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'''W''"'< I* V\z /*\ 7Wy / s \EDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE a X * NATIONAL LIBRARY O 3NIDIQ3W JO AHVMfln TVNOIIVN 3NIDIQ3W JO ASVJI9 X ^ ^\ MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY O n>3l s K/ 1 >4. s ^ | ^ i. 3NIDI03W JO ADVUflll IVNOIIVN J' 3NiDia3w jq asvhsh ivnoiivn 3NOIQ3W JO AaVHS i x 5&r \< 2. /P* NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY C K/ 3NIDI03W jo Aavagn 1VNOUVN 3NIDIQ3W JO A&VHfln IVNOIIVN 3NOI03W JO ADVHt MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY ( 3NI3IQ3W JO AHVHfln TVNOUVN /' 3NIOICJ3W JO ASV8SI1 IVNOIIVN 3NIDIQ9W JO AdVl) ^ MEDICINE NATIONAL LIBRARY OF MEDICINE N 3NOI03W JO 3NI3I03W jo Ativtian IVNOIIVN E SbSihTSD WIN M0t80S£e9 NLM051478952 4AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE & NATIONAL LIBRARY OF MEDICINE vW X f SNmasw jo Aavaan ivnoiivn jni: ■a x-niu -X 2 X^'liKT "5 -&> i3w jo Aavaan ivnoiivn 3nidio:3w jo Aavaan ivnoiivn x. NATIONAL LIBRARY OF MEDICINE & aNiDioaw do xavagn IVNOIIVN 3Ni: NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE -0 ^%\/ 3w jo Aavaan ivnoiivn 3NIDIQ3W jo Aovaan ivnoiivn 3NiDia3w jo Aavaan ivnoiivn #x I 4AL LIBRARY OF MEDICINE NATIONAL LIBRARY -X I y^^ 1 -ex#X I3VV JO A0V08II IVNOIIVN 3NOI03W JO AqVaail IVNOIIVN NATIONAL LIBRARY OF MEDICINE NATI c o • K\/ * X 3NIDI03W jo Aavaan IVNOIIVN 3NI3 NATIONAL LIBRARY OF MEDICINE NATK \ THE PRACTITIONER'S •*/. REFERENCE. BOOK. BY RICHARr J. DUNGLISON, A.M., M.D., Editor Dunglison's "Medical Dictionary," Secretary of the American Academy of Medicine, etc. etc. SECOND EDITIOX, REVISED AND ENLARGED. PHILADELPHIA.^" LINDSAY AND BLAKl'STON 1880. <&;: WB \220 Entered according to the Act of Congress, in the year 1880, by RICHARD J. DUNGLISON, M.D., in the Office of the Librarian of Congress. All rights reserved COLLINS, PRINTER. PREFACE TO THE SECOND EDITION. The very aavorab.e reception accorded to the first edition of this work by those whom it was specially in- tended to aid—professional men in active practice—has induced the author to endeavor to render it still more worthy of their attention by the addition of numerous important practical chapters. So voluminous have these additions been, that the second edition of the Practi- tioner's Reference Book is now nearly one-half larger than its predecessor. Among the most useful chapters introduced in this edition may be mentioned the follow- ing :— How to Write Metric Prescriptions. Directions as to the Use of the Hypodermic Syringe iu Diseases in which it is applicable. How to Use a Galvanic Battery iu Medicine and Surgery. How to Apply Trusses to Heinise. How to Use the Clinical Thermometer. How to Prepare Stained Sections of Animal Tissues. Reference Tables of Size, Weight, and. Specific^ Gravity of all the organs, etc., in the body. ' --:• , Celebrated Prescriptions or Remedies. Therapeutics of the Bowel Affections of Children. >, Diagnostic Tables of the Principal Fevers. Diagnostic Tables of Acute Pulmonary Diseases. Diagnostic Tables of Diseases of the Larynx and Naso-pharynx. Diagnostic Syllabus of Tumors of the Groiu. Ready Reference Table of Antidotes, on a new plan. Rules of Medical Etiquette, etc. etc. RICHARD J. DUNGLISON. Philadelphia, June 1, 188a (Hi) PREFACE TO THE FIRST EDITION. From personal experience of the wants of the busy; practitioner, the author is confident that a work of ready ' reference containing, in a compact and tangible shape, information of a purely practical character, will prove a ■ desirable addition to his medical armamentarium. The physician is frequently at a loss to know in what direction to look, in order to procure such facts and hints as are here collected, some of which are widely scattered through] voluminous professional treatises or the—in many in- stances—inaccessible pages of medical periodicals; whi'e • the other original suggestions and precepts offered for * his guidance will, it is believed, meet many of his daily needs. The cordial indorsement of the objects of the' work, with which the author has already been favored by leading and active members of the profession, induces l him to indulge the hope that it may become an indis- pensable companion as a handy-book for every-da-y con-; suhation. RICHARD J. DUNGLISON. ' Philadf.lphia, May, 1877. CONTENTS. INTRODUCTION. PAGE The Hippocratic oath........17 GENERAL INFORMATION F£R THE PRACTITIONER. Weights and measures . ■.......23 Weights and measures of the U. S. Pharmacopoeia . . 23 Weights and measures of the metrical system . . . 24 Relation of weights of the U. S. Pharmacopoeia to metrical weights..........28 Relation of metrical weights to weights of the U. S. Phar- macopoeia .........30 Relation of measures of the U. S. Pharmacopoeia to metrical measures..........30 Relation of metrical measures to measures of the U. S. Phar- macopoeia .........31 Approximate conversion of ordinary measures into gramme weights........u . 31 Conversion of cubic centimetres into fluidrachms . . 33 How to write metric prescriptions.....34 Number of drops in a fluidrachm.....36 Relative value of drop and minim.....38 Approximate measurements......39 Solubility of medicines in water, alcohol, ether, glycerine, etc. 40 Abbreviations in common use . . . . . . . 59 Comparison of thermometric scales ...... 63 Reference tables of weights, measurements, and specific gravity 64 THERAPEUTIC AND PRACTICAL HINTS. Rules for the practitioner........71 Rules of medical etiquette . . . . . . . . 74 What the practitioner must learn of the patient ... 89 ( v ) CONTENTS. Doses of medicines ... ... Doses for children . . ... Doses for young children..... Doses based on the weight of the patient . Doses of remedies in general .... Maximum doses . . . Doses of medicines administered hypodermically Doses of atomized fluids for inhalation Doses of medicines in the form of gargles . Doses of medicines for collyria or eye-washes . Doses of medicines for injection into the urethra Doses of medicines for injection into the vagina Doses of medicines in the form of suppositories . Doses for rectal suppositories Doses for vaginal suppositories . Doses for uterine suppositories Doses for urethral suppositories (soluble bougies) Doses for enemata...... Baths, and how to medicate them .... Pharmacopceial groups, simplified for ready reference Incompatibles or remedies that should not be prescribed in bination ......... What to prescribe in the solid or the liquid form The modern treatment of diseases .... Celebrated prescriptions or remedies Selected prescriptions from practitioners' case-books Rules for management of infants during the hot season Period of eruption of the teeth . Brief rules for cases of emergency in children Therapeutics of the bowel affections of children Diagnostic syllabus of uterine inflammations . Diagnostic table of the principal fevers Diagnostic table of acute pulmonary diseases . Diagnostic table of the more common diseases of the larynx Diagnostic table of the more common diseases of the naso pharynx....... Diagnostic syllabus of tumors of the groin Obstetric memoranda .... Calculation of the date of labor . Diameters of the female pelvis . Diameters of the foetal skull Presentations and positions of the foetus CONTENTS. Brief rules for clinical examination of the urine Mode of detection of abnormal constituents (albumen, sugar, bile, etc.)........ Examination of the sediments of urine .... I. Deposits found occasionally in acid or alkaline urine II. Deposits found occasionally in alkaline urine only III. Organized deposits (blood, mucus, etc.) Poisons, their nature and treatment . Classification of poisons Treatment of poisoning Ready reference table of poisons Ready reference table of antidotes Directions for restoring the apparently drowned To restore breathing .... Dr. Marshall Hall's method Dr. Silvester's method Treatment after natural breathing has been restored Disinfectants and their practical application The principles of disinfection Disinfectants in common use How to use disinfectants Places that must be disinfected, and how to disinfect them Things to be disinfected Rules for fumigation Directions for preventing the spread of infectious diseases Directions to persons in charge of the unburied dead from infectious disease .... How to use the hypodermic syringe in various diseases in which it is applicable ... .... How to use a galvanic battery in medicine and surgery How to apply trusses in hernise .... How to use the clinical thermometer How to remove spots of blood, mucus, etc. How to prepare stained sections of animal tissues 273 274 279 279 281 281 283 284 285 286 292 299 300 300 303 305 807 307 310 311 316 319 320 321 326 327 332 352 367 376 377 DIETETIC RULES AND PRECEPTS. Digestibility of alimentary substances Composition of various articles of food Relative digestibility of animal substances . Relative digestibility of vegetable substances Dietetic preparations for the sick 399 899 402 403 403 viii CONTENTS. Special forms of diet.........432 Dietary for the diabetic......• ^32 Dietetic rules for reducing weight (Bantingism) . . 434 Rules for testing and disinfecting impure drinking water . 433 HOW TO CONDUCT A POST-MORTEM EXAMINATION. What to provide, instruments.......445 What to observe, notes of cases......447 External examination ........ 448 Position of the body, clothing, condition, age, sex, confor- mation, warmth, color ....... 448 Anomalies, abrasions, wounds, etc......449 Internal examination........450 Average weight of various organs ..... 450 Incisions, order of examination......451 Coloration and condition of vessels.....452 Examination of the thorax.......453 Heart...........454 Lungs...........458 Larynx..........459 Examination of the abdomen.......459 Spleen...........460 Urinary organs.........460 Kidneys, suprarenal capsules, ureters, and bladder . . 460 Urethra, prostate, vesiculae seminales, testicle, etc. . . 4G1 Uterus, vagina, etc.........461 Duodenum, liver, gall-bladder, etc......461 Stomach..........462 Pancreas, etc..........463 Intestines, etc..........4G3 Examination of the cranium...... 464 Brain...........433 Orbit...........4(57 Optic nerve ......... 437 Examination of the spinal cord...... 408 Index........... 