagnosis.—If physical exploration reveals a much enlarged or much reduced liver in association with symptoms pointing to impeded portal circulation, causing gastric catarrh, hemorrhoids, and oedema of the lower extremities, in a subject of sallow com- plexion who gives an alcoholic history, suspicion is strongly directed to this condition. Two forms must be differentiated: that which remains hypertrophic, and that which undergoes the shrinking process. The former is more likely to be as- sociated with jaundice, but not with ascites. It is rare. The atrophic form is mostly seen in gin drinkers, and is usually attended with marked ascites. It furnishes almost two-thirds of the instances. A point of the greatest worth (when it occurs) is the presence of ascites without dropsy in other portions of the body. Haematemesis is a not uncommon symptom. Hypertrophy of the last phalanx of the fingers with in- LIVER, CIRRHOSIS. 497 curved and altered nail is a not infrequent symptom of hyper- trophic cirrhosis in children.—Gilbert. Differentiation.—Dropsical effusion attends tuberculous peritonitis, and many of the symptoms in the two conditions are similar, but in cirrhosis there is absence of fever and abdominal tenderness. The enlarged liver of cirrhosis simulates that of amyloid and cancerous degeneration, as well as hydatid liver. In cancer the liver is more uneven, the patient is apt to be older, often gives no history of alcoholic excess, and ascites is more common. The presence of jaundice excludes amyloid liver. Obstructive biliary or secondary cirrhosis presents a liver at first hard and enlarged, afterward diminishing in size, but the course is more rapid than in hypertrophic cirrhosis proper. The existence of mixed cirrhoses explains the ascites sometimes oc- curring in hypertrophic cirrhosis or a jaundice occurring in the course of an otherwise typical form of Laennec's cirrhosis. Prognosis.—Moderate degrees of cirrhosis are compatible with long life, and the course of the disease is chronic; the pa- tient is usually carried away by some intervening or associated complication. Symptoms of cerebral oppression with a typhoid state may precede by a few days the lethal outcome. Treatment.— Prophylaxis would require attention to diet and abstinence from alcoholic drinks at other times than at meals. Chronic gastric catarrh, which always accompanies the new condition, is to be vigorously combated by washing out the stomach, and by the free use of hot water and of alkaline waters taken before meals. Occasionally a pill containing: B Argenti nitratis, Extr. hyoscyami, Extr. nucis vomica?.......................................aa, gr. 8S. —J. Barr. The condition of congestion requires daily saline and mercu- rial purgatives, or a course of Carlsbad or Vichy waters. Alco- 32 498 the practitioner's manual. hoi must be forsworn at first. Freshly made lemonade and toast water furnish the best drinks. In later stages, not merely comfort but benefit may be derived from alcohol.—Dyce Duck- worth. Exclusive milk diet, potassium iodide, gm. 1-2 daily.—Lan- CEREAUX. Potassium iodide is badly tolerated in some instances of hepatic disease. The sodium salt may prepare such patients, as well as those in whom depressing effects result from the potassium iodide, for the subsequent favorable use of the latter. —Briquet. In non-chronic cases: R Sodii bicarb................................................... I ss. Infusi gentiana?............................................... I vb M. S. Tablespoonful three times daily. —Da Costa. For the ascites: R Diuretini................................................. gr. ex. Aqua? mentha? pip....................................... 5 ij- Spir. gallici.............................................. 1 b Eucalyptoli.............................................. gtt. xxv. M. S. To be taken during twenty-four hours. —Best. R Resina? copaiba?.............................................. 3 iij- Spiritus rectificati............................................ § b Mucilag. acacia?.............................................. 1 ij- Aquae..................................................q.s. ad § xij. Fiat mistura. S. A tablespoonful to be taken three times a day. When pressure symptoms occur from fluid, there should be no delay in tapping. Caution.—Employ slow method with Southey's cannula, or bandage as the fluid flows. In the later stages do not tap fre- quently unless respiration becomes too much embarrassed. In chronic forms quinine and the mineral acids are useful. R Podophyllin................................................ gr. vi. Capsici.................................................... gr. iv. Pulv. rhei.................................................. gr- xij. M. ft. pil. No. xii. S. One every second night. —Da Costa. LIVER, CIRRHOSIS. 499 Or— B Pulv. rhei rad............................................. 3 ij- Ext. aloes.................................................. 3 ss. Ext. colocynthidis.......................................... gr. vi. Ext. rhei..................................................- q- s. M. et ft. pil. No. Ix. S. To be taken twice daily. —Bamberger. For a bath: R Acidi muriatici............................................... § iij. Acidi nitrici.................................................. 1 ij. Aqua?........................................................ 1 v. M. S. Add six ounces to two gallons of water. —Ronald Martin. In hypertrophic cirrhosis, milk diet, bitter tonics, strych- nine. In the active crises, rest in bed, calomel in small doses, and quinine when fever is present.—Semmola. For jaundice, which is always a result of obstruction of the ducts, and not due to sluggish secretion, give belladonna in full doses to dilate the tubes by its action on the unstriped muscular fibres, and bicarbonate of sodium to render the bile more fluid ; the salines to deplete and relieve pressure. In biliousness we stimulate the functions of the liver. For this we use ipecac and euonymus. These in combination with calomel are best.—Michaux. For sluggish liver: B Acid, nitrohydrochlor. dil..................................... ttj, x. Ext. podophylli fld............................................ v\, x. Ext. taraxaci fld.............................................. 3 i. Tinct. nucis vomica?........................................ n^ x. Syrup, zingiberis............................................. 3 ss. Aqua? menth. pip.......................................q.s. ad § ss. M. S. In water three times a day. Urea, 5 to 20 gm. as daily dose, has been recommended. 500 THE PRACTITIONER'S MANUAL. Liver, Fatty Here the enlargement is uniform but usually of moderate degree, and the fact of its occurrence in those who have been high livers and hard drinkers points to this condition, but espe- cially so does the existence of pulmonary phthisis. Diagnosis.—Aside from the greater tendency to diarrhcea, the symptoms are much the same as in hepatic congestion. Jaundice is frequently absent (never present—Osler). While smooth and soft at first, the edges, later on, may be found in- durated on palpation. This may be due to a form of sclerosis, and the cirrhotic signs may increase as the organ diminishes in size. Acute fatty degeneration may be seen in those poisoned by phosphorus and in acute yellow atrophy. Rosenfeld says there is no fatty degeneration, but an albu- minous degeneration of the cell followed by infiltration as a reparative attempt. Liver, Hydatid Cyst. Echinococcic disease of the liver is rare in this as in all tem- perate climates. When small, the cysts may cause no symp- toms; when large, they produce a discomfort by reason of their weight and may, by upward pressure, cause dyspnoea or inter- ference with the heart action. Diagnosis.—The peculiar fremitus known as the hydatid thrill, when it can be felt by the palpating hand while the abdomen is tapped lightly with the finger, denotes superficially situated cysts. Differentiation must depend upon something more than this usually characteristic sign, since carcinoma and other liver lesions have at times given a deceptive fremitus of similar nature. The history of slow development is of value. Tap- LITH.EMIA, acute. 501 ping and obtaining a fluid which gives a saccharine reaction is strongly in favor of this disease, while if hooklets are found the diagnosis is confirmed. Prognosis.—Spontaneous recovery is possible, but scarcely ever observed after the cysts have reached such a size as to pro- duce symptoms. Surgical operation may give relief. Treatment.—Incision over the lower border of the liver and evacuation of the cyst have been successfully carried out, while even tapping has in some instances been followed by re- covery. If abscess develop, with symptoms of chill, fever, and sweating, the treatment is that indicated under "Abscess of the Liver." (See also hydatid disease.") Liver, Passive Hyperaemia. This condition of enlargement is attended with a peculiar pulsation or apparent dilatation from the inflow of blood. There is tenderness upon pressure, ascites is often present, and occasionally jaundice. A congested state of the stomach mu- cosa accompanies it from the same cardiac cause. Treatment is directed to the valvular heart affection usu- ally present. Lithaemia, Acute. In the condition usually termed "biliousness," or what Fagge has called "hepatic dyspepsia," there are furring of the tongue, anorexia, vomiting, especially in the morning, and persistent bitter taste in the mouth along with symptoms of slight fever- ishness. In lithiasis—the equivalent of gouty or uric-acid dia- thesis—besides the presence of lithuria as a more or less constant condition, the symptoms are often those of indigestion, with distress after eating, flatulency, and constipation, perhaps alter- nating with diarrhcea. The skin is usually hot and heat flashes alternate with cold perspiration. Jaundice of moderate degree is usually present. There is frontal headache, drowsiness, irri- 502 THE PRACTITIONER'S MANUAL. tability, depression, or vertigo. The urine, as a rule, is scanty, high colored, and very acid ; xanthin and paraxanthin are pres- ent. Infants show lithaemia by the reddish deposit in the diaper. In the adult oxaluria or phosphaturia may exist, or the urine may show no deposit. Differentiation.—Gastro-intestinal catarrh presents an al- most identical train of symptoms. Gout is excluded by the absence of joint symptoms. However, in those predisposed by heredity, typical gouty attacks may follow, indicating that the symptoms were properly attributable to gout. Treatment.—See under "Cholelithiasis." In infants, hot bath.—Rachford. Lithaemia, Chronic. The symptoms are here mainly those of chronic intestinal indigestion with catarrh. Diagnosis.—Gastric and intestinal flatulency is a pronounced symptom, and constipation is usually present. The complexion is sallow and frequently bile stained. Morning headache, de- pression and dull memory, pain in the loins and the right shoul- der are common, while myalgias in general are frequent symp- toms. Various paraesthesias, such as tingling, pricking sensations of the peripheral nerves, or numbness, are frequently complained of. The subject's skin is dry, and eczemas as well as erythema- tous rashes are likely to occur. The harsh inactive skin may at times become moist from an excess of sweating. As in the acute form tbe urine is dark colored and shows an abundance of uric acid and of urates. Cylindroids are not uncommonly found, but true casts are rare. There is quite frequently rapid heart action, and pseudo- angina pectoris may occur late in the disease. Differentiation.—The jaundice of chronic lithiasis is dis- tinguished from that due to other forms of obstruction by: 1. LITH.EMIA, CHRONIC. 503 The continuous or occasional presence of bile in the faeces. 2. Distinct remissions in the intensity of the jaundice. 3. Nor- mal size or only slight enlargement of the liver. 4. Absence of distention of the gall bladder. 5. Presence of febrile disturb- ances. 6. Duration of jaundice for more than a year.— Naunyn. Prognosis.—The condition predisposes to the formation of calculi in the gall bladder, in the kidney, and in the urinary bladder. Beside being subject to nephritic and renal colic, li- thsemic individuals are prone to muscular rheumatism, gouti- ness, and glycosuria, and they often, too, become obese. Chronic interstitial nephritis may also be the outcome of the lithaemic state. Treatment.— In biliary lithiasis: B Sodii benzoatis, Sodii salicylatis, Pulv. rhei................ ............................aa 5 gm. Pulv. nucis vomica?...................................... 0.50 cgm. M. Divide into twenty wafers. S. To be taken with each meal for one or two months. —Huchard. Alkalies and alkaline waters.—Bartholow. Lithium citrate, gr. xx., three times daily.—Da Costa. In those who do not observe proper diet, acidum nitricum dil., m x., in half a glass of water thrice daily. Pil. rhei comp. at bedtime occasionally.—Hughes. B Tinct. belladonna?......................................... th„ xviij. Vini colchici rad.......................................... 3 \j. Liq. potass, citrat...................................q.s. ad § iv. M. S. Dessertspoonful well diluted, every three hours. —Potter. Diet.— Plenty of water with meals. No alcoholic beverages. Minimize the amount of nitrogenous food ingested. 504 the practitioner's manual. Lumbago. Pain in the small of the back is a symptom in so many varied affections that, when due to myalgia or to neuritis of rheumatic origin, it must be carefully distinguished from kid- ney, spinal, and other affections. Diagnosis.—It is desirable if possible to separate the muscu- lar from the nerve cases, and both from those instances of kidney pain attended with very acid urine. In rheumatic myalgia the pain, usually bilateral, is intensified, and indeed often present only on motion; bending and twisting movements especially aggravating it. Resuming the upright posture after stooping over is particularly painful. The urine does not scald. Rheumatic neuritis is less persistent during rest. At points where nerves pass through the fascia there is local tenderness. Differentiation.—Kidney pain with hyperacidity, according to Edgeworth, is constant, not made worse by movement, and extends from the lumbar region forward around the trunk, at times into the groin, and down into the testes, much as in the pain of renal calculus. The muscles are here not tender to the touch, but hyperaesthetic zones are found above the pubes and Poupart's ligament. The urine is clear at first, but deposits brick-red urates on cooling. The backache from uterine disease is associated with symp- toms referable to the pelvic organs. The lumbar pain of early variola ceases upon the appearance of the eruption. Incipient caries of the spine gives a fixed local point of ten- derness. Rachialgia of meningeal disease is likewise localized and radiating. Treatment.—Salicylates up to point of tolerance, especially in neurotic cases. LUMBAGO. 505 R Salol............................................................. 5 Phenacetin....................................................... 3 M. ft. capsub No. xv. S. Three or four daily. B Tinct. capsici.................................................... 1 Aqua?........................................ ................... 5 M. S. Soak a piece of lint in the above, apply, and cover with oiled silk or protective, for half an hour three or four times daily. —Edgeworth. Or— R Atropine..................................................... gr. iv. Oleic acid (more or less, p.r.n.).............................. Si. Castor oil................................................... 3 b Oil of lavender.............................................. th, v. Rectified spirit.......................................q. s. ad § i. M. S. Apply locally. —Martindale and Westcott. Or— B Tinct. iodi, Liq. ammon., Collodion...................................................aa p.a?. S. Apply with brush. B Potass, iodidi................................................ 3 ij. Vini colchici sem............................................ § i. Syr. zingiberis............................................... § iss. Aqua?..................................................q.s. ad § iv. M. S. Dessertspoonful every three hours. —Gerhard. Or— B Sodium salicylate............................................. \ ss. Potassium iodide............................................. 3 ij. Compound syrup of sarsaparilla............................... § iss. Water............................................v___q.s. ad 1 iij. M. S. A teaspoonful in water thrice daily, after meals. —SOLIS-COHEN. Rest in bed, warmth, hot applications, hypodermic of mor- phine. B Sodii glycerophosphatis................................ gr. iv.-vij. S. Hypodermatically. —Robin. Dry cupping often acts as if by magic. Hot ironing often gives relief. —C. J. Hare. 506 THE PRACTITIONER'S MANUAL. R Olei succini, Spiritus camphora?, Spiritus ammonia? arom..................... .............aa 10 M. S. As a linament. — Wm. Murrell. R Extr. cimicifuga? fld., Syr. acacia?.................................................aa § ss. Aqua? amygdala? amarae...................................... | iij. M. S. Teaspoonful every three hours. —Bartlett. Or— R Extr. cimicifugae fld........................................... | ij, Ammonii chloridi............................................. ? { Aqua? laurocerasi, Syr. simplicis...............................................aa | i. M. S. Teaspoonful thrice daily. —Potter. After a brisk purgative: R Sodii salicylatis.............................................. gr. v. Infusi gentiana?.............................................. | i. atheris..................................................... fj[ x. Tinct. zingiberis............................................. m, x. M. S. Every four hours. Or inject subcutaneously sulphuric ether, th, x. daily, in- creased to ttl xxx.—Brindley James. Typical lumbago arising suddenly during an effort, showing severe pain, increased by the slightest movement, is really a sprain of the sacro-vertebral articulation. It is best relieved by rest on the back, a hard pad under the joint, and exercises con- sisting in flexion and extension of the lower limbs on the trunk. —Heldenberg. (See also "Rheumatism, Muscular.") Lungs, (Edema of. Acute pulmonary oedema may come on suddenly as the re- sult of congestion from any cause. It is more likely, however, to be of chronic nature, in connection with other dropsical symp- toms of organic disease. LUNGS, CEDEMA OF. 507 Diagnosis.—There is embarrassed respiration, and over both lung surfaces are heard fine bubbling rales and crepitation. Differentiation from the acute stage of pneumonia, which may be closely simulated, by the oppressed breathing and aus- cultatory sounds, by the coarser nature of the rales, their wider distribution, absence of fever, presence of cyanosis and some- what noisy character of the breathing, and especially by the frothy expectoration. From angina pectoris, by the dyspnoea. From syncope, by the active beating of the heart. From simple urcemic dyspnoea, by the greater suddenness of attack. Prognosis is very bad for the acute form coming on in the course of grave organic disease, in injury to the nervous sys- tem, or as a sequel of other acute pulmonary affections. Treatment.—A large blister over the chest wall or mustard plaster. Ammonium carbonate, camphor, and other stimulat- ing expectorants. B Plumbi acetatis................................................ 0.05 Sacchari....................................................... 1 M. ft. pulv. Dentur tales doses decern. S. One every hour. —NOTHNAGEL. Give diffusible cardiac stimulants, alcohol, brandy, cham- pagne, black coffee, or caffeine. Sodium benzoate, gr. v., subcu- taneously. B Ammon. carb................................................. gr. v. Spir. a?theris comp............................................ tti, x. Syr. senega?................................................ 3 ss. Syr. pruni virg................................................ 3 ss. Aqua?...................................................q.s. ad \ i. S. For a dose. In idiopathic oedema, strong coffee, alcoholics, musk. B ^Ether. camphorat.......................................... tti, xx. S. By hypodermic every half-hour or hourly. —Roth.5 508 the practitioner's manual. Or— B Camphora?........................................... .......... 5 Olei oliva? (sterib)............................................. 10 M. S. Inject five to ten drops. In inflammatory oedema in pneumonia, as a last resort, venesection.—Goodman. With dropsy, drastic cathartics and diuretics. When very acute, inhalation of oxygen; cupping the chest; hypodermic of morphine.—Gannett. B Aqua? camphora?.............................................. § i. At dose every hour or two. Our chief reliance will be counter-irritation and poultices. Phlebotomy would suggest itself for a strong person suffer- ing from an acute disease. The heart should be stimulated.— L. F. Bishop. Copious bleeding is, at times, alone capable of saving the patient from almost certain death.—Huchard. In children : R Tinct. strophanthi......................................... tti, i.-iij. Every three hours to child of seven to nine years. —A. M. Gregor. Lymphadenitis. Tuberculous inflammation of the lymphatic nodes is the form requiring the most careful differentiation. It is usually spoken of as scrofula, for whose clinical picture we refer the reader to the chapter thus entitled. Diagnosis.—The submaxillary nodes and the cervical, usu- ally more upon one side of the neck than the other, become tender, inflamed, and suppurate, especially in children. Other nodes become involved, as the bronchial, retroperitoneal (phthisis mesenterica). Caseation without suppuration is the usual out- come, and an abdominal tumor may be palpated or it may give rise to pressure symptoms. lymphangitis. 509 Differentiation.—From lymphadenoma, by the nodular swellings being more tender, more closely matted together, and hence less freely movable than is the case in Hodgkin's disease. In the latter, too, the growth does not tend to suppurate, but pursues a more rapid course and may occur at any age. From leucocythaemia, by the absence of characteristic leuco- cytosis and by the comparative rarity of the latter. From lymphoma implicating a single group of lymph nodes, by the lesser degree of tenderness and pain and the greater hardness of the mass. Cervical enlargements from syphilis are accompanied by other signs of infection, especially upon the mucous membranes when excessive, and suppuration does not occur. If due to carcinoma, the nodular enlargement is secondary and more indurated, while in sarcoma the progress is very rapid. Prognosis.—Spontaneous cure not infrequently takes place. Characteristic scarring in the region of the neck is not uncom- mon in adults who give no history of having been treated with any degree of care during the active progress of the affection in their childhood. Treatment.—The same as that for tuberculosis in general, including all that pertains to hygiene, etc. Local applications of iodine are usually very efficacious. Lymphangitis. Streaks of bright red extending in the axis of a limb, with tenderness along the course of lymphatic chains, oedema, pain and swollen nodes, should cause close inspection of the distal extremity for a purulent focus or point of infection. Diagnosis.—A history of infection at autopsy or dissection, in handling meat and fish, from the bite of some venomous animal or insect, from exposure of a wounded surface to decom- posing matter, the presence of a skin disease or of gonorrhoea will 510 the practitioner's manual. aid us in deciding upon the nature of an acute inflammation of the skin, attended perhaps at first with so much oedema as to mask the cordlike thickenings of lymphatic channels subse- quently to be made out. In the superficial variety of tubular form the tender red streaks suffice for an immediate recognition of the condition. Differentiation.—From erysipelas by the more streaked nature of the redness instead of the creeping patch with mar- ginate outline. Erysipeloid (Rosenbach) is a special form of reticular lym- phangitis, starting usually upon the finger and spreading in a ring-like manner upon the back of the hand, while the part nearest the point of infection (putrid animal matter) tends to get well. Prognosis.—In virulent forms successive clusters of lym- phatic nodes may swell and suppurate. Sepsis from absorption may endanger the patient. Chronicity and lymphatic occlusion may be a result, causing conditions of elephantiasis or lymph- oedema. Treatment.—Let out any pent-up pus at source of inflam- mation ; disinfect all wounds. Place limb at perfect rest. Apply wet antiseptic compresses. Institute supporting and stimulating treatment early. In the superficial form, scarifi- cation. Apply liq. plumbi subacetat. dil. constantly until the inflam- mation is reduced. Over the inflamed nodes, tincture of iodine. When great pain : R Extr. belladonna?....................................... § i. Glycerini...........................................q.s. ut ft. molle. S. Apply freely. —Waring. Caution.—If a large surface is involved or there is any open surface, use with care. meningitis, acute. 511 In erysipeloid: B Ichthyoli...................................................... 3 b Lanolini..................................................... 3 ij. Adipis..................................................qs. ad § i. M. S. Apply. Or— B Ichthyoli, Tinct. benzoini co., Bals. peruviani.............................................aa p. a?. M. S. Apply. Meningitis, Acute. Headache of severe type, exacerbating at regular intervals and quickly followed by high fever, delirium, and possibly con- vulsions, is the most striking symptom. Diagnosis.—The pain is augmented by bright light and by all noise. Vomiting is an early symptom. The pulse is fre- quently rapid. Besides photophobia we may have inequality of the pupils, disturbances of vision, neuritis, and ptosis. In all conditions suggesting meningitis the eyes should be care- fully examined for both motor and visual defects. The chest shows early evidence of inharmonious action with the dia- phragm. Inspection of the naked trunk is necessary, but the clothing should be removed slowly not to excite undue activity of respiration. There is likewise immobility or depression at the umbilicus instead of normal elevation with each inspira- tion. Differentiation.—Various acute diseases, including pneu- monia and typhoid fever, may be closely simulated by the early symptoms. An involvement of the cranial nerves renders the diagnosis simpler. > From tuberculous meningitis, by the lack of history of infec- tion and prodromal symptoms. The course is more rapid. Herpes labialis is frequently present, while it is almost never seen in the tuberculous form. A circumscribed meningitis may complicate disease of the ear. 512 the practitioner's manual. A basic meningitis in infants under one year of age, coming on with severe vomiting, extreme head retraction, and stupor passing into coma, which may last for several weeks—the re- traction persisting till death—has been shown to be independent of tuberculosis. Cerebral effusion may be simulated in children showing early collapse and stupor with gradually increasing unconsciousness. The following table, given by Mr. Langford Symes, will serve to distinguish the conditions: Hydrocephaloid state from diarrhoea. Diarrhoea. No ocular paralysis. No rise of temperature. No headache. No tension or bulging of the fontanelle. No rigidity. No retraction. ■ Cerebral effusion (as in tuberculous meningitis). Constipation. Ocular paralysis and squint. Slight feverishness. Headache (if old enough to complain). Bulging fontanelle. Rigidity and retraction in many cases. Treatment.—In children with signs of posterior basic men- ingitis, incision of the tympanic membrane of the ear often gives prompt relief from threatening symptoms, even in the ab- sence of evidences of ear affection.—G. P. Field. Puncture of the tympanum.—Barlow. For an adult, cold compresses to the head. R Hydrarg. chlor. mitis...................................... gr. ij. Extr. jalapa?...............................................gr. viij. M. For two pills. S. To be taken at once. —Niemeyer. Meningitis, Chronic. Here, just as in haematoma of the dura mater, unless we have injury, sunstroke, or syphilitic infection to guide us, the diagnosis may be established only with great difficulty. Many instances are due to alcoholic excesses. Diagnosis.—Irritability, headache, perhaps loss of mental power, delirium, etc., are present. When purulent the condition meningitis, cerebro-spinal. 513 is attended with high temperature and an aggravation of all uhe symptoms, plus convulsions and perhaps coma. Differentiation.—In brain tumor, there is loss of power in the limb, and incresaing optic neuritis. If after two weeks optic neuritis continues to increase and coma does not develop, the diagnosis of tumor is almost certain. —Gowers. Hysteria lacks the increase in temperature, and if strabismus is present it is convergent. (See "Hydrocephalus.") Meningitis, Cerebro-Spinal. Spotted fever presents such an ever-varying symptom com- plex that only the salient points in early diagnosis can be touched upon. We have the usual chill, headache, backache in the prodromal or invasion stage, but the most characteristic pain is that in the back of the neck, which may be of a stinging character, short in duration, and followed by retraction of the head. There is usually early and repeated vomiting, which may be of a projectile character. The facies is expressive of suffer- ing and the patient tosses in bed, demanding relief from the excruciating pain in the head. Darting pains may extend es- pecially into the limbs, and since the joints at times become swollen and tender an erroneous diagnosis of rheumatism has more than once been made. The spinal muscles are, however, often rigid and the skin is hyperaesthetic. The delirium, which may alternate with convulsive seizures or with stupor, is often of a cheerful type, in which singing, animated conversation, and tendency to joking are striking features. Eruption.—The spotting is not so constant as the name would imply. When pronounced it is macular, somewhat re- sembling measles, but with greater tendency to purpuric colora- 33 514 THE PRACTITIONER'S MANUAL. tion. When purpuric from the onset, with ecchymoses, the type of fever is usually severe and the prognosis of a rapidly fatal ending is warranted. Differentiation.—Differential diagnosis involves the dis- tinction from tuberculous meningitis as well as from typhus, rheumatism, and from the nervous variety of influenza. A pseudo-meningitis has also been described resembling a rudi- mentary or infectious cerebro-spinal meningitis. In some in- stances the symptoms must be considered the product of hys- teria. The temperature is not so high nor so lasting and does not correspond to the severity of the symptoms. The chief aids are the epidemic prevalence and the inconstant nature of the symptomatology. Lumbar puncture (for technique see "Tuber- culous Meningitis") may disclose the presence of Weichselbaum's meningococcus intracellularis, confirming a doubtful case. These cocci have strong light-refracting capsules. They resem- ble the gonococci and are generally decolorized by Gram's method. Hysterical pseudo-meningitis improves under suggestion. Prognosis.—Malignant forms may end in death following a mild delirium which lasts but a few hours. A protracted form of the disease ma}7 extend over several months. In a moderate average case convulsions may set in after a fort- night. Treatment.—Hot packs and hot cloths applied for about an hour at a time. This is more easily carried out than are hot baths.—Schlesinger. When temperature is low and pulse small, baths at 104° F. of ten minutes' duration.—Aurecht. R Potass, bromidi.............................................. 3 iss. Sol. opii comp. (Squibb's)..................................... 3 iss. Syr. zingiberis, Aqua? caryophylli, Aqua? pura?..........................................aa, q.s. ad 3 iv. M. S. A teaspoonful every two or three hours by day ; less often by night. meningitis, cerebro-spinal. 515 A suitable formula for eggnog is as follows: R Granulated sugar................................... 1 tablespoonful. Pure rye whiskey.................................. 1 tablespoonful. Fresh milk........................................ £ tumblerful. A fresh egg well beaten up. Hot water enough to fill a common-sized tumbler. —Hutton. R Tinct. opii deodorat. Extr. gelsemii fld.........................................aa 3 i. Syr. limonis................................................ 3 ij- Aqua? foeniculi............................................... § iss. M. S. Teaspoonful every two hours. —Bartholow. After the effusion : B Olei tiglii.............................•....................... tti v. Saponis, Pulv. acacia?...............................................aa 3 i. M. et ft. pil. No. xx. S. One to three pills. —SUNDELIN. In after-remaining convulsions : B Potassii bromidi.............................................. | ss. Syr. simplicis................................................. § ss. Aqua? destill................................................. 1 i. M. S. Teaspoonful every two hours. —Ringer. B Tinct. physostigmatis.......................................... § i. Extr. ergota? fld.............................................. g iss. M. S. One-half teaspoonful every two hours. —N. S. Davis. B Potassii bromidi.......................................... gr. v. -vi. Every two, three, or four hours to a child of five years. —J. Lewis Smith. For subcutaneous injection, hydrargyri chloridum corro- sivum, 0.0005-0.01, depending upon the age of the patient.— B. Angyan. 516 the practitioner's manual. Meningitis, Acute Serous. This form occurs at all ages. A history of otitis media, acute infectious processes, alcoholism, excessive use of morphine or cocaine, traumatism, or undue mental strain, may give an etiological clew for diagnosis. Only about twenty-seven cases have been recorded in litera- ture, to which are to be added twenty instances of alcoholic "wet brain" by Dana.15 Boenninghaus says that so-called idio- pathic acute hydrocephalus is always an exudative, never a transudative process. The benign form is an affection sui generis and may end spontaneously. Diagnosis.—This is to be made only when an affection giv- ing the symptoms of purulent meningitis, abscess, or tumor of the brain is cured suddenly within a very short time either with or without lumbar or ventricular puncture. The local signs in- clude rigidity of the neck, hyperaesthesia, exophthalmos, pain in the limbs, and possibly paralysis. Differentiation is from latent abscess of brain, acute en- cephalitis, etc. The acute form suggests simple purulent or tuberculous meningitis; the chronic resembles tumor, or, in some instances, neurasthenia. There is little headache and no explosive vomit- ing. In suppurative meningitis the temperature goes higher. Prognosis.—In the alcoholic form, if the patient has a stiff neck he usually dies.'—Dana. A malignant form occurs, which is always fatal.—Boenning- haus. Treatment.—Mercurials.—Quincke. When fatal issue seems imminent, tap the ventricles.— Morton Prince. In alcoholic form, wash out stomach. Hot milk every two MENINGITIS, TUBERCULOUS. 517 hours, eggs, etc. Strychnine, gr. ■£$, every two hours; ice cap; leeches; blister at back of neck. In coma, tap spinal cord.— Dana. Meningitis, Tuberculous. If a meningitis develop in a child suffering from pulmonary disease, it is probably tuberculous. There are, however, no posi- tive differential signs in the first stage. Diagnosis.—Vomiting of propulsive character without pain, nausea, or discoverable cause, convulsions with opisthotonos, drowsiness, irregular respiration and pulse, and unusual consti- pation, all point to this affection. There is a preponderance of nervous symptoms and a general failing of the health is noted, with disagreeable change of the child's nature shown by morose- ness and irritability. Headache is paroxysmal and severe. If tubercle bacilli can be found in the spinal serum drawn off by lumbar puncture, the diagnosis is thus made positive. After several weeks of prodromal symptoms the temperature in- creases, there is difficulty of respiration and the abdomen is retracted. In meningitis the cerebro-spinal fluid is invariably cloudy, and microscopic examination will show the presence of the bacilli if it be tuberculous. There is also an increase in albu- min. Culture and inoculation experiments can be made. To tap the vertebral canal, a large sized hypodermic needle is inserted between the third and fourth, or fourth and fifth lumbar vertebrae in the median line, or laterally, under strict antisepsis. Differentiation.—In simple meningitis the onset has been described as "stormy," with rapid development and higher tem- perature. A convulsion perhaps ushers in the symptoms, while in the tuberculous form this is a late manifestation. In cerebro-spinal meningitis, there is a characteristic erup- tion and vasomotor symptoms occur earlier. 518 THE PRACTITIONER'S MANUAL. In malaria, the therapeutic test by quinine may solve the question. In typhoid with brain symptoms and atypical course, appro- priate tests upon both sides may have to be made. Rhythmic disturbance of breathing is strongly in favor of meningitis. Herpes labialis is usually not present; still its occurrence in meningitis cannot be taken as absolutely indicative of the puru- lent form. In the presence of disease capable of producing cerebral symptoms the diagnosis of meningitis should be made with the utmost reserve. Inoculation experiments afford the surest means of differen- tiation.— Wentworth. Prognosis.—Recovery is rarely seen; a general miliary tuberculosis usually coexists. Recovery warrants a sus- picion that cerebro-spinal meningitis was the affection in question, unless positive tests were made, as was the case in an instance of recovery at the Friedrichshain Hospital two years ago. Treatment.— In an adult, shave the head, apply ice cap, and give large doses of potassium iodide, beginning with two drachms daily and gradually increasing. Remove intracranial pressure. Recovery has followed potassium iodide, 8gm., gradually in- creased up to 40 gm. daily, until about thirty ounces in all had been taken.—Janssen. R Moschi................................................... gr. iij- Camphora?............................................... gr. xv. Chloral................................................... gr. viiss. Vitelli ovi............................................... No. i. Aq. destill............................................... I iv. M. S. Wash out the rectum with simple enema and inject two ounces. —Simon. Poultices over the whole body up to the neck. Antitubercu- lous serum. Trepanation and drainage. morphinism. 519 Morphinism. The use of opium as a habit is similar in many respects to the condition of alcoholism. The physician is unfortunately to blame in many instances for permitting continued employment of this most useful of remedial agents beyond the necessities of the case. Diagnosis.—When the craving for the drug is not acknowl- edged or truthful statements concerning the quantities taken are not obtainable, we may suspect the condition from the rest- lessness, anxiety, mental depression, impaired digestion, de- creased nutrition, sallowness of complexion, irregular sleep, and the sudden change to a condition of well-being otherwise inexplicable. The "small pupil," a usual symptom, is sometimes unac- countably absent in the habitue, and indeed the pupils may be widely dilated much of the time. There are two tests of morphinism—one by urine analysis, the other by enforced abstinence. The urine test consists in rendering the specimen alkaline by the addition of bicarbo- nate of sodium; to this add a certain proportion of chloroform or amylic alcohol, shake thoroughly, let settle, draw off, add a small proportion of hydriodic acid. If morphine is present there will be a violet tinge to the urine. Regarding enforced abstinence from morphine, no morphinist could stand it for forty-eight hours without showing reflex symptoms.—J. B. Mattison. Prognosis.—The morphine habit becomes practically incura- ble after five years. The difficulty of controlling the patient makes the outcome most uncertain. The habit is compatible with long life, but the morphinomaniac falls an easy victim to acute disease. Treatment.—Outside of an institution the difficulties are almost insurmountable. 5-20 THE PRACTITIONER'S MANUAL. Withdraw the drug gradually but as rapidly as the patient can stand it. When the reduction is badly borne, warm baths (five to fifteen minutes) followed by cold shower or pack.—Ober- STEINER. Sudden withdrawal of the drug is too rigorous a method. Enforced abstinence produces reflex symptoms and at times fatal collapse. Substitution of a milder alkaloid of opium with prolonged hygienic care will often bring about a lasting cure.— J. B. Mattison. Counteract the reflex nervous disturbances on the part of the stomach by lavage and the introduction of an alkaline Carls- bad-salt solution.—Hitzig. R Cocaina? muriatis............................................ 0.5 Acidi salicylici............................................. q j Aqua? destillata?............................................ 100 M. S. For a daily dose, which should never be exceeded, and the drug should never be used hypodermatically. Cocaine is useful only when the patient becomes violent, four to forty-eight hours after the last dose of morphine, and never continued longer than five or six days. In case of collapse, morphine must be resorted to again. Caution.—Patients with heart disease should not be sub- jected to complete withdrawal.—Obersteiner. Gradual reduction, each withdrawal being effected under hypnotic suggestion, is the only rational and safe method of cure.-—Berillon. Caution.—Watch for relapses into the habit after the influ- ence of the hypnotism is withdrawn. Sudden withdrawal of the drug results in hyperacid dyspep- sia. Neutralize the acid by washing out the stomach with water containing 0.35 per cent, of bicarbonate of sodium, while the morphine is being gradually decreased.—Erlenmeyer. Reduce the morphine by halving the dose each day, not giv- ing it if not asked for. Push bromide administration but not MYELITIS. 521 beyond the stage of marked torpor, stopping it altogether if patient has ceased to ask for morphine. B Sodii bromidi............................................... 3 xij, Aqua?........................................................ z xjj M. S. Tablespoonful every four hours. —Neil Macleod. (See also "Poisoning by Morphine.") Myelitis. Inflammation of the spinal cord is spoken of as transverse when it includes the entire thickness through a short segment; diffuse when a large section is involved; disseminated when there are scattered areas; focal when there is but a single lim- ited area; and poliomyelitis when the gray matter is wholly or partially involved. These conditions may be acute or chronic. Symptoms vary within wide limits, according to the portion and extent of the cord involved. There are, however, symptoms more or less common to all, such as motor paralysis or irrita- tion, disturbances of sensibility, of the reflexes, of the sphincters, and trophic changes. Acute Transverse Myelitis. Paralytic manifestations, including weariness in the limbs, feeling of dragging weight, perhaps attended with numbness or tingling, are among the early signs. Paraplegia may develop gradually or may seem to come on suddenly after evidences of paresis have preceded it by some days. A sensation as though a tight girdle were about the trunk is indicative of the level of the lesion. Paralysis of the sphincters is an early and frequent sign. Convulsions may usher in the symptoms, especially in children. Diagnosis.—If a sponge wrung out in very hot water be passed down the back it produces a sensation of pain when a point just above the level of the girdle sensation is reached. 522 the practitioner's manual. During the progress of the disease fever is present, rarely going over 101° F., though at the onset of a severe case the temperature may be as high as 107° or 108° F.—Tyson.3 Differentiation.—Poliomyelitis shows an absence of pain and of muscular spasms, as well as of trophic changes. In peripheral neuritis there is marked tenderness in the course of the nerve trunks, paralytic and trophic changes de- velop less rapidly, and symptoms of local pain are prolonged and more severe; while in myelitis they are lacking even in the subacute form. Prognosis.—Death may occur early from involvement of the respiratory nerves, or subsequently from paralysis of the respiratory centre in the medulla. When recovery takes place convalescence is slow. Disseminated Myelitis. An inflammation which continues to extend after the first few days is certainly disseminated, and most subacute cases are of this variety. Constitutional symptoms may be absent.— Gowers. Diffuse Myelitis. This is a chronic form, presenting the same symptoms as the acute but of slower development. There are impaired motion and sensation. Pain and sensation of weight in the legs cause slow dragging progression, the feet not being raised sufficiently from the surface. The girdle sensation is more pronounced, the reflexes are greatly exaggerated, and the expulsive power of both bladder and rectum is diminished. Differentiation.—The loss of co-ordination may suggest ataxia. From hysterical paraplegia, by the presence of inconti- nence of urine rather than retention, which accompanies the latter. MYELITIS. 523 Anaesthesia in hysteria follows less the distribution of the motor paralyses. From compression of the cord it is distinguished by absence of any obvious cause of pressure, such as injury or caries of the vertebrae, and by absence of root pains, which would indicate that the process had begun outside the cord. From tumor of the cord it is distinguished by the compara- tive absence of root pains. Either may involve one-half of the cord more than the opposite half, but myelitis is more likely than tumor to present absolutely unilateral symptoms. From primary lettered sclerosis (spastic paraplegia) it is distinguished by the existence of both motor and sensory im- pairment, whereas in spastic paraplegia the symptoms are en- tirely motor. From progressive muscular atrophy it is distinguished by the fact that atrophies of myelitis are irregularly distributed, while those of progressive muscular atrophy are symmetrical. Moreover, in the former there are other cord symptoms and sensory disturbances. Pachymeningitis is distinguished principally by greater pain and by a more pronounced and extensive anaesthesia. Gowers says that if there are similar symptoms in both arms and legs, myelitis is far more probable than pachymeningitis, since the chronic inflammation of the membranes is less extensive than that of the cord.—Musser.38 Treatment.—Counter-irritation to the spinal columns by means of fly blisters, actual cautery, icebags. To relieve the pains : B Potassii bromidi..................................... gr. xx.-xxx. Repeat p.r.n. B Antipyrin.................................................. gr xv Repeat p.r.n. Or— B Extr. opii.................................................. gr, xjj. Ft. pil. No. xii. S. One three times daily or oftener. 524 the practitioner's manual. Electricity by continuous or interrupted current. In chronic myelitis, prophylaxis requires those of neuro- pathic tendency to secure abundant sleep and to avoid excesses of mental and bodily work, violent emotion, and undue excite- ment. In the acute attack, cups to the back. When lues is suspected: B Potassii iodidi, Sodii iodidi.................................................aa | ss. Aqua? destil.................................................... \ ij, M. S. Gtt. v.-x. in water, gradually increased by drop doses until an effect is produced or the stomach rebels. At the same time give: B Hydrarg. chloridi corrosivi, Sodii chloridi................................................aa 2 Aqua? destillat................................................ 100 M. S. Filter, ttj, v.-x. by intramuscular injection three times each week, to be gradually increased. Bath at 85° to 95° F. of ten minutes' duration every second day, or salt baths or natural thermal baths as at the Hot Springs of Virginia or Arkansas. Myocarditis. The symptoms here, as a rule, are so obscured by implication of the endocardium and pericardium that the diagnosis becomes most difficult. Muffling of the heart sounds is one of the most important symptoms upon which the diagnosis of acute diffuse myocarditis is to be based. There is diminished impulse, and signs of dilatation are present. Tachycardia persisting for one or more days, especially in the course of typhoid fever, should cause this condition to be suspected. Diagnosis.—The symptoms, in a general way, are those of dilatation of the heart, with absence of valvular sounds, per- sistent slowness of pulse, with occasional attacks of palpitation or of angina. MYOCARDITIS. 525 Chronic sclerosing myocarditis, usually secondary to scle- rotic changes in the vessels and habitually due to syphilis, gives symptoms of indefinite nature, but which may be said to include precordial pain on slight exertion, with arrhythmia and shortness of breath after exercise. The rarer acute form comes on sud- denly in the course of other disease and has an irregularly rapid, feeble, compressible pulse. Prognosis often depends upon the seriousness of the affec- tion of which myocarditis is a complication. Aneurism of the heart may result from the sclerosing form, or sudden death may occur from some unusual exertion or from paralysis. Chronic myocarditis may exist as a progressive affection ex- tending over a number of years, and without presenting symp- toms of alarming nature. Treatment.