471 INTEODUCTION. THE HIPPOCRATIC OATH. 2 ( 17 ) THE HIPPOCRATIC OATH. The following oath from the works of Hippocrates is so frequently referred to that the medical man of the present day should be made more familiar with its phraseology. As has been truly remarked, it exhibits the practitioners of medicine in a very remote age already formed into a regular corporation, bound by an oath to observe certain regulations, and having regular instructions in the art. The piece here quoted would seem to be an indenture between a physician and his pupil ; and it is most honorable to the profession that so ancient a document per- taining to it, instead of displaying a narrow-minded and exclusive self- ishness, inculcates a generous line of conduct, and enjoins an observ- ance of the rules of propriety and of the laws of domestic morality.1 THE OATH. I swear by Apollo the physician, and iEsculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation—to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this Art, if they shall wish to learn it. without fee or stipulation ; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my 1 Genuine Works of Hippocrates, Sydenham Society's edition, by Francis Adams, LL.D., ii. 775, London, 1849. The Oath was translated into English under the title of "The Protestation, which Hippocrates caused his scholars to make," by Peter Low, Loudon, 1597. (19) 20 THE HIPPOCRATIC OATH. teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like man- ner I will not give to a woman a pessary to produce abor- tion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work.1 Into whatever liouses I enter, I will go into them lor the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and further, from the seduction of fe- males or males, of freemen and slaves. Whatever, in connection with my professional practice, or not in con- nection with it, I see or hear in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times! But should I trespass and vio- late this Oath, may the reverse be my lot! 1 "The circumstance that the novitiate in the art is interdicted from the practice of lithotomy shows that this operation in antiquity was always practised by a class of operators separated from the general profession, and that the regular members of the latter never meddled with it on any account. Hence, in the whole compass of ancient medi- cal literature, there is not a single description of tlie operation by a person who himself had actually performed it. Avenzoar pronounced it to be an operation which no respectable physician would witness and far less perform." (Adams, loc. cit.) GENERAL INFORMATION FOR THE PRACTITIONER. (WEIGHTS AND MEASURES, SOLUBILITIES, ABBREVIATIONS, ETC.) (21) WEIGHTS AM) MEASURES. The study of Weights and Measures has now become" one of the necessities as well as one of the accomplish- ments of the day. Those in common use are generally sufficiently well known for the ordinary purposes of the practitioner; but the day is not far distant when the French system will be so frequently employed, as the most convenient international standard, that the physician must be able to interpret it understandingly, if he wishes to keep abreast of the times in which he lives.1 Weights and Measures of the United States Pharmacopoeia. One Pound, ffi = 12 Ounces = 5,760 Grains. One Ounce, g = 8 Drachms = 480 Grains. One Drachm, 5=3 Scruples = 60 Grains. One Scruple, 9 ......= 20 Grains. One Grain, gr. ......= 1 Grain. One Gallon, C = 8 Pints = 61,440 Minims. One Pint, O = 16 Fluidounces = 7,680 Minims. One Fluidounce, fg = 8 Fluidrachms = 480 Minims. One Fluidrachm, 13 ......= 60 Minims. One Minim, ""l ......= 1 Minim. ' The tables of weights and measures here given are almost wholly based on those published in the last edition (1873) of the U. S. Phar- macopoeia. (23) 24 METRICAL WEIGHTS AND MEASURES. Relation of Weights and Measures of the U. S. Pharmacopoeia to each other. In distilled water at a temperature of 60° One Pound One Ounce One Drachm One Scruple One Grain One Gallon One Pint One Fluidounce One Fluidrachm One Minim = 0.7900031 Pint = = 1.0533376 Fluidounces = = 1.0533376 Fluidrachms = 10.1265427 Pounds 1.2658178 Pounds " 0.9493633 Ounce 0.9493633 Drachm 6,067.2238 Minims. 505.6019 Minims. 63.2002 Minims. 21.0667 Minims. 1.0533 Minims. = 58,328.8862 Grains. = 7,291.1107 Grains. = 455.6944 Grains. = 56.9618 Grains. = 0.9493 Grain. Relation of Measures of the U. S. Pharmacopoeia to Cubic Measure. One Gallon = One Pint = One Fluidounce = One Fluidrachm = One Minim = 231. Cubic Inches. 28.875 Cubic Inches. 1.80468 Cubic Inches. 0.22558 Cubic Inch. 0.00375 Cubic Inch. Weights and Measures of the Metrical System. The metric or metrical system is intended to secure uniformity throughout the world in all measurements of length, weight, and capacity. The units selected, the Metre, Gramme, and Litre, are denned in the following tables. As the great mnjority of practitioners regard the metric system as one of very recent introduction, it will be appropriate here to give a short sketch of its history, showing that, though only now becoming popularized in different countries of the world, it has been for many years a subject of agitation.1 1 This historical description and explanation of the metric svstem is taken from Photographic Mosaics, Philadelphia, 1877, article Metric System, by H. A. Pintard. METRICAL WEIGHTS AND MEASURES. 25 This system of weights and measures was first adopted in France. In the absence of any other natural standard it was determined, at the period of the first Revolution, to adopt an aliquot part of the terrestrial meridian; and in 1799 a provisional measure was adopted, supposed to be the ten millionth of the quadrant, or the forty millionth of the whole circumference measured over the poles. A commission of the Academy of Sciences, consisting of five of the most eminent mathematicians of Europe — Borda, Lagrange, Laplace, Monge, and Condorcet—were subsequently appointed, under a decree of the Constituent Assembly, to report upon the selection of a natural standard, and Delambre and Mechain were selected to measure an arc of the meridian between the parallel of Dunkirk and Barcelona. This labor was begun at the most agitated period of theEevolution, and accomplished only after many difficulties and dangers, as the astrono- mers and geometricians who carried on the operations were frequently molested, being taken for spies or enemies of France. The result was a wonderful approximation of the true length, the error being only about ^Vf of the length, or less in a single metre than g^1^ of an inch. By means of the arc of the meridian measured between Dunkirk and Barcelona, and of the arc measured in Peru, in 1736, bv Bouguer and La Condamine, the length of the quarter of the meridian, or the distance from the pole to the equator, was calculated. This length was then divided into ten millions of equal parts, and one of these parts was taken for the unit of length, and called a metre, from the Greek word pitpov (a measure). The length of the metre as thus fixed is equal to 3.2808992 English feet, or very nearly 39.37079 English inches. From this unit of linear measure are derived all measures of length, surface, and solidity. The unit of long measure is therefore the metre, 26 METRICAL WEIGHTS AND MEASURES. and from it is derived land measure, by calling.100 square metres an are. The are equals 3.955 English perches. Liquid measure is obtained by making the unit or standard a litre, equal in capacity to a cubic decimetre = 0.2617 English gallon; dry measure, by making the standard a hectolitre = 2 bushels and 3.35 pecks; while for solid measure the standard is a stere, equal to a cubic metre = 35.317 cubic feet English. Lastly, to complete the series, weight is allied to the metre, by making the kilo- gramme to correspond with the contents of a cubic vessel of distilled water at the temperature of 4° C, or slightly above melting ice, the side of which cube is the tenth part of a metre (the decimetre), and the gramme to answer to the contents of a cubic vessel, the side of which is the hundredth part of the metre (the centimetre); for the con- tents of all cubic vessels are to each other in a triplicate ratio of their sides (Euclid, 33, xi.). All these units, by the prefixes, deca, deci, hecto, milli, etc., become applica- ble to any weights and measures, and, as the multiple of 10 connects all the larger and smaller measures, the whole becomes susceptible of decimal computation. No system of metrology hitherto invented can compare with this of the French in a scientific point of view, whilst its conve- nience for the purposes of commerce cannot fail to obtain its adoption by all civilized nations. The system was declared obligatory in France after November 2, 1801, and it has since been adopted in Spain, Belgium, Portugal, Holland, Greece, Sweden, Mexico, Brazil, and in 1868 was made compulsory in the German Empire. It was also legalized in Great Britain in 1864, and in 1866 an act was adopted by the Congress of the United States, making it lawful, after the passage of the act, throughout the United States, to employ the weights and measures of the metric system. Another act authorizes in post-offices the use of METRICAL WEIGHTS AND MEASURES. 27 weights of the denomination of grammes. The decimal system is now employed almost to the exclusion of others in science, and the United States Coast Survey has adopted it. in its Avork. As all the formulae published in Conti- nental journals are based on the metric system, the fol- lowing tables will prove of value to those who may have occasion to use the processes of their foreign associates. In order to express the decimal proportions, the follow- ing prefixes are used :— Subdivision. !Milli (from Millesimus), meaning a thousandth. Centi ( " Centesimus), " a hundredth. Deci ( " Decimus) " a tenth. Multiples. Deca, . Ten. Hecto, . One hundred. Greek \ KUo> _ Qne tll0Usand# Myria, . Ten thousand. It may assist the memory to observe that the terms for multiplying are Greek, and those for dividing, Latin. Measures of Length. One Myriametre = 10,000 Metres. One Kilometre = 1.000 Metres. One Hectometre = 100 Metres. One Decametre = 10 Metres. One METRE1 = the ten millionth part of a quarter of the meri- dian of the earth. One Decimetre = the tenth part of one Metre, or 0.1 Metre. One Centimetre = the hundredth part of one Metre, or 0.01 Metre. One Millimetre = the thousandth part of one Metre, or 0.001 Metre. 1 The unit of length. 28 METRICAL WEIGHTS AND MEASURES. One Myriagramme = One Kilogramme = One Hectogramme = One Decagramme = One GRAMME1 = One Decigramme = One Centigramme = One Milligramme = One Myrialitre = One Kilolitre = One Hectolitre = One Decalitre = One LITRE* = One Decilitre = One Centilitre = One Millilitre = Weights. 10,000 Grammes. 1,000 Grammes. 100 Grammes. 10 Grammes. the weight of a cubic centimetre of water at its maximum density, 4° C. the tenth part of one Gramme, or 0.1 Gramme. the hundredth part of one Gramme, or 0.01 Gramme. the thousandth part of one Gramme, or 0.001 Gramme. Measures of Capacity. 10 cubic Metres, or the measure of 10 Milliers of water. 1 cubic Metre, or the measure of 1 Millier of water. 100 cubic Decimetres, or the measure of 1 Quintal of water. 10 cubic Decimetres, or the measure of 1 Myria- gramme of water. 1 cubic Decimetre, or the measure of 1 Kilo- gramme of water. 100 cubic Centimetres, or the measure of 1 Hecto- gramme of water. 10 cubic Centimetres, or the measure of 1 Deci- gramme of water. 1 cubic Centimetre, or the measure of 1 Gramme of water. Relation of Weights of the TJ. S. Pharmacopoeia to Metrical Weights. A comparison between the metric system and that adopted in our own Pharmacopoeia may also be made, exhibiting at a glance the convertibility of one into the other. It is not probable that the whole of the French system will ever come into common use; in other words that the refinement of decimal division will ever be closely followed in the writing of prescriptions. If the prescriber 1 The unit of weight. 2 The unit of capacity. METRICAL WEIGHTS AND MEASURES. 29 will restrict himself to the use of the gramme and the centigramme, or the gramme alone, to express integral and fractional quantities approximately, he will avoid the apparent confusion that seems to attend the employment of the decimal system to its minutest ramifications. Fractions of a Grain in Milligrammes. Milligrammes. Grain. Milligram 1.012 l 1 6 = 4.049 1.079 1 15 = 4.319 1.295 I = 5.399 1.349 1 1 0 = 6.479 1.619 1 8 = 8.098 1.799 1 6 = 10.798 2.159 1 5 = 12.958 2.591 1 5 = 16.197 2.699 1 3 = 21.597 3.239 1 2 = 32.395 Grains in Equivalent Metrical Weights. Centigrammes. Grains. Grammes. 6.479 16 = 1.036 Decigrammes. 20 = 1.295 1.295 24 = 1.555 1.943 25 — 1.619 2.591 30 ^= 1.943 3.239 40 = 2.591 3.887 50 z= 3.239 4.535 60 — 3.887 5.183 5.831 6.479 7.775 9.718 Drachms, Ounces, and Pounds in Equivalent Metrical Weights. chms Grammes. Ounces. Hectogrammes. 1 = 3.887 4 = 1.2441 2 = 7.775 5 = 1.5551 Decagrammes. 6 =: 1.8661 3 = 1.166 7 == 2.1772 4 = 1.555 8 = 2.48S2 5 = 1.943 9 = 2.7992 6 = 2.332 10 — 3.1103 7 = 2.721 11 — 3.4il3 nces. Pounds. 1 = 3.1103 1 = 3.7324 2 = 6.2206 2 - 7.4648 3 = 9.3309 3 = Kilogrammes. 1.1197 Grain, l "cl i ■%s 1 ii 48 1_ 40 1 35 1 30" 1 55 1 21 1 2(J Grains. 1 2 3 4 5 6 7 8 9 10 12 15 30 METRICAL WEIGHTS AND MEASURES. Relation of Metrical Weights to Weights of the U. S. Pharmacopoeia. Metrical weights. Milligrames. 1 = 2 = 3 = 4 = 5 = 6 = 7 = 9 = Centigrammes. 1 = 2 = 3 = 4 = 5 = 6 = 7 = Decigrammes. 1 = 2 = 3 = 4 = 5 = 6 = 8 = 9 • = Exact equiv. in grs. .0154 .0308 .0463 .0617 .0771 .0926 .1080 .1234 .1389 .1543 .3086 .4630 .6173 .7717 .9260 0803 2347 Approx. equiv. in grs. l 65 l 32 1 22 1 TS 1 T3 1 II 1 1 1.3890 1.543 3.086 4.630 6.173 7.717 9.260 10.803 12.347 13.890 3 4i 6^ n 9 11 12i Metrical weights. Grammes. 1 = 2 = 3 = 4 = 5 = 6 = 7 = 8 = 9 = Decagrammes. 2 = 3 = 4 == 5 = 6 = 7 = 8 = • 9 = Hectogrammes 2 == 3 = 4 = 5 = 6 = 7 = 8 = 9 = Kilogramme. Exact equivalents in grains. 15.434 30.868 46.302 61.736 77.170 92.604 108.038 123.472 138.906 154.340 308.680 463.020 617.360 771.701 926.041 1,080.381 1,234.721 1,389.062 1,543.402 3,086.804 4,630.206 6,173.609 7,717.011 9,260.413 10,803.816 12,347.218 13,890.620 15,434.023 Myriagramme. 1 = 154,340.23 Approximate equivalents, Troy weight. gr*. xv. 3i- ^iv. 3iss. PJvss. 3ij- Bvij. 5iiss. 3V- 5viiss. 3*. 3xiiJ- 3xv. gxviij. 3xx. gxxiij. ovJ Siij- Six 3v. Bi 3viJ fbi .^iv. M |vij. Bbi t,x giv. aiJ §i 3V- Ibij gv. Bij gviij. (Ibxxvi. ( §ix 3iv. Relation of Measures of the TJ. S. Pharmacopoeia to Metrical Measures. One Gallon One Pint One Fluidounce One Fluidrachm One Minim 3.785 Litres. 4.732 Decilitres. 2.957 Centilitres. 3.697 Millilitres. 0.061 Millilitre. METRICAL WEIGHTS AND MEASURES. 31 Relation of Metrical Measures to Measures of the TJ. S. Pharmacopoeia. One Myrialitre One Kilolitre One Hectolitre One Decalitre One Litre One Decilitre One Centilitre One Millilitre (Cubic centimetre) 2641.9 Gallons. 264.19 " 26.419 " 2.641 " 2.113 Pints. 3.381 Fluidounces. 2.705 Fluidrachms. = 16.231 Minims. Approximate Conversion of Ordinary Measures into Gramme Weights (Metric System). As a matter of convenience in the writing of prescrip- tions containing fluid ingredients, the following table will be found of considerable importance for reference. As will be seen, it is arranged to include the estimated valu- ation, in the metric system, of menstrua or fluids of dif- ferent densities, in quantities varying from a minim to four fluidounces. It forms a fitting sequel to the tables of weights and measures already given:— Approximate Conversion of Measures into Gramme Weights.* Grammes for Liquids. Apothecaries' measure. Minims. 1 . 2 . 3 . 4 . 5 . 6 . 7 . ' Amer. Journal of Pharmacy, Feb. 1877, p. 92, by Prof. J. M. Maisch, in continuation of an article in the same number, p. 49, chiefly in defence of the expression of liquid preparations by metric weights. 2 Including spirits, tinctures prepared with alcohol, fixed and vola- tile oils. 3 Including waters, fluid extracts, and tinctures prepared with diluted alcohol. * Including glycerine and the syrups. Lighter than water.2 Of the sp.'gr. of water.* Heavier than water.4 .055 .06 .08 .10 .12 .15 .16 .18 .24 .22 .24 .32 .28 .30 .40 .32 .36 .48 .38 .42 .55 Sis a t>3 fl £ s ^ < ou C? C3 *>H j= ^ h a) =3 a *> © fn* «H W HHHH««(Nn*1,lO'0»Ciod'floco rHI-lr-ll-Hi-l ^ ^ ©©»o©io©©©©© TftiommCDCCci©'-HCOso'cO©cn O CO © i-IhhNNNWM^1 !C> CO c. © S5 .„' .„ to o 3 s •4 00 35 O N il O to to to K*> tO tw; <*-t <4-t • <*-( «*H C** ©o©©©o©©© > i> av os © cn o to oo rn tji to tO *0 tO tO tO * x 1 :^ :- •= :~ •- to tO *0 NO WO NO NO NO CONVERSION OF CUBIC CENTIMETRES. 33 Conversion of Cubic Centimetres into Fluidrachms. The following approximate table is based on the fact that a millilitre, or a cubic centimetre, is the measure of one gramme of water. To assist in the conversion of cubic centimetres into fluidrachms and minims, the state- ment here given has been carefully prepared. The value of a millilitre or cubic centimetre (according to the U. S. Ph. 1873) is 16.231 minims.1 Table for Converting Cubic Centimetres into Fluidrachms. Cubic Centimetres. o. l. dr. m. 3. dr. m. 3. 4. 5. 6. 7. 8. 9. dr. m. dr. m. dr. m. dr. m. dr. m. dr. m. dr. m. dr. m. 0 0 0 16 0 32 0 49 1 5 1 21 1 37 1 53 2 10 2 26 10 2 42 2 58 3 15 3 31 3 47 43 4 19 4 36 4 52 5 8 20 5 24 5 41 5 57 6 13 6 29 6 46 72 7 18 7 34 7 51 30 87 8 23 8 39' 8 56 •9 12 9 28 944 10 10 17 10 33 40 10 49 11 5 11 22 11 38 11 54 12 10 12 27 12 43 12 59 13 15 50 13 31 13 48 14 4 14 20 14 36 14 53 15 9 15 25 15 41 15 5S 60 16 14 16 30 16 46 17 2 17 19 17 35 17 51 18 7 18 24 18 40 70 18 56 19 12 19 28 19 44 20 1 20 17 20 34 20 50 21 6 21 22 80 21 38 21 5522 11 22 27 22 43 23 23 16 23 32 23 48 24 4 90 24 20 24 37 24 53 25 9 25 26 25 42 25 58 26 14 26 31 26 47 100 cubic centimetres are equal to 27 fluidrachms 3 minims, or 3 fluidounces 3 fluidrachms and 3 minims. 1 Alfred B. Taylor, Med. and Surg. Reporter, Feb. 24, 1877, suggests that, as the cubic centimetre, or gramme of distilled water, represents nearly 16£ minims, and differs but slightly from the one-fourth part of a fluidrachm, or 15 minims, it might very appropriately and sugges- tively be designated a "fluigram," being required only for medicinal uses, and being directly related to the assumed standard weight of pharmacy. Four of these "fluigrams" represent a capacity of 64.9 minims, or not quite 5 minims more than onr fluidrachm, which, trans- lated into the " vulgate," signifies 5 drops over the average teaspoonful. 3 34 HOW TO WRITE METRIC PRESCRIPTIONS. HOW TO WRITE METRIC PRESCRIPTIONS.1 In writing prescriptions it is sufficiently accurate and safe to consider 1 gramme as exactly equal to 15 troy grains, and to consider 1 cubic-centimetre as equal to 15 minims. We accordingly have:— 1 gramme equal to ^ troy grains. 1 troy grain equal to y1^ gramme. 1 cubic-centimetre equal to \ fluidrachm. 1 fluidrachm equal to f cubic-centimetre. Hence— 1. TO CONVERT TROY GRAINS INTO GRAMMES, OR MINIMS INTO CUBIC-CENTIMETRES: a. Divide by 10, and from the quotient subtract one-third; or, b. Divide by 15. 2. TO CONVERT APOTHECARIES' DRACHMS INTO GRAMMES, OR FLUIDRACHMS INTO CUBIC-CENTIMETRES, multiply by 4. In writing prescriptions the "gramme" (abbreviated "Gm.") and "cubic-centimetre,*' (abbreviated " C. C," which may be called "fluigramme," and written "f Gm") only, should be used. The centigramme, a convenient unit in medicine and pharmacy, is used in books, but not in prescriptions. All other terms, and units, and prefixes, used in the metric system, may be wholly ignored by the physician and pharmacist. R. Hydrarg. chloridi corros. 0 25 Gm. Potassii iodidi 10 00 Gm. Aquse 100 00 C. C. Tinct. cinch, comp. 100 00 C. C. Mix. The use of a decimal line prevents possible errors. To write a prescription for fifteen doses of any medicine write it first for one dose in grains and minims, and then substitute the same number of " grammes" and " cubic- centimetres," thus:— ' From a paper on Metric or French Decimal System of Weights and Measures. By 0. Oldberg, Phar.D., Med. Purveyor, U. S. Marine Service. HOW TO WRITE METRIC PRESCRIPTIONS. 35 5- Opii gr. i. CamphorsB gr. ij. and to get fifteen such doses in metric terms, write:— $. Opii 1 Gm. Camphorse 2 Gm. Make fifteen pills. The gramme and the cubic-centimetre (fluigramme), when referring to liquids, may be considered as equal quantities, unless the liquids be very heavy (as in the case ofchloroform) or very light (as in the case of ether). Measures may be discarded and weights exclusively employed, if preferred. All quantities in a prescription would then be expressed in grammes.1 The average " drop" (water) may be considered equal to 0.05 C. G, or 0.05 Gm. An average teaspoon holds 5 0. C, and an average tablespoon 20 G. G. Decimal numbers should be used as far as practicable without sac- rifice of accuracy as to strength and dose of the prepara- tion. It is safe to prescribe 30 Gm. for one troy ounce, and 250 G. G. for eight fluidounces. The above contains ALL THAT IT IS necessary TO KNOW or learn of the metric system in order to write metric prescriptions with or without a metric posological table. To become familiar with, the system, the rules pre- viously given for the conversion of Apothecaries' into metric weights and measures, may be profitably used. 1 As any liquid medicine must necessarily be administered to the pa- tient in measured, and not in weighed doses, it will of course be more convenient to the physician to continue to make use of fluid measures in writing prescriptions, especially as he is already accustomed to this, and would not then have to bear in mind the specific gravity of any liquid ingredient in the prescription. To the pharmacist it makes but little difference, as he will have both weights and measures, and can use one or the other, as may be directed. If the physician discards mea- sures, he must, of necessity, adjust the proportion in his formula to pro- duce a mixture of which after all the dose must be a " teaspoonful," or other convenient measure, and this is as unnecessary as it is difficult.— 0. 0. 36 RELATION OF DROPS TO FLUIDRACHM. Number of Drops in a Fluidrachm. The importance of becoming familiar with the relation of the drop to the fluidrachm is at once evident by an in- spection of the following table. The wide range between the smallest number of drops (44) in one of the fluids cited, and the largest number (276), suggests to the prac- titioner the exercise of very great caution in the admin- istration of medicines calculated guttatim. In writing prescriptions based on an estimate of a certain number of drops to each dose, serious error might be committed in the employment of a large number of the potent arti- cles here enumerated, by a blind adherence to the view that any average number of drops is equivalent to a fluidrachm. The only true course for the practitioner is to make a special study of these agents, as offered in some such table as that here furnished, and to endeavor to fix in his mind the relative tenuity of the liquid arti- cles he may desire to prescribe. Acetum colchici " destillatum " opii " scillse . Acidum aceticum " hydrocyanicum . dilutum " muriaticum " nitricum " " dilutum " sulphuricum " " aromaticum " " dilutum . » According to measurements by Durand, Procter, Parrish, Farquhar- son, and others. Some of these measurements are from ordinary bottles others from Oj tincture bottles. Such a table is merely an approximate one, not absolutely exact under all circumstances. From From minim bottles.» measure. 75 78 90 69 78 73 102 53 52 45 54 84 62 44 90 116 148 54 49 RELATION OF DROPS TO FLUIDRACHM. 37 iEther Alcohol . " dilutum Aqua " ammonise Creasotum Chloroformum Glycerina Liquor iodinii compositus " hydrargyri et arsenici iodidi " potassii arsenitis Oleum amygdala3 dulcis " anisi " carui " caryophylli . " chenopodii . " cinnamomi . " cubebse. " foeniculi " gaultheriaa " menthas piperitae " " viridis " olivae . " ricini " rosmarini " sabinae . " sassafras " terebinthinae. tiglii . Spiritus aetherisnitrosi " " compositus Syrnpus acacias " scillae Tinctura aconiti " assafoetidae " digitalis " ferri chloridi " guaiaci " iodinii " opii • From From minim bottles. measure. 150 118 143 98 124 64 46 49 62 91 95 180 276 55 85 75 75 52 52 60 63 120 85 86 106 108 103 103 97 100 100 102 86 96 103 103 102 101 103 109 89 94 76 99 55 104 105 102 108 102 100 110 80 92 90 148 90 140 58 56 85 88 118 130 120 120 114 106 151 120 144 113 147 106 38 RELATIVE VALUE OF THE DROP. From From minim bottles. measure. Tinctura opii camphorata .... 110 95 " tola.......138 120 Vinum antimonii ...... 