—In acute diffuse myocarditis, absolute rest. Ice bag to the chest is grateful and beneficial. If much nervous agitation : B Elix. ammon. valerian......................... S. Dessertspoonful repeated as required. Or— B Sodii bromidi, Potassii bromidi.............................. Aqua?......................................... M. S. Teaspoonful repeated according to the effect In evidence of heart failure : B Tinct. digitalis................................. Tinct. strophanthi............................., Dose. Repeat every three hours. Or— B Sparteina? sulph............................... Caffeina?....................................... For one pill or tablet. B Strychnina?................................ Spir. frumenti.............................. Every two to four hours. S ij- .aa 3 i. ... 5 ij- TTI viij. TU, vi. • gr. i • gr- ij. gr- A li- 526 THE PRACTITIONER'S MANUAL. Or— R Spir. amnion, aromatic.............................-......... 3 ss. -i. Or— R Liq. ammon. acetatis..................................... 3 ij.-iii —Patton. Caution.—At times the heart will not respond to cardiac tonics and it becomes dangerous to increase the dose unduly. For after-treatment: R Potassii iodidi............................................. gr xvj Aquse.................................................... i ij. M. S. Teaspoonful in water three times a day. Or— R Strychnina? sulphatis...................................... gr ^ For one tablet. S. Three such daily. In interstitial myocarditis of specific origin with dyspnoea, pain on motion, and arrhythmia: R Hydrarg. chloridi corrosivi................................... gr_ [ Sodii iodidi, Potassii iodidi............................................§,£, 3 \ Tinct. nuc. vom ica?....................................... 3 i_ Tinct. cinchon. comp..................................q.s. ad ? iv. M. S. Teaspoonful t.i.d. in water. Myositis. The most important inflammatory affection involving the muscles is universal myositis, in which groups of muscles be- come hard, tender, and subsequently atrophic. Diagnosis.—It shows itself first in the lower extremities and gradually extends over the entire body, accompanied by oedema of the skin overlying the muscles involved. There are func- tional disturbances, pain on motion, and a more or less exten- sive erythematous eruption of irregular distribution, at times followed by pigmentation. In the rare myositis ossificans, there is deposit of bone replacing muscle tissue. Rheumatic myositis is considered elsewhere. MYXCEDEMA. 527 Differentiation.—Trichinosis is the disease most likely to come into question, and it can be excluded most readily by ex- cision of a portion of the tender, hardened muscular tissue, in which the trichina spiralis will be found absent. In idiopathic or acute progressive muscular atrophy there is hereditary predisposition, as in the juvenile form of Erb. Prognosis.—The affection lasts for a few months or may persist for several years. In the form showing deposit of bone in the muscle, ankylo- sis and rigidity are prominent symptoms, and death may result from inability to masticate. Treatment is supporting, stimulating, and otherwise symp- tomatic. In the ossifying variety the various animal extracts might be tried.—Lock wood. Myxodermia. This designation has been applied by Dr. H. de Brun to an affection of unknown nature resembling typhoid, characterized by rapid onset with high fever (39° C), oscillating for ten days between 39° and 40° C. and then falling to subnormal for a period of about eight days. Typhoidal phenomena, with great agitation and at night with delirium of violent character, de- velop early. There is trismus, and stiffness of the neck makes it impossible to turn the head. The skin becomes like soft wax, shows subcutaneous hemorrhage, large and painful ecchymoses distinguished from those of scorbutus and other affections by a surrounding white zone. There is no meteorism and there are no rosy spots. Duration, three to four weeks. Prognosis grave. Myxoedema. Mental sluggishness, gelatinous infiltration of the connec- tive tissue, and atrophy of the thyroid gland form the tripod upon which a diagnosis of this condition stands. The face, 528 THE PRACTITIONER'S MANUAL. neck, and hands have a bloated appearance without pitting on pressure. The face appears broadened, the lips are thickened, and the tongue is greatly enlarged. The patient's appearance and actions indicate a sluggish or stupid state. The memory is deficient and the speech slow. Diagnosis.—-The puffmess of the hands, face, and occasion- ally the neck, with inability to flex the fingers naturally, the dull and apathetic condition of the patient, the presence of transitory albuminuria and perhaps of casts, and the diminished size of the thyroid, together with a history of congenital origin of the affection, or of subsequent gradual development, make a rather characteristic clinical picture. It often appears first after unusual and prolonged exertion. There may be pronounced thirst. Differentiation.—From dropsy, by the absence of pitting. From nephritis, by this deceptive appearance of dropsy and by the other signs being of temporary duration. Some instances may strongly suggest Bright's disease. From sporadic cretin- ism, by the absence of dwarfed body. From cachexia strumi- priva, by the fact that the thyroid has not been removed. From chronic dementia, by the absence of more pronounced indica- tions of insanity. Prognosis.—The disease is at present amenable to treatment and capable of cure, but spontaneous cure is scarcely to be looked for. Early or late reappearance of symptoms of cachexia after cessation of treatment is to be expected. Treatment.—Thyroid feeding offers the best therapeutic measure. It is almost specific. lodothyrin has given brilliant results in the practice of Ewald, Meltzer, and many others. After apparent cure, continue thyroid in small doses for a long period, possibly for life. Caution.—Symptoms of thyroidism, apt to develop after about two weeks of treatment, are shown by cutaneous irrita- tion, nervousness and restlessness, rapid heart action, shortness NEPHRITIS, ACUTE. 529 of breath, and perhaps delirium. When long continued, thyroid feeding may produce symptoms like those of Basedow's disease. Glycerin extract of thyroid, HI xii. every four days. (Less than the equivalent in weight of a quarter of a single lobe of a sheep's gland). —Kinnicutt. To preserve the fresh gland, remove the fat and all extrane- ous matter, make into a pulp, and mix at once with biborate of sodium and powdered wood charcoal.—Vigier. Begin thyroid treatment with a powder or tablet correspond- ing to two grains of the fresh gland (half a tablet, Burroughs & Wellcome; gr. i., Parke, Davis & Co. "s powder). Gradual daily increase until a dose of six or eight grains is reached, then no increase for several days, and so on. Fifteen grains a day should be final maximum. Or, a dose of ten to twelve grains once or twice a week for three or four weeks. Then discontinue treatment for some weeks. Then three grains three times a day for two weeks and go back to once-a-week doses.—Meltzer. For headache, phenacetin; for general pains, salicylate of sodium; to relieve the urticaria which may be ocasioned, a few small doses of pilocarpine. B Thyroid extract............................................. gr. iij. Three times daily. ~ —Osler. B lodothyrin.................................................... 0.30 S. Three or four times daily. ,T , T —Marie and Jolly. Caution.—lodothyrin has given the best results, but careful watching is necessary. Go slowly and avoid danger. Death has occurred.—Briquet. Nephritis, Acute. Acute Bright's disease often passes through its early stages, when of mild form, without occasioning marked symptoms. In children the dropsy may be preceded bv severe symptoms and 34 ' . ;">:>0 THE PRACTITIONKR'S MANUAL. convulsions, or the affection may come on insidiously after in- fectious processes such as scarlatina, influenza, etc. Diagnosis.—Fever may be an early sign, due to the infec- tious process responsible for the kidney inflammation or due to the latter itself. When dropsy has already occurred we have in it the most valuable of guiding symptoms. If dropsy is not present, ex- amination of the urine, perhaps in a routine way, or because of some suspicion cast upon the kidneys, may show the presence of albumin. Chill, fever, vomiting, and backache may be fol- lowed in the course of a few days by a puffiness of the lids, swelling about the genitalia or lower extremities. The urine is diminished in amount, at times almost to the point of actual suppression, and often has a "smoky" hue. Differentiation.—Ascites may be due to organic heart disease, cirrhosis, tuberculous peritonitis, cancer or tumor press- ing upon important vessels, etc. If, after scarlatina, during pregnancy, or in malaria, the dropsy be extensive, glomerular or acute exudative nephritis is the variety most likely present, while if little dropsy exists this would point to parenchymatous nephritis. Blood and blood casts in the urine indicate the hemorrhagic form, while an abundance of leucocytes and epithelial cells point to the desqua- mative variety. Hemorrhage from the nose or into the middle ear is an early sign of Bright's disease. The so-called spontaneous hemorrhage into the ear ought always to be investigated as to the possibility of an underlying nephritic cause. Here we should use the term tympanitis aibuminurica, just as we speak of retinitis albumi- n urica.—Haug. By examination of the urine in the newly born it will fre- quently happen that a nephritis is found when the prominent symptoms suggested the diagnosis of encephalitis or meningitis. —Jacobi. nephritis, acute. 531 Prognosis has a wide range. Recovery may take place promptly or only after months, or the acute may merge into the chronic form. Prognosis in instances due to infection, as in scarlatina, diphtheria, etc., is more favorable than in the nephri- tis of pregnancy. The glomerular form is more serious than the parenchymatous. In young children the mortality is high. Nephritis arising in cholera and other grave infectious diseases is usually of severe type. Treatment.—Cupping over the kidneys, wet cups being used in sthenic cases. There should be no fear to abstract blood freely.—Wood and Fitz.9 Relieve the kidneys of extra work. Endeavor by intelligent medication and diet to prevent further damage. Calomel is in- dispensable to meet the requirement. Hot-water baths are useful for their diaphoretic action. The best method of applying heat is by the use of an apparatus which will supply hot air under the bed clothes.—Suley. Pure water may be given freely; if not drunk in sufficient quantities it can be administered by the rectum. Milk diet is of value in acute and subacute forms. In the anuria of scarlatinal nephritis : R Extr. jaborandi fld........................................ 15 gm. Potassii citratis............................................. 25 « Aqua? destill................................................ 75 « M. S. Teaspoonful every four hours. Starr. B Tinct. cantharidis.............................................. ? 8S S. Gtt. xii. in divided doses extending over twenty-four hours. —Du Cazal. Also in the anasarca when the epithelial tissues are involved. —Lancereaux. Also in acute infectious nephritis of the young. Dry cupping to dorso-lumbar region, followed by: B Pilocarpine............................................... or. iss. Vaseline...................................... ^ ii-i M. S. Rub in each morning. —Pettidi. 532 the practitioner's manual. Nephritis in children, calomel. Salines as hydragogues. Hot-air baths. Bleeding in high tension of arteries, water ad libitum, or if not taken sufficiently, as enema.—Henry E. Tuley. Headache and insomnia : R Sodii bromidi.......................................... gr. xx.-xxx. Chloral................................................ gr. x.-xx. For one dose. —W. M. Ord. Strontium lactate, tiO-90 gr. daily, is a pure diuretic, and is more valuable than any other remedy in the treatment of acute inflammatory conditions of the kidney.—Brouovski. R Creolin........................................................ 3 vi. Glycerini..................................................... 3 vi. Aq. aurant. flor..............................................§ vi. Mucil. tragacanth............................................. 3 vi. M. S. Teaspoonful three or four times a day. —F. H. Woods. R Tinct. digitalis............................................... 3 ss. Vini scilla? (Fr. Cod.)........................................ I iss. Spir. a?ther. nitrosi........................................... ? ij. M. S. Teaspoonful everv three or four hours. —H. B. Millard. For a child of six or eight years : R Tinct. digitalis................................................ 3 ss. Liq. ammon. acetatis......................................... I iss. Spir. a?ther. nitrosi........................................... 3 ij- Syr. tolutani................................................. 3 ss. Aqua? cari............................................q.s. ad § iij. M. S. Teaspoonful every two hours. —GOODHART AND STARR. R Strontii lactat.............................................. gr. xx T.i.d. —J. C. Da Costa. Nephritis, Chronic. We speak of chronic Bright's disease when the symptoms have persisted for six or more months. Like the acute, it is diagnosticated more readily and more often after the devel- nephritis, chronic. 533 opment of its resulting secondary manifestations—anaemia, oedema, etc. Diagnosis.—In chronic parenchymatous nephritis we have a disease comparatively frank and open in its manifestations, which, moreover, point unmistakably to the kidney as the source of trouble. There are beside profound anaemia, early and pro- gressive oedema, scanty, high-colored urine of variable specific gravity, rich in albumin and hyaline, granular, and epithelial casts.—C. L. Greene. The parenchymatous form is most often seen during the period of adolescence. Dropsy is a regular symptom. General anasarca and dropsy of the serous cavities appear early and are more common in this form. The specific gravity and the proportion of urea to the ounce of urine slowly and gradually diminish from the beginning of the inflammation; so the specific gravity is an indication of the advancement of the disease.—F. Delafield. In interstitial nephritis, on the other hand, the morbid proc- ess produces few definite clinical signs referable to the kidney. This disease is as insidious and misleading as it is treacherous and deadly.—C. L. Greene. Interstitial nephritis develops stealthily, with very early nervous symptoms which may attain suicidal or maniacal pro- portions. Irritability, worry over trifles, headache, neuralgia, depression, and frequently uraemic symptoms are noted. Hemiplegia, with or without aphasia, may be the first symp- tom to call attention to the nephritis. Albumin is least abundant and least constant in certain special forms of renal disease, of which interstitial nephritis is one.—Francis Delafield. Epistaxis may be an early sign of interstitial nephritis or of granular kidney. Early symptoms in children include progressive wasting, anemia, dry skin, high arterial tension, polyuria with low 584 the practitioner's .manual. specific gravity. Gastro-intestinal disturbances, morning vomiting, periodic headaches, d}Tspncea, and precordial (listless should excite suspicion.—Guthrie. Eye symptoms may first direct attention to the kidney. The retina is engorged and the fundus sprinkled with white patches on a red background; blindness comes on suddenly with vomit- ing, etc. Retinitis albuminurica, when discovered, almost always means this variety of nephritis. The typical urine of this condition is a urine increased in quantity, of a specific gravity of about 1.010, containing a di- minished quantity of urea, without albumin or casts, or only a trace of albumin and very few casts, except during acute exacerbations.—F. Delafield. Temporary albuminuria, hyaline casts, and urine of low specific gravity are the signs which are to be looked for. Albumin is usually to be found when the whole daily quan- tity of urine passed is examined, and casts can be discovered when albumin is temporarily absent. A delicate test for albumin when the latter is not found by heat and nitric acid is to add urine to a tube containing tri- chloracetic acid in saturated solution or drop a crystal of the acid into urine in a tube. A distinct zone is formed at the point of juncture.—Boymund and Raabe. This is almost too delicate for general use, though valuable in the hands of an expert clinician.—C. L. Greene. If we find retinitis, in conjunction with casts and albu- min, and especially if cardio-vascular alterations are present. it is probable that we have the interstitial form before us. The interdependence of heart and kidney usually aids in diagnosis. but, as Edwards points out, it may be the source of clinical confusion, since primary cardiac disease ma3T cause renal con- gestion or even acute or chronic nephritis. The interstitial form occurs in advanced life and is usually nephritis, chronic. 535 associated with cardiac hypertrophy and sclerotic changes in the vascular system. It may cause little or no disturbance during life, or may be discovered post mortem. It frequently gives rise to headache and vertigo, or the first symptoms may be those of uraemia, drowsiness, muscular twitchings, stupor, and coma; or a comatose condition with Cheyne-Stokes breathing, aphasia, and paraplegia may suddenly develop. Differentiation.—This is difficult when nephritis coexists with diabetes. Another difficulty of differentiation is the co- existence of pyelitis and nephritis. Differentiation seems pos- sible by the application of the Goldberg test. According to the latter, true albuminuria exists at the same time with the false, when more than one part of albumin per thousand, as shown by Esbach's test, is found with 50,000 pus cells in a cubic milli- meter of urine. When the quantity of urine is very large and the specific gravity very low, the case may be mistaken for diabetes insipidus. Dropsy of renal origin results from vascular changes and transudation takes places where there is the least resistance, namely, in the cellular tissue, especially that of the eyelids, ankles, and back of hands. Cardiac dropsy is due to impeded circulation or stasis; hence it appears first in the feet and lower extremities, where resistance is greatest, because farthest away from the heart. Hepatic dropsy is due to portal obstruction; hence ascites is the first to make its appearance. In pyuria the leucocytes are polynuclear, while in nephritis of uncomplicated nature few such forms are found. In distinguishing between vesical catarrh and beginning contraction of the kidney, the specific gravity and the presence or absence of retinitis and hypertrophy of the heart must be taken into consideration. Wash out the bladder before collecting urine for analysis. The persistent hemicrania of renal inadequacy must not be mistaken for migraine. Diffuse nephritis with large white kidney is distinguished 530 the practitioner's manual. from amyloid degeneration of the kidney by the absence of cause for the existence of the latter condition, and the fact that the urine is of lower specific gravity and freer from sediment, espe- cially from red blood corpuscles. This form occurs after middle life. Myxoedema should not be mistaken for oedema of kidney origin. Prognosis in chronic diffuse nephritis is unfavorable for the severe forms. In individual cases it depends largely on the daily percentage of urea and the general severity of the symptoms. Even when some impairment of kidney function exists recovery may take place, or the progress of the disease may be arrested. While the disease is serious and often fatal, it is not incom- patible with a long and comparatively comfortable life. Prophylaxis calls for frequent examination of the urine in those of apparent health ; for early investigation of the sediment by the microscope in suspected instances; and the adoption of all necessary measures to prevent a mild and beginning affec- tion when discovered from becoming one of most serious import. Remove all strain from the heart, kidneys, and blood-vessels. The life should be quiet, with avoidance of dampness, chill, fatigue, worry. Gentle exercise and open-air life in a genial climate will do more than any specific drug medication. Regular life, eating in moderation, proper exercise, habitual bathing, and especially Turkish baths.—H. C. Wood. Treatment.—Attention to diet and mode of life are impor- tant. Interdict alcohol and tobacco, limit the carbohydrates, and encourage the ingestion of fats. To neutralize the toxic, products contained in the urine : R Antipyrin..................................................... 3 i. Ft. cht. No. xx. S. One or two four times daily. —Modinos. To stimulate the kidneys : R Diuretin...................................................... 3 ij. Ft. cht. No. vii. S. One every four hours. nephritis, chronic. 537 Or— B Hydrarg. chl. mitis...................................... gr. xviij. Sacchari lactis........................................... q. s. M. et ft. cht. No. vi. S. One three times daily, while the bowels are kept closed by means of opium. —J. M. Patton. Or, caffeine sodio-benzoate, in gr. iii. doses, three or four times daily, may also be employed hypodermatically. B Ergotini..............................................,........ 5 Acidi gallici................................................... 8 Ext. et pulv. krameria?........................................ q.s. Ft. pil. No. xx. S. Four pills daily. In the different forms of BrighVs disease, strontium lactate, gr. i. to viii. daily, diminishes the albumin, increases diuresis, and ameliorates the symptoms without unpleasant effect.— Pick. Diuretic wine : B Junip. contus................................................. 3 x. Pulv. digitalis................................................ 3 ij. Pulv. scilla?.................................................. 3 i. Vini Xerici...................................................Ob After macerating for four days add : Potassii acetatis............................................... 3 iij. Express and filter. S. For an adult a tablespoonful three times daily. —Trousseau. Diuretic mixtures: B Spir. a?theris nitrosi.......................................... ? iss. Tinct. ferri chloridi, Tinct. nucis vomica?......................................aa 3 i. Syrupi..................................................... | iij. M. S. Two teaspoonfuls. —W. H. Thompson. B Tinct. grindelia? robusta?.................................... § i. Tinct. convallaria? majalis.........,....................... 3 iiss. Tinct. scilla?................................................. 3 i-j.. M. S. Fifteen drops thrice daily. —Huchard. 53S THE PRACTITIONER'S MANUAL. In children : B Caffeina? pur.............................................. 0.10 gm. Pulv. digitalis......................................... . . 0.20 " Sacch..................................................... q.s. M. ft. pulv. No. xii., of which five are giveu daily to a child of ten years —SlE(iEHT. Caution,.— Salol should not be administered for any purpose to nephritic subjects.—Tyson. For ascites : B Potassii bitartratis............................................ 1 iss. Potassii sul phatis............................................ 3 ss. Pulveris scilla?................................................ 3 ij. Antimonii et potassii tartratis................................. gr. i. M. S. One teaspoonful every four hours until active purgation and diu- resis follow. —Eberle. Caution.—The dose of squills as here given is double the maximum as usually prescribed. B Theobromine............................................... 10 gm. Make wafers No. xx. S. One every two hours or eight in all the first day, six the second and third, and four the last day of the course. Diuresis may continue for twenty-four hours. For dropsy of renal or cardiac disease: B Hydrargyri chloridi mitis, • Pulv. digitalis fob, Pulv. scilla? radicis........................................aa gr. i. S. For one pill, to be given every four hours, until oedema disappears or the bowels act too freely. —H. P. LOOMIS. To diminish the large quantity of urine in contracted kidney : R Sodii bromidi................................................. 3 iv. Tinct. nucis vomica?.......................................... 3 ij- Glycerini.....................................................1'\y Aqua?......................................................... 1 vi. M. S. Tablespoonful three times daily. Caution.—Stop the medicine before the quantity of urine gets below sixty to eighty ounces.—F. Delafield. NEPHRITIS, CHRONIC. 530 B Tinct. ferri chloridi........................................... § ss. Acidi acetici.................................................. 3 ss. Misce et adde: Liq. ammonii acetatis......................................... I v. Curacoa?...................................................... I1]- M S. 3 b thrice daily. —J. M. Da Costa. In children, with high arterial tension, nitrites and nitrates, associated with diaphoretics and active purgation.—Guthrie. In respiratory difficulties with high-tension pulse, nitro- glycerin, gr. t^t-tItd t.i.d. Or, if this fail in extreme cases and in insomnia, chloral, gr. xx., by mouth or injected beneath the skin, or combined with ammonium bromide, gr. xxx. Caution.—Opium is not safe, because it diminishes the ex- cretory activity of the kidneys. — W. M. Ord. In the earlier stages : B Pota?sii nitratis.............................................. 3 iv. Extracti galii fluidi......................................... 1 iiss. Extracti uva? ursi fluidi...................................... § iiss. Extracti ergota? fluidi........................................ § i. M. S. Give 3 i. in half a wineglassful of sweetened water, three or four times a day. —Davis.22 B Ferri sulphatis.............................................. gr. iij. Magnesii sulphatis.......................................... gr. xl. Acidi sulphurici diluti...................................... tti, iij. Aqua? mentha? piperita?...........'.......................... § i. M. S. To be taken three times daily. Or— B Tinct. digitalis.............................................. m x. Potassii iodidi............................................... gr. v. Spiritus ammonia? aromatici................................ m, xv. Aquae.................................................q.s. ad 5 i. M. S. Dose : repeat three times daily. Occasionally at bedtime: B Euonymin.................................................. gr. i. Ext. aloes................................................... gr. ij. Ext. belladonna?............................................ gr. } M. S. Dose. —Robert Saundby. ;>40 THE PRACTITIONER'S MANUAL. R Cantharidin........................................... gtt. vi.-xij. For daily dose. —Lancereaux. Caution.—The use of this drug is dangerous.—See. Idiopathic chronic parenchymatous : R Auri et sodii chloridi............................................ 1 Aqua?........................................................... 60 S. Gtt. x.-xii. six times daily to children according to age. R Nitroglycerin.............................................. gr. ^ Tinct. digitalis............................................ ni, ij. Tinct. strophanthi......................................... Tq, ij. Tinct. belladonna?........................................ tti, ss. To be used in cases marked by high arterial tension. —Da Costa. In threatened heart failure, oxygen inhalations.—Rey- nolds. For the constipation, weak action of heart, and general aucemic state : R Feb bovis inspissati et purificati............................ 3 ij. Ext. pancreatin........................................... 3 i. Ha?mogallol................................................ 3 ij. Caffeina? hydrochlor........................................ 3 i. Ext. colocynthidis co...................................... gr. xx. Euonymi.................................................. gr. x. Ext. aloes.................................................. gr. vi. Ext. calumbo............................................ 3 ss. M. et ft. caps. No. xl. S. Two before each meal. To aid digestion : R Strychnina? sulphatis........................................ gr. as. Acidi phosphorici diluti..................................... 3 vi. Aqua?................................................q.s. ad § iij. M. S. Teaspoonful in water after meals. —W. H. Porter. In Infective Nephritis.—Hot-air bath; electuary of bitar- trate of potassium and honey. R Pulv. digitalis, Pulv. scilla?, Caffeina? citratis...........................................aa gr. i. M. ft. pil. One such thrice daily. —Saundbt. NEPTHRIIS, CHRONIC. 541 In chronic diffuse nephritis, with exudation, the patients void urine containing less than the normal quantity of urea; hence they need to pass more than the normal quantity of urine; about sixty ounces a day is sufficient. Increase the amount of fluids imbibed, but do not give too much mineral water.—F. Delafield. In suppression, hot packs. Digitalin, gr. -}$, four times daily. —Delafield. Pilocarpine, gr. yV-i- Caution.—Avoid in cardiac and respiratory difficulties. In depression, whiskey and stimulants, oxygen inhalations. In convalescence ansemia is aways present, so that iron fur- nishes the routine treatment.—Torrey. B Liquor ferri et ammonii acetatis............................... § ss. S. Three times a day. In Urcemia.—Attacks of uraemic coma are usually associated with vasoconstriction; arterial dilators are indicated. Calo- mel, gr. xx. at dose. There is no more effectual way of stimulating kidney secre- tion in uraemia than by intravenous saline infusions. (See page 307.) Purgatives are to be prescribed without hesitation each time a subject of Bright's complains of cephalalgia, heaviness in the head, and shows intellectual hebetude or dyspnoea, all of which are to be looked upon as precursors of uraemia. B Acidi benzoici................................................ 3 v. Ft. cht. No. v. S. One in a half-tumbler of water every three hours. —Da Costa. For urcemic attacks, chloral, gr. x. per os or gr. xx. per rectum, every three or four hours. Or nitroglycerin, gr. y^ to j\, repeated as indicated by pulse tension. Hot packs, except in cases with cerebral symptoms and feeble pulse.—Delafield. Pilocarpine muriate, gr. y1^. 54-2 THE PRACTITIONER'S MANUAL. Or, an ointment of pilocarpine nitrate to secure local dia- phoresis.—Molliere. Caution.—-It should not be used in Bright's disease, and especially not in old people, it being a decided cardiac depres- sant.—C. J. Proben. For urcemic convulsions : B Tinct. veratri viridis........................................... | i S. Gtt. xv.-gtt. xx. hypodermatically and repeat half-hourly a dose (if ten or twelve drops as conditions indicate. —Norwood. It is not contraindicated in any form of renal disease. It is eliminated by diaphoresis, diuresis, enuresis, and catharsis, and thus has a great advantage over morphine.—A. F. Myers. Bloodletting except in feeble subjects.—Nilson. Hot baths at 4<»° C, continued for an hour and followed by means to keep up perspiration for several hours. Caution.—Avoid in advanced cases. They may cause heart weakness and congestion of lungs.—Talamon. When hot packs produce no reaction of the skin, employ cathartics. Drastic purgatives. Mode of Giving a Vapor Bath.—-A woollen blanket is placed on the bed under the patient, who keeps on his night robe. Under each foot and at each side of the body a stone bottle con- taining boiling water is placed, each bottle having previously been wrapped in a very wet towel and the whole covered with flannel. The woollen blanket is then wrapped around the patient, and another blanket and a quilt are put over him. At the end of fifteen minutes the patient is in a profuse per- spiration. In order to favor sweating, one or two cupfuls of some hot infusion should be taken. After the patient has re- mained a sufficient length of time in the bath, the woollen blanket under him and the bottles are carefully withdrawn without exposing him, and he is then wiped dry under the other NEPHRITIS, CHRONIC. 543 blanket and the quilt. At the end of twenty or thirty minutes the patient may have a change of linen. Urcemic Convulsions.—Remove ten or fifteen ounces of blood, to be repeated if necessary. Inhalations of chloroform until the convulsions are controlled. B Musk..................................................... gr. viiss. Chloral................................................... gr. xlv. Yolk of one egg. Distilled water........................................... § v. M. S. Administer by enema. B Strontium bromide........................................... 3 b Syrup of orange flower....................................... § iss- Distilled water............................................... § iij. M. S. Administer hourly a tablespoonful. Restraint of thighs and legs to be wrapped in cotton. Absolute milk diet.—Malbec. Headache.—Potassium sulphate, gr. x.-xx.—J. B. White. Diet is all important. Control the production of effete material having toxic effect upon the economy by careful supervision of food stuffs. Give fish, fruit, fowl, and exclude butchers' meat. The diet should be light, easy of digestion, and limited in quantity.—Hood. It is agreed that the most rational diet is a mixed one. The estimate commonly given is that meat should constitute one- fourth and vegetable food three-fourths of the dietary.—Elliot. Absolute milk diet is not only unnecessary and extremely distasteful but positively harmful.—Robert Saundby. Milk is the typical food for this condition. As an habitual drink : B Sodium iodide............................................ gr Xv. Sodium phosphate......................................... gr. Xxx. Sodium chloride.......................................... gr. Xc. Drinking- water........................................... § xxxvi. This should be drunk daily, either alone or mixed with milk —Semmola. 544 THE PRACTITIONERS MANUAL. Caution.— Meat diet favors cerebral hemorrhage from in- creased vascular tension. After degenerative changes have occurred an exclusive milk diet is positively injurious. In the acute stages it must form the basis of treatment.—Ralfe. The best diuretic is milk, and this too is the best food. To avoid intolerance in protracted cases we may permit the addi- tion of green vegetables, farinaceous foods, and fats, but we must forbid absolutely the use of dark meats, game, condi- ments, spices, alcohol, and beer.—Lyonnais. A vegetable and fish diet is advised: 1. When the quantity of urine passed exceeds eight hundred grams in the twenty-four hours. 2. When the urea and the density are somewhat aug- mented, or, at least, normal. 3. When there is increase of phosphates and phosphoric acid. 4. When the quantity of al- bumin is not exaggerated or subject to great variation.— Ferran. Nephrolithiasis. When sand-grain-sized renal calculi exist their presence is announced by transient pains in the loins. When a calculus is large enough to cause irritation in the kidney pelvis or of the ureter in passing through to the bladder we have the symptom of renal colic. This is a sign of value as indicating that the stone is mov- able, and probably making efforts to escape. Diagnosis.—The discovery of small sand-like particles or small fragments of stone or a small stone intact in the urine is the only absolute diagnostic sign. The urine is at times bloody and may contain pus. The colicky pain when it occurs is very severe and extends from the loin upon one side around to the front of the abdomen toward the bladder, down the thigh, or into the testicle, perhaps inducing vomiting. Tn the early stages an uneasy feeling NEPHROLITHIASIS. 545 rather than a pain is noticed in one loin, below the ribs, or severe pain may come at first and be greatly increased by every movement. Stabbing pain is at times induced by sudden deep finger pressure in the loin toward the kidney. Differentiation.—Intercostal neuralgia may at times be simulated by the pain, but the urine would show no change and vomiting would not occur. Biliary colic is suggested only when the right kidney is in question. Intestinal colic does not remain so persistently one-sided. Nephralgia giving neuralgic pain of a recurrent paroxysmal nature has been mistaken for calculous disease. Lumbago is rarely so one-sided. Exclude malignant dis- ease, tuberculosis, chronic nephritis, painful movable kidney, urine charged with uric acid and urates. Gastralgia and appendicitis are also to be excluded. Prognosis.—Large stones and those composed of oxalate of lime are not to be disintegrated, and require operation. In uric- acid calculi medicinal treatment may succeed. Treatment.—By careful attention to diet and digestion in subjects who pass crystals of any kind in the urine, stone may be prevented from forming. In oxaluria cut off sugars, sweet wines. In phosphaturia order rest, avoidance of jolting exer- cises, bicycling, etc. The most reliable investigations indicate that fat, sugar, and starchy matters have not the slightest direct influence on the production and excretion of uric acid. The only point which is really clear is that the excretion of uric acid is diminished by lessening the albuminoid ingredients of the food, and that it is heightened by increasing these ingredi- ents.—Roberts. In calculi fixed in the pelvis, dilute nitric acid, m x. in water, repeated p.r.n. Careful dieting, excluding butchers' meat, and long courses of alkalies.—Heaton. 35 54() the practitioner's manual To relieve the pain of nephritic colic as well as the cystitis, ammonii valerianatis, gr. iiss., in capsule every half-hour until five or six doses have been taken.—Blanc. Hypodermic injection of morphine, chloral by the rectum, hot bath, suppository of belladonna or opium, alone or combined. Hot poultices containing laudanum to the lumbar region or abdominal wall. In slight attacks, ammonium valerianate, gr. i. —viii., in pills or by enema. For insomnia : R Chloral................................................... gr. xlv. Sydenham's laudanum..................................... gtt. x. Decoction of marshmallow root............................. § v. To be given as a tepid enema. If the pains become too severe, chloroform administered by the physician himself.—Gaucher and Gallois. B Lycetol.................................................... gr. xv. Bicarb, of sodium......................................... gr. viij. M. ft. chart. No. i. S. To be taken morning and evening, dissolved in a glass of mineral water. —Wettzack. Or— R Lithi um iodide............................................. gr. xv. Distilled water............................................. 3 iiss. M. A Pravaz syringeful to be injected once a day. Or— B Lithium iodide....................................... 3 i j. Mucilage of tragacanth............................... a sufficiency M. Divide into fifty pills. One to be taken three times a day. —Ruhemann. As a suppository: B Ext. belladonna?...........................................gr. $ Ext. opii................................................. gr. £ Olei theobroma?............................................ gr. xlv M. To relieve pain, overcome obstruction, and cause expulsion of stone, tinct. belladonnae, gtt. xxx.-xl. Repeat every hour NEURALGIA. 547 or every two hours until drug is pushed to toxic effect (dilata tion of pupils, dryness of throat, delirium).—Murray. Neuralgia. Pain in the various nerve trunks of the body occasions a variety of secondary symptoms which cannot here be entered into. The term should be restricted to nerve pains which are functional and without accompanying organic lesion in the nerve centres or in other organs upon which the pain depends. Nie- meyer's definition may well be applied, that neuralgia is the cry of the nerve for better blood, since most instances depend upon some exhaustion of nerve tissue often due to ansemia or toxic influences. Diagnosis.—In a large proportion of the nerve pains, casu- ally spoken of as neuralgia, gout undoubtedly lies at the bottom of the trouble and the painful affection is often one of gouty neuritis. In the absence of gout, when persistent neuralgic pain implicates a limited region, some disease of a nerve centre should be thought of. Thus persistent pains in the limbs usually lead to an investigation, which will exclude or confirm a posterior spinal sclerosis. The diagnosis of trigeminal neuralgia rests mainly upon the following points: 1. The pain is limited to a definite nerve path, either trunk, branch, or area of distribution, and is usually confined to one side. 2. It is, without any obvious reason, either intermitting or at least distinctly remitting in character. 3. It presents very peculiar characters, and is extraordinarily acute. 4. There are certain spots in the course of the nerve or in the area of its distribution which are very sensitive to pressure. 5. The pain is associated with sensorimotor, vasomotor, and secretory phenomena. 548 THE PRACTITIONER'S MANUAL. G. The pain is unaccompanied by any inflammatory or local symptoms. —Erb. In phrenic neuralgia there exists a constant painful point in the median line of the sternum, at the level of the fourth or fifth chondrosternal articulation, not to be confounded with the diffuse retrosternal pain of chronic aortic affections.—Jousset. Differentiation.—Intercostal neuralgia is distinguished from pleurisy by the pains being sharp, localized, and possibly modifying the chest movements; being increased by pressure over those points corresponding to the surface distribution of the terminal filaments. Neuralgia in another part of the body will aid in diagnosis, while the physical signs of pleurisy are absent. From pleurodynia it is distinguished by the sensitiveness of the muscles when caught up between the fingers. Pain in the side, thought to be due to neuralgia, often de- pends upon caries of a rib or is due to an unsuspected fracture. Charcot has called attention to hysterical neuralgia, which comes on in the evening, in contradistinction to tic douloureux, which is a matutinal affection. The latter or trifacial neural- gia involving the fifth pair in one or more of its branches is the most common form in which neuralgia occurs. Here infra- orbital and supra-orbital tender points are usually to be made out and the involvement of the first division or the ophthalmic nerve occasions the frequent radiating pain over the anterior half of the head, which is sometimes confounded with catarrh of the frontal sinuses. In the latter, however, the pain is usually more dull in its severity, often bilateral, accompanied by coryza, and terminates coincidentally with a purulent discharge from the nostrils. Plantar neuralgia giving the following symptoms has been recently described by Jones:39 Pain over metatarsophalangeal region on standing or walk- ing, only slightly relieved by mechanical contrivances. Pain neuralgia. 549 on pinching the fourth metatarso-phalangeal. Relief of pain on circumferential pressure around base of toes, assisted still further by repeatedly flexing the toes. Sensation of walking on something hot. Presence generally of flattened arches of the foot. Besides distinguishing it from neuritis already mentioned, which usually has a symmetrical distribution, the pains chang- ing from one spot to another and being characterized by remis- sions and intermissions, we must further distinguish the condi- tion from rheumatism. There is a painful affection of the heel called erythro-melal- gia, described by Weir Mitchell, which is too often confounded with the latter. In reflex neuralgias, recently studied by Dana, the pain is referred to regions at a distance from the actual seat of the affection. Thus in ulcer of the stomach, as mentioned elsewhere, the pain may be referred to the region of the spine, especially at the time of perforation; and in treating of renal colic we have pointed out that pain of a neuralgic character may occur in the testicle even as quite an early symptom. The pain of hepatic disease commonly referred to the shoulder or scapular region and of uterine disease to the sacrum, need not be further insisted upon. Generally speaking, the pain of muscular rheu- matism is distinguished by its increase upon motion. A malarial origin may often be rightly suspected when periodic recurrent pains show a marked regularity and especially when preceded by slight chills. There may be, too, a decided periodicity in syphilitic neural- gias, which, however, are likely to be aggravated at night. Ap- propriate medication will in both instances serve to confirm or negative these suspicions. The neuralgias of tabes, often ex- ceedingly acute, are characterized by the fact that while they occur suddenly they do not remain long localized. Abdominal neuralgia affecting the mesenteric or solar plexus with agonizing paroxysms is often distinguished from gastralgia 550 the practitioner's manual. by the absence of gastric symptoms and the greater faintness and prostration attending the former. So-called "neuralgia" confined to one side of the head and attended with inflammatory eye symptoms is often the result of glaucoma or iritis. Treatment.— B Tinct. aconiti, Tinct. colchici seminis, Tinct. cimicifuga?, Tinct. belladonna?............................................aa 3 b M. S. Six drops every hour until relieved. —Metcalf. B Ext. hyoscyami, Ext. conii..............................................aa gr. xl. Ext. ignatia?, Ext. opii................................................aa gr. xxx. Ext. aconiti............................................... gr. xx. Ext. cannabis ind......................................... gr. xv. Ext. stramonii............................................ gr. xij. Ext. belladonna?.......................................... gr. x. M. Divide into sixty pills. —Brown-Sequard. R Quinina? sulphatis.......................................... 3 ij- Morphina? sulphatis.........................................gr. iij. Strychnina1................................................. gr. ij. Acidi arsenosi............................................... gr. iij. Ext. aconiti................................................ gr. x. M. Divide into sixty pills. —Gross. R Potassii iodidi............................................. gr. xxx. Tinct. opii................................................. ^ xxx. Ext. gelsemii fl............................................ H xlv. Ext. cimicifuga? fl......................................... m lxxv. Syr. sarsaparilla? comp.................................... 3 vi. Aqua?..............................................q.s. ad § ij. Dissolve and mix. Dose : a tablespoonful every four hours, in muscular rheumatism and neuralgia affecting the chest. —S. S. Burt. R Benzacetin(aceto-amido-methyl salicylate)................ So.8 parts Caffeine.................................................. 8.5 Citric acid............................................... 5.7 In doses of fifteen to thirty grains of the combination, and repeated in one hour if relief is not obtained. NEURALGIA. 551 The pain is said generally to be alleviated in less than three hours, and does not return for several days. In intractable neuralgias: B Croton chloralis............................................... 3 b Glycerini, Syr. aurantii.................................................aa § i. M. S. 3 i • as required. —E. P. Hurd. In hemicrania: B Menthol....................................................... 3 i. Alcohol, Glycerin, Syrup.......................................................aa § i. M. S. 3 i. in warm water as required. —McLaury. As an alterative to diseased nerves, in chronic neuralgic headaches, etc.: B Zinci phosphidi............................................. gr. to Ext. cannabis indica?........................................ gr. \ Ext. nucis vomica?........................................... gr. \ Sodii arsenatis.............................................gr. ^ Quinina? sulphatis...........................................gr. \ Ext. aconiti rad.............................................. gr. ^ M. ft. tab. No. i. S. One such at 10 A.M. and at 4 and 9 p.m. —Henry J. Ken yon. Neuralgic headache: B Antipyrin..................................................... 3 i8S. Antifebrin..................................,................ 3 ss. Camphor monobromate........................................ 3 i. Caffeine...................................................... 3 ss. Phenacetin................................................... 3 ij. M. div. in chart. No. xx. S. Take one and repeat in one hour if unre- lieved. —E. C. Wendt. B Ammonii bromidi, Sodii salicylatis.............................................aa 3 i. Tinct. hyoscyami............................................ 3 ij. Aquam......................................................ad § iv. Teaspoonful every half-hour till relieved, or four doses are taken. —HlGHTOWER. 552 THE practitioner's manual. Hemicrania.—The patient is put in a wet pack for one to one and a half hours, and is then energetically rubbed down, the whole procedure exercising a marked effect on the vasomotor centre and system, which effect becomes permanent after con- tinued application.—Buxbaum. R Tinct. aconiti.............................................. ni viij. Tinct. gelsemii............................................. ttj, xij. Ext. cimicifuga? fld........................................ § iss. Spts. a?theris comp......................................... 3 ss. M. S. One teaspoonful every hour. Antineuralgic pannier: R Powdered guarana......................................... 0.75 cgm. Sulphate of quinine...................................... 0.20 " Bicarbonate of sodium................................... 0.75 " Salicylate of sodium...................................... 0.75 " Make three cachets. To be taken during the day. R Exalgin................................................... gr. i.-ij. Spir. chloroformi......................................... Ul x. Aquam.................................................ad § i. One dose, to be repeated every four hours. —Younger. Neuralgia of the Plantar Digital Nerves.—Treatment varies with the stage. Abstain from action which causes pain. Wear thick soles, with additional thickness behind the bases of the metatarsals. A band of plaster around the instep. Massage. Contrast baths (hot, then cold). Elevate foot of bed at night. —Jones. Of Rheumatic Origin.—Alternate application of heat and cold, as in the Scotch douche.—Buxbaum. Of the Bladder.