87 62 " colchici . . • • • .to As this table does not include a number of liquid pre- parations, which are also in common use, it is desirable that the practitioner should possess general rules for his guidance:— 1. Liquids which contain a small proportion of water afford a small drop; while, on the contrary, liquids con- taining a large quantity of water furnish a large drop. For instance, concentrated acids, ethers, rectified alcohol, fixed and essential oils, etc., which contain but a very small proportion of water, yield a smaller drop than diluted acids, weak alcohol, wine, vinegar, etc. 2. Amongst the liquids containing a large proportion of water, those which are not charged with remedial sub- stances give a larger and heavier drop than these same liquids containing extraneous bodies in solution. Thus, weak alcohol, wine, vinegar and water furnish a larger and heavier drop than the tinctures prepared from them.1 Relative Value of the Drop and Minim. The view, so long entertained and even loosely taught, that the minim was usually to be accepted as synonymous with the drop, has been wholly abandoned in the light of modern experimental research. Sixty minims always, of course, constitute a fluidrachm, but sixty drops are seldom equivalent to the same measurement, as may be deduced" from the table just given. The fact becomes of vital importance in the calculation of quantities in prescription- 1 E. Durand, Journal Phila. Col. of Pharmacy, i. 168. A PPR OX IMA TE ME A S UREMENTS. 39 writing, as in ignorance of this relative valuation of the drop a larger dose may be ordered than is desired by the practitioner, or than the welfare of the patient demands. Approximate Measurements. With the varying dimensions of teaspoons, tablespoons, wineglasses, etc., depending on the caprices of fashion or the fanciful manipulation of the silversmith or the glass- maker, no absolutely exact quantity can be fixed upon as the definite contents of any one of these articles. Custom, not law, has decided only approximately the measurement of each, and the practitioner can merely in- dicate, in a general way, the dose which he wishes to be administered to his patient, although the latter's modern teaspoon may sometimes be nearly as large again as the old-fashioned ones of his ancestors. A wineglassful is a very uncertain quantity, but when such a dose is em- ployed, it is usually that of an infusion or decoction, which does not require absolutely exact measurement of the dose. Indeed this quantity is comparatively seldom prescribed in the United States, not nearly so often as by some of our transatlantic bretl Teaspoonful Dessertspoonful Tablespoonful . Wineglassful Teacupful Breakfastcupful Tumblerful Thimbleful Pinch (of leaves or flower Handful . ren. about 1 fluidrachm. " 2 fluidrachms. « 4 << " 1^ to 2 fluidounces. u 4 « " 6 to 8 " " 8 to 10 " " 3 fluidrachm. " 1 drachm, Troy. " 10 drachms, Troy. 40 SOLUBILITY OF MEDICINES. SOLUBILITY OF MEDICINES 15 WATER, ALCOHOL, ETHER, GLYCERI5E, ETC. The practitioner is hardly sufficiently armed with a proper knowledge of the art of prescribing who is not informed as to the solubility of the substances which he is about to employ. The young prescriber, especially, is often embarrassed as to the effective solution of the arti- cles he may wish to introduce into his prescription ; shall it be an alcoholic or an aqueous solution, and, if so, is the substance soluble in one or the other, and are the other ingredients miscible with it? Such are the questions he often asks himself, and the accompanying table, which includes all the prominent remedies, will supply the answer. Even those who are experienced prescribers and dispensers will find such a summary valuable for daily use. The table has been carefully prepared by the author from results arrived at in the researches of various undoubted authorities,1 and offers the advantage of immediate and ready reference at the moment it is needed. For much of the information here conveyed the prac- titioner might search his text-books in vain. The works on chemistry proper, of course, take no cognizance of the solubility'of purely medicinal agents, and medico- ,chemical treatises content themselves with only a brief mention of the solvent powers of such a useful excipient as glycerine. There are many opportunities, indeed, for 1 Pharmacopoeia of the United States, 1873 ; United States Dispen- satory, 14th edition, 1877 ; Frank H. Storer, First Outlines of a Dic- tionary of Solubilities of Chemical Substances, 1864 ; etc. SOLUBILITY OF MEDICINES. 41 the employment of these solutions in glycerine, both ex- ternally and internally, which are neglected from the usual inaccessibility of such information. No allusion is made in the following table of solu- bilities to such articles of the materia medica as give up only a portion of their virtues to alcohol, water, etc., leaving undissolved a considerable amount of residue. We shall allude to preparations formed in this way, such as tinctures, in another place. (See Pharmacopceial Groups.) Nor is mention made of the solubility of substances in acids, when such solution is really nothing less than actual decomposition or disintegration, sometimes amounting to the formation of a salt with totally different properties. The solvents referred to in the table are those which are of constantly recurring interest to the physician and the pharmaceutist, being those most commonly resorted to by the former in prescribing, and by the latter in com- pounding. The solvent powers of these menstrua— water, alcohol, ether, glycerine—are exerted in a discrimi- nating way, for which we can offer no satisfactory expla- nation, some substances being soluble either in water or alcohol, while others of a somewhat similar chemical nature are insoluble in one or both of these fluids. Very few articles employed by the practitioner are wholly in- soluble. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc. Boiling Name. Cold water. water. Alcohol. Ether. Soluble. Soluble. Insoluble. Insoluble. Insoluble in oils ; soluble in dilute acids. Acidum arseniosum At 55°, a pint dissolves Dissolves 100 parts of glycerine dis- 293 grains of trans- 807 grains solve 20 parts. parent variety; 92 of of both the opaque. varieties. u benzoicum i Soluble in 200 parts. Soluble in 24 parts. Soluble. Soluble in fixed oils and alkaline solutions. 100 parts of glycerine dis-solve 10 parts. it carbolicum • • Soluble in 20 to 33 parts, according to purity. Soluble. Soluble. Soluble in acetic acid, in glycerine, in fixed and volatile oils. It citricum • • Soluble in f its weight. Soluble in £its w'ght. Soluble. Insoluble. it gallicum . • • Soluble in 100 parts. Soluble in 3 parts. Very soluble. Slightly so-luble. Soluble in glycerine, gr. xl. to Sj. « lacticum . Soluble. Soluble. Soluble. it oxalicum . Soluble in 9 times its Soluble in Moderately solu- Solub. with weight. • its weight. ble. difficulty. it tannicum . • • Very soluble. Soluble. Soluble. Insoluble in fixed and volatile oils. 100 parts " salicylicum • Soluble in 600 parts. Soluble in 150 parts. Soluble. Soluble. of glycerine dissolve 50 parts. (i taitaricum Soluble in rather less than its weight. Soluble in £ its w'ght. Soluble. Insoluble. o b I Name. Acidum valerianicum Aconitia .... Alcohol amylicum . Aloes..... Alumen .... Ammonii benzoas . " bromidum " carbonas . " chloridum " iodidum . " valerianas Ammoniacum Amyl nitris Amylum . Boiling Cold water. water. Alcohol. Ether. Soluble in 30 parts. ... Soluble. Soluble. Soluble in strong acetic acid. Soluble in 150 parts. ( Soluble in 50 parts. Readily soluble. Readily soluble. Soluble in chloroform. Sparingly soluble. Soluble. Soluble. Soluble in essential oils. Partially soluble. Soluble. Soluble. Soluble in 14 to 15 Soluble inf Insoluble. 100 parts of glycerine times its weight. its weight. dissolve 40 parts. Soluble. Soluble. Soluble in 1.5 parts. Soluble in 13 parts. Soluble in 4 times its Decom- Abundantly solu- 100 parts of glycerine weight. posed by boiling water. ble in dilute al-cohol, and in heated alcohol, sp. gr. 0.836. dissolve 20 parts. Soluble in 3 parts. Soluble in Moderately solu- Insoluble. 100 parts of glycerine one part. ble in rectified spirit; sparingly so in absolute al-cohol. dissolve 20 parts. Very soluble. Very soluble. Very soluble. Very soluble. Partially soluble. Partly soluble. Partly sol-uble. Partly soluble in vinegar and alkaline solutions. Insoluble. Soluble. Insoluble. Soluble. Insoluble. Insoluble. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Boiling Name. Cold water. water. Alcohol. Ether. Antimonii et potassii tar- Soluble in 15 parts at Soluble in 2 Insoluble; par- 100 parts of glycerine 60°. or 3 parts, tially soluble in dissolve 5.5 parts. proof spirit. Antimonium sulphuratum Insoluble. Argenti nitras .... Soluble in its own weight; when pure, wholly dissolved in distilled water. Soluble. Soluble. Soluble in glycerine. " oxidum . Slightly soluble. Arsenici iodidum . . Very soluble. Soluble in boiling alcohol. Soluble in 300 parts at Soluble in 8 parts. Soluble in Soluble in 50 parts of 60°. 25 parts. glycerine; in rather more than 3 parts of chloro-form ; 100 parts of olive oil dissolve 2.62 parts. Atropiae sulphas . . . Very soluble. Very soluble. Insoluble. Insoluble in chloroform. 100 parts of glycerine dissolve 33 parts. Balsamum tolutanum . . Soluble. Barii chloridum .... Soluble in 2^ times its Soluble in Almost insoluble Insoluble. weight. its own weight. in absolute alco-hol ; soluble in rectified spirit. Bismuthi subcarbonas Insoluble. Name. Cold water. Bismuthi subnitras . . Very slightly soluble. Sparingly soluble. Soluble in 850 parts. Cadmii iodidum . . . Freely soluble. " sulphas .... fnffm,,. Very soluble. Calcii bromidum . . . " carbonas prsecipi- tata..... " chloridum " hypophosphis . . " phosphas praecipi- tata..... Soluble in twice its weight. Insoluble. Very soluble. Soluble in 6 parts. Insoluble. Boiling water. Soluble ii 500 parts. Alcohol. solu- Moderately ble. Very soluble. Freely soluble. Soluble. Soluble. Insoluble. Soluble. Slightly soluble in diluted alcohol. Insoluble in offi- cinal alcohol. Ether. Soluble. Insoluble. Sparingly soluble in boiling ether. Soluble. Insoluble. Soluble in strong acids and ammonia, sparingly so in fixed alkalies. Insoluble in fixed oils; slightly soluble in vola- tile oils. 100 parts of glycerine dissolve 2.25 parts. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Boiling Name. Cold water. water. Alcohol. Ether. Soluble in about 700 times its weight at 60°. Soluble in about 1300 parts. Almost insoluble. Insoluble. " chlorinata .... Partially soluble. Camphor...... Triturated with water, Alcohol takes up Soluble. Soluble in fixed and vola- latter dissolves only 75 per cent, of tile oils, strong acetic 1000th part. its weight. 100 parts of alcohol, sp. gr. 0.806, dis-solve 120 parts at 50° Fah. (Ber-zelius). acid, and diluted mine-ral acids ; extremely soluble in chloroform. " monobromated . Insoluble. Soluble. Soluble. Insoluble. Insoluble. Insoluble. Soluble in its own Soluble in abso- Soluble. Insoluble in oil of turpen- weight of distilled lute alcohol. tine, chloroform, bisul- water. phide of carbon. Solu-ble in fixed oils. Chloroforniuin . . . Soluble in 100 parts. Soluble. Soluble. Almost insoluble. Soluble in Soluble in boiling Slightly Slightly soluble in fixed 2500 parts. alcohol. soluble. and volatile oils. 100 parts of glycerine dis-solve 0.3 part. Cinchonise sulphas . . . Soluble in 54 parts. Moderately Soluble. Sparingly 100 parts of glycerine dis- soluble. soluble. solve 6.78 parts. Name. Ciuchonidia . . . Codeia..... Copaiba .... Creasotum . . . Creta prjepnrata . Cupri acetas . " subacetas. . " sulphas . . Cuprum ammoniatum Digitalinum . . . Ferri arsenias " bromidum . " chloridum . Boiling Cold water. water. Alcohol. Ether. Very sparingly solu- Soluble. Sparingly ble. soluble. Dissolves 1.26 per Dissolves Soluble. Soluble. Insoluble in alkaline so- cent. 5.9 per c. lutious. Insoluble. Soluble in abso-lute alcohol. Soluble. Soluble in fixed and vola-tile oils and strong alka-line solutions. Forms two solutions ; Soluble. Soluble. Soluble in naphtha and 1 part creasote, 80 bisulphide of carbon. water, and 1 part water, 10 creasote. Insoluble. Insoluble. Insoluble. Soluble in 14 parts. Soluble in 13 parts ofboilingalcohol. Insoluble. 100 parts of glycerine dis-solve 10 parts. Decomposed by water. Insoluble. Soluble in 4 parts. Soluble in 2 parts. Insoluble. 100 parts of glycerine dis-solve 30 parts. Soluble. Insoluble. Soluble in 12 parts of cold alcohol of 90 per cent.; in 6 parts boiling al-cohol. Very soluble in chloro-form. Insoluble. Dissolved by muriatic acid. Soluble. Soluble. Soluble. Soluble. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Boiling Name. Cold water. water. Alcohol. Ether. Abundantly but slowly soluble. Soluble. " et ammonii citras . Soluble. Almost insoluble. " " " sulphas Soluble in 1.5 parts at 60°. Soluble in less than its weight. " " " tartras . Slowly soluble. Insoluble. Insoluble. " " potassii " . . Soluble in 4 parts. Sparingly soluble. 100 parts of glycerine dis-solve 8 parts. " " quinise citras . Slowly soluble. Soluble. Insoluble in offici-nal alcohol. Insoluble. " " sti'vchniae " Very soluble. " ferrocyanidum Insoluble. Insoluble. Insoluble. " hypophosphis Insoluble. Soluble in hydrochloric acid. " iodidum .... Very soluble. Very soluble. Soluble in glycerine. Soluble in 48 parts. Soluble in 12 parts. Almost insoluble. Insoluble. 100 parts of glycerine dis-solve 16 parts. Insoluble. " phosphas .... Insoluble. Soluble in acids. " pyropliosphas. . . Freely soluble. " subcarbonas . Insoluble. Soluble in twice its Soluble in Insoluble. 100 parts of glycerine dis- weight. i|its w'ght. solve 25 parts. Name. *" Ferrum redactnm Galla Glycerina . Gutta-percha Hydrargyri chloridum cor- rosivum..... Hydrargyri chloridum mite....... Hydrargyri cyanidum . . Hydrargyri iodidum ru- brum...... Hydrargyri iodidum viride Cold water. Insoluble. Soluble. Insoluble. Soluble in 16 parts. Insoluble. Soluble. Soluble in 150 parts. Soluble in 2375 parts. Boiling water. Insoluble. Partially soluble. Soluble in 3 parts. Soluble. Alcohol. Insoluble. Partially soluble. Soluble. Insoluble. Soluble in 2.3 parts of cold, in its own weight of boiling alcohol. Insoluble. Sparingly soluble. Ether. Insoluble. Partially soluble. Insoluble. Imperfectly soluble by aid of heat. Soluble in 3 parts of ether. Insoluble. Sparingly soluble. jFreely sol- uble. Insoluble. Insoluble. Insoluble in alkaline solutions and in weak acids. Soluble in oil of turpentine, bisulphide of carbon, chloroform, and benzole. Soluble in sulphuric, ni- tric, and muriatic acids. 100 parts of glycerine dissolve 7.5 parts. 100 parts of glycerine dis- solve 27 parts. Soluble in muriatic acid, solutions of iodide of potassium, chloride of sodium, etc. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Name. Hydrargyri oxidum ru- brum...... Hydrargyri oxiduniflavum " sulphas flava . " sulphuretum rubrum...... II yd rargy rum ammonia- tum....... Hydrargyrum cum creta . Ichthyocolla..... Iodinium...... Iodoformum..... Lithii carbonas .... " citras ..... Lupulina...... Magnesia...... Cold water. Soluble in 20,000 parts. Soluble in 200,000 p'ts. Soluble in 2000 parts. Insoluble. Insoluble. Insoluble. Soluble in 7000 times its weight. Insoluble. Soluble in about 100 parts. Soluble in 2.5 parts. Water dissolves 5 per cent, of its weight. Soluble in 5142 parts at 60°. Boiling water. Alcohol. Soluble in Insoluble. 7000 parts. Soluble in 600 parts. Soluble. Soluble in 36,000 p'ts. Insoluble Insoluble. Insoluble. Soluble. Soluble. Insoluble. Soluble. Ether. Insoluble. Insoluble. Very solu ble. Soluble. Almost in- soluble. Soluble in dilute acids and alkaline solutions. 100 parts of glycerine dis- solve 1.9 parts. Soluble in chloroform. Soluble in fixed and vola- tile oils. Soluble in carbonic acid water. o § o C3 Name. Magnesii carbonas . " sulphas . Manganesii sulphas Manna ..... Morphia Morphias acetas . " murias " sulphas Boiling Cold water. water. Alcohol. [Soluble in 2493 parts. Soluble in 9000 parts of hot water. At 32° F. 100 parts of Insoluble. water dissolve 25.76 parts of anhydrous salt, and nearly 0.86 part for every addi- tional degree. When anhydrous, dis- Soluble, in Insoluble. solved by 2 parts at its own 60°. weight. Soluble in 3 parts. Soluble in its own weight. Soluble. Nearly insoluble. S.luble in Slightly soluble in rather less cold, freely in than 100 boiling, alcohol. parts. Soluble when pure. Moderately solu-ble. Soluble in 16 parts at Soluble in Soluble. 60°. its own weight. Soluble in twice its Soluble. weight. Ether Insoluble. Slightly soluble. Soluble in fixed and vola- tile oils; insoluble in chloroform. 100 parts of glycerine dissolve 0.45 part. 100 parts of glycerine dis- solve 20 parts. 100 parts of glycerine dis- solve 20 parts. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Boiling Name. Cold water. Water. Alcohol. Ether. Partially soluble. Partially soluble. Partially soluble. Soluble iu solutions of the alkalies. Oleum amygdalae amarse . Slightly soluble. Soluble. Soluble. " morrhuse Dissolves 0.637 to 1.28 per cent, of different varieties. Dissolves 2.5 to 6 per cent, of dif-ferent varieties. Soluble. Insoluble. Nearly insoluble. Soluble in twice its volume. Readily soluble in chlo-roform, benzine, and bi-sulphide of carbon. Insoluble. Soluble in all pro-portions in cold absolute alcohol. Alcohol, sp. gr. 0.8425 takes up about | of its weight. Soluble. " terebinthinse . . Very slightly soluble. Moderately solu-Readily ble. soluble. Soluble in volatile oils. " tiglii..... Insoluble. .... Partially soluble. Soluble. Soluble in oil of turpen-tine. Sparingly soluble in the Insoluble. Sparingly in an- Sparingly hydrous alcohol. soluble. oils; abundantly so in bisulphide of carbon and chloroform. 100 parts of glycerine dis- solve 0.20 part. ' _ 1 Boiling Name. Cold water. water. Alcohol. Ether. Slightly Soluble. Soluble. Soluble in acetic acid. soluble. Plumbi aceta3 .... Soluble in 4 times its weight; soluble in Soluble. 100 parts of glycerine dis-solve 20 parts. Co distilled water. o " carbonas ... Almost insoluble. " iodidum ... Soluble in 1235 parts. Soluble in Soluble. 194 parts. s " nitras .... Soluble in 7^ parts. Soluble in less than its weight. Slightly soluble. Readily soluble. Soluble. Readily soluble in glyce-rine. N H ^ Potassii acetas .... Soluble in half its Soluble in twice O weight. its weight. " bicarbonas . . Soluble in 4 parts. Insoluble. g " bitartras Soluble in 184 parts. Soluble in Insoluble. 0 N " bromidum. . . Very soluble. 18 parts. Slightly soluble. 100 parts of glycerine dissolve 25 parts. 1 " carbonas . . . Soluble in its own weight. Insoluble. C<3 " " pura . Soluble in its own Insoluble. " chloras .... weight. Soluble in 16 parts at Soluble in CO0. 2.1 parts. Slightly soluble. 100 parts of glycerine dissolve 3.5 parts. " citras .... " cyanidum . Soluble. Very soluble. Insoluble. Moderately solu-ble. 100 parts of glycerine dissolve 32 parts. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Boiling Name. Cold water. water. Alcohol. Ether. Potassii ferrocyanidum . Soluble in 3 or 4 times its weight. Soluble in its own weight. Insoluble. " hypophosphis Very soluble. Very soluble. Insoluble. " iodidum . . . Very soluble. Soluble in 5^ parts of alcohol, sp. gr. 0.85 at 55°. 100 parts of glycerine dissolve 40 parts. " nitras .... Soluble in 4 or 5 times Soluble in Sparingly soluble Almost in- its weight. | of its in rectified spirit; soluble. weight. insoluble in ab-solute alcohol. " permanganas . . Soluble iu 5 times its weight at ordinary temperatures. " et sodii tartras . Soluble. Soluble in 5 times its weight. Insoluble. " sulphas . . . Slowly soluble in 9^'Soluble in Insoluble. Soluble in glycerine. times its weight. less tban4 times its weight. " sulphis .... Soluble in an equal " sulphuretum . weight. Soluble. Soluble Soluble in glycerine. Name. Potassii tartras . . Quinia...... Quiniae sulphas . " valerianas . . Resina jalapae . . . " podophylli . . " scammonii . Saccharum . . . . Boiling Cold water. water. Alcohol. Ether. Soluble in its own Soluble in Nearly insoluble. weight. half its weight. Soluble in 400 parts. Soluble in 250 parts. Soluble. Soluble. Soluble in fixed and vola-tile oils. 100 parts of glycerine dissolve ^ part. Soluble in 740 parts at Soluble in Soluble in 60 Almost in- Slightly soluble in cold 54°. 30 parts. parts, sp. gr. 0.835. soluble. glycerine ; freely so in hot. Soluble in 110 parts. Soluble in 40 parts. Soluble in 6 parts of cold alcohol, and in an equal weight of boiling alcohol. Soluble. Insoluble. Soluble. Partially soluble. Insoluble in oil of turpen-tine. Insoluble. Soluble. Partially soluble. Soluble in alkaline solu-tions ; insoluble in oil of turpentine. Insoluble. Very soluble ; also in boiling proof spirit. Very solu-ble. Soluble in half its Very solu- Nearly insoluble Insoluble. weight. ble. in absolute alco-hol; soluble in 4 times its weight of boiling alcohol, sp. gr. 0.83. Solubility of Medicines in Water, Alcohol, Ether, Glycerine, etc.—Continued. Name. Cold water. Boiling water. Alcohol. Ether. Saccharum lactis . " arsenias .... " bicarbonas . . . " bromidum " carbonas .... " chloridum . . . Slowly soluble in 6 parts. Soluble. Soluble in 3 parts. Soluble in 2 parts. Soluble in 13 parts. Soluble in 12 times its weight. Soluble. 100 parts dissolve 60 parts at 57°. At 54° water dissolves 36 per cent. Slowly sol-uble in 3 parts. Decom-posed. Soluble in twice its weight. 100 parts dissolve 445 parts at 219°. Dissolves 40 per cent. Slightly soluble. Partially soluble; alsoin boilingdi-lute alcohol. Soluble. Soluble in 24 parts. Insoluble. Nearly insoluble. Sparingly soluble. Insoluble. 100 parts of alco-hol, sp. gr. 0.815, dissolve, at 59 °, only 0.174 part. Insoluble. Partially soluble. Moderately soluble. Soluble in glycerine. 100 parts of glycerine dissolve 50 parts. 100 parts of glycerine dissolve 8 parts. 100 parts of glycerine dissolve 60 parts. 100 parts of glycerine dissolve 98 parts. Soluble in glycerine. Name. Sodii hypophosphis hyposulphis nitras . . phosphas . sulphas sulphis sulphocarbolas Strychnia. . . Strychnise sulphas . . Sulphur prsecipitatum Boiling Cold water. water. Alcohol. Ether. Very soluble. Very soluble in absolute alcohol. Insoluble. Soluble in 1J parts at Insoluble. GO3. Soluble in about twice Soluble in boiling Soluble in glycerine. its weight of water at alcohol. 60°. Soluble in 4 parts. Soluble in 2 parts. Insoluble. Soluble in 3 times its Soluble in Insoluble. Soluble in glycerine. weight. its own weight. Soluble in 4 parts. Soluble in Insoluble. Soluble. less than its weight. Soluble in 6667 parts Soluble in Soluble in 387 Soluble in Soluble in chloroform and at 50°. 2000 parts. parts officinal al-cohol sp. gr. 0.835; more solu-ble in boiling al-cohol ; soluble in 179 parts of abso-lute alcohol. 682 parts. volatile oils. 100 parts of olive oil dissolve 1 part. 100 parts of glycerine dissolve 0.25 part. Freely soluble. Sparingly soluble. Insoluble. 100 parts of glycerine dissolve 22.5 parts. Insoluble. Slightly soluble. Slightly soluble. &5 o § s § in- 3T5( Breadth. T5o"~7o" in« 82170 in- zsso iQ- ^ysts in* — S-37HT iU- — So~To~o iu- 1 _ 1 in __ 2 3 1* 34"0(T 1U* l _ l in __ T23TT IJ5S 1I]- 1__ 1 in __ l _ 1 ;„ __ 3TS0 5 33(To '"• _ 1 _ 1 in __ TT4S T63T ln* 1 1 :„ __ TTTT T2 (To ln- fTTcny in- 24Tnr"TTT(T0 1D* ?C)(T-T4"0'0 in# 4~0"0 0~~2~5cl(7 'n' — JFD-o in- ~ To~0"TO in- — T3iT(r"T31oTr i"* — ¥TTo"(5 road. j^ott in- broad. — rh in- " - rfaiu- " — ScTtTo" in- " — ■sfa in. long. — tttoittt in- diameter. — REFERENCE TABLES OF SIZE, WEIGHTS, ETC. b7 3. Tubes. Bloodvessels { Fine ' TTo"o"TTTir in- diameter. ( Medium 11 « TjO 100 Capillaries . 11 II lS0(J 30(T Dentine 1 _ 1 « • T>0 0 0 lTTo'OO Urinary tubules . 4. Fibres. 1____1_ U 240 G 00 Enamel "Scnio i11, diameter. Muscle, striated . 4~iy& " striae of . i « 17(100" Nerve fibres, white 1 1 11 T2TT00 550(7 " gray __1 _ 1 « 600TT^3000 White fibrous tissue 1 ii 1500(7 Yellow elastic 1 _ 1 « 24000 400T7 III.