—Passage of a metallic instrument.— Guyon. Of syphilitic origin : R Pulv. iodoformi.............................................. 1 gm. Ext. et pulv. gentianae...................................... q.s. M. et ft. pilula? No. xx. S. Two or three daily. —Mauriac. neuralgia. r>5?> Periodic neuralgia: B Extract, ergota? fluidi, Elixir cinchona?.............................................aa § i. M. S. Two teaspoonfuls in water every two hours, unless pain is relieved, when the intervals might be lengthened. —W. H. Thompson. .4 nervine tonic : B Asafoetida?.................................................. 3 b Acidi arsenosi................... ........................... gr. ss. Strychnina? sulphatis....................................... gr. ss. Ext. sumbul................................................. 3 iss. Ferri subcarbonatis.......................................... 3 ij. Quinina? valerianatis........................................ 3i. M. Make capsules No. xxiv. S. One capsule after each meal. —Brown. Intercostal neuralgia: B Tinct. gelsemii.............................................. gtt. c. Syr. simplicis................................................ 3* iss. Aquae destillata?............................................ 3 vi. M. S. One or two teaspoonfuls two or three times daily. —Cheron. Caution.—If the heart is feeble this formula should not be employed. B Ichthyol..................................................... 0.30 Aqua? destillata?............................................. 100 M. S. Inject a syringeful into the painful area once a day. —Goldberg. For hypodermatic use: B Antipyrin.............................................. 10 gm. Cocain. hydrochloratis................................. 0.15 cgm. Aqua? destillata?........................................ 10 gm. M. S. For injection. In inveterate cases: R Ar-idi osmici............................................ 0.10 cgm. Aqua? destillata?......................................... 6 gm. Glycerin i................................................ 4 gm M. S. Inject 0.01 cgm. (or five to ten drops of a one-percent, solution), —Shapiro. 554 THE PRACTITIONER S .MANUAL. R Quinina? sulphatis........................................... 3 ij. Morphina? sulphatis......................................... gr. iij. Strychnina1................................................. gr. ij. Acidi arsenosi....................... ..................... gr. iij. Extr. aconiti...............•................................ gr. x. M. et ft. pil. No. Ix. —Carpenteb. B Phenacetin, Caffeine..................................................aa gr. iij. Given hourly. Or— B Gelsemii................................................. gr. ^V-A Hypodermatically. Or, cocaine, gr. £, or a smaller dose to begin with.—Tyson. Odontalgia: B Cocaine hydrochlorate.................................... 1 part. Camphor................................................. 50 parts. Choral.................................................... 50 parts. Water.........................a few drops to obtain a clear solution. A little of this solution is placed on a small piece of cotton, introduced into the cavity of the tooth, and allowed to remain there for twenty-four hours. Neuralgia of dental origin : B Tinct. gelsemii.............................................gtt. v. Give three times a day, gradually increased to ten-drop doses. —Da Costa. Caution.—When patient sees double stop administration. Locally: B Lini aconiti (B. P.), Chloroformi...............................................aa 3 iij. Tinct. capsici................................................. 3 i Tinct. pyrethri, Olei caryophylli, Pulv. camphora?............................................aa, 3 ss. M. S. A few drops on cotton to be placed in the cavity. NEURALGIA. -i;)5 When sleep is disturbed by the pain R Quinina? sulphatis........................ Acidi hydrobromici dil................... Tinct. gelsemii............................ Syrup..........'........................... Aqua?:................................... T.i.d. Or, exalgin, gr. ii., in solution. In pain after taking food (stomach contents acid), Seidlitz powder minus about a quarter of the acid, leaving an excess of the alkali.—F. C. Coley. Otalgia : B Menthol, Camphor....................................................aa, gr. v. Liquid vaseline................................................ ^ j. Instil into the ear several times a day. Fumes of Chloroform.—Place a pledget of cotton in the bow of a clay pipe, moisten with chloroform, place the end of stem within the external meatus, and with the mouth over the bowl slowly blow in the warm breath. Earache in Children.—Irrigate the external auditory canal with water as hot as can be borne with comfort, for twenty minutes. Then pour into the ear two or three drops of atropine sul., gr. iii. ; morphine sub, gr. xx.; water, 1\. When sup- puration is feared, place a cantharides plaster over the entire mastoid region.—Briggs. In temjtoro-occipital neuralgia (when persistent), insufflate compressed air into middle ear. If successful, investigate and treat nasopharynx, Eustachian tubes, or ear itself. Facial Neuralgia. Two classes of facial neuralgia must be differentiated—the first usually due to exposure, cold, etc.. of transitory nature, the other perhaps permanent and incurable. Diagnosis.—In the milder form the pain is less severe. ....... gr- ij. ....... ni xv. ....... 'ul xv. ....... 3 iss. .q.s. ad %i. f>5f) the practitioner's matual. There is sudden onset with increase up to a certain point, then decline, but rarely entire freedom between the paroxysms. In the severe variety the paroxysmal nature is more pro- nounced. In the intervals there is entire absence of pain. There may be fifty or a hundred short paroxysms in the day, each reaching its maximum of intensity quickly and subsiding abruptly. Differentiation.—In hysteria, attacks are of irregular oc- currence, each lasting longer and perhaps terminating in hys- terical convulsions. Treatment.—In the first form, analgesics; hydrobromate and valerianate of quinine. Opium is the only reliable drug in true tic of severe type. B Ext. thebaici..................................................0.02 For one pill freshly made, not hard. S. Three pills daily at first and add one pill daily until under close watching the desired effect is produced. —GlLLES DE LA TOURETTE. When rebellious, destruction of the ganglion is less apt to be followed by recurrence than simple section of the branches. Complete extirpation should be superior to simple destruction of the ganglion.—Marchant and Herbert. Have patient's teeth thoroughly examined. Do not sanction the extraction of healthy teeth. Put the muscles of mastication and articulation at rest. Before resorting to surgical operations be satisfied that suit- able, thorough, and persistent treatment has proven ineffectual. Cocaine introduced by electric cataphoresis may give temporary relief. When other methods have failed, morphine subcutaneously in sufficient dose to insure absolute freedom from pain, while the general nutrition is improved as rapidly as possible. Supra-orbital neuralgia of malarial origin : B Quinine................................................. gr. x.-xv. Morning and night. —Leszynsky. NEURALGIA. 557 Neurexaresis, or extraction of the nerve by torsion.— Thiersch. The extraction should be made as slowly as possible to include the finest twigs, and branches apparently free from pain should also be dealt with, since pain is rarely limited to one particular trunk.—Angerer. Facial neuralgia when obstinate : B Aconitine................................................. gr. ^hi Every two hours. —Hausberger. B Butyl-chloral......................................... gr. xl.-lxxv. Alcohol, rectificat.................................... 3 iiss. Glycerini............................................ 3 v. Aqua? destillata?................................q.s. ad § iv. M. S. From two to four teaspoonfuls, p.r.n. —LlEBREICH. B Liquor potassii arsenitis..................................... gtt. v. Syr. rhei aromatici......................................... 3 b For one dose, thrice daily, after meals. At night, apply a hot salt bag to the back of the neck and order the following pill: R Ext. belladonna?............................................ gr. i Ext. hyoscyami, Ext. colocynthidis comp., Pulv. zingiberis...........................................aa gr. i. M. etft. pil. No. i. —J. M. Da Costa. B Potassii bicarbonatis......................................... 3 iss. Ext. ergotae fld............................................... 3 i. Inf. ergota?................................................... § vi. M. S. Two tablespoonfuls every four hours. —Edward Waakes. B Fl. ext. black cohosh.......................................... | iss. Fl. ext. gelsemium........................................... 3 iss. Fl. ext. valerian,............................................. 3 i. M. S. Teaspoonful every four hours. —Swinney. When of gouty origin, as indicated by ruddy complexion, presence of tophi, uric acid, history of gravel, etc., colchicum and Epsom salts. 558 THR PRACTITIONERS MANUAL. In the 7nost obstinate forms, ligation of the common carotid is safer and more certain than any of the intracranial opera- tions.—Eicketts. Nitroglycerin or nitrite of amyl.—Leech. In supra- or infra-orbital, application of warmth and of vera trine externally.—Evans. Hydrargyri iodidum rubrum, gr. ^V' increased to \. Potassium iodide, gr. xx.-xlv., after each meal, continued two to three months, in addition to aconitine.—Seguin. To produce sleeji : B Chloral.................................................. gr. x.-xx. Morphine............................................... gr. fV - i Caution.—Be careful about permitting habit to be formed. For restorative effect, rest in bed until remedies have taken effect, careful diet, avoidance of alcohol. For alterative : B Hydrarg. bichloridi...................................... gr. ^ -^ Potassii iodidi........................................... gr. vi.-x. Tonic measures, massage, etc. —EWART. B Antipyrini................................................... 3 i. Cocaina? hydrochloratis..................................... gr. ss. Aqua? destillata?............................................. 3 iiss. M. S. Inject subcutaneously tti, xv.-xx. —Grandclement. Rest in bed, milk diet, and strychnine, gr. ■£%, injected hypo- dermatically each day and increased gradually to gr. \. Agents which act on the vasomotor system, such as aconitine, nitroglycerin, etc.—Dana. In trigeminal neuralgia : B Aconitinae (Duquesnel's)..................................... 0.006 Glycerini, Spir. v ini rectiflcati..............................,.........aa 4 Aqua? mentha? piperita?................................q.s. ad 62 M. S. Teaspoonful two or three times a day on an empty stomach. —E. C. Seguin. neuralgia. 559 li Chloral., Camphor, pulv...........................................aa 3 i. Morphina? sulph............................................ gr. ij. Chloroformi................................................ tti. xl. M. S. tti xx. the dose. May be used locally. —Bartholow. R Chloroformi, Tinct. belladonna?..........................................aa 3 iij ■ Syr. aurantii corticis........................................ § iij. M. S. 3 i- every two hours until the pupils become slightly dilated, when the interval between the doses should be doubled. —N. S. Davis. R Strychnina? sulphatis..................................... gr. i. Quinina? sulphatis.......................................... 3 i. Ferri reducti............................................... gr. xv. Ext. gentiana?.............................................. 3 as. M. ft. pil. No. Ix. S. One three times a day. This is especially good for facial and stomach neuralgias. If there is a marked malarial element present, add arsenious acid, five grains, to the formula.—D. E. Ruff. For trigeminal neuralgia : B Tinct. aconiti................................................. 3 ss. Tinct. gelsemii..............................................ad 3 v. M. S. Ten drops every twenty minutes as directed. Directions.—Take every twenty minutes until pain is relieved ; not, however, to exceed eight doses, and stop earlier if any tingling is felt in the tips of fingers. —H. B. Whitney. Locally apply over the painful area with gentle rubbing a few drops of: B Menthol, Guaiacol...............................................aa gr. xv. Alcoh. absoluti...................................... 3 v M. S. Repeat as often as required. Cover the parts with cotton. Or— B Camphora?, Chloral...............................................aa 3i. „ fentho1............................................... gr.x.-3ss. Rub in a few drops with fingers. 500 the practitioner's manual. Or— B Chloroform................................................. 3 v. Tincture of opium.......................................... 3 iv. Salicylic acid............................................... 3 iv, Alcohol..................................................... I iiiss. Olive oil.................................................... I vij. M. S. Apply. Or— B Guaiacol, Glycerini...................................................aa 3 ij. M. S. Apply with a brush. Caution.—Burning of tender skin may occur. Or— B Veratrina?.................................................gr. viij. Lanolin................................................... 3 ij. Ung. simp...............................................ad 3 ij. M. Or— R Aconitina?.................................................. gr. iv. Veratrina?.................................................. gr. xv. Glycerini................................................... 3 ij, Cerati..................................................... 3 vi. M. S. Rub over the painful spots. Caution.—Do not rub where the cuticle is abraded.—J. M. Da Costa. (See also "Sciatica," "Neuritis.") Neurasthenia. Essential nerve prostration is a condition without demon- strable pathological lesion. Cerebral neurasthenia includes in its symptoms drowsiness, irritability, and depression. Diagnosis.—There are headaches, occipital or frontal, with a feeling of fulness or tightness, as by the pressure of a helmet upon or of weight in the head, or a dragging sensation in the back of the head associated with a dull ache in the back of the neck, which may be relieved for a time by recumbency, rest, neurasthenia. 561 or change of position. Brain work is carried out with decided effort and with an excessive sense of fatigue soon following. The neurasthenic is always in a state of physical and mental depression. He analyzes his every symptom and is inclined to speak of them to every listener. In spinal neurasthenia there may be the same dull ache in the cervical region, the same weariness on exertion, but usually backache and pains extend- ing into the lower extremities are more common. In frequent association with lithsemia we find gastro-instestinal symptoms, vertigo, neuralgia, insomnia, and in some instances hysteria, In another class of cases, the symptoms will implicate more the circulatory apparatus and there will be attacks of palpitation and precordial pain, transitory flushing of the face, momentary development of erythematous blotches; and pulsations in the carotids and aorta. Critzman speaks of absence of cremasteric reflex as a valu- able sign of neurasthenia. Differentiation.—The diagnosis is to be made from ner- vousness, or what the Germans call " Nervositat," which is an excessive excitability of the nervous system; and from simple cerebral fatigue. In all instances of supposed neurasthenia an exhaustive ex- amination of the whole system should be carried out to detect some organic defect of which these manifestations may prove to be but symptomatic. In those who have taken bromide of po- tassium the toxic effects of the drug, including irritability, de- pression, a tendency to moderate melancholia, gastric irritation, and disturbances of circulation, must not be confounded with the symptoms of neurasthenia. From hysteria, by the absence of anaasthesia of the skin, lesser frequency of convulsions or paroxysms, a more moderate train of symptoms, occurring in mentally well-balanced individ- uals, usually males, after excesses or in association with physi- cal deterioration. Recovery is gradual, while in hysteria it 562 the practitioner's manual. may be sudden, and in the latter emotional disturbances and functional perversions predominate. In spinal irritation, there is characteristic sensitiveness over the vertebrae. Sexual neurasthenia, depending upon excesses and abuses of function and attended with lack of vigor and a preponderance of local symptoms, should not be confounded with the nervous manifestations habitually associated with pathological lesions in the genito-urinary tract. In insanity the lack of will power, delusions, and hallucina- tions are more permanent in kind and duration. The nervous manifestations of Graves' disease may simulate this state before the characteristic signs develop. Prognosis for most instances is good. Whenever a re- movable cause can be discovered, so much better becomes the outlook. Treatment.—Few drugs are useful, but intelligent treat- ment must be carried out systematically. The patient's confi- dence must be gained by impressing upon him your entire familiarity with the disease in general and with his own case in particular. Neurasthenics are usually apprehensive. They desire and deserve attentive service. It is not well, however, that they should constantly be reminded of their condition by having frequent doses of medicine to take; by having special diet lists to follow at table, or by having a routine course of exercise laid out for them. If not already engaged in pursuits of a laborious rather than of a mental nature, some occupation should be found which will keep them engaged at manual labor out of doors, or pleasantly employed, as in bicycle exercise. As Dr. Glorieux has suggested, since these patients like to relate their woes at frequent intervals to the physician, a course of treatment embracing electricity or a species of suggestion in the waking state may be carried out at regular intervals in the physician's office. Caution.—There is often a decided desire for alcoholic stim- neurasthenia. 563 ulants. These must be used with great discrimination to avoid a habit easily formed in this class of patients. Prophylaxis.—The children of neurasthenic parents should have the best hygienic surroundings and their training and sub- sequent occupation should receive careful consideration. In sexual neurasthenia: B Zinci bromidi, Zinci valerianates, Zinci oxidi..............................................aa, gr. xv. Rosa? conserv............................................... q.s. M. ft. pil. No. xx. S. One an hour after breakfast and dinner, and before retiring. As a tonic in the same affection: B Strychnina?, Phosphori................................................aa gr. \ Ext. cannabis indica?....................................... gr. ij. Ferri carbonatis........................................... gr. xx. M. ft. pil. No. xxv. S. One before meals. As a sedative : B Potassii bromidi........................................... 3 ij. Ammonii bromidi........................................ 3 i. Potassii bicarbonatis...................................... gr. viij. Tinct. calumba?............................................ § i. Aqua?..................................................... 1 iv. M. S. Teaspoonful to tablespoonful night and morning. —Rockwell. In the spermatorrhoea and anaphrodisia of sexual neuras- thenia : B Cornutina? citrat......................................... 0.03 cgm. Creta? praeparat.......................................... 3 gm. Gum. tragacanth........................................ 6 gm. M. ft. pil. No. xx. S. Two to four pills daily. —BOZZOLO AND MANGIANTI. Caution.—Cornutine is a powerful alkaloid extracted from the ergot of rye. Strong galvanic currents to the abdomen and general gal- vanic stimulation are preferable to the routine methods of using the faradic current.—G. B. Massey. 564 THE PRACTITIONER'S MANUAL. plied to the prostatic urethra through the two-ways cooling- sound. When seminal vesiculitis is found, appropriate treatment by finger massage, etc., is to be carried out. In sexual neurasthenia: B Quinina? sulphatis.......................................... gr. xx. Ferri subcarbonatis (U. S. Pn.. 1870)........................ 3 i. Strychnina? sulphatis...................................... gr. ss. Ext. damiana?............................................. gr. xx. Ext. cinchona?............................ ................gr. xl. M. ft. caps. No. xx. S. One after each meal. —Bedford Brown. Neurasthenic debility: R Acidi phosphorici diluti......................................3 i. Ext. coca? fld................................................. 3 ss. Ext. damiana? fld............................................. 3 ss. Tinct. nucis vomica.......................................... tti, x. Syrup, zingiberis............................................. 3 i. Aqua?..................................................q. s. ad "% ss. Ft. dosis. S. To be taken in water at 11 a.m. and 6 p.m. —Sir Andrew Clark. Or— R Sodii phosphatis . ............................................ 3 ss. Carabafia water............................................... § ss. M. S. Drink in a full glass of hot water a half-hour before breakfast every morning- —Fredk. Peterson. When the symptoms are attributable to the cerebro-spinal system, moral treatment with suggestion to restore to the pa- tient confidence in himself. Hydrotherapy and tonics. Most subjects will derive more benefit from tepid than from cold douches. Among tonic drugs iron, especially the peptonate, and kola.—Lorchet. An excellent nerve tonic and sedative is: R Quinine valerianate....................................... gr. xl. Iron subcarbonate.......................................gr. lxxx. Arsenious acid........................................... Ki". i. Strychnine sulphate..................................... gr. i. Asafcetida.............................................. 3 ij. Extract sumbui.......................................... 3 b Make forty-eight capsules. One after each meal. neurasthenia. 565 Or— R Strychnina? arsenitis........................................... 0.1 Zinci phosphidi................................................ 0.4 Calcii iodidi, Ferri sulphatis, Saponis amygdalin. anisati (Fr. Cod.)........................aa 4 M. et ft. pilula? xl. S. One after breakfast and dinner. In the spinal form, rest. In hyperesthesia and mental agitation, codeine phosphate, gr. i, after dinner and supper. This can be increased until gr. vii. or more are given daily.—Dornbluth. B Tinct. kola, Tinct. coca.............................................aa, § iss. Citric acid................................................. gr. xv. Aiseniate of sodium........................................ gr. \ M. S. Teaspoonful three times daily. When gastric symptoms are prominent : R Zinci phosphidi........................................... 0.1 gm. Zinci bromidi............................................ 1 Quinina? hydrobromatis................................... 1.5 Ext. nucis vomica?........................................ 0.15 M. ft. pil. No. xxx. S. One three times a day. In neurasthenia gravis, due to physical or sexual overexer- tion, electricity, cold water or thermal baths, massage, moderate exercise, sojourn at the sea, etc.—Leonard Weber. The monotony of complete rest acts as an irritant rather than as a tonic sedative. Activity tempered to the necessities of the patient is far more potent. Electrization, for its influence upon metabolic function and secondarily upon nutrition. The three bromides, combined with zinc and cannabis indica, furnish per- haps the most efficient form of internal medication.—A. D. Rockwell. A system of mild gymnastics or drill, including medicinal baths.—Schott. In looking for causes to be eliminated do not overlook coitus reservatus. The symptoms of groundless anxiety and painful apathy for surroundings are here commonly present. 566 the practitioner's manual. Recumbent rest alternating with active exercise. Hot fo- mentation to the entire spinal region alternating with ice appli- cations. —Pettyjohn. In the early stages, characterized by general fidgettiness, in- ability to keep quiet, with restless look in the eyes, disagreeable feeling in the epigastrium, and perhaps insomnia, rest and food may avert a catastrophe. When all work becomes impossible, a settled melancholy suc- ceeding the previous exaltation and hysterical disturbances man- ifesting themselves, a rest extending over a couple of years or perhaps more may become necessary.—Ivatts. The gray substance of sheep's brain diluted with water, by injection.—Constantin Paul. Pearls of phosphorus containing gr. t^o~tio' valerianate of quinine and zinc, cod-liver oil, maltine, hypophosphites. If heart's action be not impaired, cold baths. Caution.—Avoid strychnine and nux vomica, as they increase muscular twitchings.—Thos. D. Savill. Calcium glycero-phosphate, gr. v. in capsule, with each meal, and continue for a year or until cured. When there is marked physical depression : R Vini calcii glycerophosphatis............................... 5 viij. S. Sherry glass full before meals. To promote nutrition of the cord add strychnine sulphate, gr. 7V ~iVj to each dose for a month, then leave off for a week or two. Cathartic mineral waters before breakfast or a dessertspoon- ful of Carlsbad Sprudel salts in a cupful of hot water. Vichy or plain water between meals.—Quackenbos. In traumatic neurasthenia, or "railway spine," with inabil- ity to use mind or muscle, it is our duty to discourage litiga- tion. Worry and trouble in connection with the latter may trans- neurasthenia. 567 form the neurosis into a cortex habit and make the subject an invalid for life.—Quackenbos. B Ferrous lactate ...........................................gr- ij- Quinine sulphate........................................... gr. i. Ext. of ignatia.............................................. gr. i For one pill. Dose, one or two before eating. —S. Weir Mitchell. In brain fag with continual headache, phosphorus, 0.0006 gm., to be gradually increased.—Hartcop. To induce sleep, sponge off with cool water, wrap in blanket wrung out in hot water, cover with dry blanket, outside of which hot bottles are applied.—D'Aubray. For insomnia, flannel bandages, six to eight inches wide and five yards long, wrung out of water at 95° P. and applied about the chest and abdomen. The bed must be protected by rubber sheeting.—G. Richard. B Paraldehyde........................................... gr. xxxviij. Fluid extract of piscidia............................... gr. lxxv. Syrup of wild cherry.................................. § iss. M. S. To be taken at once in a cup of orange-flower water. —Monin. Or— B Chloral formamidate, Tincture of ginger....................................aa, 1 part. Mint water............................................... 15 parts. M. S. A tablespoonful to be taken at the time of going to bed. When due to exhaustion or emotional causes, trional, 1.5 gm. To be taken in milk an hour before bedtime. If satisfac- tory sleep is produced, give one gram the following night. A warm sitz bath may be given just before retiring. Avoid coffee. —Dornbluth. It is perfectly safe to give thirty grains of trional in hot beef tea. In milder cases: B Tinct. passiflora? incarnata?.....................................§ i. S. Teaspoonful at bedtime. —Daniel. When all drugs fail, hypnotism.—Quackenbos. 568 the practitioner's manual. Neuritis. Here a single nerve or a large number may be simultane- ously involved, giving the simple or multiple forms. Diagnosis.—In the first or localized variety, pain may be circumscribed or extend over the whole course of the inflamed nerve distribution. In character it is burning or of a boring or shooting nature. Glossy skin, oedema, and muscular wast- ing may follow; sometimes an ichthyotic condition of the surface is noted. Differentiation.—It is to be differentiated especially from neuralgia. The pain is increased by pressure and motion and there may be tenderness over the parts supplied by the nerve or a condition of hypersesthesia and wasting or paralysis of the muscles. In neuralgia, on the other hand, the nerve trunks are not tender and the pain is more intermittent in its character. CEdema, cutaneous eruptions along the nerve's course, alteration in the nails and various paresthesias, includ- ing diminished sensitiveness of given areas, point to neuritis. Distinction is also to be made from myalgia, thrombosis, and embolism. Prognosis.—An acute case running a favorable course is well in a few weeks' time. Most cases, however, pursue a chronic course and recurrences are not unusual. Treatment.—Seek for such underlying causes as syphilis and gout. Perfect rest of the patient and of the affected limb. Fly blisters; heat or cold, according to the greatest relief secured. Firing along the course of the painful nerves with the Paquelin point. Galvanism with the positive electrode over the painful area. If gout is discovered, colchicum. Salicylate of sodium or salophen. When pain is severe morphine subcutaneously. Peripheral Neuritis.—Strychnine, grain ■gL/_T three times daily.—Stodart Walker. neuritis, multiple. 569 Neuritis, Multiple. In peripheral or polyneuritis a number of nerves, especially those of the arms and legs, become simultaneously or succes- sively inflamed. There are tenderness, sweating, and spon- taneous pain. There may be paralysis of the muscles supplied by the affected nerves and subsequently wristdrop or foot- drop may be noted. The early symptoms include numbness, dull pain along the course of the limb, sometimes shooting or burning in character and with more or less constant tingling. Tendon reflexes are lost. Symmetry is a characteristic feature. Epidemics have been reported. There are a variety of clinical forms, including the alcoholic, diphtheritic, plumbic, lepric, tabetic, beriberic, diabetic, enteric, arsenical, etc. Coal gas, mercury, copper, zinc, and phosphorus are at times also causative agents. Differentiation.—From anterior poliomyelitis, by pain and tenderness along the nerves, sensory symptoms, distribution of paralysis symmetrically. From myelitis, by absence of affection of bladder and rec- tum, by absence of bed sores and tenderness of spine to heat, and by distribution of symptoms in periphery.—M. Allen- Starr. In neuralgia the pain is very persistent, less symmetrical, and less widely distributed. In locomotor ataxia there is not such early loss of muscular power but rather inco-ordination, and the pains are lightning-like in their suddenness and intensity, though less persistent. There is loss of bladder control and the pupils do not react to light. In poliomyelitis the pain is in the muscles and made worse by motion, and not in the course of the nerves, as in neuritis. Poliomyelitis anterior tends specially to attack young chil- dren and is rapidly followed by paralysis. 570 THE practitioner's manual. Acute ascending paralysis may be very closely simulated by a neuritis of acute onset. It ascends rapidly to the trunk with- out causing loss of sensation. Diffuse myelitis does not have the symmetrical distribution of neuritis and there is less alteration of electrical reaction. Syringomyelia is distinguished by the tactile sense being pre- served while pain and heat sense is abolished, and by the char- acteristic association of atrophic paralysis and spastic paraplegia. Hysteria with emaciation simulating muscle atrophy has absence of the characteristic nerve-trunk and muscle pain of neuritis, and stigmata are to be found. Prognosis depends on the primary cause and severity of attack, being especially bad in locomotor ataxia, diabetes, tuberculosis, and lepra. After a few weeks of increasing symptoms improvement may slowly set in, but most instances are protracted. The re- sulting paralysis disappears first from the lower extremities. In incurable disease of which neuritis is a symptom it is apt to persist for life. Treatment.—Strychnine is almost invariably of benefit.— Walker. Acetanilid.—Bartholow. If history or suspicion of specific origin, antisyphilitic medi- cation. Electricity after acute stage. Massage, when atrophy is marked and pains are decreased. Multiple neuritis following influenza, rest in bed, morphine injection to relieve pain. When the latter is not verjr severe: R Cinchonidina? salicylat......................................gr. v. Every two hours in pill or cachet. For pain in an extremity, firm pressure with a flannel bandage. When painful nerve trunks are superficial, blisters applied over them may give relief.—Allyn. neuroses of occupation. 571 Neuroses of Occupation. Writer's Cramp. Among the professional neuroses this is one of the most common and difficult to manage. It comes on gradually, the fingers stiffening and refusing to respond to the* volition each time the pen is taken in hand. In one form there is trembling, in another a spasmodic contraction of different muscles, the index being extended or flexed while the thumb is thrown out in an opposite direction, or the terminal phalanges may be flexed while the first phalanx is extended. The movements are pro- duced at first after the hand is tired from writing, but later on they occur at the beginning of the attempt. At times the cramp is painful. It affects chiefly those mentally overworked and neurasthenics. Treatment.—Prolonged rest from attempts at writing, asso- ciated with static electricity and massage, active and passive. The use of especially constructed penholders enables some to continue to write. Bouchut claimed cures from the use of copper penholders bound with zinc. Watchmaker's Tic. Twitching about the eye and in the muscles of the face on the side upon which the watchmaker wears the monocle lens may seriously interfere with his work. Cohn, of Berlin, has reported such an instance. Habit Spasms. Implicating certain muscles and resulting from some repeated act or mimicry do not properly belong to this same group. In the young they may be cured by moral training. 572 the practitioner's manual. Convulsive Tics. Spasms implicating the face and neck muscles especially, but also the arms and shoulders in quick jerky motions and contor- tions, furnish still another condition to be differentiated. An exclamatory tic with repetitions of some particular word may constitute the whole affection. It is often difficult to cure and relapses are frequent. Treatment consists in isolation, quiet, rest, change of scene, exercise, gymnastics, horseback and bicycle exercise. Conium and atropine.—Graeme Hammond. Ironer's Cramp. This occupation neurosis is in the nature of a compression paralysis. Clothes pressers and laundresses at constant work with heavy irons occasionally suffer from numbness, shooting pains, and weakness of the muscles. The fingers may become cramped and stiff, accompanied by paraesthesia symptoms. Colporteur's Tic. This has recently been reported by Grasset. The spasm implicated the trapezius, pectoralis major, sterno-mastoid, and dorsalis major on the right side; the subject frequently executing just the movements to which he was habituated in slinging his pack over the shoulder. Cigarette Maker's Cramp. Such an affection has been described implicating the muscles of the thumb and first finger of each hand. Telegraphers and others engaged at constant work of a par- ticular kind suffer in a like way. Treatment.—Occupation must often be changed on account of recurrences. OBESITY. 573 Systematic muscular exercise of the affected hand together with massage may result in some benefit.—L. Pierce Clark. Neuroses, Traumatic. Symptoms may come on soon after an injury, as, for in- stance, after a railway collision, or at some more remote period. They are chiefly those of neurasthenia, including muscular and nervous irritability, depression, spinal tenderness, occipital pain, or hysterical manifestations. There is increased knee jerk. The difficulties of diagnosis are often very great. Diagnosis is based chiefly on the history of injury, usually in association with severe mental shock. Differentiation.—From hysteria, the spinal lesion is dis- tinguished by true paralysis of distinct groups of muscles or of the bladder, loss of sexual power, distinct anaesthesia, etc. The fact that the symptoms are subject to rapid and wide changes does not necessarily indicate simulation on the part of the patient. Prognosis depends upon the presence or absence of organic change. If such is not present recovery usually follows, but possibly not for months or years. Treatment.—Absolute mental and bodily rest. Careful feeding, electricity (galvanism), massage, and measures appli- cable to neurasthenic conditions. Caution.—Narcotics are to be avoided. Obesity. Though not, in the majority of instances, what one may strictly define as a disease, overfatness is frequently an abnor- mality for which relief is sought. Diagnosis.—In the absence of a standard of normal weight, corresponding to height, age, and other conditions, we are gov- erned by the discomfort of which the overfat subject complains, 574 the practitioners manual. The excessive deposit of adipose tissue may be localized or generally distributed. Differentiation is to be made from conditions of oedema, elephantiasis, myxoedema, cretinism. Prognosis depends upon whether the overfatness is of congenital origin, of long duration, or recently acquired. The conditions of general health making it possible or not to carry out a rigid course of treatment influence largely the results. Treatment.—OerteVs Diet List.—Breakfast. Wheat bread, 50 gm. ; coffee, 130 c.c.; milk, 20 c.c. ; sugar, 10 gm. Dinner. Soup, 150 c.c.; stewed beef, 200 gm.; vegetables, 100 gm.; salad, 50 gm.; farinaceous dessert, K»o gm.; black bread, 50 gm.; wine, 125 c.c. Afternoon coffee. Coffee, 130 c.c; milk, 20 c.c; sugar, 10 gm. Supper. Egg (soft-boiled), 1; fried meat, 150 gm.; green salad, 50 gm.; roll, 50 gm.; Pfalz wine, 250 c.c ; water, 250 c.c. Artificial Kissingen water, a large glassful twenty or thirty minutes after meal, and artificial Vichy water in the same way on alternate days, in connection with suitable diet and moderate out-of-door exercise.—W. T. Cathell. Diet.—Bread, 150-300 gm. ; lean meat, 300-350 gm.; green vegetables or salad, 200-300 gm.; fruits (green), 200-300 gm.; water, 1,200-1,500 gm.—Mathieu. R Iodi...................................................... 2 gm. Potassii iodidi............................................. 4 Aqua?..................................................... 200 " M. S. A dessertspoonful two or three times daily. —Descroizilles. R Potassii permanganatis................................. gr. iv.-xvi. Aqua?................................................. 3 iv M. S. 3 ii- t.i.d. —Bartholow. In ancemic subjects, iron in small doses. OBESITY 575 Or— B Magnesii sulphatis......................................... % ss- Ferri sulphatis............................................ gr- viij. Acidi sulphurici diluti............................ v...... 3 b Aqua?.................................................... 1 iy- M. S. Dessertspoonful in a glass of water through a tube three or four times daily. Thyroid Medication.—In the beginning, fresh thyroid gland, gr. iii.-v., gradually increased, not to exceed gr. xv. daily, but continued for a long period. The extract or desiccated thyroid may also be used. Caution. —Discontinue, if shortness of breath or other evi- dence of systemic disturbance makes its appearance. An oc- casional intermission is in order. When thyroid disagrees, iodothyrin, gr. ii.-v., cautiously increased. As a rule, avoid thyroid treatment in all subjects presenting heart symptoms. Avoid too large doses and too rapid reduction. In fatty infiltration of the heart, the practical results follow- ing the cautious administration of very small doses of thyroid have been exceedingly satisfactory to me.—Meltzer.5 In simple obesity without other treatment this will bring about a reduction of weight, without giving rise to serious com- plications. Iodothyrin, 0.25-0.50 cgm., in compressed tablet. Ascer- tain for each case the dosage tolerated. Six tablets daily, in- creased to eight, after a week to ten, and after a fortnight to twelve. Suspend after fifteen or twenty days and resume later. —Lutaud. One advantage of cure by thyroid is that special diet does net enter so largely into it as in the older methods. Banting Cure.—The diet list originally prescribed by Dr. Harvey allows an abundance of meat, fish, and alcoholics. Carbohydrates are scarcely permitted and fats are especially advised against. 576 the practitioner's manual. Caution.—Digestion becomes impaired and various conditions of debility are produced, leading, in some instances, to death. Ebstein Cure.—Meat and carbohydrates are restricted but fat is freely allowed. Caution.— Dyspepsia may result from this too fatty diet. If the stomach will bear it, ext. fuci vesiculosi fid., 3 i.— 3 ii. of a reliable preparation, before each meal, is said to have been followed by good results. CEdema, Acute Circumscribed. A sudden attack of circumscribed swelling, especially upon the face, lasting but a short time and recurring periodically, characterizes this peculiar symptom of a vasomotor neurosis. Diagnosis is important as an aid in doubtful neurotic affec- tions. Differentiation.—Angioneurotic oedema is distinguished from urticaria, the giant form of which closely resembles it, by the absence of itching and of characteristic wheals elsewhere. From erythema nodosum of the non-febrile form, by the ab- sence of tenderness and of rheumatoid pains. Prognosis.—It may endanger life from oedema of the larynx and in several instances the latter has proved fatal. Treatment.—Peripheral irritation of any kind should be corrected and measures for improving the state of the nervous system should be instituted. Salt moistened with water briskly rubbed with a firm hand over the entire spinal region. Sponge for several minutes with water at first hot and then gradually cooled, until the surface is well reddened.—J. N. Hyde. Osteomalacia. This chronic affection of the adult skeleton, otherwise known as mollifies ossium, in which the bones become so soft as to break osteomalacia. 577 upon the slightest external pressure or muscular effort, results in shortening of the body and rounding of the back, provided the patient is up and about. There is a peculiar hobbling gait. The earliest symptom is usually pain in the sacrum, pelvic bones, or spinal column.—Ritchie. Differentiation.—On pressing upon the affected bones crepi- tation, like that of eggshells crushing beneath the fingers, is ex- perienced. Osteosarcoma of a joint gives this same crepitation, but sarcoma and carcinoma of bones in general are preceded by pain, and when spontaneous fracture has occurred, as it also does in these affections, there is local swelling. From disease of the cord and spinal bones, by the gait. Prognosis.—-Recovery is possible. Death after from one to ten years from complication or exhaustion. Treatment.— B Phosphori.................................................... gr. i. Olei morrhua?............................................... £ i j. M. S. Teaspoonful once daily. —Steinberg. Caution.—-The above is the maximum dose. Phosphorus in -^ to ^\ grain doses. If no benefit is derived, castration is to be considered. Bone marrow may be tried.—- GUTLLAUME. Glycerin extract of bone marrow, 3 i.-3 iss., after each meal, increased until 5 iv. weekly is taken. Or, tabloids of the thyroid extract, which seems to have greater therapeutic value.—Alliston. B Phosphori.............................................. 0.01 cgm. Olei amygdala? dulcis................................... 10 gm. M. deinde adde: Pulv. acacia?, Syr. simplicis.........................................aa 5 gm. Aqua? destillata?...................................... 80 gm. M. S. Teaspoonful two to four times daily. —Strumpell. B Syr. calcii lactophosphatis.................................. 3 i.—ij. 37 578 the practitioners manual. Or— R Syr. hypophosphitum...................................... 3 i.-ij. —Tyson.3 Hydrotherapy.—Cold-water cure gave a good result.—Bern- hart. Osteomyelitis. A typical feature of this affection, which is a staphylococcic pysemia in growing children, is the rapidly increasing pain of a deep-seated nature in one of the extremities near a joint, accom- panied by swelling without redness or fluctuation, and attended with elevated temperature and possibly chills. Diagnosis.—The chief diagnostic feature is a markedly sensitive point at or near the junction of the epiphyses. Pysemie symptoms are to be looked for. Differentiation.—It is often confounded with rheumatism, under which heading the differential diagnosis has been given. Typhoid fever and erysipelas have also been erroneously diag- nosticated. Prognosis.—Death or deformity may be the penalty of de- layed diagnosis. Treatment.—Necrosis and subsequent damage are prevented by immediate incision to and through the periosteum, even chisel- ling into the marrow of the bone. Pachymeningitis. Inflammation of the dura mater, unless it produce a paraly- sis to be made out as due to cortical pressure, has no distinctive signs. The headache, convulsions, and perhaps delirium are to he differentiated chiefly by exclusion from those due to other causes. If the headache be attended with marked somnolence, and a history of syphilis, sunstroke, chronic alcoholism, or trauma can be elicited, the hemorrhagic form or haematoma may be justly suspected. pancreatitis, acute. 579 The tuberculous form occurs only in association with other intracranial tuberculosis. Treatment. — Small doses of mercurials and iodides, espe- cially in the presence of syphilitic history. Counter-irritation, as by the actual cautery. If tuberculosis elsewhere causes this condition to be suspected, treatment as for phthisis or tuberculosis is general. In the hemorrhagic variety treat as for apoplexy. Pancreatitis, Acute. Vomiting of a continuous nature with intense pain in the upper abdomen, increased on deep inspiration and pressure, subnormal temperature, cold sweats, constipation, and collapse, go to make up the symptom complex which necessitates the differentiation from acute intestinal obstruction, perforation in the digestive tract, perforation of the gall bladder or of a bile duct, and attacks due to some irritant poison. The swelling, which is at first in the epigastrium, soon becomes general. Fitz describes hemorrhagic, suppurative, and gangrenous forms. Bleeding into the organ may be rapidly fatal. There is deep-seated pain in the epigastric region, coming on suddenly. Delirium may occur. Diagnosis embraces the following points: 1. The location of the primary seat of the disease in the epigastrium. 2. The suddenness of the attack, with severe gastric, epigastric, or ab- dominal pain, accompanied by great prostration and vomiting. 3. Tenderness in the epigastric region, with tympanites and a mass recognizable by deep palpation. 4. Absence of fever, or but moderate fever during the first two or three days of the attack.—Fowler. Differentiation.—Biliary affections, including perforation, are excluded by the absence of history of gall stones, by the ab- sence of jaundice and attacks of indigestion. A sudden attack without history of previous pain after eating, or of hemor- 580 the practitioner's manual. rhages, would exclude perforation following ulcer of the stomach or duodenum. Poisons would be discovered by an examination of the stomach contents. Intussusception may be simulated by the presence of a sausage-like mass. Obstructions arc rare in the epigastric region, and, as Fitz has pointed out, "the immediate presence of a localized tender- ness and the usual absence of a conspicuous general tympany are material aids in the differentiation.'' In carcinoma of the pancreas there are irregular or voracious appetite, great weakness, loss of flesh, and deep epigastric pain, which is often very severe. Perforative peritonitis is excluded by lack of evidence point- ing to previous gastro-intestinal disease. Prognosis.—If not rapidly fatal, recovery is possible in acute pancreatitis. The suppurative form ends fatally after three or four weeks. Spontaneous evacuation of a necrosed pancreas may be followed by recovery7. Treatment.—Surgical intervention might succeed after the reaction from collapse. The tail of the pancreas has been successfully removed by Kleberg. /;/ the hemorrhagic variety treatment can be but palliative. Rupture of the pancreas as a possible result of a blow upon the abdomen must be borne in mind when the symptoms include fainting and vomiting followed by perverted appetite. A cyst may form and protrude into the epigastrium. Punc- ture in the middle line between the stomach and transverse colon will demonstrate a white-of-egg-like limpid fluid.—Hadra. Paralysis, Acute Ascending. Landry's paralysis is rare. Male subjects between the ages of twenty and forty are those mostly affected. Diagnosis.—It begins in the legs and extends within a few paralysis agitans. 581 hours or days to the parts above, at times even implicating the facial muscles. Sensation is unimpaired, there is no pain, reflex action is lost. The functions of the bladder and rectum are undisturbed. Prognosis is grave, death being generally due to respiratory- paralysis. Paralysis Agitans. In Parkinson's disease, or shaking palsy, the character of the tremor, as the initial manifestation, serves to distinguish the affection from the toxic, hemiplegic, hysterical, and other affections which somewhat resemble it. Diagnosis.—The onset may be gradual or sudden, and impli- cates all the limbs or single groups of muscles. The head does not, as a rule, participate in the trembling movement. The tremor is peculiar in that it is suspended during voluntary- movements and is manifested in repose. It ceases, however, during sleep. The oscillations are regular and rhythmical, but of slight extent and number about five to the second. The phalanges are extended, while the fingers are flexed almost to a right angle and the thumb is carried inward. Involuntary movements in the muscles of the head are exceptional. The head usually presents a striking appearance, as though immobi- lized in some way upon the shoulders. The gaze is fixed, the jaw drooping, perhaps permitting the saliva to dribble. The attitude and gait are peculiar, the subject appearing as though propelled forward or as though about to run. Differentiation.—Senile trembling affects especially the head and upper extremities. Hysterical tremor is suspected when the subject is of the female sex and stigmata are detected. Toxic tremors, as from alcohol, mercurials, etc., are lacking in some of the characteristics above given and show other signs of the particular poison at fault. 5s2 the practitioner's .manual. In the tremor of general paralysis of the insane there arc psychical manifestations, pupillary changes, and disturbances of speech which make it possible to be distinguished. Multiple sclerosis is perhaps the condition most likely to be mistaken for paralysis agitans; here the involuntary7 movements alone induce the trembling. The marked test is to have the patient reach for some object and note the increased tremor as the object is approached by the hand. There are also head symptoms and head movements, which are usually absent in paralysis agitans. Treatment.— To combat the tremor : B Strychnina' sulphatis, Acidi arsenosi...............................................aa 0.06 Ext. belladonna?............................................... 0.3 Quininae sulphatis, Mas. pil. Blaud..............................................aa 2.4 Ext. taraxaci...............................................q.s. M. ft. pil. No. xc. S. Three pills daily. —S. W. Gboss. R Hyoscyami.................................................. gr. -fa Gradually increased to gr. ^. —Bartholow. " Or— R Hyoscyamina? hydrobromat..................................gr. ij. Aqua?..................................................... I i. M. S. One drop into the eye may give relief from the shaking of several hours' duration. —Chalmers. Caution.—A partial paralysis may come on, but it will grad- ually disappear. R Duboisine sulphate.......................................... gr. j^t Codeine....................................................gr. \ M. ft. tab. No. i. S. One or two night and morning. —Frederick Peterson. R Uranii bromidi.............................................gr. ?V —C. L. Dana. R Sparteina? sulph........................................... gr. i- i S. At dose t.i.d. —Potts. paralysis, bell's. 583 Paralysis, Bell's. In facial-nerve paralysis the face is drawn forcibly to the sound side whenever the facial muscles are called into play. The angle of the mouth droops, the eve cannot entirely close, and the affected side is motionless, allowing food to collect be- tween the teeth and buccal mucous membrane. Hearing and taste may be impaired. When of cerebral origin paralysis of the facial nerve is distinguished by the electrical reaction remain- ing normal and the fact that the frontalis muscle and the orbi- cularis palpebrarum habitually escape involvement. The abil- ity to whistle is lost; the tongue, when protruded, seems to incline toward the paralyzed side because of the pronounced deformity. Facial paralysis due to otitis media may be wrongly attrib- uted to catching cold. The prognosis in this form is good. Treatment.—In rheumatic facial paralysis recovery may be hastened by electrical treatment. In severe forms complete restoration of function may be promoted and the onset of con- tracture and spasm combated.—Erb. The electro-therapeidic formula may be as follows: Place one electrode (anode), having a diameter of 1^ inches, over the auriculo-mastoid fossa of the affected side; the other electrode, ^X2, in the corresponding position on the sound side. Use a continuous current stabile; intensity, 2-4 m.a.; duration, two minutes. Make and break very gradually. Peripheral treat- ment : Apply one electrode (anode), 2X2, behind the affected ear. The other electrode, fin. diameter, is used labile over the affected muscles in the direction of the ramifications of the plexus an- serinus; intensity, 3-4 m.a.; duration, three to four minutes. The movement of the electrode is in a circular direction over the orbicularis palpebrarum. Strong faradization has been blamed, and probably with justice, for inducing contracture.— Neumann. 584 THE PRACTITIONER'S MANUAL. Paralysis, Hemiplegic. Hemiplegia or unilateral paralysis, including the face, arm, and leg upon the same side of the body, is a symptomatic mani- festation of disease or injury of the brain in the region of the motor area of the cortex. Diagnosis.—If the lesion is above the pons the opposite side is the one paralyzed. Generally in lesions of the pons there is palsy of the face on one side and of the extremities on the other. Table of Differential Localization. Hemiplegia. With motor aphasia With hemianaesthesia. With paralysis of lower portion of face. With crossed facial paralysis. With crossed motor-oculi paralysis. With anarthria (difficulty of articula- tion). With difficulty in swallowing. Seat of Lesion. Third left inferior frontal convolution (Broca's). Posterior horn of internal capsule. Posterior horn of internal capsule. Pons. Crus cerebri. Medulla oblongata. Medulla oblongata. Dilatation of one pupil, and more especially unilateral papil- litis, upon the same side as the paralysis of the extremities, is indicative of a lesion upon the same side of the brain.—Led- derhose. In collateral hemiplegia (cerebral lesion and paralysis upon the same side of the body) there is greater respiratory activity upon the side of the chest corresponding to the paralyzed muscles. In contralateral hemiplegia (cerebral lesion and paralysis upon opposite sides) insufficiency of respiratory motion is noted upon the same side as that of paralyzed extremities, face, and tongue. —Ortner. Treatment.—Passive movements from the first. Massage. Artificial warmth is essential (pine-wool coverings). Galva- PARALYSIS, GENERAL PROGRESSIVE. 585 nism (not over five milliamperes. Negative stabile, positive mobile). Faradism is useful in flaccid cases (primary current). The most important part of treatment is to encourage the patient to make the most of each return of power as it occurs.—■ L. G. Guthrie. Electrical treatment should not be begun before the end of the third week, and should be limited to faradization for fifteen or twenty days. Then continued current to spinal column (4-5 milliamperes at first, for ten to fifteen minutes). It is often well to substitute electric baths.—Dignat. Paralysis, General Progressive. General paresis, dementia paralytica, or progressive general paralysis of the insane, presents a train of mental and motor de- rangements without constancy of order in their development. It is only after the early symptoms resembling neurasthenia have existed for some time that their persistence suggests the actual condition. There may be headaches of erratic nature, word blindness, stuttering or slurring of words, word deafness, overacute hearing, tremors of tongue or of facial muscles. While more frequent in brain workers, it is not confined to any class or social stratum. It is more frequent in men than in women and between the ages of thirty and fifty. Diagnosis.■—The most pronounced early symptom is an al- teration of the mental personality. A man previously of cheerful disposition becomes the victim of causeless depression or grows irritable and excitable. The deepest depression follows upon the most trivial causes. Failure of memory, especially for recent events, becomes noticeable, and careless, indolent, and altogether unusual habits are formed. The most important early symptoms, according to C. L. Allen, are unequal size and altered reaction of the pupils, ab- 5sii the practitioner's manual. normality of reflexes, especially of the knee jerk, disturbances of speech and handwriting, and paretic seizures. Differentiation.—Neurasthenia with pronounced cerebral symptoms may simulate paresis. A constitutional neurotic his- tory, perhaps extending back to childhood, may be elicited. There is absence of true mental failure. There is no alteration of the pupils. Paralysis agitans has clear intelligence and peculiar gait. Chronic alcoholism may resemble very closely general paresis in its symptomatology; the same vertigo, sleeplessness, and tremor may be present. Epileptiform attacks and the altera- tion in speech and writing may exist in both. Withholding alcohol and observing the case for a time may make a decision possible. From cerebral syphilis the diagnosis may be extremely diffi- cult. A history of infection, sudden onset, and early develop- ment of paralytic symptoms, irregularity in the manifestations, severe headache at night, absence of delirium of the expansive form, and improvement under treatment, all favor the specific affection. The fact that a large percentage of paretics give a history of syphilis complicates the subject decidedly. Seizures of convulsive nature and disordered sleep are common to both. The Argyll-Eobertson pupil (which fails to react to light while reacting for accommodation, with inequality in the size of the pupils) is a symptom common to paresis and tabes. The delusions of grandiose nature in paresis differ from those in paranoia, in that in the former the subject is too dull of in- tellect to enter into argument, while in the latter he can sus- tain with more or less sound reasoning the points he makes.. In multiple sclerosis there is a more characteristic "inten- tion" tremor. In brain tumor, eye symptoms, including choked disc, are more likely to be found. In cerebral manifestation of chronic lead poisoning we have other symptoms and history pointing to the cause. PARALYSIS, INFANTILE SPINAL. 587 Prognosis is unfavorable, though the length of time before the fatal ending may be a number of years. Treatment.—Most instances, or at least many, having a history of lues behind them, require energetic specific medica- tion. Mercurials may best be given by injection or inunction. and the iodides in gradually increasing dose by the mouth. Prophylaxis may be best accomplished by increasing our knowledge of how to eradicate syphilis from the system in its early stages. In the depressed form, change of scene, travel. In the stages of excitement and exaltation, quiet surround- ings, sedative remedies, bromides, chloral, etc., in sufficient doses to maintain the nerves in a quiet state and permit sleep. Lumbar puncture affords temporary- relief from pressure symptoms in over fifty per cent of cases submitted to operation. —Babcocic. In the first and second periods: B Auri et sodii chloridi...................................0.001 mgm. For one pill. From two to thirty daily. —Boubila. Paralysis, Infantile Spinal. Poliomyelitis anterior or myelitis of the anterior horns, has a characteristic sudden onset. It affects children, usually under three and from this up to five years of age, who were previously in good health* Just before the attack there may be feverislmess, headache, perhaps pain in the limbs. Convulsions are rare. The paraly- sis, which may affect many7 muscles at first, subsequently be- comes restricted to certain groups. It reaches its climax within twenty-four hours. The limbs of the lower or upper extremity or one in each may be the seat of the paralysis. Pain may be an early symptom, though sensory disturbances are usually absent and the intelligence is not affected. 588 the practitioner's manual. Diagnosis is attended with little or no difficulty. The par- alyzed limb is flaccid with absence of reflex. There is rapid wasting of the patient, whose muscles give reaction of degenera- tion. The mental state remaining undisturbed points unmis- takably to disease of the anterior horns. Differentiation.—In paralysis due to injury at birth the brachial-plexus and facial-nerve distributions suffer. That due to diphtheria shows difficulty in swallowing with regurgitation of food by the nose. That due to measles is paraplegic and there is the history to guide. In rachitis there is pseudo-paresis of somewhat similar nature but not a true paralysis. Other signs of rachitis, in- cluding hypersesthesia and much sweating, will be sufficient for the differentiation. From peripheral neuritis, by the absence of nerve pains and nerve tenderness. Choreic paralysis has characteristic move- ments. Paralysis of sudden onset, following the slightest traumatism and attended with great pain, is distinguished from that due to partial dislocation of the head of the radius by the absence of the pathognomonic sign of the latter, viz. impossibility of supination. Infantile I Jem i]>legia. Limbs rigid. No reaction of degeneration. Arm and leg of the same side affected. Bladder and rectal disturbance. Atrophy of all muscles affected. Atrophy late. Mental disturbance. Reflexes exaggerated. Infantile Spinal Paralysis. Limbs flabby. Reaction of degeneration Arm, and leg of opposite side, as a rule. None. Of some only. Early. None. Lost. —M. Allen Starr. Acute atrophic spinal paralysis of the adult is a very rare condition, chiefly to be differentiated from multiple neuritis. The diagnosis is the same as that given for the infantile form. There is, however, more commonly vomiting; head symp- paralysis, infantile spastic. 589 toms are less marked and resulting deformities less con- spicuous. Prognosis is unfavorable for complete and lasting recovery, though improvement is often very great. Deformities, such as kyphosis, lordosis, scoliosis, knock knee, rigid joints, and dis- torted extremities, may result. The paralysis abates in the inverse order to that in which it began. The limb last involved will be the first to show improvement. Landry's paralysis, which is infrequent in childhood, does not present the same febrile and trophic manifestations. Treatment.—If an early diagnosis has been made, anti- febrile measures may be taken and cold applied along the spine. When paralysis occurs, wrap the child in cotton wool and put at absolute rest. After the acute stage, galvanism ; the large sponge electrode covering the area supposed to be implicated, the opposite pole being applied to the paralyzed parts. To keep up nutrition, faradization, massage, baths. For contractures and relaxation of muscles, orthopaedic ap- pliances. Keep in quiet room; give small doses of antipyretics; cold applications and mild counter-irritants over the affected portion of the spine; small doses of calomel.—Courtney. Paralysis, Infantile Spastic. This is a congenital paraplegia, affecting all four extremi- ties, but especially the lower. It occurs in those of premature birth. The term "Little's disease" would appear to include not only conditions arising from asphyxia neonatorum, but also in- stances of general rigidity occurring at or shortly after birth. The following types are distinguished by Massalongo: (1) General spastic rigidity; (2) paraplegic rigidity; (:>) bilateral spastic hemiplegia; (4) bilateral athetosis; (5) congeni- tal spastic chorea. 5M the practitioner's manual. Convulsions may occur soon after birth and subsequent lack of intelligence may be noted, amounting at times to a condition of idiocy. Differentiation.—Spasmodic tabes is distinguished by being an affection of adolescence and one which tends to grow worse. Treatment.—Since syphilis may be an etiological factor, a course based upon this presumption may be found to give the best results. Massage, cod-liver oil, and calcium lactophosphate. Injec- tion of strychnine into the muscles.—Bartholow. Paralysis, Primary Spastic. This primary7 lateral sclerosis is a chronic degenerative proc- ess affecting the cord. There are loss of motor power, spasmodic contraction of muscles, exaggerated reflexes, and a peculiar gait, the result of rigidity7 and spasm. Diagnosis.—The affection may be of congenital origin and here the fingers are widely separated and in attempts to grasp an object go through a series of irregular movements. The foot drags and as the toe catches spasmodic contraction is excited. Differentiation.—Absence of wasting, exaggeration of pa- tellar reflex, and the peculiar rigidity of muscle distinguish it from pseudo-hypertrophic paralysis. In the latter, too, impair- ment of locomotion increases, while in this affection it decreases. From locomotor ataxia, by the lack of painful crises, shoot- ing pains, and eye symptoms. From hysterical paralysis, byr the spasmodic rigidity and ex- aggerated reflexes. Parotitis. Mumps, or epidemic parotitis, is more likely to be confounded with an acute swelling of the lymphatic nodules beneath the ear and behind the ramus of the jaw than with any other proc- PAROTITIS. 591 ess. The latter, however, presents a tumefaction whic does not extend forward toward the zygomatic arch. There is less pain on chewing; it is not intensified by sour substances; the swelling is smaller, comes on less abruptly, and does not tend to involve the opposite side. The lobe of the ear corresponds to the centre of the swelling in mumps, while in enlarged lymph node the tumefaction is located farther down and backward. The lobe of the ear is ele- vated, and the tip of the finger can no longer be inserted in the groove behind it. The subsequent course may have to be relied upon to clear up the diagnosis when the parotid has escaped involvement and the sublingual and submaxillary glands are alone implicated. Parotitis not of epidemic nature and not going on to suppuration is reported by W. S. Morrow as occur- ring in pelvic disease. In the symptomatic form evidences of suppuration are usu- ally soon manifest. It may be a sequel of influenza. Prognosis is good, but a severe form of nerve deafness may result. In rare instances the ovaries, labia majora, or breasts may swell. Treatment.—Avoid exposure, which, in the case of boys, may favor metastasis to the testes. Mild cathartics. Liquid diet. B Tinct. belladonna?, Tinct. aconiti, Tinct. opii..................................................aa 3 iv. M. S. Apply several times daily over the swelling with the finger tips or a camel's-hair pencil. Or— B Ichthyol, Plumbi iodidi..........................................aa gr. xlv. Ammonii chloridi..................................... „r xxx Adipis.................................. z j M. S. Apply three times daily and cover with a cotton-wool dressing. —Trouchet. 59'2 THE PRACTITIONER'S MANUAL. For relief of pjain and swelling and to ward off nerve deaf- ness, jaborandi.—Dundas Grant. R Olei hyoscyami, Olei anthemidis.......................................aa § i. Vini opii (Sydenham's laudanum)........................ § i.-j-3 ij, M. S. Apply and cover with cotton. As mouth wash and to irrigate the ear : R Thymol....................................................gr. iv. Acidi carbolici.............................................gr. xv. Olei eucalypti.............................................. fi[ cl. Aqua?...................................................... 0 ij. M. S. For local use. In symptomatic parotitis, poultices, fomentations; incision when suppuration. General stimulation and tonics. Turpentine is said to be a specific. Internally: R Sodii salicylatis..........................................gr. lxxv. Sodii benzoatis...........................................gr. cl. Syr. aurantii flor..................................... .. § i. Aqua? tilise (linden water)................................ § iv. M. S. Teaspoonful t.i.d. Pericarditis. Friction fremitus, though not always present, may be detected by palpation, especially in the fourth intercostal space as the patient leans forward. Over the same area is heard on auscul- tation a friction sound described as a grating or scratching and as though close to the ear, especially while the patient sits or stands. The impression is made by this to-and-fro rubbing sound that it is superadded to the normal heart sounds. It is quite frequent during the course of pneumonia. Diagnosis.—Scarcely any affection is more commonly over- looked. The symptoms are masked by the primary disease, and the diagnosis rests chiefly upon physical examination. The friction sound of acute pericarditis without effusion is apt to be looked upon either as a pleural friction or as an or- ganic heart murmur, especially that of a double aortic affection. PERICARDITIS. 593 When it is found not to be transmitted, aortic disease may be thrown out of question. The absence of pleuro-pneumonia and phthisis helps us to exclude a pleuro-pericardial sound. It is apt to be decreased on deep inspiration, though it may be increased, and is uninfluenced by posture. Pericarditis with effusion produces prominence in the heart region, in children especially, and the impulse given on palpa- tion is often in proportion to the extent to which the effusion has gone. If effusion is small there may be no symptoms. Upon applying the ear or the stethoscope the friction sound be- fore present is found to have disappeared. According to the direction of the pressure exerted by the fluid, we may find dysp- noea and cough, dysphagia, aphonia, and alteration in the heart beat. Besides pressing down of the liver, dulness over the sternum and dulness in the fifth intercartilaginous space upon the right side (Rotch's sign), we may find, in pericardial effusion of considerable extent, tubular breathing below the right mam- mary region as well as at the outer side of the angle of the scap- ula upon the left side. The diagnosis is rendered probable by the presence of such predipsosing causes as gout, rheumatism, chronic nephritis, scorbutus, and diabetes. Pulsus paradoxus is significant of the presence of pericardial adhesions, or, rather, of the dilatation that succeeds the adhesions. The pulse is small and feeble during inspiration (may disappear), assuming greater strength during the period of expiration.—Musser." The symptoms arising from pericardial adhesions as well as the physical signs are largely those of preponderating hyper- trophy, or dilatation in a given case. An early sign is a noisiness of the second sound upon the left side of the sternum, preceding the friction by from one to three days. 38 594 the practitioner's manual. Chronic adhesive pericarditis may result from the acute. Visible retraction of the back in the region of the eleventh and twelfth ribs, especially upon the left side, coincident with cardiac systole, is a symptom of decided import in this condition. —Walter Broadbent. The existence of pulsus paradoxus, retraction of the apex during systole, and a swelling of the veins of the neck during inspiration make the diagnosis of concretio pericardii or ad- hesive pericarditis practically positive. Differentiation. —Dilatation of the heart is the condition most likely to be mistaken. The dulness does not extend up- ward in dilatation unless the right auricle is enlarged. The area of dulness, too, is of square outline in dilatation, while in effusion it is pear shaped with the apex pointing upward, and the heart sounds over this area are muffled. The right lower angle of the pericardial dulness extends to the right (outward), and is not curved inward toward the sternum as is the normal cardiac duless.—Ewart. The area of dulness is commonly that of the normal heart equally extended in all directions.—F. C. Shattuck. In other words, the dull area extends beyond the apex beat if the latter can be felt. In dilatation this is not so. At the angle of the scapula as the patient sits there is a small area of dulness over which bronchial breathing is heard. If the patient now bends forward, the physical signs of consolidation, includ- ing increased fremitus, disappear, but return when the previous position is resumed. If absorption takes place, the friction sound may return. In chronic aortitis the second sound is more marked, louder, and more metallic upon the right side. Anaemic and extracar- diac sounds must also be excluded.—Josserand. Pericardial are distinguished from endocardial murmurs by their quality (rubbing, grating, creaking), their superficial char- acter, their limitation to a small area, their changeableness in pericarditis. 595 position and intensity from hour to hour, their greater intensity when the patient leans forward or fills the lung, or, when the chest wall is pressed upon, their want of synchronism with the heart sounds.—Delafield. Hydropericardium is excluded chiefly by the history. Prognosis.—Based upon one hundred cases, of which forty- three were fatal, the prognosis must be considered grave.— G. G. Sears. There mayT be collapse of the cervical veins occurring during diastole. —Friedreich. That of alcoholism, pneumonia, and chronic Bright's is much more serious than that of rheumatism. Treatment.—Rest, revulsives, relief of pain by morphine. If occurring during an attack of acute rheumatism apply a blister over the precordial region.—Billroth. Salicylates do not seem to prevent the occurrence of pericar- ditis.—Sears. With effusion : B Infusi digitalis.............................................. ? jv Potissii acetatis.............................................. 3 ji Spir. aetheris nitrosi.......................................... 3 h Aqua? cassia?................................................. 1 iss. M. S. 3 ss. every fourth hour. —KlLGOUR. If much pain : B Ext. aconiti fld.......................................... 3 ss Vini antimonii..................................... z ss M. S. Gtt. x.-xv. t.i.d. —Rust. Hahn's diuretic liniment: B Olei terebinthina?.......................... z \ Vitelliovi.......................... '.'. ''^'.'.'''.'.''.'.'''.'.'.'. No. ij. Aqua? mentha? piperita?................................. z xx M. S. Rub over the kidneys t. i.d. Flannel around the loins. — Kraus. 596 the practitioner's manual. B Tinct. veratri viridis, Tinct. opii.................................................aa 3 b Sodii bicarbonatis............................................ 3 ij Sacch. albi................................................... 3 iv. Aqua?..................................................qs. ad ? vi. M. S. Tablespoonful every two or three hours. —J. L. Lynch. Paracentesis.—Tapping the pericardium has now been re- sorted to in one hundred cases, with only one death reported from the operation. If the fluid is purulent, drainage is required. The puncture may be made in the left costo-xiphoid angle, a moderate-sized cannula and trocar with switch attachment being thrust upward and backward. Blisters are of no use. —F. C. Shattuck. Peri-Encephalitis, Acute. The distinction between this condition and acute mania is difficult. The former has higher fever and the symptoms are all of a more intense nature. Septic peri-encephalitis is a condition often present in so-called puerperal insanity. Differentiation.—In confusional insanity evidences of con- fusion are early present and hallucinations are more common and more pronounced. Prognosis.—Unfavorable both as for life and for recovery with unaffected mind. Treatment.--Phlebotomy in robust, full-blooded subjects. Blisters. Cold to the head. Drastic cathartics. Ergotin, gr. xv. hypodermatically every eight hours.—Salivetti. Quiet restraint, concentrated food, stomach tube if neces- sary. Hyoscinae hydrobromas, gr. TV Repeat every six hours. —Wood and Fitz.' peritonitis. 597 Peritonitis. The signs of inflammation of the peritoneal covering of the intestines vary as it occurs in perforation, rupture of abscess into the peritoneum, or as part of a general infectious process. In the latter the fact of abdominal distention following rapidly upon persistent and obstinate vomiting gives us one of the most positive indications for this diagnosis. Diagnosis.—The onset of acute peritonitis is chiefly char- acterized by pain, abdominal tenderness, and fever. The early tympanites may later on give way to a dull percussion note. The legs are usually drawn up and the shoulders elevated. Respiration is often of the costal variety. Coughing is re- strained. The affection may exist without pain and without tender- ness. —Delafield. Tuberculous peritonitis, when it is confined to the lower sur- face of the diaphragm, may not show tenderness on pressure. It commonly occasions secondary pleuritis by traversing the dia- phragm, and when it does so it furnishes a strong point in favor of the tuberculous origin. Ascites is a common symptom. A circumscribed erythematous zone about the umbilicus is pathognomonic.—F. P. Henry.10 Differentiation.—Various forms of colic at times simulate closely peritoneal inflammation. Renal colic is more sudden in onset, more localized in the kidney7 region of one side, and is soon diagnosticated by urinary analysis. Gall-stone colic is likewise more restricted in area; fever is slighter or entirely absent; gastro-intestinal pains are relieved by pressure, while those of peritonitis are intensified. In acute intestinal obstruction vomiting may be omitted, the pain is more paroxysmal and more localized, while the pulse gives an indication by an occasional slow heart beat. The fever, 59S the practitioner's manual. too, is often not pronounced in the early stages of obstruction. Difficulty is augmented when the conditions coexist. Not in- frequently obstruction leads to peritonitis with or without per- foration. The origin of general peritonitis in a diseased appendix must be constantly kept in mind, and, in women, the presence of diseased adnexa must be remembered as a possible source. Typhoid fever is to be differentiated from the comparatively painless tuberculous peritonitis. Peritonitis may complicate typhoid with perforation. In salpingitis, vomiting and pronounced distention are ab- sent. The knowledge of a plausible cause for the existence of peritonitis greatly simplifies matters. When other means, in- cluding the use of the catheter and the use of the aspirating needle to determine the nature of the exudation fluid, have been exhausted, resort may have to be had to exploratory laparotomy. Perforative peritonitis of gastric ulcer may be distinguished from gastric ulcer itself by the sudden and violent onset, the severe pains being located in the epigastrium, tension of the upper part of the abdomen, and absence of nausea and vomit- ing. In pelvic cellulitis retraction of the thigh is an important symptom never seen in pelvic peritonitis. Phlebitis and en- largement of the. limbs are also present. An infiltration into the lateral wall of the vagina and continuous with the lateral vaginal vault is likewise a highly characteristic sign.—Van de Warker. Differentiation is also to be made from embolism of the superior mesenteric artery, rupture of an abdominal aneurism, acute pancreatitis, and so-called hysterical peritonitis. Prognosis.—A week to ten days is the usual limit in acute general peritonitis. Early collapse and coffee-ground vomit portend an early and bad ending. Regurgitant vomiting is to be placed among the unfavorable signs preceding death; like- wise a rapid rise in the pulse rate. Among unfavorable indica- PERITONITIS. 599 tions are to be reckoned thready or gaseous pulse, the inability to secure bowel motion, persistent high temperature with livid- ity. Recovery may follow the tuberculous form. Treatment.—The danger arising from absorption of toxic products into the system calls for assistance in elimination. In- testinal drainage, at the present day, holds the important place formerly occupied by opium. Saline purgatives find their indi- cations in an occluded intestine and especially if irritating food is suspected as a causative factor. If perforation is the cause purgatives should be omitted. In suitable cases, deodorized tincture of opium may be given by the mouth, but at least the alternate dose should be sul- phate of morphine (gr. ■£ to ^) hypodermatically. Enough opium may be given to produce continuous decided narcotism, but the patient may be carefully watched by an attendant and the drug suspended whenever the narcotic symptoms become pronounced.—H. C. Wood.9 In giving opium preparations the breathing should be the guide and respirations should not be permitted to fall below twelve to the minute.—Delafield. In advanced peritonitis laparotomy and irrigation give such uniformly fatal results that it is safer to accept the slim chances of recovery under purely medical care.—Richardson. The best treatment is by the administration of large doses of saline cathartics (sulphate of magnesium, 3 ii. every two hours until the bowels have been opened eight or ten times).—Keen. All laxatives by the mouth are to be avoided as long as there is no possibility of the alimentary canal being the source of peri- tonitic symptoms.—H. R. Fitz. In tuberculous peritonitis, mercurial ointment to the ab- dominal surface, especially in children.—Fagge. Applications of tincture of iodine. If pressure symptoms arise, tapping. Evacuate all fluid by incision. The most favorably reported 600 THE PRACTITIONER'S MANUAL. cases are those in which an acute or subacute inflammation with ascites has been operated on simply by abdominal section with evacuation and immediate closure.—Abbe. Li grave cases with distention intestinal incision and drain- age.— Mixter. In localized pelvic peritonitis, operative treatment (pref- erably by the vagina) after saline cathartics and hot douches. Of vermiform-appendix origin, and when of other origin resulting in abscess, and in general septic peritonitis, operation is called for.-—Cole. Peritonitis, Chronic. Instead of ending fatally within a limited number of days, the inflammation may pursue a chronic course and death may occur only at the end of a number of weeks. Or circumscribed areas of inflammatory exudation may become encapsulated, as it were, and communications be established through which the contents may escape into the adjacent organs. There is almost always some preceding visceral disease, such as tuberculosis or cancer. Perihepatitis is a form of localized inflammation frequently assumed by peritonitis and associated with ascites from com- pression of the liver. Perleche. This contagious affection of the lips and regions about the mouth, with Assuring at the commissures, is generally seen in epidemic form in schools and institutions; also in infants. It is distinguished from eczema and syphilis by the above facts and by the greater amount of swelling present, followed by the de- velopment of a white membranous covering over the ulceration. It runs a course of about three weeks and relapses are not in- frequent. Treatment.—At first remove crusts if present and apply to commisures of the lips weak nitrate-of-silver solution. PERTUSSIS. ()01 Or— B Acidi borici..................................................... * Petrolati........................................................ 10 Subsequently: B Cupri sulphatis.......................................... 0.20 cgm. Ext. thebaici............................................ 0. 02 cgm. Petrolati............................................... 30 gm. And wash morning and night with: B Aluminis.................................................. 3 gm. Spir. camphorae............................................ 10 Aqua? destillata?............................................ 80 Or- B Hydrargyri sozoiodol........................................... 1 Petrolati....................................................... 100 Or— B Potassii permangauatis....................................... 1 Aqua?...................................................... 1,000 Or— B Methylene blue *................................................ 1 Water.......................................................... 30 S. Pencil on. Nursing-bottles should receive unusual care. Pertussis. Whooping-cough is of paroxysmal nature with succeeding spasmodic closure of the glottis, which is attended with an inspi- ratory noise, from which the name is derived. In the first stage the child's condition is scarcely to be distinguished from that of ordinary acute catarrh with abundant discharge from the mucous surfaces. Often slight bronchitis in the larger tubes can be made out. The cough is dry7, but becomes more frequent and occurs in more distinct paroxysms. A peculiar puffiness of the face, especially about the eyes, is frequently to be noted. Diagnosis.—It is in the second stage that the characteristic "whoop" occurs. This is a crowing inspiration following a suc- cession of expiratory efforts. The attack of coughing differs 60-2 THE PRACTITIONER'S MANUAL. from that of ordinary colds by the marked redness of the face. flow of tears from the eyes, and discharge from the nose. If the child is old enough to be about the room, it clutches some object or piece of furniture when the attack comes on, perhaps burying its face during the repeated expulsive efforts, which often end in an attack of vomiting. If the child has lower incisors there will often be an ulceration at the frenum of the tongue. It is not uncommon in severe attacks and especially in certain epidemics to observe purpuric spots upon the skin especially of the face and upon mucous membranes. Slight hemorrhages may occur in these cases, especially during the access of cough. The intervals between the paroxysms are at times quite long and sometimes the child appears well between the coughing-fits. Even when there are only two or three attacks during the day the number is apt to be increased at night. When nightly attacks decrease and the general symptoms improve the child is said to be in the third stage. If in doubt at first, bring on a paroxysm by depressing the tongue. Differentiation is very difficult before the "whoop" has developed and in those instances in which it is wholly lacking, as in very young children. Prognosis.—The course, usually of six weeks' duration. may be extended for several months. The mortality is chiefly from complication with broncho-pneumonia. Treatment.—Therapy is usually a thankless task. The chief object of treatment must often be to diminish the severity and frequency of paroxysms until the natural course has been run. B Belladonna leaves......................................... gr. viij. Distilled water............................................ I v. Antipyrin................................................. gr. xv. Syrup of gooseberry....................................... 1 i. M. S. A teaspoonful every two hours for a child of five years. PERTUSSIS. 603 B Sulfonal..................................................... o qo Creosoti................................................... 0.50 Syr. tolutani, Aqua?.....................................................aa 30 M. S. Two teaspoonfuls every two hours. B Tinct. belladonna?........................................... 3 j j Tinct. Valeriana?, Tinct. digitalis..............................................aa 3 i. M. S. For cliildren under five years of age five to ten drops should be daily administered, increasing within one week to from thirty to sixty drops daily, in divided doses. Whooping-cough in adults: B Bromoform......................................-....... 15 partg Tincture of gelsemium................................. 16 « Syrup of lactucarium................................... 120 " Powdered gum arabic.................................... a sufficiency. M. S. Three or four teaspoonfuls to be taken in the course of a day. —Bancock. B Bromoform................................................ Rtt xl Green tinct aconite.................................... „.tt j Syr. codeine (Br. P.)................................ 3 jsg Syr. tolu, Syr. red poppy...........................................aa § {vsg Alcoho1.................................................... 3iiss. Dose according to age. B Antipyrin................................................... gr gg Sodii bromidi....................................... er ii M. S. Every two hours to a child of eight months. To a child of from two and one-half to four years: B Antipyrin.............................................. gr ^ Sodii bromidi................................... ii -iii Every two hours. n .. TT —Kerley. Cauhon. —Hygroscopic. For administration by day : B Atropine. ... x j S. Every two to four hours. " ' " " i^br the night: B Chloral.... ............................................. gr iii —vi Potassii bromidi...................................... v Jx S. Twice during the night. 604 THE PRACTITIONER'S MANUAL. In this way the patient does not become accustomed to either medicine and the dose does not have to be increased. Do not give antipyrin as a routine practice but reserve it for distinct indications—hyperpyrexia, pulmonary congestion, or pneumonia—when it can be combined with infusion of digitalis, as also in nervous excitement and during dentition. During an intercurrent pneumonia the cough of pertussis often subsides.—S. S. Jones. Tussol (antipyrin mandelate) is preferable to antipyrin. The dose is the same.—Behn. B Tinct. belladonna? ......................................... 10 gm. Phenacetin................................................. 5 " Spirit, frumenti............................................ 15 " Ext. fol. castanea? fld....................................... 60 " S. For infants of one year, ten drops. For children of ten years, one drachm every two to six hours. —Lancaster. B Pbenocoll hydrochlorate, Antipyrin..........................................aa gr. viiss. Potassium bromide.................................... gr. vi. Syrup of bitter orange peel, Orange-flower water................................aa gr. 3 vi. M. A child eight years old may take the whole amount, in four doses, in the course of twenty-four hours. —Guaita. Or— R Chinoidine tartrate....................................... 1 part. Distilled water, Syrup.......................,...........................aa 75 parts. M. S. A tablespoonful every three hours. —Marius Martin. Ouabain, gr. -oVo to -rro- in water every three hours for a child of five years. Caution.—Gr. - »S. Ammonii bromidi............................ ,j Syr. simplicis.................................'. .'.'.'.".'.'.'.'.q.s. ad 5 ij. M. S. Teaspoonful every two, three, or four hours. —Stidham. 606 THE PRACTITIONER'S MANUAL. Or— R Codeina? sulphatis......................................... gr. i. Acidi carbolici puri....................................... gr. viij, Syrupi limonis, Syrupi simplicis........................................aa 3 ss. Glycerini puri............................................ 5 i. S. A teaspoonful every two or three hours. —Hughes. Or— R Hydrogen peroxide (10 vols.).................................. 3 vi. Glycerine.................................................... 3 iv. Water.....................................................ad § iij Dose, half a fluid ounce, in a wineglassful of water, five or six times a day. —ElCHARDSON. Or— R Dried thyme.............................................. 5 parts. Boiling water............................................ 12 " M. Infuse for ten minutes, sweeten to the taste, and give a tablespoonful every hour. R Thyme......................................................... 100 Aqua?......................................................... 700 M. ft. infus. et adde : Syr. altba?a?.................................................. 50 M. S. 3 i. eight to twelve times daily. —Moevius. Or— R Olei succini.................................................. ^1 x. Pulv. acaciae................................................ 3 i- Syr. aurantii flor............................................. 3 ij. Olei anisi................................................. T|l' ij Aqua?................................................q.s. ad §i. M. S. Teaspoonful every four hours. —MURRELL. Or— R Tinct. digitalis......................................... m xvi. Antipyrini.............................................. gr. xxxij. Tinct. opii camphorata?.................................. 3 ij Syr. tolutani...........................................ad 1 ij. M. S. 3 i. t.i.d. for a child two years of age. —Koplik. PERTUSSIS. 607 Or— B Bromoform............................................. 48 gtt. Sweet-almond oil....................................... 20 gm. Powd. tragacanth....................................... 2 gm. Powdered acacia........................................ 4 gm. Cherry-laurel water..................................... 4 gm. Distilled water..................................to make 120 gin. The bromoform should be well shaken with the almond oil and then the other ingredients added. A teaspoonful of the mixture contains two drops of bromoform. Give four drops in twenty-four hours for each year of age.—Marfan. Rectal injections containing two litres of carbon dioxide mixed with a few centigrams of pyridin, repeated after each access of cough, or at intervals of a few hours. The worst cases yield to treatment in a week.—Bergeon. Or, quinine, one centigram for each month of age and ten for each year.—Fischer. local.—Introduce into the back of the mouth a small tam- pon of cotton saturated with a 1 to 1,000 solution of corrosive sublimate, and press it against the lower part of the tongue in such a way that the liquid will bathe the epiglottis and the neighboring mucous membrane. One of the greatest benefits derived is rapid cessation of the vomiting. The patients lend themselves very7 readily to the treatment and become rapidly accustomed to the introduction of the tampon. Never make more than one application upon the same day.—Rabinschek. Apply to the glottis with a fine sponge every four hours and once or twice during the night: B Resorcini puri.................................................. 2-3 Aqua? destillata'............................................... ]00 M. —ROSKAM. To abort an cdtack : R Resorcini...................................................... 10 Aqua?......................................................... 100 S. Apply to the perilaryngeal mucus membrane every two or three hours. —MONCORVO. bOS THE PRACTITIONER'S MANUAL. Insufflations into the nasal fossae five times daily of: R Powdered benzoin, Bismuth salicylate...........................................aa 10 Quinine sulphate................................................ 2 —MOIZARD. R Tr. belladonna?......................................... gtt. xxxij. Acid, carbolici (C. P.).................................. gtt. viij. Ammonii bromidi...................................... 3 ij. Potassii bromidi....................................... 3 vi. Aquae mentha? pip...................................... § iij. M. S. Spray this in child's throat every two hours. —Caldwell. R Acidi carbolici............................................. 0.03 Sol. menthol (4 per cent)..................................... 20 Sol. cocaine (3 per cent)...................................... 15 Aqua? laurocerasi............................................ 60 S. Spray the throat every hour. —SCHMTD. Nasopharyngeal insufflations: R Quinina? sulphatis....................................... 4 parts. Resorcini................................................. 1 part. Pulv. sacch. albi.......................................... 25 parts Five or six times daily. —Lauriaux. For inhalation, ozone, two to four times daily, for from ten to fifteen minutes each time.—Labbe and Oudin. Hypersulphurous baths, 75 cgm. of polysulphate of potas- sium per litre being employed. The temperature of the bath should be 36° C. and the duration twenty-five to forty-five min- utes, according to the age. Fifteen baths are, at most, required. —JOSSET. R Ichthyol......................................................... 1 Glycerin...................................................,..... 3 M. S. As a local application to the nares. Pharyngitis, Acute. Catarrhal inflammation of the pharynx or angina simplex may be preceded or not by catarrhal process of the contiguous parts. The constitutional disturbances are slight but may in- clude a moderate rise of temperature. PHARYNGITIS, chronic. 609 The diagnosis is of importance in distinguishing this mild affection from the beginning diphtheritic or deeper-seated phlegmonous inflammations. Both may be excluded if the temperature remains low and the other symptoms do not become rapidly aggravated. Retropharyngeal abscess developing in young children gives a rigidity to the neck associated with fluctuation in the posterior pharyngeal wall with marked difficulty in swallowing and diffi- cult respiration. Pharyngitis, Chronic. There is here a dryness of the throat leading to frequent swallowing. An expectoration of whitish viscid mucus occurs in the early7 morning. Inspection shows the posterior pharyn- geal wall dry and shiny and the vessels injected. B Tinct. aconiti.............................................. gtt. xv. Acidi hydrocyanici diluti.................................. tti, xx. Liq. ammonii acetatis..................................... § ij. M. S. Teaspoonful every fifteen minutes for four doses and then every hour or two hours. —Delafield. Wlien there is ulceration : B Tinct. iodi, Tinct. opii.................................................aa. 3 b Aqua?........................................................ z vj_ M. S. Gargle ; shake well. Use thrice daily. —Ellis. For a child: B Tinct. ferri chloridi..................................... ni xxiv. Potassii chloratis......................................... gr Xxiv. Syr. zingiberis........................................... ? \ A9use.............................................q.s. ad 1 iij. M. S. 3 i. every two hours. —Powell. In the chronic form, proper outdoor exercise and indoor ven- tilation. Avoidance of excesses. B Argenti nitratis........................................... „r xj Aqua? destillata?.................................. z j M. S. Paint over the shiny surface. 39 610 THE PRACTITIONERS MANUAL. To relieve excessive dryness, ext. cubebae fld., gtt. x. mi sugar three times daily.—Seller. In acute form as a lozenge : R Ext. eucalypti............................................ gr. xxx. Sodii biboratis............................................ gr- x. Pulv. pimenta?........................................... gr- vij. Ext. glycyrrhiza?......................................... 3 iiss. M. ft. massa in trochisci No. xxx. div. —BOSWORTH." When cough, with raw and irritable throat: R Codeina?.................................................. gr- v. Ext. catechu.............................................. gr. xxx. Ext. glycyrrhiza?.......................................... 3 iiss. Ft. massa in trochisci No. xxx. div. —Lefferts. When secretions are thick and tenacious : R Ammonii muriatici....................................... gr. xxx. Pulv. ipecacuanha?........................................ gr. ij. Pulv. capsici.............................................. gr- ss. Ext. glycyrrhiza?.......................................... 3 iiss. Ft. massa in trochisci No. xxx. div. —Lefferts. In the atrophic form : R Pilocarpine muriat......................................... gr. ij- Aqua?, Glycerini.................................................aa § l. M. S. 3i. t.i.d. —Sajous. R Sodii biboratis.............................................. bO gm. Aq. laurocerasi............................................ 25 Glycerini................................................... 15 M. S. To apply locally. —VlDAL. R Zinci sulphatis.......................................... gr- x.-xx. Aqua? destillata?......................................... 3 ' M. S. Apply every two or three days. e —BOSWORTH. In chronic rhino-pharyngitis : R Menthol......................................................... ' Oil of sweet almonds, or Liquid vaseline................................................. Apply locally with a brush. —Hamon de Fougeray. 1HE PLAGUE. Oil B Sodii bicarbonatis Potassii iodidi... Mentholi......... Petrolati......... M. S. Locally t.i.d. .-I Spray for Pharyngitis Sicca."" B Carbolic acid.............................................. gr. Ix. Tincture of iodine, Tincture of aloes, Tincture of opium........................................aa gtt. x. Glycerin....................................enough to make § i. M. S. To be used as a spray several times a day. The Plague. An isolated instance of the contagious and epidemic affec- tion known as bubonic plague may have so many symptoms in common with typhoid that, were it not for the occurrence of the bubonic swellings in the groins, axillae, and elsewhere, and the fact that the mind clears as the symptoms develop, one might be led into error. There are cerebral and pulmonary forms as well. The only characteristic feature of the disease would seem to be the lymphatic-gland swellings, especially those of the groin and armpit, and, in the vast majority of instances, death occurs before this stage is reached. Diagnosis.—After an incubation of from three to six days the onset is sudden, with vertigo, headache, and a dull, stupid, stricken look, well designated fades pestilentialis, due rather to muscular relaxation than to anxiety. The pulse, at first strong, soon grows feeble and very rapid. After a few hours or days there are violent chill, high fever, vomiting, abdominal pain, and perhaps diarrhcea, delirium, and coma. An attack may be of mild character, not interfering with the patient's oc- cupation (pestis minor). Carbuncles occur in two or three per cent of the cases. The ocular conjunctiva is usually con- gested. ....... gr. vi. ...... gr. xvij. ....... 3 b ,q.s. ad 1 i. 612 THE PRACTITIONER'S MANUAL. Nervous symptoms are among the most constant and impor- tant. Insomnia maybe obstinate and distressing; memory is defective. A "thick-tongued" manner of speech and a mus- cular inco-ordination, at times simulating paresis, are noted in many instances. The Kitasato bacillus is found in the buboes, lymph nodes, and fasces. It is a thick, short rod -with rounded ends, some- times in chains and somewhat motile. It grows readily on blood serum, forming white iridescent colonies within forty- eight hours. In doubtful instances cultures on agar can be made. The bacillus stains more deeply at its extremities. Differentiation from typhoid is well shown in the follow- ing table, prepared by Surgeon-Captain Hojel, of Bombay: Plague. 1. Onset sudden, usually ushered in by a well-marked rigor. 2. Temperature shows a high initial rise in most cases, followed by a marked remission to normal or a little above or below it on second, third, or fourth day. 3. Pulse large and full at first, peculiarly soft, great want of sharp- ness in stroke, very compressible at an early stage, and dicrotic ; butthedicro- tism is not very easily recognized by the finger. 4. Aspect dull, heavy, and apathetic ; has a peculiar stricken look 5. Eyes dull and muddy looking, conjunctiva? suffused, pupils mostly normal, general flushing of face. 6. Diarrhoea simple, but very offen- sive (when present). 7. Delirium and other cerebral dis- turbance early, and great prostration from the first. s. Abdominal distention early, third, fourth, fifth day !). Eruption not readily effaced, a "deep red color, petechial." 10. Severe lumbar pain in many ca-es. Typhoid. Insidious in onset, may liave "chills." A gradual rise to end of first week, with slight daily remissions. Pulse moderately large, walls of vessels relaxed, beat sharp and short, dicrotism well marked and easily dis tinguished. Not so, but patient often has a bright energetic appearance. Eyes bright and clear, no suffusion of conjunctiva?, pupils dilated, a cir- cumscribed malar flush. Diarrhoea "pea soupy." Later, toward end of severe cases. Later. Eruption readily effaced, "rose-red color, non-petechiab" Slight. THE PLAGUE. 6l;j Glandular fever, described by Pfeiffer, and referred to on page 320, might be confounded in name with bubonic fever; but the symptoms differ and the course of the former is much more benign, so that confusion could otherwise scarcely arise. Pneu- monia may come into question by reason of a preponderance of respiratory symptoms, and deaths have been attributed to this disease in which post-mortem bacteriological investigations have demonstrated the error. There is a variety of plague in which pneumonia is the primary condition. Alcoholism may be simulated by the speech, stupor, and by the subsequent delirium. Prognosis.—The malignant form is fatal within twenty-four hours, and in the ordinary form 90 per cent of untreated cases succumb. Serum therapy has reduced the mortality to 50 per cent. Hemorrhages in certain epidemics have given to the dis- ease the name "black death/1 In the early days of the Hong Kong epidemic of 1894 the mortality among the Chinese was 100 per cent; Japanese, 60 percent; and Europeans, 1 s.2 per cent.—Lowson. Prophylaxis.'—To prevent the disease in the other members of a family, inject the serum in all exposed.—Roux. Hygiene, pure water, isolation, disinfection of dejections, cremation of dead bodies.—Kitasato. Treatment.—Yersin serum, two drachms injected subcu- taneously. Thirty cubic centimetres suffice for a cure. The more ad- vanced the case the more serum is required. Most rapid results are obtained when treatment is instituted early, as upon the first day of the disease, and we may expect better results from more perfected and stronger serums. As a curative agent it seems to succeed unless begun too late. For active delirium, cold applications to the head. Hyoscine, gr- ihr hypodermatically, or morphine with atropine. For the fever, cold spongings, wet pack, cold drinks, or cool baths. 614 THE PRACTITIONER'S MANUAL. /// collapse, ether, camphor, musk, strychnine hypodermati- cally, and oxygen by inhalation. As a purgative, calomel, gr. iii.-viii., followed in an hour by saline purge. In diarrhoea, salol, 0.50 cgm.—James Cantlie. Or— R Morphine..................................................... gr. J Cocaine...................................................... gr. \ Make one suppository. As a stimulant, strychnine is held in the greatest favor.— Lowson. Local treatment of the inflamed glands: B Ext. belladonna?, Petrolati...................................................aa p. a?. Apply alone or in conjunction with poultices. When fluctuation is present, open and establish drainage. Nutritious food, free stimulation. Pleuritis. Although the occurrence of sudden pain in the chest, aggra- vated by deep inspiration and attended by fever, is usually an indication of pleurisy, physical signs must be depended upon for the absolute diagnosis. The discovery of friction sounds may be looked upon as pathognomonic of "dry pleurisy" or the dry stage. While intercostal neuralgia and pleurodynia may be thrown but, as a rule, because of the febrile symptoms, the pos sibility of their occurring in a patient who already has fever from some other cause must not be lost sight of. Sero-fibriuous jdeuritis cannot be diagnosticated with cer- tainty until several days after the pain and friction, since the presence of effusion is to be detected only after a sufficient quantity of fluid has been poured out to give physical si^ns upon which the diagnosis must depend. Diagnosis.—It is only the effusions of moderate amount which occasion difficulty in diagnosis. The flatness on percus- pleuritis. 615 sion, displacement of the heart, and especially flatness over the entire lung, make the diagnosis certain. Loud bronchial respi- ration and bronchophony are heard over this area. A moderate effusion is distinguished from consolidation of a lower lobe by percussion. The effusion is lowest at the spine and highest at the axillary line, while in pneumonia the dull area has its highest limit near the spine. In mediastinal tumor there is less diminution in the vocal fremitus, the dulness is more irregular and circumscribed in its upward extension. In mediastinal pleurisy alone, which is very7 uncommon, the circulatory disturbances are pronounced. The area of flatness may extend slightly beyond the sternum on the unaffected side. The differentiation is chiefly7 from pericardial effusion, but, as Whitney says, it would seem as though the characteristic area of flatness produced by the latter would make confusion impossible. Diaphragmatic pleurisy presents great difficulties of early diagnosis. It may occur as a result of rheumatism, and pursue a chronic course. The symptoms point rather to abdominal dis- ease, but the respiration is increased beyond the point usual in affections of the abdomen. Certain points of tenderness have been described as characteristic; one at the insertion of the sterno-mastoid, another in the intercostal space along the margin of the sternum at a point on a level with the tenth rib and one-half an inch from the median line. Aneurism may be simulated by pulsating pleurisy, but the absence of murmur upon pressure and other signs will ex- clude it. Differentiation.—The chief distinction is to be made be- tween this disease and pneumonia. The absence of chill is a valuable aid, but not an infallible sign, since certain pneumo- nias may develop without chill. The friction sound comes 616 the practitioner's manual. early, and, while it resembles the crepitant rale, it is more superficially situated and has an intermittent character, is pres- ent during expiration as well as during inspiration, and if con- fined to one respiratory act alone goes with the expiration, while the crepitant rale is heard only during inspiration. In infants and young children dry pleurisy is said not to exist, but broncho-pneumonia may give signs simulating it. Children from ten to fourteen, according to Holt, may refer pain to the abdomen, while the physical signs are those of dry pleurisy, as in the adult. As adhesions form, the creakmg of leather may be suggested by the friction sound carried to the ear. In pneu- monia the bronchial breathing is best heard over the area of greatest consolidation, while in pleurisy it is most marked at the borders of the flat areas. The diminished vocal fremitus and vocal resonance are in marked contradistinction to the in- crease of both of these habitually found in pneumonia. A most important point is the possibility of changing the outline of flatness byr changing the patient's position; this depending upon the alteration in the fluid level. While in elderly persons the cough of pneumonia may be almost nothing, in others the marked difference in the amount of coughing helps greatly in distinguishing pleurisy from pneumonia; in the former it being sharp and teazing, and in the latter requiring great effort to bring up the tenacious mucus. The so-called " Baccelli sign" consists in our ability to hear the whispered voice transmitted through a serous fluid, while if the exudate be purulent it is not so transmitted. Baccelli says that if the layer is thin and the patient is told to spell a word containing t's and r's, every letter will be heard. In proportion to the fluid's thickness the letters become gradually lost. First the r, then the t sound, and finally all sound conduction disap- pears. An especial nasal squeaking tone of voice (segophony) is not unusual in typical forms of acute pleurisy. A twang-like qual- pleuritis. 617 ity is by no means rare, particularly at the outer angle of the scapula.—Osler. Subphrenic abscess with flatness reaching as high as the fourth rib in front gives a displacement of the diaphragm, whose upper border is invariably level, while that from effusion is never so. New growths springing from the convexity of the liver produce areas of flatness, which only in rare instances simulate the line of flatness in pleurisy. Empyema can be positively differentiated from serous effu- sions by means of the exploratory puncture alone, but intermit- tent high temperature after a week or so, followed by a fall of the fever to a low point and profuse sweating, should cause us to suspect pus. Here the presence of local oedema is a guide of value. Hectic fever, often with marked oscillations, may be absent, and only the slightest rise of temperature accompany decided pus production. By injecting a few drops of a one-per- cent solution of cocaine, the pain of puncture, even in children, may be entirely avoided. The needle should be thoroughly boiled, and be at least one and one-half inches in length, but need not be of larger calibre than the usual hypodermic nee- dle. The point of insertion should be above the diaphragm and well within the flat area; in children, the sixth intercostal space in the axillary line when the pleurisy is on the right side. The etiological variety of empyema is to be determined abso- lutely only by bacteriological examination. If pneumococci are present, they are found in chains made up of lanceolate ele- ments; while streptococci give chains which are longer and less rigid, the individual cocci being round; tubercle bacilli are but rarely made out, either by the microscope or by culture, and inoculation experiments are required for absolute certainty. If no pathogenic organisms or only staphylococci are found, the tuberculous nature is strongly suggested. Prognosis is good in dry and sero-fibrinous pleurisy, except when secondary to some dangerous affection. The effusion 618 THE PRACTITIONERS manual. recurring after aspiration renders the ultimate outcome less favorable; still the effusion may remain for a long time without materially affecting the health. Subjects of sero-fibrinous pleurisy are unquestionably-more prone to contract phthisis. Empyema, while of fatal termination if left without operation, does w7ell under adequate interference, although tapping may have to be resorted to repeatedly. Treatment.—To cut short a beginning inflammation, ap- ply a large blister.—Lancereaux. Sodium salicylate, 3i.-iss. as a daily dose.—Dock. In infants: R Pulv. digitalis............................................ gr. iss. Hydrarg. chloridi mitis.................................... gr. vi. Pulv. gum. acacia?.........................................gr. xvi. M. etft. chart. No. xx. S. Two to five daily. Keep up a moderate, even temperature; liquid diet, mustard poultice, diuretics. If effusion, small blister left for two or three hours, followed by a poultice. For insomnia, chloral or bromides, but no opium. Thoracentesis if effusion is extensive, displacing the heart. In the acute stage: R Potassii acetatis............................................ gr. xv. Tinct. aconiti radicis...................................... gtt. ij. Codeina? sulphatis.......... ...... .......................gr. i Spir. Mindereri........................................... 3 ij, M. S. To be given every three hours. When the pleuritis is of the rheumatic type, add ten grains of salicylate of sodium. To get rid of an effusion of serum, withhold liquids as much as possible and give saline purgatives and diuretics. The aspirator should be used and from ten to twelve ounces of liquid withdrawn. When pus is found neither the aspirator nor the trocar and cannula should be used, but a free incision should be made in the seventh or eighth intercostal space on a line with the posterior axillary fold; the pus and PLEURITIS. 619 fibrinous clots can thus be thoroughly evacuated, after which a drainage tube guarded with a safety pin should be introduced and a dressing of sterile gauze and cotton applied. The tube may be shortened from time to time, and when the discharge is thin or serous may be withdrawn. The initial operation as well as all subsequent dressings must be done with strict aseptic methods. It is necessary to excise a portion of rib when drain- age cannot properly be secured by thoracotomy. Irrigation of the pleural sac I believe is harmful.—E. H. James. In acute pie ur it is : B Tinct. aconiti radicis..................................... tti, xxx. Potassii acetatis........................................... § ss. Morphina? sulphatis........................................ gr. ss. Liq. potassii citratis....................................... § ij. Syrupi tolutani............................................ § i. M. S. Two teaspoonfuls every three hours. In subacute : B Potassii acetatis........................................... gr. xv. Spir. a?theris nitrosi....................................... 3 ss. Vini ipecacuanha?......................................... gtt. iij. Syr. tolu.................................................. 3 ss. M. S. For one dose. Repeat four times daily. —Da Costa. To prevent extension of exudation, rest on the back until some time after the temperature has become normal. Aspiration when the fluid half fills the pleural cavity, re- mains stationary for a week, or is on the increase.—Loomis. Paracentesis. —When the effusion occasions grave symptoms, paracentesis, repeated if the fluid reaccumulates. Likewise when the effusion is large. Caution.—As long as the effusion is of moderate dimensions postpone paracentesis till the active stage is past.—Samuel West. ' Caution.—At the first puncture do not draw off more than a litre.—Dieulafoy. In chronic and tuberculous pleurisy, ordinary treatment is of little use. Kepeated tappings (ten to thirty ounces). 620 THE PRACTITIONER'S MANUAL. Or, withdraw a quantity of fluid and allow a lesser quantity of warm saline solution to flow into the pleural cavity. Or, free drainage, by incison, resection of rib and tube, or by puncturing with trocar and cannula, inserting a piece of drainage tube through the cannula and withdrawing the latter. —Alexander James. If pulmonary congestion is slight: R Pulv. Doveri, Pulv. scilla?, Quinina? sulphatis......................................aa gr. xlv. M. et ft. caps. No. xxx. 8. One every three or four hours. In diaphragmatic pleurisy, if pains along the course of the phrenic nerves, apply wet cups over the region and inject morphine. —Huchard. In serous exudedions of long standing, sodium salicylate, gr. xv., repeated as required.—Oertle. If kidneys need stimulating : R Potassii iodidi.............................................. 3 viij. Infusi digitalis............................................. § viij. M. S. Tablespoonful after each meal. —Page." After-treatment, exercise stopping short of actual fatigue. Cause the patient to breathe through a fairly large tube, the mouth of which is placed at the bottom of a tall jar or jug filled with water, so that expiration is made under a pressure of about eighteen to twenty-four inches of water.—Samuel West. ' Pleurodynia. While pressure with the finger tips increases the pain in this variety of myalgia, pressure with the flat hand diminishes it. We have here a point of value in distinguishing this affec- tion from intercostal neuralgia, which shows only certain definite painful points under pressure. Motion of the chest wall, as in deep inspiration, causes pain, and the latter is made worse by certain efforts, as in coughing and singing. pneumonia, acute. 621 These signs, while present in pleurisy, are then accompanied by fever and friction sounds, both of which are absent in pleu- rodynia. The latter, too, presents a pain of less darting char- acter and usually there is absence of cough. The muscles, too, if caught up between the fingers, are sensitive. The pain is more continuous and is of an aching or burning quality, and is less localized than in pleurisy. Its occurrence in a rheumatic subject will assist us in diagnosis, and especially if the pain leaves one side suddenly to affect the opposite side of the body. Treatment.—(See "Eheumatism, Muscular.") Pneumonia, Acute. In inflammation of the lungs, after an initial chill, which is usually severe, there occur dull pain upon one side of the chest, attended with rapid respiration (60, and in children 100, to the minute); a full, strong, rapid pulse of 120 beats or less, resist- ing finger pressure; and a temperature which may go as high as 105° F. The face is flushed, especially the cheek upon the affected side. (This symptom has no weight with many ob- servers.) An anatomical distinction between the several different forms in which pneumonia may occur will not here be at- tempted. Unless otherwise specified, the fibrinous, croupous, or lobar form is meant, the term broncho-pneumonia is employed to cover the lobular or catarrhal variety. Diagnosis.—Crepitant rales are heard over the affected lung area. The resonance is either at first slightly changed or it may be tympanitic in character. Within twenty-four hours, the sputa are tenacious, frothy, streaked with blood or dark red, and later take on a characteristic "prune-juice" color. They are ejected with some difficulty. Little difficulty attends a frank, uncomplicated case. When, however, the characteristic signs are obscured, as in pneumonia developing in the course of or as a sequel to acute articular <>22 THE practitioner's manual. rheumatism, in which the chill is slight or wholly lacking, more difficulty is experienced. The sputum is usually brighter than the rusty expectoration of ordinary pneumonia. The on- set is abrupt and it mayT subside quite suddenly as new joints become implicated. Other intercurrent pneumonias may also be overlooked, especially in subjects with feeble respiratory murmur, because of some severe chronic affection already pres- ent, such as nephritis, diabetes, phthisis, organic heart disease. In aged subjects, the symptom of cough with expectoration may be wholly absent. The occurrence of chill and fever may here, as well as occasionally in younger subjects, lead to physi- cal exploration. In alcoholic subjects, delirium tremens may be so closely simulated in the early stages that the pneumonia is overlooked unless careful examination is made. In children, vomiting may occur at the outset and symp- toms referable to the digestive tract may be so persistent as to obscure the evidences of lung inflammation and lead into error, or convulsions or other cerebral manifestations at a very early date may throw one off the track. The pain of pneumonia in children may be referred to the abdomen. In children the diagnosis between croupous and broncho- pneumonia is either easy, difficult, or impossible; the latter be- cause of mixed forms. The onset is more sudden in croupous.— Griffith. Differentiation.—Pleurisy is distinguished by7 the char- acter of the chest pain being sharp, and there being a friction sound instead of crepitation. Chill is lacking and febrile symp- toms are usually slight. There is often dulness on percussion and the respiratory murmur is enfeebled or absent. In pneu- monia dulness is never so absolute as in pleurisy. Increased pectoral fremitus speaks for pneumonia, increased chest circum- ference for pleurisy. In left-side pleurisy there is dulness in pneumonia, acute. 623 Traube's semilunar space (outlined by liver, lung, spleen, and free border of ribs). This space is clear in pneumonia. Unless exudation is very great, there is no displacement of heart or liver in pleurisy and practically never in pneumonia. The ex- pectoration, besides being free from blood staining, is less abun- dant. The onset is slower. Defervescence is not by crisis. It is the form of effusion which occasions most confusion. The combination pleuro-pneumonia is of common occurrence. Pleu- risy with effusion in children is often distinguished with great difficulty from unresolved pneumonia. In pleuro-pneumonia children cry from the pain of handling. In acute pneumonic phthisis, the presence of characteristic bacilli in a more purulent sputum and the greater emaciation, more profuse sweating, and a more intermittent or remittent type of fever, suffice for the distinction. Involvement of both apices primarily is, in itself, suspicious of a tuberculous process; a suspicion which is often confirmed subsequently by consolidation followed by cavity formation and the discovery of bacilli. This form is said to be frequent in negro children. Acute miliary tuberculosis, which also gives tympanitic dul- ness, faint respiratory murmur, and double-side rales, is to be distinguished from pneumonia with more or less diffuse bron- chitis, associated with limited areas of consolidation. There is more tendency to perspiration and the countenance has a some- what cyanotic or dusky appearance. Broncho-pneumonia itself is distinguished from croupous or lobar, by its occurring chiefly in infants and children and following the various infectious fevers and conditions of debility. The onset is more gradual with less tendency to chill, but with greater degree of prostration, cough, and dyspnoea and less rustiness of sputum. Evidences of consolidation are slight, the signs being chiefly those of bronchitis. When the alveoli be- come implicated after the bronchi, along with the increased 624 the practitioner's manual. temperature, pulse rate, and respirations, the cough changes in character and there is an expiratory moan as well as expiratory dyspnoea. Crepitant rales are usually to be found. Morrison has referred to "jerky expiration" as an early sign heard in children before dulness or crepitation. Meningitis is often closely simulated in the early stages of pneumonia, especially when situated at the apex, or centrally in children, the physical signs not becoming distinctive for several days. It is to be distinguished from true meningitis by a sub- sidence of the cerebral symptoms, whereas in the latter they persist to the end. Cough and expression of pain are often, too, in evidence along with the vomiting, convulsions, and de- lirium. Delirium tremens may be complicated with a hidden pneu- monia which careful physical exploration will alone reveal, or, as already mentioned, a condition closely7 simulating the delirium from drink may be an early misleading symptom. Fever and rapid respiration without corresponding pulse rate should direct attention to the lungs. Acute oedema with most of the signs belonging to the con- gestive stage of pneumonia is distinguished by lack of fever, more widely distributed rales, and the existence of heart or renal disease to account for its presence. QEdema, associated with collapse of the lung with moist and crepitant rales, is at times almost impossible to distinguish from catarrhal pneumonia, while the lobar form is more readily dis- tinguished by its inflammatory symptoms, higher fever, and history of onset. In the catarrhal form areas of dulness are subject to fre- quent change of location. Influenza simulating pneumonia by its high initial fever, headache, flushed cheek, chest pain, etc., is distinguished by the fact of epidemic prevalence, the greater amount of prostra- tion from the onset, the lesser frequency of respiration, greater pneumonia, acute. 625 amount of sweating, and the chest signs being rather those of congestion and oedema along with some bronchitis. In capillary bronchitis the temperature does not remain high so long as in pneumonia and the course is more rapid. Herpes speaks for pneumonia. Prognosis.—Pneumonia is the most fatal of the acute in- fectious diseases of adults in temperate climes, the mortality varying according to age from twenty to thirty per cent, hospi- tal statistics showing from twenty to forty per cent. In dia- betic, chronic nephritic, and cardiac patients, the prognosis is proportionately grave. Negroes, according to Osier, show a higher death rate than whites. Old age and intemperate habits make prognosis bad. Excluding individuals over fifty years of age, and those who are delicate, intemperate, or the subject of complications, the death rate is little over ten per cent.—Townsend. When acute delirium at the onset simulates insanity the prognosis is bad.—Osler. Patients die with heart failure just before defervescence, from the extension of the inflammation, from general poisoning, from one of the complications, from thrombosis of the coronary arteries. —Delafield. Treatment.—There is no routine treatment applicable to every case, and drugs often play a secondary part. At the onset, calomel, gr. £, in form of tablet triturate, every half-hour until six or eight are taken. Or, calomel, gr. ii.-v., at once. The following morning, pulv. effervescens comp. (Seidlitz powder), No. i. Or, liq. magnesii citratis, %iv.-%vi. Or, magnesii sulphatis, §ss.-3i. in water. In early pulmonary hypercemia with lividity, gasping respi- ration, and distended veins, phlebotomy up to half a pint for the average adult.—Arthur Foxwell. 40 626 THE PRACTITIONER'S MANUAL. Pneumonia is a self-limited disease, not influenced by medi- cine and not cut short by any means at our command.— Osler In the treatment of lobar pneumonia, hypodermic injections of strychnine.—J. R. Tyson. In acute lobar pneumonia, blisters, the greatest single agent in treating this disease, have saved more lives than all the drugs in the materia medica. If used skilfully and when indi- cated, that is, in the beginning of the third stage, they will afford prompt relief from pain, aid the expectoration of the clogged lung, and very materially hasten convalescence.—Ramon D. Garcln. Complete rest of body and mind. Thorough ventilation of the sick-room. Diet restricted to milk and farinaceous broth, four to six ounces every two hours. Plenty of water. Alcohol is not necessary, as a rule. A good dose of calomel at the out- set. It is probably of benefit in indirectly relieving the engorged lung by acting upon the portal circulation.—Baruch. For the first stage, counter-irritation and bleeding; for the second, digitalis and nitroglycerin; for the third, ammonia and alcohol. —C ADWALLADER. R Reechwood creosote......................................... ~,) £m- Tincture of gentian........................................ ,r>0 M. S. From twenty-five to one hundred and fifty drops a day in wine. —CASATb Perfect repose in bed so far as possible, and for the first few days, calomel, gr. TV-£ according to effect, every three to six hours. R Liq. ammonii acetatis........................................ 3 *• Tinct. opii camph............................................ 3 vi. Spir. a?theris nitrosi.......................................... 3 iv. Aqua? laurocerasi............................................ 5 s9 Syr. tolutani................................................. I s&- Aqua? camphorse....................................... by hypo- dermic injection. B Calomel.................................................. gr. xxx. Lemon juice.............................................. 1 i. Take every two hours for three doses. —D'UTREA, of Brazil. C aid ion.—Authorities state that lemon juice should not be taken by a person who is employing calomel. Alcoholic stimulants in large quantities. This sustains while the poison is being eliminated. Tourniquet first, free incisions second, permanganate of po- tassium third, Esmarch's bandage fourth, alcohol and digitalis last.—J. G. Tuten. Solution of caustic ammonia locally applied, a few drops in water internally, and thirty drops diluted with one to four parts of water injected into a vein.—Roth.6 In serpent and scorpion bites, as well as those of the mos- quito and gnat, applications of formol; after evaporation, a second coat is applied.—Gonin. Rattlesnake Bite.—Excise the wound, if seen sufficiently early, and administer nitrate of strychnine.—J. F. Brewer. Inject a ten-per-cent solution of chromic acid into the sub- cutaneous tissue around the wound.—Karlinski. The Intermittent Ligature.—The early application of the Spanish windlass tourniquet beyond the injured part for a num- ber of hours may prevent a fatal issue. The pressure may be very gradually lessened to restore the circulation by harmless degrees. Serum Treatment.—Antivenin, perfected by Calmette by in- jecting into horses increasing doses of cobra venom mixed with decreasing quantities of a weak solution of calcium hypochlorite. pott's disease. 661 Administer by intravenous injections from ten to twenty cu- bic centimetres of serum, and even more when the wound has been inflicted upon a person of large size by a dangerous reptile —as the rattlesnake. Calmette advocates injection, while Fraser believes in swal- lowing the venom. Krait bite (Bungarus cceruleus, a most deadly Indian snake) was cured by the Calmette antivenin serum; locally and hypo- dermatically about the wound permanganate solution was em- ployed.—S. J. Rennie. Pott's Disease. The diagnosis of this affection is difficult, according to Gib- ney, because of "the lack of confidence in one's opinion, the lack of courage in one's convictions, and the failure to make a thorough examination." Pain, tenderness, faulty attitude are the symptoms usually present when the patient comes under the physician's care. Diagnosis.—The most characteristic and constant early symptom is rigidity, the result of reflex spasm. Preceding this there have been restlessness, disinclination to move about much, and a constant tired feeling. There may be an evening rise of temperature of one or two degrees, such as accompanies other tuberculous lesions, and exaggeration of reflexes. If deformity has already taken place, the diagnosis is not difficult. The fact, however, must be remembered that there may be a normal prominence opposite the sixth and seventh cervical and the first dorsal, as well as at the junction of the last dorsal and first lumbar vertebrae. A psoas abscess, with pus coming to the sur- face at some remote point, may be the first prominent symptom in a given case. Radiating pains along nerve trunks of abdomen or extremi- ties, giving sciatic-like or girdle-like pains about the waist, are 662 the practitioner's manual. among the early symptoms. Sudden arthralgia, especially in the knee, is apt to be mistaken for rheumatism. Lumbar neuralgia may precede abscess by as much as two years.—Grognot. Differentiation.—Caries in the cervical region may simu- late cerebral disease by reason of the acute pain, rigidity of the neck, retracted head, and grunting respiration. The latter symptom may suggest bronchitis or pneumonia, which is fur- ther brought into question by reason of manifest pain in the chest attended with cough, dyspnoea, and cyanosis. Both can be excluded by examination. In muscular rheumatism very often the spinal muscles show a stiffness which is more marked after a rest in bed. In case of doubt rheumatism may be ex eluded by treatment. Dr. Dillon Brown says: t- Always examine the spine of a child who complains of persistent pains in the chest, abdomen, legs, or occipital region, especially if they be increased by movement and relieved by rest and support." In the adult, according to Gibney, Pott's disease is to be dis- tinguished from irritable spine with neurosis of the hip or knee, from railroad spine, hysterical spine, multiple osteomyelitis, fracture, rheumatic spondylitis, and malignant disease of the spine. Malignant disease is excluded by the deformity and by the absence of local disability and local pain.—A. B. Judson. Renal affections, thoracic or abdominal aneurism, subdia- phragmatic abscess, are also to be distinguished. True rotary lateral curvature can usually be distinguished from caries without difficulty by attention to the following points: 1. The curve is rounded, not angular. 2. The rotation is always on the side of the convexity of the curve; in caries it may be on either side. 3. The limitation to motion is only in the direction which tends to straighten the curve; in caries it is in every direction. pott's disease. 663 4. Pain is usually absent, and, if present, local, and not at the periphery of the spinal nerves. 5. The curve is not diminished by rest in bed or by anaesthe- sia, as it is in caries. 6. It is frequently associated with other evidences of some central lesion, as atrophy of the mammary gland and non- deforming clubfoot. 7. There are no psoas contraction, no fever, no suppuration, and none of the other characteristic signs of spinal caries. However, the diagnosis may7 be so obscure that only careful observation of the case over a long period of time will make it clear.—Dillon Brown. Rachialgia of hysterical origin or simply hyperaesthesia over the lumbar spinal region must not be too readily taken for evi- dence of Pott's. Treatment.—During the acute stage, recumbency. Trac- tion applied to the head and legs to quiet muscular spasm im- proves the position of the spine and hastens recovery.—Lovett. Efficient mechanical support of the spine is the prime factor in the treatment of caries of the spine associated with abscess. —Burrell. Sustain the general condition by measures indicated for other manifestations of tuberculous disease.—Royal Whitman. At the first signs immobilize the child, keep up horizontal position, and advise seashore or country air. In winter, give cod-liver oil; in summer, antiscorbutic syrup, alternating every fortnight with iodo-tannic syrup. Fowler's solution, gtt. i.-iv., alternating as above with syrup of iodide of iron. At long intervals replace above with: B Potassii phosphatis (F. Ph.), Sodii phosphatis........................................aa 5 gm. Syr. gentiana?............................................. 100 " Elix. cinchona?, Vini Malaga?............................................aa 250 " M. S. Dessertspoonful twice daily. __PERD3R. 664 THE PRACTITIONER'S MANUAL. In pressure paralysis, iodide of potassium is an excellent remedy, whose good effects are increased by combining proper support of the spine.—Gibney. Proctitis. In inflammation of the rectal portion of the intestine there are diarrhcea, characterized by tenesmus, frequent passages con- taining streaks of blood and mucus, pain in the left lower part of the abdomen, and tenderness or itching about the anus. For an acidely inflamed rectum : R Chloral hydrate...................................... gr. xlv.-lxxv. Tannic acid......................................... gr. xxiv. Lime water......................................... O i. S. One-fourth to one third of this quantity is to be mixed with twelve ounces of warm water or thin starch water, and five or six ounces injected into the rectum at a time and retained as long as possible. —Ewald. In ulceration: R Cupri sulphatis, Morphinae sulphatis....................................aa gr. ij. Quinina? sulphatis........................................gr. xxiv. M. ft. pil. No. xxiv. S. One t.i.d. —Potter. Or— R Argenti nitratis......................................... gr. x.-xx. Aqua?................................................... O i. M. S. By enema. —Bartholow.13 In irritable ulcer: R Iodoformi................. ................................ gr. iij. 01. theobrom........."..................................... q.s. Ft. supposit. And internally: R Sulphur. pra?cipitat., Confeot. senna?.............................................aa p.a?. S. Teaspoonful. To relieve pain, unguentum stramonii, made from fresh leaves. —Philltps. PSITTACOSIS. 665 Pseudo-Meningitis. False or serous meningitis may occur after influenza or in- jury, and present symptoms of stiff neck, rachialgia, general hyperesthesia, difference in pupils, irregularity of pulse and breathing, photophobia, etc., leading to the diagnosis of infec- tious cerebro-spinal meningitis. Chronic hydrocephalus may develop. Alcoholic pseudo-meningitis gives symptoms of meningitis, along with those of alcoholism. Differentiation from hysteria, from true meningitis, etc., by the temperature curve. The fever does not go or remain high, and bears no due relation to the severity of the symptoms complained of.—Desplats. The symptoms are all less severe than in meningitis, and do not develop with so great suddenness and severity as in ordi- nary leptomeningitis. In complicated instances lumbar puncture or puncture of the fontanelle may be required to distinguish the condition. Treatment.—In the febrile hysterical imitation of meningi- tis, energetic suggestion in the waking state may7 be made that improvement begin at once.—Thibaudet. In delirium, etc., paraldehyde, 3ii- per rectum. In the alcoholic form with high fever, Brand tubbing.— Collins.4 (See Leptomeningitis.) Psittacosis. An infectious and usually fatal disease of parrots and other birds, developing especially after transfer by steamer to foreign lands, and transmissible to man. Diagnosis.—In the latter, after an incubation of from eight to twelve days, headache, pains in the muscles, and a temperature reaching 104° F. by the second day, are noted. After remain- 666 the practitioner's manual. ing at this point for three days, the fever usually goes down. Vomiting, diarrhcea (or constipation), delirium, and lung symptoms (bronchitis or, more commonly, lobular pneumonia). The local symptoms are, first, a slight j^dch of crdema on the lips • then, secondly^, patches very similar to those of diphtheria in the mouth and pharynx. Differentiation is chiefly to be made from typhoid, which the early manifestations simulate. The diagnosis must rest upon the Widal reaction rather than upon the fact that a re- cently imported parrot has died in the house, with symptoms of drooping and diarrhoea after a two-days' illness. In dilutions of one in ten the reaction occurs in both condi- tions, but from this up to one in forty a point is reached at which the psittacosis bacillus no longer reacts. The masses are also said to be smaller. Prognosis.—In the beginning of some epidemics the mortal- ity has been about seventy-five per cent. Convalescence is pro- longed. Children appear to be immune, while the old seem predisposed. Treatment is largely7 symptomatic. Prophylaxis requires us to place the possessors of such pets upon their guard, espe- cially in relation to the custom of feeding from the mouth, and particularly when the bird is sick. Digitalis is useful because of its tendency to destroy the toxins of the diplococcus, and quinine for its internal antiseptic properties. —Maragliano. Pyaemia. Though somewhat bordering upon the surgeon's realm, py- aemic conditions must oftentimes be combated by the physician. Diagnosis.—The vital powers are depressed, there are rapid pulse and a low type of fever, beginning perhaps with a chill and followed by profuse sweating. The temperature range is one of wide limit, the highest point being perhaps 108° F. PYAEMIA. 667 Differentiation.—The association of diarrhcea and possibly cerebral symptoms with an adynamic fever makes differentia- tion from typhoid a necessity. The eruption of the latter is, however, absent, and finding deposits of pus in some portion of the economy tends to exclude typhoid, while it confirms the diagnosis of pyaemia. Rheumatic fever may also be closely simulated by the in- volvement of several joints in successive swellings. The history of the two affections in the onset and early7 course is somewhat different, and the constitutional manifestations of septicaemia with its more pronounced exhaustion and rigors tend to exclude the rheumatic disease. The joint presents a deeper red color than is the case in rheumatism. Glanders at times strikingly simulates the pyaemic state. Examination of the nose for erosions and ulcerations, a ropy discharge from the nostrils, and the offensive odor associated with marked glanders have some- thing distinctive even in the absence of a history pointing to association with horses. When a jaundiced state accompanies pyaemia, the history7 of the case may have to be gone into care- fully to exclude acute disease of the liver. In septicaemia there is hyperleucocytosis, and in typhoid there is none, or indeed at times a diminution of the white corpuscles. Prognosis.—While septicaemia is often followed by7 recov- ery, that form known as pyaemic with metastatic abscesses is almost uniformly fatal. Partial recovery may follow the chronic variety, especially if continued reinfection can be prevented. Treatment.—Disinfect the local source of pus poison. Maintain the strength with stimulants, which include alcohol, strychnine, quinine, an abundance of stimulating food. Salicylate of sodium, guarded by sustaining doses of digi- talis or strophanthus. 668 the practitioner's manual. Pyelitis. Pain in the loin constitutes the most frequent symptom. This may extend to both sides and radiate down the leg upon the affected side. Frequency of urination is another common symptom. The urine is pale, acid, and cloudy. Pus is found in the urine, at times in large quantities, settling as a thick creamy mass in the glass. Diagnosis.—Besides the symptoms above noted, there may occur rigors or shivering, with yawning and perhaps vomiting. Suppression of urine in a subject of renal colic due to stone, or with a history of calculous disease, is usually directly due to the stone, and often both kidneys are affected. Differentiation.—Cystitis may be simulated, but if, after withdrawing the bladder contents and washing out, another specimen of urine be taken soon afterward which shows pus, if the pus is at all abundant, it is most likely of renal origin. The urine, too, is acid. By the cystoscope the pus can be seen to flow from the mouth of the ureter. Renal calculus is excluded by the absence of haematuria and of a history that a stone has been previously passed. The presence of pus may continue to manifest itself for months or even years after apparent cure. Prognosis.—If pyonephrosis develops, operation is the only means of cure. Treatment.—Rest in bed ; bland diet; an abundance of pure water. R Liq. potassa?................................................. 3 ij- Olei santali flavi............................................ 3 ij- Aquae cinnamomi.....................................ll-s- aa 3 vn3- M. S. Two tablespoonfuls three times a day. —Saundby. R Scammony, Calomel..................................................** Kr- iv' At dose. Salol, gr. iii.-v., four times daily; or gr. i. every hour. RABIES. 669 R Potassii bromidi, Sodii bicarbonatis.......................................aa gr. cix. Ext. belladonna?........................................... gr. iv. Ext. buchu............................................... 3 i- Syr. sarsaparilla? comp..............................q. s. ad f iv. M. S. |ss. t.i.d. —Pepper. For the pain : B Ext. belladonna?............................................ gr. | Ext. opii.................................................. gr. \ Olei theobroma?............................................ q. s. As a suppository. Dry cups over lumbar regions; hot fomentations. In chronic pyelitis when pain is present: B Venice turpentine.......................................... 3 iss. Powdered camphor......................................... 3 iss. Extract of opium.......................................... gr. v. Extract of aconite root.....................................gr. iij. Mix and make into twenty pills. S. One pill to be taken every eight hours, and at the same time a small glassful of infusion of uva ursi, slightly sweetened. —Robin. Or— B Sodii benzoatis............................................... 3 i. Syr. rubi ida?i................................................ | i. Aqua? tilia?.......................... ........................ § iij. M. S. Soupspoonful in an infusion of buchu three hours after meals. —Dreyfus-Brisac. Pyelitic haematuria : B Ergotin.................................................. 60 gr. Gallic acid............................................... 7£ " Syrup of turpentine..................................... 450 " Linden water............................................ 1,800 " M. S. A teaspoonful every hour. The French sirop de terebenthine is made by digesting 10 parts of Strassburg turpentine in 100 of syrup.—Robin. Methylene blue, gr. iss.-iii., in capsule, three times daily. Rabies. After an incubation of from several weeks up to six months, the subject, bitten by a rabid animal, in the first or melancholic stage, which lasts two or three days and follows a prodromal 670 THE PRACTITIONER'S MANUAL. period of the same duration, is depressed and irritable. He shows signs of fear and sensitiveness to draughts of air, strong light, and sounds. While thirst is present, attempts to drink often result in painful spasms of the laryngeal muscles. In the second or spasmodic stage the spasms may be of con- vulsive nature, with struggling, gasping, difficult breathing. The facies is expressive of intense fear or mental suffering, and froth appears about the mouth. After about three days the third or paralytic stage begins, marked by great cardiac weakness, and death may occur from heart failure or terminate a severe convulsion. Differentiation from tetanus by the latter's shorter incu- bation, higher temperature, tonic or clonic rather than convul- sive spasm, absence of anxiety, and presence of risus sardoni- cus. Prognosis.—Recovery may frequently follow the early em- ployment of Pasteur's attenuated virus, by which the mortality has been very greatly reduced. It is estimated that, in bites upon the face, without treat- ment eighty-two per cent will prove fatal; and with treatment, eighty7 per cent are curable.—Keirle. A fatal termination always occurs after from two to seven days.—J. H. Anderson. On the fourth or fifth day.—F. W. A. Fabric ius.' Treatment.—Local Treatment of the Wound.—Facilitate bleeding by ligature and cupping-glass. Cauterization with caustic potash or carbolic acid. Excision of the wound. Treatment of the Developed Symptoms.—Quietness and nour- ishment by the bowel. Chloral and morphine for restlessness. Chloroform for convulsions.-—J. H. Anderson. Caution.—Do not administer sufficient narcotic poisons to produce death and attribute the results to rabies. I am satisfied that it would be better to administer no medi- cine at all than to continue the pernicious practice of giving RACHITIS. 