—Measures of Length of Various Ducts and Canals in the Human Body. Testicles (vas deferens) . . 20 Eustachian tube . . -If Meatus anditorius externus Urethra < " 1 Female . Ureter.....16 Bile dnct . 3 Cowper's gland, duct of . • 1 Ejaculatory duct . 1 Hepatic " . 2 Nasal " Parotid " . 2 Submaxillary duct. . 2 IV.—Size of the more Important Parts in Connection with Organs of Special Sense. Cochlea (Waldeyer). Lamina spiralis membranacea; total length in man . . 30 mm. . .. „ ( 1st turn . . 900 micro'-mm.1 Reissnenan membrane, length of,< 2d turn . Distance between the bases of the pillars of Corti Height of arches at centre .... Cell bodies of the inner hair cells \ eilg \ ( breadth . External hair cells; total length with basilar process 900 micr 700 66-70 12 18 6-9 6-7 1 A niicromillimetre —■ yuWof a millimetre. (18 REFERENCE TABLES OF SIZE, WEIGHTS, ETC. Number of the foramina nervina 3,000 " internal pillars 4.5(H) " internal hair cells . . 3,3(30 " external hair cells . . 18,000 Cornea. Cornea proper ...... thickness 1 mm. External epithelium ..... " 30 micro-mm. Descemet's membrane .... 8 -10 Gustatory Organ. Length of gustatory bulb .... 80 micro-mm. Breadth " " . 40 " Width of gustatory pore .... 3 " Retina (Schultze). Rods { le"Sth...... 1 thickness ..... 60 micro-mm. 2 " Cones in fovea centralis ; thickness at base 3 " " elsewhere ..... 6 " Distance between cones .... . 8 -10 " Distance between striae on rods . 3 » Touch. 42 micro-mm. Pacinian bodies ...... = 130 " T..uch "...... = 85 " V.—Specific Gravity of Various Constituents of the Body- Water = 1000. Lungs .... 342 Serum 1026 Fat . 924 Milk . 1030 Sweat.... 1004 Gray matter of brain 1034 Saliva. 1006 White " " 1040 Cerebro-spinal fluid 1006 Cartilage 1050 Liquor amnii 1008 Kidney 1052 Intestinal juice . 1011 Blood . 1056 Pancreatic juice . 1012 Liver . 1056 Muscle 1020 Foetal lungs 1056 Urine . . 1020 1 Spleen 1060 Bile .... 1020 Body (entire) 1065 Lymph 1020 Blood corpuscles 1088 Gastric juice . 1023 Bone . 1900 Chyle .... . 1024 THERAPEUTIC AND PRACTICAL HINTS. (69) RULES FOR THE PRACTITIONER. As an aid to the practitioner, in the daily routine of his profession, the following rules, framed by one of its most distinguished ornaments,1 will be, if carefully fol- lowed, of inestimable value to him, and enure to the comfort and physical improvement of those under his professional care. 1. When a disease is progressing favorably towards recovery, it is unwise to interfere with the spontaneous effort at cure by the administration of drugs. The end and aim of treatment is not only to restore health, but to do so safely and speedily and pleasantly. 2. Where drugs are needed, and there is a choice of remedies, employ that one which will be the least dis- tressing at the time, and subsequently the least injurious to the constitution. 3. Put the medicine into that form in which it can be most easily taken. When possible, especially with children, cover the disagreeable taste of the draught by syrups, etc. 4. If there be an idiosyncrasy with respect to any spe- cial medicine, such as mercury, arsenic, iodide of potas- sium, opium, nux vomica, assafcetida, turpentine, etc., avoid administering it. That a peculiarity of constitu- tion, causing an extreme susceptibility to the influence of certain drugs and foods and odors, sometimes exists, cannot be disputed. It is as certain that it can seldom be safely combated. 1 Tanner, Practice of Medicine, 5th Amer. ed.,p. 1047, Phila. 1872. (71) 72 RULES FOR THE PRACTITIONER. 5. Attend to the condition under which the patient will be at the period of the medicine's action; for example, it will be .worse than useless to give a sudorific to an in- dividual obliged to be in the open air soon after taking it. 6. Be careful that the various agents in the prescrip- tion are not incompatible with each other, unless it be desired to form some new or particular compound. Chem- ical incompatibility, however, is by no means synony- mous with therapeutic inertness; for experience tells us that certain unchemical compounds—perchloride of mer- cury and tincture of bark, gallic acid and tincture of opium, calomel and compound ipecacuanha powder, etc., are all valuable preparations in curing diseases. 7. Eemember that if a disease be incurable, it may still admit of great alleviation. Hence, it is cruel to give up any case; although, at the same time, the patient is not to be deceived by false promises. 8. Never order, or sanction the use of, a quack medi- cine; that is, one the composition of which is kept a secret. 9. Bearing in mind the weakness of human nature, as well as the prejudices and superstitions which are current, it is not only necessary to give good advice, but pains must be taken so to impress the patient and attendants that the necessary treatment may be thoroughly carried out. Hope and confidence are no mean remedial agents, and in many chronic diseases at least, the individual who lias faith, will recover more speedily, cseteris paribus, than he who is shy of belief. 10. Simply to prescribe drugs, without regulating the diet and general management of the patient, is to omit a most important duty. In acute diseases plain directions RULES FOR THE PRACTITIONER. 73 must be given as to the ventilation and warmth of the sick-room, the amount of light, the position of the bed (not to be placed in a corner), the degree of quiet to be maintained, the avoidance of excitement and whispering, the exclusion of visitors, the cleanliness of the sufferer, and the nature and quantity and times for administra- tion of food. No cooking whatever should be permitted in the sick-room. In cases of long illness, when the patient can be moved without risk, it is often desirable to have two beds in the room, one to be occupied during the day, the other at night. Every precaution must be taken to prevent the spread of infectious disorders. Soiled linen, dirty water, etc., must be immediately removed. In all instances the evacuations ought to be passed in a bed-pan or night-stool containing some disin- fectant material (carbolic acid, permanganate of potash, sulphate of iron, etc.). 11. While it is allowed that formula? may often be employed with great advantage, yet they should not be prescribed with servile exactness; for it should never be forgotten that all medicines of any power have to be adapted to the requirements of the special case under treatment. It has been quaintly but truly observed, that a bundle of ready-made receipts in the hands of the routine practitioner is but a well-equipped quiver on the back of an unskilful archer. 12. In watching the restoration of a sick man to health, it is a mistake to attribute the improvement too confidently to the action of the medicine prescribed, for it may not have been taken, or it may not have been absorbed, or its properties may have been destroyed by adulteration, or it may have even proved injurious—recovery occur- ring in spite of it. 74 RULES OF MEDICAL ETIQUETTE. RULES OF MEDICAL ETIQUETTE.1 The aim of the few following rules of Medical Eti- quette is to place before the profession a definite law for the guidance of those who wish to act on friendly terms with their professional brethren, and thereby to prevent those constant unpleasant feelings which are caused by a want of knowledge of professional etiquette. It is not thought necessary to dwell upon more than the most common difficulties which beset us in our daily work. It is a difficult task to make any law, for what- ever purpose, to please every one. At the present time there is no work upon the subject, and the only light that has been thrown upon etiquette laws has been through the medical press and through codes of ethics, as of the American Medical Association. Medical Etiquette, if carried out strictly, as it should be, is one of the greatest ties which medical men have to bind them together and make them work happily; and it is frequently from a misunderstanding as to what consti- tutes etiquette that we so often find one man falling out with another. If we had distinct rules to lead us we should, perhaps, hear less than we do of so much ill-feel- ing existing, and our medical press would not be troubled with so many letters upon Medical Etiquette, professional differences, etc. etc. ' These rules have been condensed and somewhat modified from those recently published by a licentiate of the Royal College of Physi- cians; but they are generally applicable in our own country, and the eveiy-day experience of the practitioner. On some points American practice may differ somewhat from the line of conduct here laid down. In other matters not alluded to by him, the reader is referred to the Code of Ethics of the American Medical Association. RULES OF MEDICAL ETIQUETTE. We, like other men, have to live, and this is one point which should always be borne in mind. If we act as be- comes gentlemen, taking care that we do that which is right, honest, and straightforward, we should never allow such trifles as a patient changing hands, or a young man commencing practice in our midst, to influence the friendly feeling which should exist in such a limited body. If we take any small town and look around us, we see amicable relations maintained between almost all classes ; but how seldom do we find, say, two or three medical men living in the same town all friendly—able and willing to assist each other, to shake hands together, and to meet at each other's houses on terms of intimacy ? Not often does this happen; and why? If we ask ourselves the ques- tion, we shall find in a majority of cases it is from some breach of Medical Etiquette; and if it be asked what are the rules of Medical Etiquette, there are few who can tell you what they are. Even as regards a new-comer into a town, you will find it is hardly known whose place it is to make the first call, and this alone may be the means of long-continued isolation. I. The question of a medical man commencing practice in a small town, without succeeding to one already in ex- istence, deserves our first attention, as a new-comer is too often looked upon as an enemy norae into the camp, to seize upon anything.he can. It, therefore, behooves such a one to be as careful as possible to do everything in his power to bring about a frienxlly feeling. As soon, then, as he begins to practise, his first calls should be upon the other medical men in the place, choosing the most convenient time he can to catch the doctors at liberty. Should they not be in—one 76 RULES OF MEDICAL ETIQUETTE. or all of them—it will be best to leave his card, and not attempt, time after time, to see any that happen to be out, or engaged. The reason for giving this advice is twofold. Firstly: They may, perhaps, not wish to see him at all, taking offence at his being an opponent; and the very fact of his forcing himself into their presence may make them treat him with scant courtesy. Secondly: If he leave his card, it will rest with them to show him, by calling at his residence, if they wish to become friendly. When a partner is taken into a practice, this introduc- tory call is frequently dispensed with; but this is a great mistake, and the reason for not calling is easily discov- ered. The senior partner says to his commencing junior: "I should have nothing to do with So-and-so, but this one and that one are very nice fellows." The consequence of this is he calls on none — those whom his partner objects to are not visited for the reasons stated, and the others are introduced from time to time as opportunity offers. Of course, there are reasons the senior partner might give which would make it impossible for the junior to make a friendly call upon some, but upon those the senior knows and can meet in consultation, it is far better for the junior to pay the usual introductory call, and know his fellow-workers at once. Unless there be any good reasons existing—which are known to be facts—let a new-comer therefore call upon all the medical men during his first week in practice, and be will then ascertain by the return calls, to a certain ex- tent, those he may look on as friends. II. Cases occur where a medical man is in attendance, and the patient's friends ivislt, to obtain a second opinion RULES OF MEDICAL ETIQUETTE. 