671 morphine, atropine, chloral, bromides, and chloroform. Nar- cotics have never rescued a single person from death.—Charles W. Dulles. In heat we have an agent capable of counteracting the poi- son of rabies. Hot water should be applied, especially in the form of Turkish baths.—C H. Shepard. Inoculation treatment in special institutes, according to the methods of Pasteur or Babes (Babes-Tizzoni). During the past fifty years about one thousand instances have been reported in this country, in many of which the diagnosis is often doubtful. Many practitioners deny the existence of such a disease. There is no specific disease hydrophobia. Septicaemia, the result of a bite from a rabid animal, differs in no degree from that produced by a sane one.—C. W. Dulles. Rachitis. Rickets varies in its manifestations as it occurs alone or in combination with scorbutus and hemorrhagic manifestations, as seen in Barlow's disease. The early detection of rachitism is of the greatest import- ance. It is characterized by abnormality of bony development in early childhood. Diagnosis.—The early symptoms embrace fretfulness and sweating, especially about the head and neck, at night or when asleep; sudden awakening with fright. The abdomen becomes distended, but the body emaciated. Rubbing the back of the head on the pillow may cause the hair to become worn off in the occipital region. Hydrocephalic symptoms are common. In infants the cranium shows the first bone changes. When the disease has existed long enough for the signs to become typical of an established rachitis, we find the face of small size, the cheek bones prominent, the fontanelles open, the breast pigeon shaped, the ribs beaded, the abdomen protuberant, 672 THE PRACTITIONER'S MANUAL, the epiphyses of the bones at the wrist thickened and causing deformity, the spine curved, the legs bowed, the muscles and ligaments relaxed. It is in the early stage that we must detect beginning cases. Then symptoms are not present in charac- teristic groups. Constipation, the occurrence of laryngismus stridulus or bronchitis following slight exposure, slow closing of fontanelles, late eruption of the teeth, distended veins over forehead, convulsive tendencies, spasms without fever, or splenic tumor—any of these should cause us to suspect rickets in artificially fed infants, and lead us to watch for other and confirmatory signs. Differentiation.—Hydrocephalus is distinguished by the tense anterior fontanelle, choked disc as shown by the ophthal- moscope, disturbance of speech, etc. Congenital lues by the earlier development of inflammation of the heads of the long bones in syphilis, at about the fourth or fifth week of life; and by concomitant signs on the part of the skin and mucous mem- branes. Pott's disease in advanced stages by its conical "hump," while that of rachitis is round.—Sterling. Acute epiphysitis may be mistaken for rheumatism, while cranial tabes, constipation, and sweating point to the actual condition.—Caille. Treatment.— R Phosphorus............................................... gr. -ffo Cod-liver oil.............................................. § iij. Saccharin............................ ...................gr. lxxv. Essence of lemon......................................... gtt. ij. M. S. A small teaspoonful may be taken daily. —Marfan. Or— R Phosphori...................................................gr. ^j 01. oliv. (refined)............................................3 b Sacch. alb., Pulv. acacise..............................................aa § ss Aquae dest.............................................q.s. ad § ij. M. ft. emuls. S. Dose, 3 b RACHITIS. 673 Or— , . ...... 0.01 cgm. R Phosphori................................... Olei amygd. dulc..................................... Pulv. sacch. alb., __ , .1 .......aa 15 gm. Pulv. gummi arab.................................. ° , .. ......... 40 gm. Aqua? dest...................................... M. S. Teaspoonful at dose. _METTENHEIMER. Or, iodo-phosphorated butter, to be used as a substitute for cod-liver oil in hot weather: „_.,,, ......... ? xviiss. R Fresh butter............................................ ■= Iodide of potassium........................................ &r> 1V- Bromide of potassium..................................... Sr- xv- Chloride of sodium........................................ 3 ^ Phosphorus................................................ gl' T M. About one-third of an ounce daily, spread on bread. —Trousseau (modified by Comby). Modified milk. Pasteurized milk, especially with the addi- tion of oatmeal, barley, animal broths, etc. R Syr. calc. lactophosphat......................................... 10° Ferri citro-ammon. pyrophosphat............................... Aqua? dest...............................................q.s. ut sob M. S. A dessertspoonful one to three times daily. —d'Espine AND Picot. Or— B Aqua? calcis, Syr. calc. lactophosphat..................................M, \ part. Olei morrhua?.............................................. 2 parts. —J. Lewis Smith. Or— B Potass, iodidi.................................................. 4 Syr. aurant. cort., Aqua?.......................................................aa, 100 M. S. Two to eight teaspoonfuls daily. —Descroizilles Or— B Tinct. iodi..................................................... 1 Syr. gentiana?.................................................. 100 M. S. Two to ten teaspoonfuls daily. 43 674 THE PRACTITIONER'S MANUAL. The most important remedy to-day is phosphorus. R Phosphori................................................... 0.01 01. morrhua?................................................ 100 M. S. Teaspoonful twice daily. Or— R Phosphori.............................................. 0.01 cgm. Dissolve in : 01. amygd. dulc........................................ 10 gm. Add: Pulv. gum. arab........................................ 5 gm. Syr. simplicis.......................................... 5 gm. Aqua? destil............................................ 80 gm. S. One teaspoonful daily, below the age of one year ; from the twelfth to the fifteenth month, two ; and over two years of age, four teaspoonfuls. Each teaspoonful contains half a milligram of phosphorus. —Kassowitz. Careful regulation of diet, modified milk to suit age of child, animal broths, keeping patient out of doors, and small doses of oleum phosphoratum combined with oleum morrhuae.—Gra- ham. For the anaemia: R Tinct. ferri chlor., Ferri pepton., Tinct. rhei vinos. (Aust. Ph.).................................aa, 20 Potas. acetat.................................................... 10 Vin. antimon................................................... 5 M. S. Five to thirty drops three times daily. —Sterling. Or— R Syr. ferri iodidi..................................... gtt. iij.-xxiv. Aq. dest.......................................q.s. ad § iij. M. S. 3 i. every four or five hours. —Hare. Rickets in the negro is frequent. Cod-liver oil is advised for the winter; syrup of hypophosphites in summer.—G. N. Acker. R Phosphori.................................................... gr. i. Alcoholis absoluti............................................ 3 v. Glycerini.................................................... 1 iss. Alcoholis................................................... 3 ij- Spir. mentha? pip.......................................... Ul, xl. rheumatism, acute. 675 Dissolve the phosphorus in the absolute alcohol with the aid of a gentle heat; then add to it the glycerin, alcohol, and spirit of peppermint, previously mixed and slightly warmed. Each fluid drachm contains nearly -gry gr. of phosphorus.—J. Ash- burton Thompson. The elixir phosphori is a more palatable preparation, and preferable to Thompson's solution.—Rice. Salt baths.—Christopher. Food rich in fat and proteids, cream, butter, the white of egg, orange juice, cod-liver oil, syrup of lactophosphate of lime, glycerole of iron.—I. W. Faison. In the laryngeal spasm of rachitis, phosphorus.—Senator. Thyroidin "Merck," 0.10 cgm., every second day; then every day for several months, if continuous control over patient can be exercised.—Heubner. Dyspepsia is the bond that unites rickets with convulsions. Intestinal antisepsis (see "Dyspepsia"). Regulation of the diet is the principal remedy, but it is a mistake to believe that food which does not disturb the bowels is for that reason alone a sufficient nutriment and safeguard.— A. Jacobi. Rheumatism, Acute. It is chiefly by the involvement of many joints in succession, and especially the larger ones, that rheumatism is distinguished from gout. Rheumatic fever is further differentiated by the recurrent and abundant acid sweating and the comparative fre- quency of cardiac involvement. A large proportion of attacks are preceded by tonsillitis. If a person is morbidly sensitive to damp and cold, and if bis susceptibility is shown by the devel- opment of pains in his joints and fascia, etc., he is rheumatic; if, on the other hand, he is sensitive to food, and if certain ar- ticles of diet produce joint pains, etc., then he is gouty.— Hutchinson. 676 the practitioner's manual. Differentiation.—Pyaemia is somewhat simulated, but here cutaneous abscesses are common, and when the inflammation has subsided over the joint the integrity of the latter is often found impaired. Acute synovitis comes also into question, but here it is one joint which swells after exposure and possible trauma, while in acute rheumatism the joints become impli- cated one after another, and the acrid sweat with severe consti- tutional symptoms makes the nature of the case clear. In phlegmasia alba dolens it is a female subject usually who com- plains of tenderness in a particular portion of the lower ex- tremity, often the calf of the leg, and there is a history of pre- ceding disease or pregnancy to guide us. In syphilitic joint involvement characterized by pain and tenderness, there is not a condition of actual acute inflamma- tion, and a history of specific infection may be elicited. Like- wise in gonorrhoeal arthritis, coexisting urethral inflammation points to the origin, and it is usually a single large joint in which the inflammatory process becomes localized for a consid- erable length of time. Osteomyelitis is a condition too often mistaken for rheumatic joint disease when the portion of the bone affected is in close proximity to a joint. The painful swell- ing is here of sudden onset, but pysemic symptoms are often superadded. Likewise in acute periostitis the tender tissues near the joint may closely simulate rheumatism. Pitting upon pressure and the early development of signs of fluctuation may prevent a wrong diagnosis. Joint inflammation of trophic origin, as in central nerve affections, is usually differentiated by concomitant signs arising from the more deeply seated dis- ease. Thermal baths have a differential diagnostic value. After six or seven baths rheumatics are made worse and gouty sub- jects have a typical attack. This almost constant effect serves to distinguish these from similar painful affections of different nature. rheumatism, acute. 677 In children the tendons of the hamstring muscles are often involved and the child walks in a characteristic way on the toe tips with bent knee to relieve tension.—Cheadle. Prophylaxis requires careful attention to the throat and the use of salicylates at the first sign of tonsillitis.—W. H. Thomson. Treatment.— R Acidi salicylici............................................... 3 iij. Sodii bicarbonatis............................................ 3 ij. Glycerini, Aqua?......................................................aa § vi. M. S. A tablespoonful every two hours for the first day, then every four hours. Caution.—In inactivity of the kidneys, especially in preg- nancy and in rheumatism complicated by albuminuria, salophen or other drug should be substituted for salicylic acid. The latter is to be suspended if delirium occurs. Too persistent use of the drug may hasten heart complication. B Phenocoll. hydrochloratis..................................... 3 ij. Aqua? destil................................................. § iv. M. S. Tablespoonful in water three times daily continuing for a few days after the pain has subsided. —Olny. Sodium salicylate is much more efficacious if administered while baths from 100° to 105.8° are being given each morning. —Moeitz. Improvement is more rapid and without complications under: B Salophen...................................................... 3 ij. M. ft. cht. No. xii. S. To be given within the first twenty-four hours, subsequently reducing the dose. —B. H. Waters. Or— B Salophen................................................... gr. Xv. Three or four times daily. In acute and subacute rheumatism in which there are con- siderable involvement of the muscles and also great pain: 678 the practitioner's manual. B Phenazon (antipyrin)......................................... 3 ij. Sodii salicylatis.............................................. 3 iij. Ammonii bromidi......................................... 3 iv. Aq. cinnamomi.............................................. § iij. M. S. A teaspoonful every three or four hours. —Eshner. When other salicylates disagree with the stomach, strontium salicylate, gr. x.-xv., gives the same results. Caution.—In acute joint rheumatism with visceral compli- cations salicylic acid does not cure or prevent these manifesta- tions and may favor their occurrence, especially cerebral ac- cidents.—Jaccoud. B Liq. potassii arsenitis........................................ 3 i. Potass, iodidi................................................ 3 iij. Sodii salicylatis.............................................. 3 iv. Tinct. gentiana? comp........................................ | i. Syr. sarsap. comp......................................q.s. ad | iv. M. S. Shake well. Teaspoonful three times a day after meals in one-third glass of water. —Richardson. For sweating, cimicifuga in small dose. An agreeable salicylate mixture : B Potassii acetatis.............................................\ i j. Acidi salicylici.............................................. § ss. Syrupi limonis............................................. § ij. Aq. menth. pip............................. ............... § viij. S. Tablespoonful every three hours. B Acetate of potassium, Nitrate of potassium...................................aa 5 parts. Distilled water......................................... 200 " Syrup of raspberry....................................... 20 " M. S. A teaspoonful to be given night and morning. The affected joints are to be painted with tincture of iodine, covered with cotton, and kept abso- lutely motionless. —Billroth. Or, injection of Marmorek serum.—Groedel. Guaiacum is useful in chronic as well as in some forms of acute rheumatism and in gout.—W. Howship Dickinson. Alkalies until the urine is about neutral; then salicylic acid. RHEUMATISM, ACUTE. 679 In subacute: B Sodii salicylat.............................................. gr. x. Potassii iodidi............................................ gr- v. Vini colchici sem.......................................... ^ viij. Syrupi, Aqua?...................................................aa, 3 ss. M. S. For one dose. To be repeated every three or four hours. When there is much fever, aconite may be cautiously added with advantage.—E. G. Tuffs. Salophen, gr. xv. every four hours. This is free from dan- ger.—Pearse. In the acute form and in those predisposed to anaemia : B Sodii salicylatis......................................... 3 iv. Tinct. ferri chloridi.................................... 3 iv. Acidi citrici............................................ gr. x. Glycerini............................................... 1 ss.-iss. 01. gaultheria?..........................................m x. -xxx Sol. ammon. citr. (B. P.).........................q. s. ad § iv. M. S. 3 ii. in water every two, three, four, or six hours. —S. SOLIS-COHEN. Salicylic acid obtained from the vegetable kingdom, given without alkali or base, gr. xl. to gr. Ixxx. daily for ten days. Milk and farinaceous food, keep bowels open.—Latham. B Potass, nitratis............................................ gr. ix. Sodii et potass, tartratis.................................... gr. xv. Extr. colchici fluidi....................................... gtt. iij. Aqua?...............................................q. s. ad 3 b M. S. At dose. Or tinct. actseae racemosae (from North American plant), §i. Gtt. iv. every two hours, increasing until forty or fifty are taken. —Hewelke. The best way to give alkalies is to give bicarbonate of sodium persistently in drachm doses as often as practicable until the urine becomes alkaline.—Bishop. B Potass, bicarb.............................................. gr. x. Tinct. digitalis.............................................. gtt. v. Aqua?....................................................... q.s. M. S. Every two hours. 680 the practitioner's manual. Cover the parts with cotton dressing. As an analgesic, Dover's powder.—W. Henry. When salicylic acid causes anaemia, add iron thus: B Acidi salicyli..............................................gr. xx. Ferri pyrophosphatis....................................... gr. v. Sodii phosphatis (crys.).................................... gr. 1. Aqua?...................................................... § ss. M. S. At a dose. This gives a clear cherry-red solution, without precipitate.— Peabody. Squibb formula for sodium salicylate : B Acidi salicyli..............................................gr. 437 Sodii bicarb................................................gr. 270 Aqua? (free from iron)...................................ad § vi. 3 i. equals gr. x. of sodium salicylate. Locally: B Veratrini, Hydrarg. iodidi virid........................................aa 3 i. Petrolati...................................................... 1 i. M. S. Apply over joints affected. —Hare. Or— B Salicylic acid, Oil of turpentine............................................aa § ss. Lanolin, Lard.......................................................aa, § iv. M. S. Apply to joints without friction. —Bourget. Or— B Salicylic acid................................................ 3 v. Proof spirit.................................................. 1 iij. Castor oil.................................................... 1 vij. Chloroform.................................................. 3 iv. M. S. Apply by means of steeped compresses and cover with oiled silk. —Ruel. Salicylic acid should appear in the urine within twenty-four hours. Or, surround the joint with lint moistened with one or two RHEUMATISM, ACUTE. 681 teaspoonfuls of oil of gaultheria; surround this with a gutta- percha sheet and apply a bandage. Or— B Salol, Sulphuric ether..............................................aa 3 b Collodion...................................................... I i- To be applied around the joints. —Hebbing. Cold applications to the joints afford immediate relief. Wring out heavy towels in ice water, wrap about joint, and cover with flannel. Renew till cure is effected.—Fraunfelter. Or, carbolic-acid solution (four per cent) applied warm on flannel.—Hancock. Or— B Guaiacol, Glycerin..................................................aa, p. a?. Apply and cover with tissue. —Ferrand. Or— B Ac. salicylic.............................................. 15 gm.- Turpentine................................................ 15 " Lanolin.................................................. 15 " Lard...................................................... 125 " Apply over the joint and put on a flannel bandage. In rheumatic endocarditis, potassium or sodium iodide, gr. x. t.i.d., in addition to salicylates, and a succession of small blis- ters over the apex with prolonged rest in bed.—Caton. If pericarditis or pleuritis occurs, ice bag influences the process favorably as well as giving relief from pain. In children, nepenthe (strength of tr. op.) in frequent small dose. In older children showing heart failure, strychnine and digitalis hypodermatically. In children, all depressing drugs, such as antipyrin, aco- nite, etc., are strongly deprecated. Cardiac inflammation is less frequent and less pronounced under full alkaline treatment. 682 the practitioner's manual. Sodium salicylate in small dose at short intervals. Or sali- cin, gr. v.-xx. Or quinine, gr. i.-iii., every four hours, with sodium citrate, gr. v.-xx.—M. B. Cheadle. B Sodii salicylatis........................................ 3 iss. Potassii iodidi........................................... 3 ss. Tinct. aconiti........................................... gtt. x.-xv. Aqua?................................................... 3 ij. M. S. One drachm t.i.d. —Caille. For the gonorrhoeal form see "Arthritis" (gonorrhceal), page 73. Rheumatism, Chronic Articular. Chronic or subacute rheumatic arthritis has usually but lit- tle swelling about the joints, although stiffness is a marked symptom, especially after rest, as in the early morning and in wet weather. It is often a nice distinction which has to be made between the pains due to gout or a complicating neuritis and those due to the arthritis. Differentiation from gouty, gonorrhceal, and traumatic arthritis is made by the numerous joints implicated; from gout also by the absence of early involvement of the smaller joints, and especially that of the great toe; from osteo-arthritis by no permanent alteration following the joint pain and stiffness. Prognosis.—Although improvement follows the acute ex- acerbations, the process goes on indefinitely; still for a long time the symptoms may be slight. Deformities are apt to occur. Treatment.—Salicin, gr. xx. every two hours until relief from pain, then the same dose three times daily. Avoid over- taxing digestion. Hydrotherapy and massage when possible. ■—L. F. Bishop. B Potassii iodidi.............................................. 3 iij- Vini colchici sem., Tinct. opii camph..........................................aa 1 ij. Tinct. stramonii............................................. 3 vi. Tinct. cimicifuga?............................................ 1 iij M. S. A teaspoonful thrice daily. rheumatism, chronic articular. 683 B Liq. potassii arsenitis......................................... 3 ij. Potass, iodidi............................................... 3 ij. Syr. simplicis................................................ 1 iij- M. S. 3 b t.i.d. p.c. in water. —Da Costa. Tincture of colchicum, ten drops one hour before dinner for eight days, then none for a week.—Simon. In the progressive subacute form, lithium salicylate gives better results than sodium salicylate.—Yulpian. Dry hot-air baths at temperature of 250° to 300° F.—Al- fred WlLLETT. By means of a copper cylinder dry air can be regulated up to 330° F. for from forty to sixty minutes, and pain and stiff- ness in time be entirely relieved. —Reed. Or the Tallerman-Sheffield localized hot-air apparatus can be used to fit any part. It may be used when Turkish baths are out of the question.—W. K. Sibley. The hot-air bath I use is a very neat-looking piece of office furniture. It is an oxidized metal cylinder, thirty inches long, fourteen inches high; a funnel and pipe of the same material carries hot air from a nickel-plated heater to a hot-air distrib- uter. There is no smoke or smell. By means of several valves the heat can be regulated. A thermometer registers the amount of heat. The cylinder is lined with asbestos; arm or leg rests in a Turkish hammock. There are attachments for arms, legs, and other regions.—G. M. Blech.21 Gentle massage of joints involved is beneficial, especially in long-standing cases with beginning contractures. Scotch douche gives better results than any other form of hydrotherapy. —Schuller. Salicylate of methyl applied locally during painful parox- ysms, acts at times as well as salicylates when given by the mouth.—Lannois and Linossier. The advantages of the above are that it acts more rapidly in controlling pain, symptoms of intolerance are exceptional, 684 THE PRACTITIONER'S MANUAL. irritation of stomach is avoided, and a more marked effect is produced upon the associated neuralgia. The usual dose is about eight to ten grams of a solution of oil of wintergreen in spirits containing forty per cent of sali- cylate of methyl.—Lemoine. Woollen clothing and especial attention to the diet, with meat as a foundation, together with eggs, fish, vegetables, but- ter, and cheese; especially milk. Water is the best beverage; alcohol and the carbohydrates should be much restricted, moral depression avoided ; a journey may be found beneficial in some cases. Fever must be combated by repose in bed and restricted diet; local pains and swellings by Priessnitz compresses, lini- ments, or salves containing opiates, or by injections of mor- phine. Absorption is hastened by painting with iodine. Punc- ture is useful in severe swellings; so, too, the elastic bandage. Some observers find salol beneficial; others prefer antipyrin, acetanilid, phenacetin.—Ott. Rheumatism, Muscular. Myalgia usually follows exposure, and the pain, generally described as dull, may be of a more acutely burning nature, greatly aggravated by motion. One set of muscles after an- other may become involved. One form has been treated of under "Lumbago" (see page 504); another form under "Tor- ticollis"; another under "Pleurodynia." Diagnosis depends largely on the increase of pain by activ- ity of the muscles and relief by rest. Differentiation.—Neuritis is probably present (perhaps as a complication) if both sides are implicated ; if the pain is inten sified at night under the influence of warmth and rest, and relieved by moving about in daytime. Treatment embraces such measures as rest, warmth, mas- sage, electricity, and drugs of the salicylic-acid group espe- cially. RHEUMATISM, MUSCULAR. 685 Recent cases are almost invariably cured by massage.— Graham. In myalgia massage is always good treatment. B Tinct. belladonna?............................................ 3 b Tinct. aconiti, Tinct. opii................................................aa 3 ij. Liniment, saponis......................................q.s. ad § vi. M. S. To be well rubbed in. —Hare.20 Or, still more efficacious : B Tincture of aconite........................................... 3 i. Camphor.................................................... 3 ij. Chloroform.................................................. 3 ij. Oil of cajuput ... ............................................ 3 ij. Tincture of capsicum......................................... 3 ij. Rectified spirit.........................................q.s. ad 1 vi. Most of the well-known " pain killers" are combinations in various proportions of aconite, turpentine, chloroform, ether, alcohol, and capsicum.—William Murrell. "Perry Davis' pain killer" is supposed to have the follow- ing composition: B Tinct. capsici....................................... ........ § i. Spir. camphora?............................................. § ij. Guaiaci resin................................................. § ss. Alcohol...................................................... § iij. Tinct. myrrha?.........................................q.s. ad col. —Potter. '' Radway's1 ready relief'': B Tinct. capsici, Aqua? ammonia?, Alcohol........................................'............aa, § i. Lin. saponis.................................................. | iij. —Hager. "St. Jacob's oil" is a weak aconite liniment contain- ing ether, alcohol, turpentine, and red coloring matter.— Squibb. 686 the practitioner's manual. Linimentum anodynum ("Jacob's oil"): R Camphora?, Chloral....................................................aa 3 ij. Chloroformi, iEtheris fortioris...........................................aa, § ij. Tinct. opii, Olei sassafras..............................................aa, 3 i. Linim. saponis........................................q.s. ad § xvi. M. R Chloroformi puri............................................ 3 v, Tinct. opii, Acidi salicylici............................................aa 3 iv. Spir. vini rect.............................................. 3" iv. Olei dulcis............................................q.s. ad § xij. M. S. Rub into the parts thoroughly or apply by means of flannel cloths. —Manley. R Amnion, bromidi........................................ gr. x.-xx. T.i.d. R Salol............................................................. 3 Phenacetin....................................................3 Quinina? sulphatis............................................... 3 M. ft. capsul. No. xv. S. One three or four times a day. This is also of use in aborting quinsy and in the treatment of tonsillitis. Or, salophen, gr. x. Rubella. German measles or rotheln bears somewhat the same rela- tion to measles that varicella does to variola. Though occur- ring mostly7 in epidemics, it is seen with some degree of fre- quency as a sporadic affection ; not infrequently in childen who have recently recovered from true measles. The prodromal stage may be said to be wholly lacking, the incubation period having extended through from five to twenty-one days. Diagnosis.—The eruption, occurring upon the trunk or inner surfaces of the arms at first and upon the face afterward, is in the form of punctate lesions resembling dots made with a fine pen dipped in red ink. The color may vary from P^e RUBELLA. 687 rose to deep red. Larger spots occur, reaching a diameter of as much as a centimetre, being lighter at the centre than at the periphery, and, usually with irregular outline or presenting an indented border. Spreading occurs rapidly, the eruption reaching the limbs perhaps within a few hours. It has been stated that the palms and soles escape, but this is by no means the invariable rule. The appearance of the eruption varies greatly in different subjects and in different epidemics. In some almost all instances will be of a scarlatiniform type; in another, morbilliform. A peculiarity of the spread which has been regarded by some as pathognomonic is the rapid invasion of one region after another, with almost complete disappear- ance of any trace in the region last invaded when the eruption is at its maximum in the new territory. The pharynx is of a diffused red, the tongue normal or cov- ered with a thick white coating, through which the papillse show much as in the tongue of a scarlatina in the early stage. There is little fever, 101.5° F. Probably the most important symptom is enlargement of the cervical lymphatic nodes, as well as those over the mastoid process and along the margin of the sterno-cleido-mastoid. An early symptom is tenderness elicited upon pressure over the jugular or subauricular lym- phatic nodes. While not pronounced, this is quite constant. Differentiation.—Rubeola naturally presents the most similarity. There should, however, be little difficulty, since even mild types of measles present quite distinctive points. The eruptive stage, for instance, is much longer, since often in rotheln all traces are gone within twenty-four hours, the whole process being terminated in three or four days. The eruption in measles tends more to run together, with no inter- vening healthy skin, and the lesions do not show so much va- riety in form. It is only in the rarer instances of rotheln, which present spots of rather uniform pea size with tendency to grouping, that measles is at all closely simulated. The chief 688 the practitioner's manual. distinction, however, must lie in the presence or absence of the buccal-membrane lesions described in the chapter on mea- sles (Koplik's pearly points). Scarlatina, as already mentioned, may be closely simulated especially in isolated instances occurring in the absence of epi- demic prevalence and attended with pronounced angina, and with an invasion period exceeding twelve hours. The eruption is, however, rarely so vividly red as in scarlatina, but petechias or purpuric spots may exist. The tongue rarely desquamates or takes on the vivid red color seen in scarlet fever. Idiopathic roseola is distinguished by the absence of papular features, the tendency to confluence, and the absence of mouth lesions. Drug eruptions are excluded by the absence of history of antipyrin, phenacetin, salophen, copaiba, quinine, or similar drugs having been taken. Urticaria is excluded by the absence of distinct wheals and the presence of a more or less intense angina. Treatment is for the most part symptomatic, and much the same as that given in the chapter on rubeola. Rubeola. The eruption in measles is usually first seen along the hair line upon the forehead. The lesions are of a pinkish, reddish, or raspberry hue, very slightly elevated, and somewhat velvety to the touch. The blotches come out upon the third or fourth day of an illness characterized by catarrhal symptoms, injected and weeping eyes, or coryza, photophobia, sneezing, cough, and quickened respiration. Prodromal eruptions may now and then occur, just as in other exanthemata. These may take on the scarlet-like, the measles-like, or an erysipelatous appearance, or may simulate prickly heat, appearing about the second day of invasion and disappearing before the actual rubeolic erup- tion shows itself. rubeola. 689 Diagnosis.—There is slight fever, irritability, and, at first, an inclination to sleep. If catarrhal symptoms and fever are otherwise of obscure origin, the red throat and pharynx as well as the roof of the mouth and soft palate often show early and confirmatory signs. When measles is suspected by reason of exposure and before the eruption appears, it is of the greatest importance that the mucous surface of the cheeks should be carefully examined, since in the stage of invasion, as Koplik has pointed out, there occur minute red dots, having a bluish- white centre, scattered over the lateral aspects of the buccal membrane and upon the inner surface of the lips. This pecu- liar eruption—disappearing by the time the eruption upon the skin is at its efflorescence, the whitish dots not becoming opaque, as in sprue, and not coalescing to form plaques—is re- garded as pathognomonic, and my own observations lead me to accept this view. The mouth lesions are of especial value in instances of lengthy prodromal stage and in dark-skinned races. The eruption on the skin remains out for from five days to a week, invading in succession the face, neck, trunk, and limbs, requiring from two to four days in its gradual spread. At first it is a slightly pointed eruption with areas of healthy skin in- tervening; patches of irregular or circular outline may form by fusion of the primary lesions after they have taken on the appearance of flattened papules. The color is deepest in the most exposed parts and fades momentarily under finger pres- sure. The temperature increases gradually up to the time the rash is well out, or the initial fever remains but little changed throughout, and while it is rarely below 102° it rarely exceeds 103° F. This is in itself one of the most valuable differential points. In defervescence the evening temperature is lower than that of the morning.—Bourgeois. In rare instances the first evidences of a rash may appear upon the calves. The gums usually present a swollen condi- 44 690 THE PRACTITIONER'S MANUAL. tion and form a pultaceous coating, but an erythemato-pulta- ceous stomatitis, it must be remembered, is occasionally seen in the beginning of scarlatina. Differentiation.—Rubella or German measles is one of the most important conditions to be distinguished, and is undoubt- edly in great part accountable for the quite numerous reports of "recurrent measles." The normal pale color of the buccal membrane is not altered during the period of invasion, and most important is the absence of Koplik's sign. Catarrhal symptoms are absent and constitutional manifestations less severe. Cough and sore throat as well as photophobia are lack- ing. The incubation and the prodromal periods are shorter. The eruptive elements remain habitually smaller, take on cres- centic shapes, but do not tend to coalesce in plaques. Espe- cially important is the tendency to generalized glandular swell- ings, most marked in the cervical region, where the lymph nodes remain tender for a long time. The fact that rotheln occurs especially in epidemics helps to simplify the diagnosis. Though the lesions may be closely packed together, they remain usually as discrete pinhead-sized lesions. Influenza in its early stages, when attended with catarrhal symptoms, may at times suggest the presence of measles, but the cheek membrane remains normal, enabling us to exclude it. The fever, too, in grippe increases rapidly, while in measles two or three days are required before the maximum is reached. Scarlatina has a uniform raspberry-colored eruption, coming out first upon the lateral aspects of the neck, behind the ears, or upon the upper chest. Catarrhal symptoms are lacking, the onset is abrupt, the angina is of a diffuse nature and more severe than in measles, there is higher fever and, perhaps, vomiting. The various erythemas and other eruptions inci- dental to early life, as well as the various drug eruptions which simulate measles, are distinguished by the absence of fever and RUBEOLA. 691 usually of catarrhal symptoms, while investigation of the mouth may give valuable aid. Prognosis.—In private practice measles is not a particu- larly fatal disease, but it is by no means to be regarded as the innocent affection which so many still consider it. In certain epidemics, especially in institutions, its ravages are at times appalling, the younger children succumbing to the greatest extent. Below the age of two years the mortality is given as thirty per cent, while above this age, according to Comby, it is seven per cent. The chances for the affection leaving behind alterations in the bronchial-gland structures leading to persis- tent bronchitis are very great. Treatment.—Since the affection pursues a self-limited course, our attention is directed chiefly to allaying symptoms and combating complications. Exposure to sudden changes and draughts is to be guarded against. To protect the respi- ratory organs the hot bath may be employed in case the erup- tion suddenly disappears. To assure an even temperature of the cutaneous surfaces a one-piece cotton-flannel garment should be worn. This obviates the necessity of much bed clothing. A sweating-out process under blankets is uncalled for. When photophobia exists the room should be darkened, but good ventilation should always be maintained. A daily tepid bath or tepid sponging may be given, followed or not by a little alcohol applied to the surface. When the temperature is very high and attended with nervous manifestations, the cold bath or cold pack may be resorted to. Frequent sips of cool water may be given. In uncomplicated instances: B Tinct. aconiti rad...........................................fli, xvi. Extr. ipecac, fld............................................ 3 ss. Tinct. opii deodorat........................................ 3 i. Aqua?................................................q.s. ad § ij. M. S. Teaspoonful every two to three hours. 692 THE PRACTITIONER'S MANUAL. For the cough: B Ammon. bromidi................................................ 3 Syr. liquirit.................................................... 25 Decoct. altha?a?.................................................. 50 M. S. Teaspoonful every hour for a child one year old. —Louis Fischeb. Or— B Extr. hyoscyami............................................ gr. ij. Syrupi...................................................... 3 iij. Aqua? destill...................................•.......q.s. ad § ij. M. S. A teaspoonful every two hours. —WlDERHOFER. In case of intense itching of the surface: B Acidi carbolici.............................................. gr. x. Vaselini..................................................... 1 i. M. S. Apply. Or— B Lanolini puri................................................. \ i. Vaselini..................................................... 3 iij. Olei ricini................................................... ni ij. Aqua? destill................................................. 3 v. Ft. ung. S. Apply as required. As a wash for the eyes: B Acidi boracici, Aqua? (sat. sol.).............................................. § iv. M. S. Wash eyes eight or ten times daily. Or, should there be a persistent discharge: B Hydrargyri chloridi mitis....................................gr. x. Vaselini (white)............................................ 3 iv. In case of severe conjunctivitis: B Zinci sulphatis, Morphina? sulphatis.......................................aa gr. ss. Aqua? rosa?.................................................. 1 i. M. S. A few drops into each eye twice or thrice daily. If the fever is accompanied by headache and restlessness: B Phenacetin................................................. gr. ij. Caffeine citrate.............................................. gr. i Salol....................................................... gr. ss. Sacchari albi............................................... q- s. M. S. For one dose and repeat as necessary. SARCOMA. 693 In distressing and persistent cough: B Antimonii et potassi i tartratis............................... gr. i. Potassii chloratis............................................gr. x. Aqua? menth. pip............................................ § iv. M. S. A teaspoonful every four hours until the expectoration is free. Or— B Ammonii chloridi......................................... gr. xxx. Morphina? sulphatis................................... ... gr. i. Pulv. glycyrrh. rad....................................... 3 i. Aqua?.................................................... § iv. M. S. A teaspoonful every four or five hours. Caution.—To be given with watchfulness to very young children or the morphine reduced in amount. Or when the cough is accompanied by high temperature, especially in the early stages: B Tinct. aconiti radicis........................ ................ 3 b Extr. ipecac, fluidi........................................... 3 ij. Tinct. opii deodorata?......................................... 3 iij. M. S. Six drops every one to two hours. —Carpenter. Application of jacket poultices to the chest, as soon as there is reasonable ground to suspect an attack of measles, and be- fore the rash appears. This proceeding lessens the risk of pulmonary complication assuming a serious form.—Dudley Owen. Sarcoma. While primary sarcoma of the skin is rare in early life, that secondary to internal sarcoma (congenital, of kidney) is occa- sionally seen. Diagnosis of sarcomatous growths, other than those above mentioned, is made by rapidity of development, early7 appear- ance of ulceration and bleeding, and by histological examina- tion. Differentiation.—Multiple pigmented sarcoma of the skin, when primary, is distinguished from other cutaneous or sub- cutaneous nodular swellings by the bluish, brownish, or per- 694 the practitioner's manual. haps black color of the lesions. When, as is usually the case, these lesions are secondary to sarcoma of some other organ of the body, the primary affection is a guide to their nature. Retroperitoneal sarcoma is accompanied by ascites, and when dipping down so as to be detected by rectal touch it may have to be carefully differentiated from solid ovarian tumor. Sarcomata are much more prone to ulcerate than are benign growths, and show differences in density in different portions of the tumor. That of the uterus is distinguished from carci- noma by its early development, less constant pain, and rela- tively slight involvement of lymph nodes. Prognosis.—While for the most part a fatal affection, and usually rapidly so, the location and variety modify prognosis. The round-celled form is the most deadly. Early and persistent treatment may prolong life in the cu- taneous variety. Treatment.—Operation may defer the fatal issue. Treatment by the toxins of the streptococcus erysipelatis and bacillus prodigiosus (Coley) has been followed by reported cures. In primary multiple cutaneous sarcoma, injections of arsenic up to the point of toleration have seemed at times to act well. R Syr. trifol. comp............................................| iiiss. Liq. arsenii et hydrargyri iodidi (Donovan's solution)........ § ss. M. S. Small teaspoonful with water t. i. d. Syr. trifol. comp. has the following composition: R Red-clover blossoms......................................gr. xxxij. Stillingia...............................................gr. xvi. Lappa................................................... gr. xvi. Phytolacca root..........................................gr. xvi. Berberis aquifol......................................... gr. xvi. Cascara amarga.........................................gr. xvi. Xanthoxylum...........................................gr. iv. Iodide of potassium..................................... gr. viij. Syrup.................................................. li. The above combined with Massey's method of electrolysis: " A soluble zinc electrode as positive pole, freshly coated with mercury SCARLATINA. 695 at each appplication, and properly insulated. This electrode, of a size and shape adapted to each case, is inserted into the tumor after a small opening is made by negative electro-puncture, under chloride-of-ethyl spray, and with a properly adjusted large negative pole, as indifferent pole, a current of from one hundred to two hundred milliamperes may be gradually turned on and repeated daily until a cure is effected."—J. Mc- FADDEN GrASTON. Scarlatina. The eruption in the form of a fine punctate rash comes out first upon the upper portion of the body, especially about the neck, upper chest, behind the ears, and at the flexures of the elbow. Preceding this, there may be a general hyperemia at- tending the initial fever. The temperature upon the first day may mark 104° F. When the eruption is at its height, in- volving the whole surface, perhaps by the second or third day, the thermometer may indicate 105° F. With the fading of the eruption there is a gradual fall until the eighth day; when desquamation begins, it is found to be normal. The pulse is high. Vomiting is a frequent early sign, even before the child begins to complain. If convulsions, nervous symptoms with agitation and especially with chill, mark the invasion, a severe attack may be predicted. The extent of eruption varies within wide limits, from a faint and scarcely noticeable redness to a uniform deep erythema pervading the entire surface, joining together and spreading over spots of a still deeper hue. If in the early period a pencil point be rapidly drawn over the body surface, even including the parts covered by eruption, a white line is formed which lasts for a considerable time. The tongue is at first thickly coated with a whitish deposit, through which the summits of enlarged papillae are seen. This . coating soon disappears from the tip and. edges, and about the third day is succeeded by a marked redness of the anterior part (\.)ii the practitioner's manual. of the organ, which is studded over with hypertrophied papil- lae. The throat is diffusely red at first, even in the prodromal stage, but the tonsils and arches of the soft palate may soon present pseudo-membranous or necrotic features. Ulcerations or gangrene may also develop. Differentiation.—If the .patient is seen for the first time only after the eruption has disappeared, and the history shows that there have been no eye symptoms, and it is found that no catarrhal affection and no cough have been left behind, it is safe to say that the affection has more likely been scarlatina than measles. When seen early, measles is excluded by the more abrupt and more violent onset in scarlet fever, and the fact that the eruption does not develop first upon the forehead or face, and is more raised above the surface and of a brighter red color. In the prodromal stage of measles the throat presents some- what the " blotchy" aspect seen on the skin. The color is of a deeper shade than in early7 scarlatinal angina. The congestion between the blotches is slight compared with that in scarlatina.-—Rotch. Minute silvery or pearly dots on the inner surface of the cheeks and lips are present in measles before the eruption.—Koplik. In rubella the general condition is better, the tongue is more natural, the post-cervical and post-auricular nodes are more involved. In diphtheria attended with a rash the nares, larynx, or trachea is likely to be involved. Bacteriological test, if it can be made, is decisive. Both conditions may, however, coexist. In influenza the early rash disappears within a few hours, and is not followed by desquamation, and the throat symptoms are less severe. In erythema resembling scarlatina desquamation often be- gins as early as the fourth day and may last for several weeks. Unless due to a septic process, fever is absent or much less pronounced. SCARLATINA. 697 Prognosis.—The mortality is greater in institutions and in some epidemics than in others. It is likewise high before the age of one year and grows less as adolescence is approached. Treatment.—The general management includes suitable diet, dress, even room temperature at 60° or 65°, ventilation, bathing, a one-pieced garment of flannel or other warm ma- terial, not too heavy bed clothing, as mentioned in the treat- ment of measles, and prophylactic measures. Milk is the most suitable food, and, if necessary, it may be given pepto- nized and ice cold, as an enema every three hours. It is not well to attribute too favorable results to any particular line of treatment, since the type varies greatly in different epidemics, in different localities, and, at times, hospital statistics give a death rate of about one-half that reported in private practice during an equal period. My practice for a number of years has been to treat scarlatina with the bichloride of mercury in frequent, full, and well-diluted doses. While it cannot be ad- mitted that sufficient quantities can with safety be administered to overpower existing micro-organisms, I believe that some- thing can be done with this class of remedies to counteract or prevent the elaboration of toxic substances. R Hydrarg. bichlor . . ........................................... gr. ^ Aqua?........................................................ § ij. M. S. For infants of a year or over, a teaspoonful every two hours. R Hydrarg. bichlor.............................................. gr. I Aqua?........................................................ § ij. M. S. For infants of one or two years, a teaspoonful every two hours. B Hydrarg. bichlor............................................ gr. ss. Aqua?....................................................... 1 ij. M. S. For children over two years a teaspoonful e\ ery two hours. This acts not only as an antiseptic but as an antipyretic to such an extent that I have rarely been forced to use inter- nal antipyretics, phenacetin, etc. I have occasionally given: B Tinct. aconiti............................................... iU xvi. ' Aqua?...................................................... § ij- S. Teaspoonful every three hours for children of five years. 698 the practitioner's manual. R Acidi boracici................................................. 3 ss Potassii chloratis.............................................. 3 j j. Tinct. ferri chloridi........................................... 3 ij. Glycerini, Syr. simplicis...............................................aa § i. Aqua?......................................................... 3 ij. M. S. Teaspoonful every two hours for a child of five years.___SMITH B Tinct. ferri chloridi......................................... 3 ij. Potassii chloratis........................................... 3 i.-ij. Syr. simplicis.............................................. § iv. M. S. A teaspoonful every hour or two to a child of four or five years. —J. Lewis Smith. Begin treatment with the administration of calomel; then give throughout the disease: B Chloralis.................................................. gr. xxx. Syr. lactucarii, Aqua?..................................................aa \ ss.-i. M. S. Teaspoonful in ice water every two or three hours. Complete narcotism should never be attained.—Wilson. The throat requires more constant attention than the skin in the early7 stages, and since it is probable that exhalations are active in disseminating the disease, mouth washes, gargles, and sprays should be employed from the very first. As a spray for the throat: B Hydrogen peroxide. .•............................................. 1 Aqua? bul.......................................................4 M. S. Use every hour or two. For the nares: B Hydrogen peroxide............................................. 12 Aquae bul............. .......................•................. 46 Sodii bicarb.................................................... 2 M. S. Heat before using and apply every half-hour. Or— B Hydrarg. bichlor............................................. gr. ij. Aqua? bul.................................................... O i. M. S. Apply every two hours. Or— B Oxygenated water........................................ § i. Sodii bicarb.............................................. gr. xviij. Aq. bul. dest............................................. % ij. M. S. Use as spray every two hours. —McCLANAHAN, SCARLATINA. 699 R Acidi boracici................................................. 3 ij. Sodii biboratis............................................... 3 ij. Sodii chloridi.................................................. 3 i. Aquae......................................................... O i. M. S. A teaspoonful injected into each nostril hourly. —J. L. Smith. Or— B Boracis................................................ q.s. sat. sol. Glycerini.......................................................| ij. S. Paint the throat several times daily. B Potass, permanganatis........................................ 1 Aqua?........................................................ 400 Sodii chloridi..................q.s. for normal (&%) saline solution. M. S. Use as an injection for the throat or nares. As a gargle : B Acidi acetici................................................ 3 ij. Glycerini.................................................... § i, Aqua?...............................................q. s. ad § viij. A daily bath may be given of SS° or 89° F. of five minutes' duration, followed by dilute alcohol, or a sponging of the sur- face with water to which a tenth part of alcohol or a fifth part of vinegar has been added. Or a cooler bath at 65° or 75° F. maybe given when the temperature goes above 103.5°, or in the anginal form with prolonged hypersemia. Or bath at 95° F. of ten minutes.—Schill. Caution.—In asthenic and other malignant cases, in the presence of cardiac affections, collapse, or pseudo-rheumatism, frequent bathing may prove too exhausting. B Acidi carbolici........................................... gr. xxx. Thymol................................................. . gr. x. Petrolati.................................................. 3 i- Ung. simplicis........................................... § b M. S. Employ after the bath. For itching of the skin surface: R Lanolin, anhydrous___:........................................ 50 Vaseline........................................................ *0 Water........................................................... 25 M. S. The evaporation of the water acts to decrease the surface heat. 700 THE PRACTITIONER'S MANUAL. When desquamation begins, to shorten this stage: R Resorcin..................................................... 5 Salicylic acid.................................................. r> Superfatted soap............................................... 100 M. S. Locally. R Hydrarg. bichlor............................................. 1 Aqua?....................................................... 1,000 M. S. As a wash for the surface especially during desquamation. R Ichthyol....................................................... 5 Unguenti...................................................... 100 M. S. Apply to produce decline of fever and for beneficial effect on skin. —Seibert. In the presence of suppuration and pyaemia: R Tinct. ferri chloridi............................................ 3 i. Glycerini puri................................................. 3 ij. Aqua? destillata?........................................q.s. ad § ij. M. S. Teaspoonful every two hours. As a diaphoretic and cardiac stimulant: R Spiritus a?theris nitrosi................................gtt. x.- 3 i. In water pro re nata. In ataxic phenomena: R Moschi.................................................." 1 gm. Ammonii carbonatis.................................... 0.20 cgm. Syrupi.................................................. 40 gm. Aqua?................................................... 80 gm. M. S. Two teaspoonfuls four to six times a day. —Descroizilles. A specific and prophylactic : R Sol. hydrarg. bichlor. (1-5,000).............................. 3 iij- Potass, iodidi.............................................. gr. x. Ferri et ammonii citratis................................... gr. xx. Syrupi..................................................... § ss. Aqua?................................................q.s. ad § ij. M. S. Teaspoonful every two hours to a child of from two to four years. —ILLING WORTH. R Acid, carbol................................................ gr. xx. Thymol.................................................... gr. x. Petrolati vel ung. simp..................................... § i. M. S. Rub in well. __STARR. Treatment by the antistreptococcic serum.—Marmorer. The majority of cases thus treated seem to recover without SCARLATINA. 701 complication. There is rapid reduction of temperature, and the mortality rate seems to have been decreased in the cases in which it has been employed. Inject ten centimetres and repeat until the temperature falls. In pseudo-diphtheritic angina in young children use Dobell's solution diluted. (See page 200.) Or 1 to 1,000 solution of bichloride of mercury to wash nose and throat. To expose in a sick-room as a disinfectant: R Formaldehyde, Alcohol...................................................aa p. a?. M. S. Pour into an open vessel. To prevent adenitis and swelling of the neck cold compresses may be employed, or a cold-water coil or an ice bag; the latter, too, may be applied to the head in hyperpyrexia. For an effect upon the throat and bowels: R Sulphur....................................................... 3 b Ft. tablets No. 30. S. Take one three or four times daily. To swab the region of the tonsils and pharynx several times daily: R Creosote................................................... 1 gm. Alcohol..................................................... 90 gm. Glycerin................................................... 28 gm. M. —Sevestre. In threatening high temperature: R Quinina? sulph........................................... 0.30 cgm. Olei theobroma?.......................................... 2 gm. M. For one suppository. For an infant five days old and repeat as necessary.—Comby. R Antifebrin................................................gr. xv. Sacch. alb................................................ gr. xxx. M. ft. chart. No. x. S. A powder as required to relieve fever, for a child of three or four years. — WlDOWITZ. 702 the practitioner's manual. If the eruption does not come out well: B Vini antimonii............................................ 2 gm. Spir. Mindereri............................................ 3 " Syr. rubi ida?i............................................. 15 " Aqua? sambuci............................................ 120 " M. S. A teaspoonful every two hours. —Archambault. In threatened collapse, caffeine, ether, or oleum camphorae, by subcutaneous injection. B Tinct. digitalis............................................ 15 gtt. Mel. scilla? acetat.......................................... 15 gm. Syr. simplicis............................................. 45 gin. Aqua?..................................................... 90 gm. M. S. Teaspoonful every two hours. —COMBY. Caidion.—In scarlatinal rheumatism salicylate of sodium is contraindicated. In malignant, toxic cases, spir. terebinth, 1 gm., by hypoder- mic injection.—Fauva. To prevent otitis: B Beta-naphthol.............................................. 10 gin. Camphor................................................... 20 " Glycerin.................................................... 30 " M. S. Apply to the throat, especially when exudation is present. —Charpentier. Sciatica. This painful neuralgia or neuritis (Gowers) may occur abruptly or after premonitions. The pain is paroxysmal, or there may be continued dull pains extending over a portion or the whole of the nerve distribution. The pain begins usually at the back of the thigh and extends down the leg. Gradually becoming worse, it is aggravated by movements which put the nerve upon the stretch. Diagnosis.—Tenderness on pressure over those points where the nerve branches emerge from the spinal canal and where they penetrate various muscles is rather characteristic. These points SCIATICA. 703 are found over the sacrum, sacro-iliac junction, about the middle of the crest of the ilium, sciatic notch, between the trochanter major and tuber ischii, in the popliteal space, over the articu- lation of the tibia and fibula, over the lower and posterior part of the external malleolus, on the dorsum of the foot, and upon the outer aspect of the sole. In neuritis these painful points are often wanting. Differentiation.—From muscular rheumatism and from hip-joint disease. In rheumatism the pain is limited to the affected muscle and there is at first tenderness over the parts affected. The paroxysms are brought on by calling the muscles into play. In hip-joint disease there is pain upon pressure over the greater trochanter, also in flexing and extending the thigh, while signs of chronic joint inflammation, including fever, emaciation, and general debility, are more pronounced than they are in sciatica. In hysteria painful points are less frequent, and pain is not increased by passive motion. Lumbago affects a higher region in the back, and there is no pain on pressure over the nerve. Pelvic and faecal tumor must be excluded as causes of pain from pressure. Disease of the nerve roots and of the vertebrae or of the cord is more apt to cause bilateral pain. Shooting pains of locomotor ataxia are excluded by the oth- er signs of tabes. In severe neuritis of different nature (ascending), reaction of degeneration may occur. [Slow contraction of muscles upon direct galvanic stimulation; the reverse of the electrical reac- tion in health, upon opening and closing the currents.] When the Achilles-tendon reflex is diminished or lost, the condition is to be regarded as a neuritis (disease of joints and spinal cord being excluded).—Biro.60 704 the practitioner's manual. The knee jerk is also at times diminished in sciatic neuritis. —Knapp. Prognosis.—Though often persisting for months and occa- sionally extending into years, the tendency is to final recovery. Treatment.—Much similar to that given under neuritis. If gout is suspected, colchicum. If of rheumatic origin, salicylate of sodium. Exclude pressure from new growths within the pelvis (rec- tal exploration) or along the course of the nerve, as well as lead poisoning, malaria, gout, and anaemia before directing treat- ment to the neuralgic condition per se. Nerve stretching.—Potter. R Chloral hydrate............................................ 3 iij. Bromide of sodium........................................ 3 iij. Morphine sulph.....................................'.......gr. vi. Quinine sulph...........................................gr- Hv. Pulv. camphor............................................. 3 ss. Elix. taraxacum comp..................................... 1 vi. Tinct. aconite.............................................. ^ xxiv. M. S. A dessertspoonful every three hours until relieved. —Wilson. R Alcoholic solution of nitroglycerin (one per cent).............. 3 ss. Tincture of capsicum......................................... 3 iss. Peppermint water............................................ 3 i"'J- M. S. Five drops thrice daily in a tablespoonful of water for the first three days, and ten drops thrice daily on the following days. —Troussevitch. R Nitroglycerin.................................................. 1 Water or alcohol.............................................. 190 M. S. tti, i. three times a day, increased to in, iv. if necessary. Caution.—If congestive headache is caused, counteract with bromides.—Krauss. Or cocaine, gr. i~i, by injection into the seat of pain.— Se AGRA YE. To lessen danger: R Cocaine....................................................... 10 Of) Resorcin...................................................... *" Watei......................................................... 10° SCIATICA. 705 If patient becomes pale or faint, give compound spirits of ammonia or amyl nitrite.—Havilland Hall. Hyperflexion of the limb upon the abdomen under anaesthe- sia if necessary. Or nerve stretching, by exposing the nerve and exerting traction upon it sufficient to raise the limb from the operating- table. When there is active inflammation, mass, hydrarg., gr. i. twice daily. For mild degrees of pain: R Phenacetin................................................. gr. x. Caffeine citrate.............................................gr. iij. —Tyson. In the chronic stage, galvanism. R Tinct. aconiti, Tinct. colchici seminis, Tinct. belladonnas, Tinct. acta?a? racemosa?..............................aa equal parts. M. S. Six drops every six hours. —Metcalf. Or— R Sodii glycerophosphat....................................... 5 gm. Aquae destill............................................... 20 " M. S. Inject one-fourth cubic centimetre deeply into muscles near the nerve. It is not painful, and recent cases soon recover, while invet- erate instances are improved.—Billard. Or— R Pulv. opii, Pulv. ipecacuanha?......................................aa gr. xij. Sodii salicylatis........................................... 3 b Extr. cascara? fluidi..................................... q.s. M. div. in pil. No. xii. S. One or two pills for a dose. —Benjamin Ward Eichardson. Or rest in bed, flannel bandage, splint from axilla to ankle, and at end of treatment careful massage. — Weir Mitchell. Methyl chloride as a spray upon the surface, cured ten and improved three out of fifteen cases.—Hertmann. 45 706 the practitioner's manual. Salol, 0.5 to 1 gm.—Aschenbach. Copaiba, gtt. xl.-l. daily in divided doses.—Glorieux. In obstinate cases nitroglycerin, beginning with one-one- hundredth grain and gradually increasing up to one-twentieth three times daily.—Law7rence. Hydrochloric acid, § ss. Apply by dipping a brush in the strong acid and painting three or four coats over the painful part of the nerve; then wrap limb in cotton wool.—Geunatas. Digital compression of the painful points while patient lies in bed with limbs completely relaxed. The right thumb is placed over the painful point and over the right the left is placed, making deep pressure for twenty seconds. Lateral pressure is exerted at the same time. Eepeat every second day. Six sittings usually suffice.—Negro. Or forced anterior flexion of body (bloodless stretching of nerve) preceded and followed by massage at intervals of one to five days.—Bonuzzi. Or under anaesthesia stretch the nerve by grasping the ankle and preventing flexion at the knee, forcibly flexing the straigthened limb upon the abdomen, using considerable force. Cotton, wool, bandage, massage, electricity.—Cureton. Scorbutus. Scurvy in the adult is not so frequent in institutions and on shipboard as in former years, thanks to better methods in food supply, and properly preserved meats for lengthy expeditions. Diagnosis.—Besides bleeding and puffiness of the gums, a fibrinous condition of the latter develops; ecchymoses occur upon various portions of the integument, especially the legs be- low the knee; and hemorrhages may take place from mucous membranes. There is marked debility and apathy, with wasting of tissue, oedema, and brawny pigmented induration, especially of the legs. In the course of a week or more a greenish pallor scorbutus. 707 or dirty gray hue of complexion is noted; the skin becomes dry, scaly, with prominent papillae, and petechiae appear, especially about the hair follicles. Unless complicated, there is little or no fever. A striking manifestation in rare instances is the occurrence of night blindness, the subject being in total dark- ness even upon a moonlight night. The occurrence of symp- toms of debility in those exposed to close quarters, and such fare as sailors and prisoners have, should cause one to think of scurvy. Differentiation.—Scorbutic anaemia depending on priva- tion and exposure has absence of fibrinous exudation (gums, flexures of joints), less skin discolorations, no night blind- ness. Purpura has more distinctly bright purplish spots, perhaps with joint pains, but the gums are not so thickened, and, though hemorrhages occur in one of its forms, the firm and darkened condition of the skin is absent or comes as a late manifesta- tion and in a mild degree. Prognosis is good if proper food can be supplied. Recovery in from one to six months. Treatment.—It is usually advised in adult scurvy to supply the patient with fruit acids and fresh vegetables. In two epi- demics of which I have had the management, one occurring in a ship's crew after a long voyage and the other in a work- house in which a large number were affected simultaneously, it was with considerable difficulty that I could induce the pa- tients to take the juice of lemons, limes, or oranges, nor were they at all inclined to partake of the vegetable diet which I ordered. It has recently been suggested, and I believe rightly, that fresh meat should constitute the chief diet in these cases. An abundance of fresh cow's milk, the juice of squeezed beef, fresh fruit and vegetables, furnish the whole treatment usually required. Tonic medication should be given for some time after the acute symptoms have passed. 708 the practitioner's manual. As prophylactic : R Potass, et sod. tart.......................................... gr. xx Calcii chloridi.............................................gr. v. M. S. Give three times daily. To enhance coagulability of blood : R Potass, et sod. tart..................... Calcii chlorid. (crystal)................ M. S. Three times daily. Pulque, the Mexican unrectified wine.—Ide. Scorbutus, Infantile. Scorbutus in infancy, or Barlow's disease, presenting lesions which are hemorrhagic in character, with subperiosteal effu- sion or hemorrhages into the mucous membrane and skin, is a disease seen in the well-to-do rather than in the poor family. Some instances resemble rachitis; and in others there is a com- bination of the two affections. Diagnosis.—We are aided in the diagnosis by the fact that artificial foods of various kinds have entered largely into, or have solely formed the infant's dietary. We may be confirmed in it if substituting proper food produces almost immediate results. The complexion is sallow or of a dirty grayish color; sweatings are often profuse, especially about the back of the head. The gums are bluish, boggy, and bleed readily, espe- cially in children with teeth ; the appetite is nil. Hemorrhages into various tissues occur (subperiosteal are considered charac- teristic). There is anaemia and often pseudo-paralysis. The onset is gradual. The symptoms which cause alarm come suddenly. Haematuria may be the first thing to attract the parent's at- tention. "Black eye" without traumatism, perhaps repeated several times, can rarely be due to anything except scurvy.— Cheney. The child with beginning scurvy will lie quietly when un- . gr. xxx.-lx. . gr. xx. —Wright. scorbutus, infantile. 709 molested, but at the slightest touch will give evidences of pain. Swelling of the legs, especially about the thigh, is a most con- stant sign in a later stage. There may be a pyriform boggy swelling about the diaphyses, gradually decreasing in size from the epiphysis toward the shaft of the bone. The appetite de- creases and diarrhcea may7 be present. The characteristic mark of infantile scurvy is the prompt recovery under a pure-milk diet. Differentiation.—Rachitis is distinguished by the charac- teristic rosary of bead-like enlargements at the junction of the cartilages with the ribs and the greater degree of gastro-intes- tinal manifestations. Scurvy rickets, or scorbutus in children already rachitic, may7 present a complex symptomatology, but quick recovery from the more acute symptoms under treatment makes all clear. From rheumatism by the slight amount of fever or its en- tire absence, and the fact that the swelling is above and to the outer side of the joint, without heat or redness. Fracture of femur has come into question. All forms of anaemia are excluded by the prompt restora- tion of health by antiscorbutic food. From purpura haemorrhagica by the greater amount of sub- periosteal and deep-seated hemorrhages, and from the hemor- rhagic forms of congenital lues by the extreme tenderness in scurvy and the absence of other characteristic symptoms of syphilis. Immobility of a limb may simulate paralysis. In syphilitic pseudo-paralysis there are the same muscular weakness, pains, and crepitation about the epiphyses, but the swelling is less extensive. Prognosis.—While fatal if untreated, the condition responds quickly to proper measures if early instituted. Treatment.—Sunshine, fresh air, tonic baths, lemon juice, orange juice, beef juice, fresh vegetables (if child is old enough), otherwise exclusive pure fresh milk modified to meet the special 710 THE PRACTITIONER'S MANUAL. requirements of each patient. Fresh cow's milk and sieved potato. —Barlow. Combine with a cereal.—Jacobi. In warm weather Pasteurize or moderately sterilize. When rachitis is present, elixir phosphori, tti x., t.i.d. Inunctions of oil for painful extremities.—Northrup and Crandall. Or cod-liver oil and phosphorus.—Carr. In pseudoparalysis of slow progress, minute doses of citrate of iron, massage, hot and cold douches to lower extremities.— Joseph Leidy. Scrofula. This chapter, which in the past century would have been a long one, can now be limited to a few words. Although to- day almost all so-called scrofulous affections can be properly classified under tuberculosis, syphilis, rachitis, the results of adenoids or some other well-defined condition, there still exist certain manifestations for which it is well to retain the name. The clinical picture, as well as the pathologic process in- volved, differs in various allied scrofulous and tuberculous states. Thus, as Wooton says, scrofula commences with mal- nutrition and tuberculosis with impaired absorption. The lymphatic temperament may be said to be the first manifestation, and it is essentially by the chronic enlargement of the nodes of the neck that subjects of this affection or dia- thesis are distinguished. Likewise in after-years the pecu- liarity of the scars left about the region of the neck are suffi- ciently distinctive to indicate the nature of the lesions which have produced them. There is a type of stunted child, with loosely hanging, doughy skin, prominent or flabby abdomen, thick lips and broad nose, whose skin and mucous membranes are peculiarly vulnerable and of low vitality. The subcuta- neous lymph nodes readily break down. SCROFULA. 711 There is a second type of tall blond individual, with pale skin, prominent blue veins, and flushed cheek. Such subjects likewise readily develop pathologic changes in the skin, espe- cially of tuberculous nature. This is also true of the internal organs. It would seem that the condition, of whatever nature it may be, prepares a soil well suited for the growth of bacil- lary diseases, and especially for those of tuberculous nature. Upon the skin surface we often find both lupus and tuberculosis cutis. Other instances clearly not syphilitic and which inocu- lation experiments have shown not to be tuberculous, present le- sions of ecthyma, keratitis, and visceral changes which can at present be classed only as scrofulous. While no characteristic symptoms or lesions can be said invariably to present them- selves, still such a similarity in temperament may pervade the various members of entire families, showing a proneness for osseous and catarrhal affections, hip-joint and spinal disease, as well as for enlargement of the neck nodes and cutaneous lesions justly termed scrofulodermata, that the designation should, for the present at least, be retained. As Gaston has well said, scrofula is not tuberculosis, but the expression of infectious states which have left their imprint upon the patient and prepared the soil for the subsequent de- velopment of the tuberculosis bacillus. Treatment.—Cod-liver oil (teaspoonful doses for an adult). Intermittent applications of iodine. Excision of glands is not satisfactory. Insert a small self-retaining drainage cannula. Two days in situ are sufficient.—F. M. Briggs. General treatment embraces most nourishing food, country and especially sea air, sea baths, good hygiene, and abundant sleep, iodine, hydriodic acid, surgical measures. In treatment distinction can well be made between the nervous and the phlegmatic type. 712 the practitioner's manual. R Potassii iodidi............................................. 2 gin. Tinct. iodi............................................... 15 gtt. Tannin.................................................... 1 gm. Syr. cinchona?............................................. 30 gm. Muc. gumma? acacia?...................................... 150 gm. M. S. To be taken in three doses during the day. —GUIBOUT. In scrofulodermic tumors and ulcerations, as well as in lu- pus which has developed from the scrofulodermic basis: R Zinci oxidi, Amyli pulv..............................................aa 3 ij. Petrolati albi............................................. § ss. Hydrarg. oleatis (5 per cent)............................... § i. Acidi salicylici,............................................ gr. xx. Ichthyoli................................................. ""1 xx. 01. lavandula?.............................................. q. s. M. ft. ung. S. Rub in well and cover with potato-starch powder. Sufficient Armenian bole and raw umber may be added to secure a skindike color.—Brooke. For young children: R Iodoform................................................... gr. iss. Mellis...................................................... 3 iv. This can be given for a long time and is preferable to iodine and the iodides.—Besnier. R Sodii arsenitis.............................................. gr. \ Elix. calisaya................................................§ ij. Teaspoonful one to five times daily. For a bath: R Sodii bromidi................................................. 10 Sodii carbonatis....................... ...................... 100 Sodii chloridi................................................. 500 To be used in a bath of twenty minutes' duration. If the skeleton develops badly : R Sodii phosphatis, Potassii phosphatis.........................................aa, 5-10 Elix. calisaya?................................................ 200 Malaga wine................................................. 800 Tablespoonful as required. No one remedy will prove efficacious in different types of the affection. Hygienic and remedial agents conjointly give SEASICKNESS. 713 the best results. Nuclein solution, five per cent, 3 i. t.i.d., be- fore meals. Dose must be larger in phlegmatic than in ner- vous temperament, and determined according to idiosyncrasy. —Dowling. In association with rachitis or anaemia: R Syr. ferri iodidi...................................... gtt. iij.-xxiv. Aqua? destillatse..................................... § iij- M. S. 3 i. every four or five hours. __HARE. Scrofulous Glands.—Anodal diffusion of iodine with aid of negative pole of galvanic battery. See also under "Lympha- denitis." Seasickness. The mere fact of being upon a vessel does not preclude the possibility that the nausea, vomiting, headache, depression, sleeplessness, pallor, perspiration, may have other cause than the one most likely under the circumstances, or that there may be some complication requiring most prompt and urgent atten- tion. Examination of the abdomen may7 disclose signs of vol- vulus, appendicitis, obstruction, etc. Begin three days before sailing and continue for first three days out to take: R Ext. taraxaci, Ext. colocynth. comp....................................aa, gr. xx. Ext. hyoscyami........................................... gr. iij. Ext. nucis vomica?.......................................... gr. v. Massa? hydrargyri.......................................... gr. xv. M. et fiant pil. No. xx. S. One or two each night. During this time let the diet be simple. Avoid fluids. Keep the recumbent posture on deck. Preventive Treatment.—For an hour before embarking give every quarter-hour strychnine sulphate (arseniate or hypo- phosphite) gr. rxo m granules or tablet triturate. A combina- tion of these three salts of strychnine, gr. t±w of each, can be given for three days three times daily, and each night half a grain of podophyllin.—Le Grix. 714 THE practitioner's manual. Wear a tight bandage or belt from the ensiform cartilage to below the umbilicus. Potassium bromide, 3ss.-3i.; take upon embarking in a large glass of soda" water and repeat for long voyages in perhaps smaller dose. Or chloral in correspondingly large dose. Remove bile by giving hot water to provoke eme- sis.—Lauder Brunton. Bromization is demanded, and this must be induced and kept up two or three days before, and continued for several days after sailing, and sometimes even through the entire voy- age. The amount necessary to produce mild bromization va- ries in individual cases. Thirty grains three times a day may be sufficient, but in many cases it is necessary to give much more than this. Because of its greater acceptability to the stomach, the bromide of sodium is much to be preferred to the bromide of potassium.—Rockwell. Cocaine, four-per-cent. solution, gtt. v. t.i.d.—Boyd. To arrest vomiting: R Cocaine hydrochlorate, Ext. of opium..........................................aa gr. iss. Powd. marshmallow root........ .......................... q.s. Mix and divide into pills No. x. S. One pill every second hour. R Chloroform, Tinctur. of nux vomica...................................aa gtt. x. Compound tincture of lavender.............................. 3 i. Water...................................................... 3 x. M. A teaspoonful to be taken every hour until the vomiting and nausea have subsided, care being taken to shake the bottle each time before the dose is poured out. —BARBAS. R Menthol.................................................. 0.10 cgm. Cocain. hydrochl........................................ 0.20 cgm. Alcohol................................................. 60 gm. Syr. simp............................................... 30 gm. M. S. Teaspoonful every half-hour. __MOREL-LAVALLEE. R Atropina? sulphatis.................................... 0.02 cgm. Strychnina? sulphatis................................... 0.04 " Aqua? mentha? piperita?.................................40. gm. M. S. Inject one cubic centimetre or one-sixth to one-fourth of this quantity for a child. _w. w. Skinner. SEPTICEMIA. 715 Hypnosis may have an effect in naupathia.—Folkes. Chlorobrom,* 3 iii. at 10 p.m.—Hutcheson. Or chlorobrom, 3 i. to 3 iii. as prophylactic after a brisk cholagogue purge.—Charteris. Elevate the extremities and apply warm flannel bandage to arms and legs.—Rawlins. Septicaemia. An initial chill usually within twenty-four hours of infection may be preceded by slight febrile symptoms. Sweating, pros- tration, high fever, delirium are often soon followed by an un- conscious state. Icterus, diarrhoea, restlessness may be among the symptoms which go with a foul-smelling wound. Differentiation.—The symptoms as they arise from poison- ing by putrid matter, the venom of serpents, or the inhalation of septic gases vary with the particular noxious substance at fault. They are in a general way much the same as those of septicaemia. Tuberculosis is at times not readily distinguished, and areas of infection must be carefully sought for in the pelvic organs, genito-urinary tract, or elsewhere. A metastatic abscess in any part of the economy may give the greatest aid in differen- tiation. The spleen is enlarged in septicaemia oftener than in tuberculosis. The respirations are not so rapid. Differentiation from pyaemia by the absence of suppuration, pus foci, and metastatic abscesses. Intermittent fever may be simulated by the remissions, which, however, are not so complete. Typhoid may be suggested by7 certain mild cases without remissions, but the more characteristic features of enteric fever, including the rash, are lacking (pseudo-typhoid).—Banti. Prognosis.—It is only in the milder forms arising from * Contains chloralamid and potassium bromide., gr. xxx. each to an ounce, flavored with licorice. 716 the practitioner's manual. accidental wounds, etc., that recovery is expected. In severe attacks death may rapidly ensue. Treatment.—In puerperal septicaemia, local antiseptic douches. Antistreptococcic serum, 20 c.c.—Mapleton. In acute hemorrhagic, antistreptococcic serum (Burroughs & Wellcome), 3.5 c.c. injected and repeated every four hours. After eight injections, dose was increased to 7 c.c, and twenty additional injections were given.—Balance and Abbott.7 Streptococcus antitoxin, 8 c.c.—Lilienthal. To reduce fever, hydrotherapy. Prophylaxis: immerse every wound, however slight, in bi- chloride solution (1-10,000); dry with sterile cloth and coat with collodion.—J. A. Wyeth. Injection of a quart of normal [yV%] salt solution into the subcutaneous cellular tissue is a treatment which has given excellent results.—Lanphear. Yeast nucleinic acid should be given at the earliest possible moment, not waiting for typical and classic symptoms. From thirty to forty minims of a five-per-cent solution un- diluted, given hypodermically if possible.—Courtney.41 Sustain force with concentrated food, milk, and alcohol. Oxygen inhalations.—Currier. In gastro-intestinal septicaemia of infancy, intestinal irri- gation followed by nutritive enema. Subcutaneous injections of salt solution. R Dry peptone............................................ 3 iss.- 3 iiss. Yolk of egg............................................ 1 or 2 Tepid milk............................................. § ij. Sydenham laudanum................................... gtt. ij. For further treatment see "Pyaemia." Spleen, Enlargement of. The enlargement of the spleen in malarial affections must be distinguished from that of splenic anaemia or leukaemia by the history of preceding malarial affection and by the presence SPLEEN, ENLARGEMENT OF. 717 in leukaemia of an increased quantity of the white blood cells and marked tendency to hemorrhage from one or more mucous surfaces, as well as into the other tissues, including the retina. Diagnosis.—A large spleen can seldom be detected by palpa- tion, while even moderate enlargement can be made out by7 per- cussion. Dulness in an oval area, seven or eight by ten cen- timetres, indicates enlargement. The diagonal position of patient is best. Try various positions.—Baumler. Differentiation.—Amyloid spleen is excluded by the ab- sence of preceding suppuration and by the hardness of the organ. Hydatid tumor, when it is sufficiently advanced to occasion discomfort and to be distinguished by palpation, shows fluctua- tion, and puncture of the cyst or aspiration will enable a verifica- tion of the diagnosis by finding hooklets with the microscope. The presence of hydatid disease in the neighborhood and the hygi- enic surroundings and habits of the patient will go far toward excluding or confirming the presence of the latter disease. In enlargement of the spleen in various infectious disorders and conditions of blood poisoning, we have the symptoms of these affections to indicate the cause. From enlarged kidney it is distinguished by the tumor not extending so far backward in the direction of the spine, ena- bling the examiner's fingers to pass behind the posterior border. There is no thoracic area of dulness in enlarged kidney, while that of the spleen extends to or above the ninth rib. Anterior- ly the spleen extends toward the median line farther than the kidney when the patient is examined in the knee-chest position. Acute splenitis may be diagnosticated, especially when en- docarditis or inflammation of other neighboring organ exists and pain increases on deep inspiration or by coughing, as well as by pressure exerted over the region of the spleen. The con- dition is rare. Splenic Abscess.—In addition to the above symptoms we 718 the practitioner's manual. have an extension of the tumor area, together with fever of a hectic type. In a general way it may be said that the larger the spleen tumor, the greater is the likelihood of its depending upon leukaemia or chronic malaria. Suppurative inflammation may be an evidence of pyaemia, whose other symptoms will point to the origin of the abscess. Rupture into an adjacent organ or into the peritoneal cavity may occur. The occurrence of chill and fever tends to exclude echinococ- cus disease. Wandering spleen is differentiated from faecal tumor by a lack of splenic dulness in the normal situation. Cirrhosis and infarcts also give rise to enlarged spleen. Treatment.— For enlarged spleen : R Quinina? sulph., Ferri reducti............................................aa 3 ij. Strychnina? sulph., Acidi arsenosi............................................aa gr. iij. Ext. gentian............................................... q.s. Misc. et fiant pil. No lxx. S. One pill three times a day. If the stomach is weak and will not bear more, begin with one pill and increase to three a day.—B. P. Wilson. Stomach, Dilatation of. Gastrectasia is the name which has been given to a dilata- tion producing digestive disturbances. Gastroptosis (partial or complete) is the term for sinking of the stomach. Downward displacement along with other vis- cera is called enteroptosis. Dilatation may be acute or chronic. The acute is rare. The atonic form is often found in those who consume large quantities of fluids. Diagnosis may be made by inspection in some instances; by percussion while patient stands. STOMACH, DILATATION OF. 719 A large amount of food in the stomach before breakfast is the only pathognomonic sign. Explore with sound. Reichmann's syndrome, with hydrochloric acid free or com- bined in larger quantities than normal after a test meal, is found when lesions exist, especially near the pylorus. Differentiation from atony by the stomach being found full of putrefactive material in the early morning; the urine being concentrated, scanty, and containing diacetic acid and acetone. From normally large stomach (megalogastria) and prolapsus, by distending with gas, the use of Hemmeter's in- tragastric bag or Einhorn's electrodiaphane, or by an a?-ray picture after a spiral electrode is made to apply itself along the greater curvature (Wegele). In atony the motility is abnor- mal, while the size is normal. In gastrectasia there is enlarge- ment in addition to motor disturbance. In other words, in gastrectasia the stomach is of abnormal size when empty; in atony only when filled. Prognosis.—In simple atony good. In obstruction at pylorus bad. Treatment.—In motor insufficiency of first degree, remove dietary and systemic causes; abdominal bandage. Little food or drink at a time. Caution.—Milk diet is not advised. Purgatives should be used only as a last resort. R Strychnina?.................................................. gr. $ Elix. gentiana? cum ferri chl.................................. § vi. M. S. Tablespoonful t.i.d. When hydrochloric acid is excessive : R Magnesia? usta?........................................... § ss. Bismuthi carbonatis, Sodii bicarbonatis....................................aa 3 i. gr. xv. Strychninse sulphatis.................................... gr. iss. M. S. Half-teaspoonful one hour after meals. —HEMMETER.36 Caution.—The dose of strychnine is heroic. 720 THE practitioner's manual. Wash out stomach before meals for a day or two, then be- fore bedtime two or three times a week. Preprandial pill: R Strychnina?................................................. gr. ^ Liq. potassii arsenitis....................................... tti iv. Creosoti.................................................... t\[ i. Ext. gentian................................................ gr. ij. S. Twice daily. In extreme cases, the constant current through middle of back; or by protected tube internally, the other over the epigastrium. Deep massage or careful pommelling of epigastric region.— Wynter. In bottle-fed infants, in whom dilatation is often responsible for auto-intoxications, lavage is easily performed with a No. 20 to 24 Nelaton tube.—Comby. Stomach, Ulcer of. Gastric ulcer is most often seen in young and anaemic wo- men, or, if much hemorrhage has occurred, the anaemia may be the result rather than the cause. There is a period during which the symptoms are those of dyspepsia, extending perhaps through months, in which the patient has pain after eating, well-defined malaise, and a sensation of weight in the epigas- trium. The stomach is often distended, and intellectual torpor is a frequently marked sign. Ulcers so situated that food rare- ly comes into contact with them may exist as "latent ulcers," until perforation results in peritonitis. Diagnosis. — When the ulcer is definitely established, the three pronounced symptoms are pain, vomiting of blood, and evidence of blood in the dejecta. The pain is dull, lancinating, or burning, paroxysmal in its intensity, and usually localized near the epigastrium, shooting at times toward the back and being most marked near the angle of the left scapula, stomach, ulcer of. 721 If an electric current is passed through a painful spot, the pain will be intensified if ulcer be really present, whereas de- crease in the pain is against ulcer being present.—Routh. The patients will indicate, with the hand over the region, the place where "food seems to become arrested," as they express it. The chief point in connection with the pain is that it comes on, or is at least intensified, after taking food. As to the loca- tion of the ulcer, if the pain appears at once it is more likely to be in the cardiac extremity; if a half-hour later it is more probably in the smaller curvature; while if the pain only appears in from one to two hours after eating, it is safe to argue that the loca- tion is near the pyloric end. Hemorrhage may, though rarely, be the initial symptom; more frequently it follows the vomit- ing of food. In the ordinary form of haematemesis the blood is of a brownish color, or it may be bright red. In rare instances it is so slight as to escape observation, and in others it is so abundant as to prove rapidly fatal. Perforation usuall\T occurs when the stomach is somewhat distended, often after some ex- ertion, as lifting, etc. There is sudden acute abdominal pain, faintness, collapse, and even death; the breathing is quick, pulse feeble, temperature subnormal. Differentiation.—From cancer, by7 the absence of tumor, by the presence of free hydrochloric acid (v/hich is usually absent in cancer), by the absence of cancerous fragments, and by the pain being more paroxysmal, while in cancer it is more continuous and influenced less by the taking of food. The age, too, may give aid, cancer being an affection of later years. From gastric neurosis it is distinguished byT the absence of marked nervous symptoms. In simple gastralgia there is absence of postprandial pain, or at least pain is not increased by taking food. Chronic catarrhal gastritis has no haematemesis. In cholelithiasis the pain is more cramp-like, more localized 46 722 the practitioner s manual. in the parasternal region, extending to the back and down- ward. Two fingers' breadth from the twelfth dorsal of the right side there is a painful point on pressure. Attacks occur, as a rule, at night and when stomach is empty. Prognosis is generally favorable, but recurrences may be predicted. Death rarely takes place suddenly from hemor- rhage. Peritonitis from perforation is more common. Steno- sis at the pylorus may be due to the cicatrix in healing. If perforation occurs, there is sudden severe pain attended with collapse. This pain may7 be referred to the back as high as the eighth dorsal vertebra. Treatment.—Milk diet. This tends also to neutralize the acidity. Add lime water and give it cold at regular intervals. Vlcer Complicated by Neuralgia.—Absolute rest in bed, small ice compresses over the region of the stomach, abstinence from food, nourishment per rectum, as by— R Milk.................................... ................. I iv. Yolk of eggs............................................... No. ij. Salt....................................................... 3 i. Red wine................................................. § ss. Starch................................................... gr. xx. First free the bowels with a warm-water clyster and inject the above, warmed to the proper temperature, three times daily. In continued hemorrhage, inject into the abdominal wall over the stomach region : R Ext. ergota? fld. (filtered).................................... TTI xv. Acidi carbolici.............................................. tti, i. Aquae destillata?............................................. 3 b After hemorrhage, rest on back, ice bag or coil over the stomach. Rectal alimentation for a few days; then milk, weak coffee, the yolk of an egg stirred up in Vichy water, and after ten days return to drug medication; some easily digested form of iron if anaemia is marked. STOMACH, ULCER OF. 723 For the painful crises: R Exalgin................................................. gr. xiv. Extract of belladonna, Codeine phosphate....................................aa gr. v. Sugar of milk............................................ gr. iXXv. Mix and divide into ten cachets. Dose, one to be taken at the onset of pain. —Boas. To prevent intense pain after eating in gastric ulcer, dys- pepsia nervosa, and other conditions of hyperacidity (gastric): R Magnesia?, Bismuthi subnitratis........................................aa 3 ij. M. div. in pulv. No. xii. S. One powder half an hour before each meal. —Baruch. In suspected superficial ulcer or abrasiou of the gastric mu- cosa, and especially when fermentative changes are evident, practice lavage and follow it with a solution of nitrate of silver: R Argenti nitratis......................................... gr. v. -x. Aquae.................................................... § viij. Pour through the tube and allow to remain for a moment before siphoning off. Caution.—It is well to begin with very weak solutions.— S. S. Jones. The danger from a soft tube is much lessened if we cocain- ize the throat.—Metcalfe. Reeled feeding, giving nothing by the mouth for about ten days excepting a little water, ice, or weak brandy and water. Rest in bed, poultices.—Ratjen. For the nausea and vomiting : R Ext. belladonna?............................................. gr. i Argenti nitratis.............................................. gr. \ For one pill. —WOLFF. To enable stomach to tolerate food, resorcin, gr. v. t.i.d. It is antiseptic, haemostatic, analgesic. In Long-Standing Ulcer, as Well as in the Acute.—Early in the morning, and on an empty stomach, the patient gets three hundred grains of bismuth subnitrate stirred up in six ounces 724 the practitioner's manual. of warm water, and washes it down with a few mouthfuls more of water. He then lies quiet on his back in bed for an hour with the pelvis somewhat raised, thus insuring that the poste- rior wall of the stomach which is the most frequent site for an ulcer, has the greater portion of the bismuth salt deposited on it. The patient is not confined to bed, and is dieted on milk, stale bread, biscuits, etc., large quantities of butter, and soups thickened with rice, sago, etc. In a short time there may be added to this shredded raw meat or ham, or a soft-boiled egg, and gradually there may be allowed a return to ordinary food, avoiding things which are notoriously indigestible. — Witthaueh. In perforation the only real chance of ultimate success lies in operation after the shock. The immediate requirements include absolute quiet in the horizontal position, rectal feeding and medication, unless the latter is given subcutaneously, as morphine.—Barling. Potassii bichromas, gr. to ~~tV two or three times daily.— T. R. Fraser. To neutralize gastric contents and prevent auto-digestion: R Magnes. usta?, Sodii carbonatis, Potassii carbonatis...........................................aa f> Sacch. lactis................................................... 25 M. S. Half a teaspoonful dry on tongue every three hours___HEMMETER. To correct hyperacidity : R Magnesia? usta?.......................................„...... 3 ss. Bismuthi subnitratis, Sodii bicarbonatis........................................aa gr. x. Pulv. opii...................................................gr. i. Lactose...................... ............................... gr. x. S. For one powder. For haematemesis, after a hypodermic of ergotin: R Ergotini..................................................... 3 i. Acidi gallici................................................ gr. x. Ext. opii.................................................... gr. ij. Spir. terebinthina?........................................... 3 iiss. Syr. simplicis............................................... | i. Aqua?.......................................................| iv. M. S. Teaspoonful every two hours. stomatitis aphthosa. 725 If vomiting is incoercible : R Picrotoxin................................................ gr [ Morphina? hydrochloratis.................................. gr. i. Atropina? sulphatis. ...................................... gr. A Ergotin...................................................gr. xx. Aqua?..................................................... 3 ij. Spt. vini rectificati....................................q.s. ut solut. M. S. Gtt. viii. to gtt. x. in water, repeated as necessary. In putrid fermentation accompanying constipation, enemata of antiseptic solutions and— R Calomel................................................gr ■ ij■ Jalap...................................................... gr. vi. Magnes. hydrat............................................ gr. xx. For subsequent ancemia and debility, perchloride of iron for ten or twelve days.—A. Robin. To allay muscular irritability, quiet pain, and allay thirst, some preparation of opium. Nourish by rectum or give peptonized milk and lime water. Caution.—bicarbonate of sodium is not a safe substitute, because of the evolution of gas. Add beef peptones and eggs to dietary7, and by degrees per- mit a more liberal diet.—F. P. Henry. Wash out stomach, inject an alkaline solution, pour in an emulsion of bismuth.-—Von Leube. Stomatitis Aphthosa. Aphtha, follicular stomatitis, vesicular stomatitis, or canker, occurs as grayish-white or yellowish spots of exuding fibrin upon the inner surface of the cheek or lips, or upon the margin, the tip, and sometimes the dorsum of the tongue. A superficial ulcer results from rubbing off the dead epithelium, but it usu- ally heals quickly. It is seen in adults at times as well as in children, especially in the debilitated and in women during menstruation, pregnancy, etc. Differentiation.—It is distinguished from herpes or pem- phigus by the characteristic fibrinous exudate which forms over • 72ii the practitioner's manual. the hemp-seed to pea-sized lesions in the various regions. The small white, yellowish-white, or yellowish flakes form upon the most superficial portions of the mucous membrane. In noma there is necrosis and loss of substance, the result of a diffuse parenchymatous inflammation. Ulcerating stomatitis gives a sensation of swelling and pulsation, while aphthae are attended with considerable pain and sensitiveness to hot and spicy arti- cles. From sprue, when it is disseminated, by the microscope, which shows the oidium albicans. Prognosis is good. Cure should be effected in about a week. When, however, an abundance of lesions have formed in the posterior parts and occasioned oedema of the glottis, the prognosis is bad. Treatment.—Being an infectious disease, prophylaxis is re- quired. Treat the accompanying gastro-enteritis, bronchitis, eczema, etc. Alkaline washes. Paint with a solution of boric acid in glycerol. When obsti- nate touch with: R Argenti nitratis...........................................gr. v. Aqua; destillata?............................................. § i. —Marshall. In erythematous stomatitis wash the child's mouth after each meal with: R Sodii boratis.................................................. 3 ss Sodii bicarbonatis........................................... 3 i. Aqua? destillata?.............................................. § iv. M. —MORAIN. Or, when pultaceous: R Sodii biboratis, Glycerini.................................................aa 2 gm. M. R Hydrozone................................................. 1 part. Aqua?..................................................... 5 parts. Followed by: R Sodii boratis.................................................. 3 ij Glycerini.................................................... 3 bv. STOMATITIS APHTHOSA. 727 In infectious stomatitis, for intestinal antisepsis: R Bismuth, salicylatis..................................... t gg Div. in pulv. No. x. S. One every two hours. Paint the affected areas four or five times with: 3 Borax.................................................... 4 parts Tincture of myrrh....................................... s " Syrup of mulberries............................ (50 " M. 3 Borax.................................................... 4 parts. Tincture of benzoin............................... 2 " Distilled water..................................... 10 « Syrup.................................................... 20 " M. R Sodium phosphate........................................ 10 parts. Orange-flower water...................................... 25 « Honey of roses............'............................... 50 « M. R Calcium chlorate............'............................. 2 parts. Honey................................................... 20 " M. R Potassium chlorate........................................ 3 parts. Distilled water................................... ....... 60 M. Apply four or five times a day. —Levi. R Sodii boratis.................................................... 4 Tinct. myrrh................................................... 8 Syrupi......................................................... 60 R Acidi salicylici................................................. 2 Spt. vini rectif.................................................. 10 Glycerini....................................................... 20 —HlRTZ. R Potassii chloratis............................................... 4 Aquae destillatae................................................ 200 Tinct. myrrh..............................,.................... 3 S. To inject into the mouth. —Monti. In obstinate cases with great pain, especially affecting the tongue: R Sodii salicylatis ............................................... 20 Aquae destillata?............................................... 100 S. As a wash. 728 THE PRACTITIONER'S MANUAL. Or— R Hydrargyri chloridi corrosivi...-.............................. 0.2. Aqua? destillatae............................................. 100 S. To apply with a brush. —Levi. R Distilled water, Glycerin..................................................aa 3 iiss. Iodine, Iodide of potassium.......................................aa gr. vi. M. S. Apply to lesions. —Marfan. R Potassii chloratis.......................................... 3 i. Tinct. myrrh..............................................gtt. xx. Elixir calisayae............................................ 5 iij- S. Teaspoonful in water every four hours. Caution.—Not to be used in acute nephritis.—Hare. Stomatitis Gangrenosa. Cancrum oris or noma begins as an infiltrated area, usually near the angle of the mouth or centre of the cheek, which soon gives way to a perforating gangrenous process, which may rap- idly destroy the cheek, portions of the jaw, and generally the life of the sufferer. It is said never to occur in infants at the breast. Diagnosis.—It occurs in those subjected to unhealthy sur- roundings, affecting children usually not over five years of age, showing a decided preference for those debilitated or convalesc- ing from measles, pertussis, scarlatina, or typhoid fever. Adults are very exceptionally affected. It is now fortunately rare. Differentiation.—In malignant pustule we have a history of contagion; the constitutional signs are of greater severity, and examination reveals the bacillus of anthrax. Ulcerative stomatitis in its severe form may be simulated, but involvement of the whole thickness of the cheek in rapid destruction ex- cludes any ordinary stomatitis. Prognosis.—It is only by instituting immediate and ener- getic treatment that any hope of saving life exists. STOMATITIS, MYCOTIC. 729 Treatment.—Clean out thoroughly, remove necrosed tissue, and pack with subnitrate of bismuth.—MacGuire. When malarial cachexia coexists give quinine, according to condition and age, and apply: R Cupri sulphatis............... ....................... 3 iv. Pulv. cinchona? rub., Pulv. cinnamomi cort.....................................aa, \ i. Aqua?........................................................ § vi. M. S. To be applied on a cotton swab every six hours. — W. M. CUMMINGS. Electro-thermal cautery to destroy7 all gangrenous tissue. Free use of Thiersch's solution : R Acidi boracici.............................................. 1 ij. Acidi salicylici............................................ 3 iij- Aquae...................................................... O viij. —Marshall. Stomatitis, Mycotic. Parasitic inflammation of the mouth, or thrush, as it is sometimes called, presents grayish-white deposits upon the va- rious mucous surfaces lining the mouth, especially in bottle-fed infants. Diagnosis.—The minute white and yellowish elevated spots unite at times into larger areas, surrounded by an inflammatory areola, and forcible removal causes bleeding. It attacks nurs- ing children, especially those in institutions, and in whom the most scrupulous cleanliness is not maintained. Debilitated adults may ocasionally develop the affection. Differentiation.—The microscope will show the form of stomatitis by disclosing the presence of the oidium albicans. The appearances after a few days suggest soft cheesy flakes or curds, while in aphtha a pseudo-membrane covers the patch, which, when removed, discloses a livid base. Prognosis.—In debilitated children occasionally fatal. In debilitated adults a bad symptom. Thrush with gastroenter- itis may prove fatal. Treatment.—Care in feeding appliances; cleanliness. Cas- 730 the practitioner's manual. tor oil. Potassii chloras, gr. i.-iii. t.i.d., is specific in its ac- tion.—Day. R Sulphite of sodium............................................. 3 j. Water......................................................... § i. M. S. Apply. —Sir Wm. Jenner. In thrush of children : R Sodii salicylatis, Sodii boratis..............................................aa gr. x. Acidi carbolici.............................................. gr. ij. Glycerini................................................... 3 ij. Aqua? rosa?............................................q. s. ad § i. M. S. Apply locally. —Starr. Stomatitis Ulcerosa. In putrid sore mouth or fetid stomatitis, various-sized ulcers of ashen-gray color with red areola are present, always start- ing from the gums, which tend to bleed readily. The breath is fetid; the gums are spongy and partly cover the teeth. Differentiation.—A milder form is that in which super- ficial rounded ulcers follow the so-called canker sores often seen in adults. The loosening of the teeth and swelling of the gums at times suggest scurvy, but other symptoms are absent, as well as the conditions upon which scorbutus depends. In infants symmetrically distributed ulcers in the roof of the month are to be distinguished from Bednar's aphtha and ulcerations pro- duced by washing out the mouth in newborn babes, or those due to pressure of a rubber nipple; from syphilitic sore mouth by the occurrence of typical, less inflammatory, and more wide- ly distributed mucous patches, and by other signs of lues; from mercurial ulceration, which also has a marked fetor of the breath, ulceration, and loosening of teeth, by a more pro- nounced salivation, and history that mercury has been em- ployed. Treatment. —Correct unsanitary surroundings. Treat under- lying debility. Relieve gastric disturbance. STOMATITIS ULCEROSA. 731 Glycozone frequently applied.—Edson. Glycerite of tannin; alum.—Ringer. In nursing children : R Acidi salicylici........................................... 1 gm. Alcohol..........................................enough to dissolve. Aqua? destillata?........................................... 100 gm. M. S. Apply five or six times daily. Or— R Acidi hydrochlorici............................................. 3 Mellis, Glycerini.....................................................aa, 20 M. S. Apply with a camel's-hair pencil. —COMBY. Or— R Acidi thyinici (thymol)..................................... gr. iv. Acidi benzoici.............................................. 3 ij- Tinct. eucalypti............................................. | ss. Spt. vini rectificati.......................................... § iij. Essen, mentha? pip.......................................... gtt. x. S. Drop enough into a glass of water to cause turbidity, and rinse the mouth morning and night. —Muller. R Tannin...................................................... 3 ij. Tinct. iodine................................................ 3 iv. Potassium iodide............................................ 3 i. Tinct. myrrh................................................ 3 i v. Rose water.................................................. § viij. A dessertspoonful in a small glassful of warm water is used to wash the mouth with thoroughly every morning. Or— R Sodii biboratis.............................................. 3 iss. Sodii bicarbonatis.......................................... 3 ss. Thymol.................................................... gr. iij. Glycerini................................................... 3 b Aq. laurocerasi......................................q.s. ad § iv. M. S. Use as a wash. R Thymol................................................... gr. iij. Benzoic acid.............................................. gr. xl. Tincture of eucalyptus..................................... 3 iij. Essence of peppermint.................................... gtt. xx. Alcohol................................................... 1 iij- Pour enough into a glass of water to render it turbid, and use as a mouth- wash. —Thomas. 732 the practitioner's manual. In mercurial stomatitis : R Liq. plumbi subacetat........................................ 3 i. Aqua?................................................ ......I viij. Wash mouth every two hours. —S. D. Gross. For antiseptic gargle : R Salol.......................................................... 2 Acidi boracic.................................................. 10 Alcoholis...................................................... 40 Aq. bullient................................................... 500 R Potassii permanganatis................................. 1 Aqua?.................................................. 1,000-2,000 R Methylene blue................................................. 3 Water.......................................................... 100 M. S. Apply with applicator. For irrigation: R Acidi carbolici.............................................. 1 Acidi boracici.............................................. 25 Thymol.................................................... 50 Spir. mentha? piperita?...................................... 20 gtt. Tinct. anisi................................................ 10 Aqua?.......................... ........................... 1 litre. —Du J ARDIN - B E AUMETZ. Sunstroke. Thermic fever or heatstroke presents a sudden loss of con- sciousness, with muttering delirium and perhaps convulsions. The surface is at first dry and subsequently may be covered with perspiration. The pulse is usually full but compressible. Diagnosis.—The most pronounced diagnostic feature of in- solation is a very high temperature, reaching perhaps 113° F. The pupils are dilated. A history of prolonged exposure to high temperature or to the direct rays of the sun aids in diagnosis, although a body temperature of 10S° F. or over justifies it. Differentiation.—From apoplexy, which has hemiplegia and one pupil dilated. From syncope occurring in hot weather by the absence of fever. From alcoholism, which gives an SUNSTROKE. 733 odor in the breath, etc. From heat exhaustion, which has a marked fall in temperature and pulse. From hysterical fever, by lack of stigmata and precautions that, if patient is conscious, artificial means are not employed by him to cause rise in the mercury. Prognosis.—Death may occur with brief delay, but life may be prolonged and sometimes saved by prompt and thor- ough treatment, even after the temperature has marked 110° F. (112° F., W. G. Thompson). The mild form is recovered from, while fifty per cent die after a severe stroke. Prophylaxis requires abstinence from alcoholic drinks, avoidance of undue exposure in heated rooms and overexertion in times of great heat, and rest from work when headache, diz- ziness, etc., give warning of an impending stroke. Treatment.—The chief point in successful treatment is to lower the bodily temperature at once. Cool baths, to which ice is from time to time added, are em- ployed for this purpose. The patient is placed in the bath at about 40° F., and the surface rubbed vigorously by the hands of the attendant or with pieces of ice, until the rectal tempera- ture shows a decided decrease. The bath is renewed as often as the temperature again approaches a dangerous elevation. In the absence of bathing facilities place the patient upon a hard mattress covered with a rubber sheet, and rub the naked body vigorously with pieces of ice while ice cloths are applied to the head, or pour cold water over the surface. High temperatures cannot be safely reduced at greater rapidity than one degree in three or four minutes.—Thomp- son. Bath with cutaneous friction, after the Brand method. Surprisingly good results have been obtained from the com- bined use of affusions of cold water, ice-water enemata (one- half to one pint). As an efficacious stimulant, pour a fine stream of water 734 the prctitionaer's manual. from an elevation upon the forehead for one or two mintues at a time.—G. F. Chandler. R Digitalis (French).......................................... gr- ^a Strychnina?............................................... gr. T1 „ Aqua? destillata?........................................... q.s. M. S. Inject hypodermatically, and repeat according to the effect on the pulse in from half an hour to an hour's time, or until three or four'such doses have been administered. —Joseph Eichberg. In the depressed type, with high internal temperature and cold surface, do not rely7 upon remedies subcutaneously admin- istered any more than you would upon those given by the stomach. Resort at once to rectal medication. In the anaemic form of insolation, remove patient to a cool, shady place, with the head lower than the knees, and inject subcutaneously twenty minims of aromatic spirits of ammonia, to be followed by : R Strychnina? sulphatis....................................... gr. -fa Atropina? sulphatis......................................... gr. -jLj Glonoin.................................................... gr. & M. f. hypo. S. One dose. In the congestive form, with violent pains in the head and back of neck, strip the patient in a cool place and apply cold in some form, preferably7 by7 means of a garden hose, allowing the stream to strike the surface with considerable force. R Tinct. strophanthi......................................... tti x. Tinct. aconiti radicis........................................ Tti ij. Glonoin................................................... gr. & Hypodermatically. Repeat in two hours. —Fap.ricius. Caution.—Do not give any drugs, as a rule, that depress the heart. When convulsions occur, chloroform inhalations, or, if fear of depressing the heart, sol. Magendie, tti, x. subcutaneously for an adult dose. To abort or relieve meningitis in sthenic subjects showing syphilis in early LIFE. 73.J apoplectic symptoms after the bodily heat is reduced, venesec- tion.—Pepper. For the after-headache, if the pulse is s*trong: R Tinctura? veratri viridis.........................."......... tti, x. Sodii bromidi............................................. 3 xij. Aqua?.................... ..........................q.s. ad § ij. M. S. Shake well and take a teaspoonful before meals and at bedtime. If the pulse is weak: R Sodii bromidi................................................ 3 xvi. Extracti ergota? fluidi....................................... 3 i. Aquae................................................q.s. ad § ij. M. S. Take one teaspoonful three times a day and at bedtime, in a table- spoonful of water. —R. CM. Page. In full-blooded subjects, bleed. In prolonged unconscious- ness, nourishment by7 stomach tube. When consciousness re- turns, alcoholic stimulation.—Chandler. Syphilis in Early Life. During infancy and childhood it is important to distinguish not only between this disease and the various exanthemata and skin affections incidental to early life, but also between the con- genital and the acquired form. The lesion upon the mouth in a nursing child may be the primary sore acquired from a parent or an infected nurse, and will often present more the features of the initial lesion in the adult. Here the first eruption is seen at the earliest, even when the disease is acquired from the mother during parturition, some weeks after birth, or after the appearance of the lesion at the point of inoculation. Diagnosis.—The family history must be relied upon for the basis of our diagnosis as between the congenital and acquired forms, when no lesion corresponding to a chancre can be made out. The eruption occurring within the first three months of life, presenting moist forms near mucous membranes and in the flexures, attended with catarrhal inflammation of the nose 736 THE PRACTITIONER'S MANUAL. causing snuffles, while the child gradually7 becomes anaime and loses in weight, is much more apt to be of congenital than of acquired origin. Likewise in the later years of childhood re- tarded growth, interstitial keratitis, sunken bridge of the nose, and the incomplete development of the teeth, which are irregu- lar in outline and show a peculiar vulnerability and proneness to decay, are to be regarded as signs of lues of congenital origin, especially when accompanied by characteristic eruptions. The permanent teeth, and especially the central incisors, show a mal- formation which, when taken in conjunction with the other signs, is of the first importance. The teeth are pointed from above downward, and are usually separated much more at the cutting border than at the gums. There is an atrophy giving a single notch in the centre of the cutting edge, of crescentic shape, with lack of enamel and discoloration of this part, often running up upon the face of the tooth. The anterior tooth surface is somewhat rounded. While examination of the teeth is of great importance, still it is never safe to affirm or deny the existence of lues upon this symptom alone. In a long record of cases I have excluded the disease in many instances in which many of the permanent teeth, both upper and lower, would suggest its existence, and, conversely, many individuals tainted from birth are found to have normal teeth. A shallow groove extending from the free margin almost to the gum upon both anterior and posterior surfaces of the tooth is regarded by many as adding to the signs pointing to congenitallues. Congenital Lues at Birth.—An eruption present upon the surface at birth is in itself strong circumstantial evidence of its being specific in nature. It does not follow by any7 means that a perfectly healthy appearing infant may not be so profoundly affected that, at death within a few weeks, characteristic changes will be found in various internal organs. In many instances the skin is wrinkled, the infant is poorly nourished. SYPHILIS IN EARLY LIFE. 737 has an aged look with drawn expression of countenance, and a brownish discoloration may occur upon the forehead or about the region of the mouth. While polymorphism is here as ev- erywhere in syphilis a leading characteristic, the chief forms of lesion observed at this time are macular, roseola being present in about forty-five per cent of instances, in association with the papular form in about the same proportion; papular, especially in the form of moist papules; papulo-squamous, vesicular, pus- tular, and bullous. These, too, may occur in various combina- tions. While bullous and pustular lesions present at birth or which develop within a few days of birth are most likely7 due to lues, their true specific nature is decided by the localization upon the palms, soles, fingers, and toes. The contents are of a yellow- ish or greenish hue, or may be wholly pustular or even hemor- rhagic. The number of lesions may vary from half a dozen, limited to the feet and hands, up to one hundred or more scattered over all surfaces. The size varies from that of French peas to that of lentils. Unless the mother presents at the same time some manifestation of the disease, we may have to depend wholly upon the symptoms in the child for our diagnosis, throw- ing out altogether the negative history given by the parents. The weazened appearance giving the old-woman facies, when not accompanied by eruptions or evidences of the disease implicat- ing internal organs, must not be confounded with conditions of marasmus due to other processes. In the specifically affected infant there is usually a condition of snuffles. The coppery or cafe-au-lait discoloration often present upon the chin, sometimes in circles, is not to be confounded with the earthy hue observed in older subjects having chronic diarrhcea. Differentiation.—Pemphigus neonatorum is rarely present at or so soon after birth; ulcers do not result and such thick crusts are not formed. If death does not occur, as it usually does, paronychial swellings may come on, the matrix becoming diseased, and suppuration resulting in shedding of the nails. 47 738 the practitioner's manual. While pustular eruptions are more often found in the newborn than the papular, the two may coexist, and in certain conical papules or tubercles suppuration may7 begin at the apex. This eruption is usually sparse, with few lesions scattered over the face, buttocks, and extremities. The concomitance of the two forms may7 serve to differentiate from the greenish papules of septic origin when the mother has puerperal septicaemia. The erythematous blush of the perineum and buttocks followed by ecthyma may closely simulate lues, which, however, is excluded by the history and the absence of other confirmatory symptoms. The specific eruption occurs upon any portion of the surface, while true ecthyma is confined chiefly to this region and the lower extremities. Petechiae and purpuric spots when due to lues are usually' accompanied by other manifestations, including bullous and pustular lesions, and icterus is often present. Fis- sures and rhagades frequently accompany the mucous papules in and about the mouth and anus. They may be present about the joint flexures and commissures of the eyelids. The nails are often undeveloped or deformed. Syphilis in the Adult. Acquired lues in the adult always begins with some point of inoculation, whether it be observable or not. The chancre, when found, may present a variety of forms. It occurs either as an erosion, as a papule, or as a rounded, raised, infiltrated area with central crater-like ulceration taking place at the expense of the infiltrated tissue, and usually attended with a characteristic induration or feeling of hardness when grasped between the fingers. Upon many skin and mucous surfaces the cartilage- like character of the induration may be lacking. From chan- croid the ulcer is distinguished by its little tendency to spread, its not undermining the surrounding skin, and the fact that it is accompanied by glandular enlargements which do not go on to suppuration. SYPHILIS IN THE ADULT. 739 Diagnosis.—The various eruptions of lues are characterized and distinguished by their slow development, chronic course, multiformity of lesions in the different outcroppings, freedom from pruritus and fever, and by being accompanied by lesions in the mouth and throat. The early roseola or macular eruption may be so slight as to escape the patient's notice. When infection is suspected, but the papule forming at the point of inoculation has not been typical, or the ulcer has resembled more a chancroid because virus of two kinds has been inoculated at the same time, or when marked induration has not been present in the primary lesion located on the lip, tonsil, tongue, or any7 surface of the integument, frequent inspection of the whole body by the phy- sician is necessary. Rounded spots of rosy or red tint apppear as though beneath rather than upon the surface, and, when first oc- curring upon the trunk, about the umbilicus, or following the direction of the ribs, are often more distinct in an oblique light. They vary in size from that of a pea to that of a bean, in- crease but little after becoming fully formed, show little ten- dency to run together, do not form circles, and usually require a week's time to become well developed and generalized. The face frequently, and the dorsum of the hands and feet usually, escape, but the palms and soles often present macules; and here, contrary to the rule, desquamation occurs, or small dry horny plugs form in the centre of the erythematous area. Mucous plaques develop at the same time in the mouth or about the anus as flat condylomata, and the tonsils are most apt to become superficially ulcerated. In subjects with seborrhcea, macules developing about the hairy margin of the forehead and lateral aspects of the chin commonly crust over with yellowish scales. A hyperaemic condition about the hair and sebaceous follicles may occasion a prominence not seen in the macule, as well as a deeper red tone. 740 THE PRACTITIONER'S MANUAL. Differentiation.—If the patient presents himself first with a circinate erythematous eruption without history of infection or preceding roseola, it must be distinguished from a form of erythema multiforme due to one of many internal causes; nothing here comes to our aid so much as the nodular swell- ings of lues. If, as sometimes happens, the rings are slightly raised and scaly, ordinary ringworm of the surface might be thought of, but they do not show the same tendency as the lat- ter to spread at the periphery, but may remain stationary or relapse over a long period of time. The absence of Tricophyton in the scraped-off scales would exclude tinea circinata. Scarlatina gives a more acutely7 active eruption, and the high fever and throat symptoms would readily distinguish it from an early roseola. Rubeola would have catarrhal symp- toms, with coryza to dispel any doubt. Medicinal rashes are not so readily differentiated, and one occasioned by mercury, either given internally or applied to the skin, while the nature of the case was still in doubt, might seriously confuse. The macules are large in most drug eruptions. If, because of a dis- charge from the urethra cubebs or copaiba has been given and a rash follows, it is not always safe to say the latter has been caused by one of these drugs. A boy came to me a number of years ago at Bellevue Dispensary with a roseola and a history that a druggist had prescribed for his gonorrhoea. The dis- charge was in reality due to an infecting sore within the mea- tus, which in turn had caused the eruption and not the copaiba which he had been taking. The copaiba rash often, too, presents raised lesions, more like those of urticaria. Pityriasis rosea with its macular and circinate spots ex- tending at the periphery7, clearing in the centre, some plaques attaining the size of the palm or even a dinner plate, and attended with desquamation, may be confounded, especially in its onset, with the macules of lues. The scaling and peculiar syphilis in the adult. 741 gradual manner of spreading usually suffices for the differentia- tion. Pityriasis versicolor occurring as large and small yellowish patches, like pigment stains upon the chest, has been mistaken for the pigmentation left after the erythematous syphilide, and when of recent development and somewhat pinkish for a macu- lar syphilide itself. Examination of the scrapings shows the characteristic clustered spores and mycelium of Microsporon furfur. The papular eruption, which may accompany the macular or follow it in the course of a few weeks or more, is distinguished from other papular eruptions by the uniformity, firmness, raw-ham, coppery, or deep brownish color, and lack of itching. If scaly lesions are present, the scales do not have the silvery lustre of those of psoriasis, nor are they grouped about the el- bows and knees, as is so common in the latter disease. Upon the palms and soles early papules remain diffuse rather than become confluent; there is no oozing or discharge, as in eczema. A small papular eruption may be seen quite early with le- sions no larger than a pinhead, either conical, rounded, or flat, and showing a tendency to group themselves in small patches of circular outline. The color is deep red at first, becoming duller, and fine scales may perhaps form upon the apices of the lesions. This is not easily confounded with any ordinary skin disease, excepting jjossibly7 lichen. Tubercular eruptions coming at an early stage upon the face may simulate variola, especially when suppuration occurs in many of the tubercles, and particularly if, as sometimes hap- pens, umbilication takes place. In another pustular variety, acne vulgaris might come into question, but the latter would not be found upon the trunk, extremities, and scalp to the same degree, and the fresh lesions of acne are of a more pinkish-red, and there are comedones. 742 the practitioner's manual. Pustules, vesicles, and bullae are rarely observed so early in acquired syphilis of the adult that there would not be the his- tory and other signs to give aid in determining their nature. In the consecutive stages, when the diagnosis must be made without the history, the scaly forms are to be distinguished chiefly from psoriasis and seborrhoeal eczema by the greater tendency of the palms and nails to become implicated, the coin- cident lymph-node involvement, and other symptoms. The tuber- cular and gummous ulcerating serpiginous syphilides with thick dirty crusts are so characteristic as scarcely7 to be mista- ken, especially as in their onward march into new territory they leave behind a pigmented and cicatricial trail. Pigmentation of the skin at the site of pre-existing lesions is always a strong point in favor of the affection being syphilis. The retiform pigmentary syphilide upon the neck, seen espe- cially in women, has been thought characteristic when occur- ring as a network enclosing whitish areas and not secondary to preceding eruption. Recently' the same appearances have been reported in a subject of tuberculosis who was not syphilitic. Some authors claim that this pigmentation is always second- ary to an eruption which may have escaped observation. This view I am not prepared to accept. It may occur within the first few months of infection. Ecthyma is strongly imitated in some of the later ulcerative processes, but both deep and superficial ulcers of this type are likely to become crusted over with heaped-up or rupial deposits. Syphilis, Cerebral. The manifestations of cerebral syphilis are as varied as are the cutaneous manifestations of the disease, and hence the diag- nosis is beset with the greatest difficulties. The history given by the patient, in the one as in the other, must often be set aside, and the manifestations themselves be depended upon, though a clear history of infection is of great aid. SYPHILIS, CEREBRAL. 743 Diagnosis.—The first intimation that more serious symp- toms will develop may consist in mild or persistent headache, mental confusion, somnolence, vertigo, or slight difficulty of speech. The headache may even be absent, although it is usually' the most characteristic prodromal feature. Urinary disturbances may occur early, either as polyuria associated with polydipsia, incontinence of urine, chiefly nocturnal, or retention, and these may alternate in the same subject. A slight weakness or dragging of a limb may precede more characteristic manifesta- tions. The occasional drooping of an eyelid, or of the corner of the mouth, or a squint of short duration affecting one eye, may be a symptom of cerebral syphilis as well as of brain tumor; but, if of frequent occurrence, is much more likely to be of spe- cific origin. Morbid somnolence, especially if associated with epileptoid seizures or localized spasms, should be regarded with suspicion. Nocturnal headaches, especially if attended with mental disturbances and vertigo by day, and that peculiar difficulty of speech known as "word stumbling," furnish strong presumptive evidence of cerebral syphilis. In subjects of hysteria the diagnosis is often difficult and complicated, the symptoms being all wrongly attributed to hys- teria. A point strongly in favor of lues is the great irregu- larity of the symptoms, both in the time of the occurrence and in their combination. Ptosis of sudden development should cause syphilis to be suspected. Differentiation.—From apoplexy the acute paroxysm of cerebral congestion is distinguished by the absence of pro- nounced and prolonged loss of consciousness and by the absence of hemiplegia. Headache, too, persists after an attack due to syphilis, but not, as a rule, after an apoplexy. A strong point, and one upon which we must often depend, is the rapid disap- pearance of cerebral syphilitic manifestations under large doses of iodide of potassium, and, while this therapeutic test is not 744 THE PRACTITIONER'S MANUAL. an absolute one, it is convincing in most instances if the drug has been pushed. Indeed, the fact of prompt recovery under antisyphilitic treatment of a man over thirty years of age presenting ner- vous manifestations not attributable to tabes, progressive pa- ralysis, or clearly conforming to the clinical picture of well- recognized nervous disorders, can be set down to syphilis, even in the entire absence of history7. Polyuria, polydipsia asso- ciated with muscular weakness, somnolence, etc., may suggest polio-encephalitis superior. Convulsive seizures may simulate epilepsy, but the aura and cry are usually wanting, and there may be no unconsciousness. As aids we have history of headaches, aphasia, mental confu- sion, hebetude, loss of memory, motor paralysis, etc., and espe- cially the specific history, if one is obtainable. If tabes and progressive paralysis can be definitely excluded, ninety per cent of instances of cerebral syphilis will be suscep- tible of cure.—Tarnowsky. Prognosis.—This depends largely upon the age of the lesions at the time of beginning treatment. Earliness of treatment is the most important consideration.—Barney. Prognosis is fair for meningo-encephalitis and small gum- mata in the meninges, dependent upon the thoroughness and audacity of treatment.—Krauss. The prognosis accordingly depends upon whether the process is limited to a productive inflammation of the membranes or connective tissue of the brain, or whether there exists in con- junction with or independently of this inflammation disease of the large arteries which may cause a diminution or loss of vascu- lar supply to the cerebral structures. The prognosis varies with these conditions, not only7 on account of the increased danger of thrombosis per se, but as well from the fact that antisyphilitic treatment is much less effectual in arterial disease than it is when the morbid process is a gumma or a meningitis. Under syphilis, cerebro-spinal. 745 all circumstances the prognosis should be guarded, for in cerebral svphilis thrombosis may occur at any time.—(4. E. Brewer. Syphilis, Cerebro-Spinal. The diagnosis of luetic diseases of the central nervous system is still involved in some obscurity. They are, however, to be differentiated from general paresis, from cerebro-spinal sclero- sis, from tuberculous disease, from tabes, and from syringo- myelia, while luetic cerebro-spinal meningitis is itself to be dif- ferentiated from basilar disease of specific origin. According to Sachs, we may have cerebro-spinal meningitis luetica and specific meningo-myelitis or a meningo-encephalitis together with one or more special gummatous deposits. When the upper portion of the medulla is affected we have pains in the nucha, between the shoulders, which must not be mistaken for symptoms of neurasthenia or for rheumatism, or neuralgia. A point of importance is the patient's inability to run while symptoms are still slight. There are exaggerated patellar reflex and most likely inequality of the pupils. Prognosis.—Unless treated in time, Erb's spasmodic para- plegia is apt to develop, after which cure is almost impossible. Syphilitic dementia resembles general paresis. Here the patient is depressed because he is unable to attend to his busi- ness, and suspects that his friends realize this. He sleeps well at night and often by day. He is very particular about certain parts of his dress and negligent about other portions. He is irritable, and the symptoms vary from day to day. In melancholia, on the other hand, there is depression unin- fluenced by the subject's surroundings. There is insomnia, and the patient is universally neglectful of his dress. He is seclu- sive rather than irritable.—Spitzka. The characteristics of the dementia secondary to syphilis, as opposed to the idiopathic general paralysis of the insane, are as follows: Precedent syphilis; precedent headache, continuous, 746 the practitioner's manual. intense, worse at night; precedent or coexistent hemiplegia, aphasia, or paralyses of cranial or other nerves, having the irregular characteristics of development and course al- ready described. Greater variety and more fantastic combina- tion or sequence of symptoms. Absence or inconspicuous- ness of the delusions of grandeur and of the tremors of face and tongue. And, finally, the beneficial effects of thor- ough antisyphilitic treatment upon many of the symptoms.— Barney. Treatment. Personally, and contrary to many recognized authorities, I begin treatment as soon as the diagnosis of infection is made from the local changes at the site of inoculation. I have practised and advised wide excision of the chancre when suit- ably7 located, not as offering any great chances of aborting a process already at this time probably going on in the blood, but simply to get rid of so much localized virus. Such nearby nodes as are involved may be removed in the same manner, or an injection of mercury7 may be made into the substance of each node separately', or local inunctions of mercury may be carried out over the enlarged nodes and about the chancre. Constitutional treatment may be begun at once, either by the mouth, by inunction, or by7 injection. I have never yet observed any contraindication to instituting treatment at the earliest possible moment, but on the contrary have seen deplorable re- sults, which I could attribute only to the delay in beginning and to inadequately carrying out treatment. My notebooks show many instances, extending now over a sufficient number of years, in which treatment was begun as soon as diagnosis of the infecting sore was established. The course of the disease in these instances has frequently been among the most favora- ble in my experience. So far there has been no instance of cerebral syphilis. A point I wish to make prominent is that in not a single instance in which mercury was begun before con- syphilis, treatment. 747 firmatory evidences appeared, did early consecutive manifesta- tions fail to occur. The importance of this is apparent to those who read in almost every work on the subject that, if mercury is begun too early, one never knows whether the dis- ease really was syphilis or not. If mercury thus given were capable of constantly preventing the manifestations of the dis- ease, it would be the strongest possible argument for giving it at the earliest moment. Such, however, is not the case. I have never yet observed a patient thus treated in whom there did not show during what is usually termed the secondary stage sufficient skin, mucous membrane, and lymph-mode changes to confirm the diagnosis. On the other hand, these are rendered so much less severe and are removed so much the quicker, as a rule, that until I become convinced of an aggravation of the later symptoms (which I have not yet seen) I shall continue to practice and teach as heretofore. Whatever form of administration is chosen, an occasional interruption is wise. In giving inunctions I order the frictions (3ss.-3i.) carried out for the six working days, with bath and rest on the seventh day. At the completion of a course of twenty-four to thirty or thirty-six rubbings I let the patient omit general treatment for a time, unless urgent symptoms are present. In the absence of pronounced manifestations medi- cines may be given by the mouth for three weeks, followed by a two-weeks' rest. In giving injections I give ten, twelve, or fifteen, according to the rapidity with which the lesions disappear, and then stop all treatment for an indefinite time, being governed by the reappearance of signs in resuming one or another form of administration. Syphilis can no more be treated in a routine manner by invariable rule than can any other disease. We must take into account the individual with his many peculiarities and requirements. 748 the practitioner's manual. Treat the chancre with emplastrum hydrargyri, dusting with calomel. Or— R Calomel......................................................... Cerat. simp..................................................... 10 M. S. Apply. If phagedenic : R Acidi pyrogallici................................................ 10 Pulv. amyli.....................................................40 M. S. Apply. R Hydrargyri tannici........................................ gr. c. Ext. hyoscyami........................................... gr. xxv. M. ft. pil. No. c. S. One pill, four, six, or more times daily. If the above prove too powerful, producing gastro-intestinal cramps or irritation, make pills of half a grain each. In obstinate forms in which the usual remedies have not acted well, Zittmann's decoction, in one of its forms, is effica- cious but not a palatable dose. More often resorted to is the method by intramuscular injection. The employment of insoluble forms of mercury—calomel suspension, gray oil—must still be looked upon as a method of exception. It is not justifiable to employ them in the routine treatment. In lesions threatening the integrity of important organs and menacing life their employment is imperative. In- jections of soluble preparations give excellent results and may constitute the initial course to replace inunctions, or may be taken up at any stage when the patient is not doing well under other methods. R Pil. hydrarg................................................ gr. xx. Ferri sulph. exsiccat....................................... gr. x. Ext. opii................................................... gr. v. Ft. pil. No. xx. S. One pill three times a day. __OTIS. Mixed treatment is indicated if lesions still persist. SYPHILIS, TREATMENT. 749 After about a year of mercury in one or another form the following: R Hydrargyri bichloridi..................................... gr. i.-ij. Potassii iodidi........................................... % ss. -i. Tinct. cinchona? co....................................... 1 iij. Aqua? destillata?....................................q.s. ad 1 iv. M. S. Teaspoonful in water an hour after meals. In subsequent stages: R Potassii iodidi................................................ 3 ij- Ammonii carbonatis......................................... ? ss. Tinct. cinch, comp............................................ 3 iv. Syr. aurantii corticis......................................... 3 iss. Glycerini..................................................... § b M. S. A teaspoonful well diluted, after each meal. —KEYES. R Hydrargyri bibiodidi....................................... gr. iss. Potassii iodidi............................................3 iv. Syrupi...................................................... 1 l j- M. S. A teaspoonful. —E. A. BANKS. R Hydrargyri biniodidi........................................ gr. ss. Potassii iodidi.............................................. 3 ij. Syr. sarsaparilla? comp., Aqua?....................................................**& 11- M. S. A teaspoonful. —R. W. TAYLOR. R Hydrargyri biniodidi......................................... gr. i- Potassii iodidi............................................... 3 ibj. Tinct. aurantii dulcis........................................ 3 i- Aqua?........................................................ § "j- M. S. A teaspoonful. —THOMPSON. GiberPs syrup : R Hydrargyri biniodidi........................................ gr- i- Potassii iodidi............................................... 3 i. Aquae....................................................... 1 *■ Filter through paper and then add : Syrupi simplicis.......................................... ... § v. M. S. Tablespoonful three times a day. To a child give from a quarter to half a teaspoonful. Or, when the iodides are not well borne : R Potassium iodide (sat. sol.)................................. gr- d*- Essence of pepsin.......................................... 1l- Sherry wine.........................................