77 without the first medical man knowing that they have called in the second. This probably gives rise to more annoyance and dis- agreements between doctors than any other cause, the reason being that the second medical man acts without knowing that the first is in attendance. An instance to make the meaning clear. A. is taken ill and sends for B.,*the regular medical attendant, who attends for a time; but A. getting no better, the friends wish this or that doctor to see the case and get his opinion ; so it is ar- ranged that Dr. C. shall be called in, to hear what he has to say. Dr. C. is, perhaps, away from home when some of A.'s friends call upon him and leave a message as follows: " Please ask Dr. C. to call as'soon as he can to see A., as he is verv ill." C. attends as wished, and, after a short conversation with the patient, he may, perhaps, discover that he is under B.'s care, or he may not find it out until after he has fully examined the case and given his opinion thereon. He instructs the patient's friends to send for the medi- cine, when he is told—"Oh, doctor, we only wished to get your opinion ; Dr. B. is attending the case, but we wished to have a little more advice." This will most likely be the case if both are of the same opinion; but should C. say the case will get well, and B. say it will prove fatal, or mo.st likely so, the result is C. will be asked to continue attending. In the first place, how are we to prevent this happen- ing? and in the second place, when it has happened, what is the proper mode of procedure? As regards the first question—How are we to prevent the above? This can generally be done, unless the pa- tient and his friends tell a direct lie. The course I follow RULES OF MEDICAL ETIQUETTE. is this: A new patient sends for me, and if I see the mes- senger, I nearly always ask the following: "Do you know what is the matter? How long has he been ill? Has any one seen him ?" Now if, to the first question, we get such an answer as " He is suffering from inflammation of the lungs," or " He has pleurisy," we may come to the conclusion he has been seen by some one. Then, again, in regard to the second question—" How long has he been ill ?" We will have the reply, "A week," "A long time," or something of that kind; if so, we may infer that some means have been used by some one, and we then put the question, "Has any one seen him?" By the two previous questions we have so far driven the messenger into a corner-, that we will most likely get to the truth, although he may wish to say nothing. Hav- ing got so far, and discovered that a medical man is in attendance, how should we act? This is easily told. There are two courses open to the friends. The proper way is to point out that we cannot interfere, but will be most happy to meet Mr. So-and-so in consultation, and that we decline to see the case without. Very frequently the parties will say, " But we wish you to take care of the case, as we are not satisfied and would rather have you." Under these circumstances we should point out to the parties interested that we cannot undertake the case until they have sent word to the other medical man that he is not required any more, and then we are at lib- erty to take charge of the case. It must be borne in mind that every person has as much right to change his medical man as he lias to change his solicitor or tailor, and every medical man has a right to take charge of a patient when his previous pro- fessional attendant has been discharged. Misapprehen- RULES OF MEDICAL ETIQUETTE. 79 sion on this point is one great cause of unfriendly feeling, but it must be borne in mind that what may happen to us to-day will happen the opposite way at some future time; and the full weight of the annoyance and loss should be shown, if at all, towards the patient and his friends, and not towards the new medical attendant. The way to act, then, in the first place, if we have dis- covered, before seeing the patient, that he is already under treatment, is to offer to meet the medical man in consultation ; and if this is not agreed to, but we are wished to attend the case altogether, to request the friends to communicate with the doctor in charge, and inform him that he is no longer required. In the second place, when we have seen the case, and given our opinion upon it, and have been then asked what our fee is and told we need not call any more, be- cause So-and-so is the regular doctor, I would say, take no fee, but inform the practitioner of the manner in which we were dragged in, and explain to him that it was done in ignorance, allowing him to charge our visit. By taking no fee we prove to him that we have not seen the patient knowing him to be in attendance. It sometimes happens in a case like the above, that the friends wish to call in a younger man as the consulting physician, and the older practitioner objects to and re- fuses to meet the junior, on the simple grounds that, if a second opinion be desired, a man who has had more ex- perience than himself should be called in. Under these circumstances the friends will sometimes try and per- suade a medical man to call quietly and say nothing about it, or will say that if the doctor who has the case in hand decline to meet a younger man, they will call in any one he may like to name; but in a majority of cases, if they have a desire for a special doctor, they prefer to give up 80 RULES OF MEDICAL ETIQUETTE. their old one and call in the new. In this case, the junior practitioner has a perfect right to take full charge of the patient, if word be first sent to the other doctor that his attendance is no longer required. It also sometimes happens, that, owing to some previ- ous disagreement, two medical men are not on speaking terms, and therefore one will not meet the other in con- sultation. In this case it is best to point out this fact, when, if it has been fully resolved to have a second doc- tor called in, there is no reason why he should not take charge of the case, if the previous notice to the other practitioner have been given. Medical men are too much inclined to look upon their patients as private property, and to consider it a griev- ance if another practitioner should have them in his list. It should be remembered, however, that it is not the doctor who is to blame, but the patient. III. Can a medical man honestly meet a homoeopath in consultation f To this I can only say, certainly not. And why? In the first place, as regards homoeopathy: I know very well that some qualified men take up that practice, and I have no reason to doubt that they practise it honestly and believe in their mode of treatment; at least, I think we should give them credit for honesty, of purpose. I know many men who would not think of giving 3ss or 3j doses of potassii iodidum, some considering 10 gr. to 15 gr. a very extreme dose, and therefore they stand between the two classes; but the point is, that if a man professes to be a homoeopath, it is impossible for him to fall in with any treatment advised by an allopath. What is the use of two men meeting in consultation, when one looks upon the other as useless, or worse? I RULES OF MEDICAL ETIQUETTE. 81 have no doubt that the true homoeopath considers that the allopath is killing his patients by the large doses of medicine he daily administers, and I can answer for the other side, that I consider the doses ordered by the homoeopath are too small to be of use, and condemn the treatment as being so much waste of time, and therefore injurious in the way of do-nothing treatment. How can two such men meet honestly in consultation and order a definite plan of treatment to be carried out? They can- not, and therefore the one or the other must pocket his fee, and be content to let the patient go on as before. IV. I now venture to suggest a rule as to hoiv one medi- cal man should act towards another xohen he attends for him. In many cases a patient says, " Doctor, if you are away from home I should like So-and-so to attend me," and he does attend. Now, as regards the fee to be charged. Midwifery, of all things, I believe, is subject to more differences as to charge for attendance than any other class of cases; and it may happen that a medical man attends for another who charges less than he does, and when the case is over, the friends will frequently say, " Well, doctor, what is your fee?" Now, the proper plan is to say, " You must settle with Dr. So-and-so when he comes home," as by this means you do not charge more and you do not accept less than your general fee. How should you act, also, with respect to the division of the fee? I believe a good rule is to offer half to the doctor who attended, but in some towns it is usual for medical men to attend for each other for nothing, and in others to take the fee. As regards taking the offered fee, this depends upon circumstances, and I for one should decline it, unless pressed, if I attended for a friend ; but it might happen 6 82 RULES OF MEDICAL ETIQUETTE. that I attended for a man with whom I was not on such friendly terms, and I then could please myself as to the course to be pursued. If it was for myself that some one else had attended, he could not say anything about being badly treated if this rule was adopted. V. When a medical man is called in consultation by ano- ther medical man in a case of operative midwifery, what is the proper line of action f I have known two courses followed, but I consider the one is right, and the other wrong. Let me first give the two modes, and then sum up my reasons for judging which is right. A man gets a case of convulsions; a consultation is held, and delivery is deemed advisable; or it may be considered, after consulting together, that the proper course is to bleed. Now, whose place is it to do the required work ? Is it the place of the regular practitioner in charge to bleed, turn, or deliver with instruments, or is it the consulting physician's place? I say most de- cidedly it is the place of the general practitioner to do so, the consulting physician having first advised, and the medical man having agreed upon the point. I have known both courses followed; that is, I have known the consult- ing physician to say that so-and-so is the proper thing to do, and to set to work and do it; and I have known the consulting physician to assist, and allow the medical man to follow out the treatment. Why should the consultant allow the general prac- titioner to undertake the treatment? Simply on these grounds—that he is most likely only called in to assist and to strengthen the hands of the one already in attend- ance, and if he obtain his fee he has no right to step in between the doctor and patient and thus make it appear RULES OF MEDICAL ETIQUETTE. 83 to those around that he is better able to undertake the treatment. What I consider the proper behavior is for a medical man to give a ready and willing hand to a brother prac- titioner, and in no way to make himself appear the better man of the two. It will frequently happen, and generally is the case, that the medical man in charge offers the consultant the option to carry out the treatment. It is best for the consultant to volunteer to assist, and then, if asked to undertake the treatment, to do so at once. VI. What is the proper manner to act when one medical man has been sent for to attend for a doctor who may be else- where engaged? As soon as ever the family doctor finds that another practitioner is attending for him, he should at the earliest opportunity free him. The labor may not be over for some considerable time, and it is undoubtedly.unfair to expect any one to sit perhaps the best part of the day over a case for another man. When he arrives he should inquire of the doctor in charge how the case is getting on, say he is sorry to have troubled him, and that as it will not be over for a short time, he will not detain him from his own work. Of course if the case be over before the arrival of the general practitioner, intimation should be sent to him by the patient's friends, with a message that he need not call that day unless he wish. VII. Cases sometimes occur, where several medical men are sent for at the same time, the patient being a stranger, and not having had a medical man before. I believe Etiquette demands in such a case that the medical man who arrives first should take charge of the 84 RULES OF MEDICAL ETIQUETTE. case, unless it be the patient's wish to have this or that medical man instead. As regards a fee for this first attendance, I think it is best not to take one, but allow the work done to go with the work to be done, and be charged by the patient's own medical attendant whom he has chosen to look after him. VIII. In cases of accident, sudden illness, or fit, the near- est medical gentleman is sent for in the hurry, nothing being said about any one else being the regular attendant. Under these circumstances, I always inquire, if I have merely been sent for in the emergency, and if so, request that the usual medical man had better be informed. Now and then a doctor will be told, " Oh no, we sent for you, and you had better call and attend to the case." Under these circumstances, he has a right to continue the attendance, and charge accordingly. Some medical men hold that, if a case of this kind happen, no matter how much the friends and patient wish the doctor who has been sent for to continue in attend- ance, it is his place to refuse, and say, " No, send for your own medical man." This, I maintain, is wrong; and, no matter who the man may be, if they have only sent for him, and they wish him to continue, there is nothing un- professional in his doing so. I have known a case where a medical man, hearing that an old patient of his had met with an accident, and knowing that another medical man had seen the case, called upon the patient, and made inquiries, and left word that he would call again. This is very objectionable, and, I hold, unprofessional, as it is possible it was intended to change the doctor, preferring the one they had sent for. I would make the following rufe as regards these cases: That whatever medical man is sent for, if he be the only RULES OF MEDICAL ETIQUETTE. 85 one called in, the case is his, if the friends and the patient wish him to continue in attendance after the offer to retire in favor of their own medical man has been made. IX. It sometimes happens that two medical men do not agree as to the treatment to be adopted after consxdtation: in such a case, what is the proper course to pursue ? They have examined the case together, have talked the matter over, and their opinions differ: one says "I would recommend this," another says "I would recommend that;" therefore, whichever course is followed, it does not meet the wishes of both. How should they act in such a case? The proper plan is to point out to the pa- tient and the friends that they do not quite agree, but that as one wishes this treatment to be tried, the other has no objection to adopt it, and to watch the result. If the case should be one for operation, and opinions differ, it may be well to suggest to them that a third opinion be obtained, and the result of the combined opinion should be acted upon. In the case of cancer of breast, for example, there is a great difference of opinion as to the good of removal ; and it is very easy to point out to the friends that a differ- ence of opinion exists amongst medical men, leaving it for them to decide upon the course they would wish followed. It is far better to act openly in matters of this kind at the time, and not to say afterwards: "Well, it is not what I should have advised; but. as you called in Mr. So-and-so, I thought it was best to follow out his treat- ment." X. If a patient call at a doctor's house, for his advife, has he any right to question him, if he has been under any other 86 RULES OF MEDICAL ETIQUETTE. medical man, or is it his place to attend to him ? If he find he has been under some one else, and has merely come to him for his opinion, how should he act? In the first case, all patients who come to your own house for consultation are your patients—they have de- cided to place themselves under your care—and it is your right to attend to them without asking why they have come. A patient has a perfect right to come to you in the morning and go to another medical man in the after- noon ; for as soon as a patient leaves the consultation- room, he is no longer a patient of yours until he again returns. If this rule did not hold good, you would have constantly to refuse those who come. For instance, a man is suffering from heart disease or consumption, and does not improve under your treatment; he is told the nature of his complaint, but does not believe; so he says: "I will not go there any more, but will try some one else." He calls upon another medical man, and asks him what is the matter, and will he prescribe for him? Surely it would not be right to refuse to do so, and tell him to go back to his own doctor. Let this be perfectly understood in the profession—that whoever calls upon a doctor at his own house is his patient as long as he continues to call. In the second case—where a person merely comes to you for your opinion—it is somewhat different, as you may be the means of shaking the confidence of that pa- tient in his late medical attendant. How, then, should you act? If you find the attendant is a man whom you could not meet, it is, perhaps, the best way to decline to interfere; but if you do not know the professional attendant, you may act in two ways, both of which I believe to be correct. The one is to examine RULES OF MEDICAL ETIQUETTE. 87 the case, and write a letter for the patient to deliver, and the other is to offer to meet in consultation. By sending a letter you let the medical man know that the patient has been to you, and you can give him your opinion, leaving it for him to follow or not as he thinks well. If you offer to meet in consultation, and the patient objects, then I would say that you could not very well give him your opinion ; but you could still do as above— examine the patient, and give him a letter to deliver. The reason why a patient may object to a consultation is the expense, because the medical men may reside some distance apart. XL In some cases you will have a person sent to you by a fellow-practitioner for your opinion, and then the course to follow is plain. You should examine the patient and write out your opinion, the reasons for coming to such a conclusion, and the treatment you would advise, and give it to the patient to deliver. He will be sure to ask you this and that question, to get your opinion as to what is the matter, etc.. but be guarded in your replies, and never give a direct answer, but tell him that the doctor will explain everything to him when he gets your letter. In conclusion, I. would wish to say that the medical profession stands almost alone in the manner in which its members should act towards each other. Illness is not like other things. Food, drink, clothing, can all be put to one side for a time, and can be obtained here and there as people wish; but with sickness, which comes on with- out a moment's warning, advice is required without delay, and if it cannot be obtained at one place at once it must be had somewhere else, and oftentimes our nearest and 88 RULES OF MEDICAL ETIQUETTE. dearest friend has to seek advice from a stranger. It is this that obliges one so often to do the work of another, and it therefore warns us to do it freely and willingly, remembering that there is no telling how soon we may require the same. As a rule, the man who has the largest practice is the one who has more trouble with his professional brethren than others, because he is constantly being dragged into difficulties by his patients—the clergyman of the village, or the squire, would like his opinion upon this or that one, and the doctor, in many cases not liking to offend, is apt to do more than he should. If we had more defi- nite rules as to what was right and what was not right, I believe we should work more in harmony than we do at the present time; but strive as we may to keep friendly with all, we cannot, and I would therefore say to my readers: Do that which is right, act honestly, and do nothing that you would not like another to do to you. No matter how we strive to follow out the above, if we have our share of practice we shall meet with many things distasteful to us, which will make us angry with each other; but if we consider our own faults, and remember that none are spotless, we shall be more inclined to look upon some of the deeds of others as not having been done with a malicious intention, but merely caused bv circumstances, which, if properly explained, would still more firmly bind us together, and make us what we should be—more friendly one towards another. PRACTITIONER AND PATIENT. 89 WHAT THE PRACTITIONER MUST LEARN OF THE PATIENT. It is often a matter of convenience, in taking notes of a case, to base them on some general system of inquiry. The young practitioner, especially, should adopt some method of this kind at an early period of his career. In his history of a case from its inception to its close, whether the result be favorable or unfavorable, such an outline sketch, well filled up, will prove valuable for present uses and future reference. As has been truth- fully remarked by Dr. Henry W. Acland, by whom the following table was prepared,1 a skilful practitioner can learn the truth of any case in any order or in no order; but it may be added that such a table will prove useful even to the most systematic :— HISTORY. When were you last quite well? at work? How did you first feel ill ? Supposed cause, mode of onset, any medical treatment? What do you now chiefly complain of? What illnesses have you had before this? (If the examination sug- gest it, obtain further information concerning resi- dence, occupation, past life, change of habits, history of the family, hereditary prediposition, etc.) PRESENT STATE. L General Aspect.—Manner, posture (in bed, out of bed), color, shape, temperature, weight (alteration in), eruption, oedema. Notice generally head, neck, chest, abdomen, limbs. 1 Handbook for Hospital Sisters, by Florence S. Lees, London, 1874. 90 PRACTITIONER AND PATIENT. II. Organs of Digestion.—Hunger, thirst, taste. Lips, color, texture. 1'eeth, loose, etc. Gums, color, size, texture, position. Tongue, protrusion, volume, form, color, surface, dryness, coating. Stomach, nausea, vomiting, eructations, pyrosis, pain during, before, after (how soon after ?) eating. III. Organs of Absorption.—Lymphatics, red, tender, hard. Glands, tender, swollen (for what length of time). [The patient must be in bed or undressed for a com- plete inquiry'into Nos. IV., V. and VI.] IV. Examination of Abdomen.—By palpation, percus- sions, measurement. Dimension of liver, spleen. Existence of pain, increased or diminished by pressure; general or circumscribed; under the hand or at another point. Existence of tumors, fluids, flatus, feces ; of hernia; of tumors in groin; of hemorrhoids; of feces in rectum. V. Organs of Circulation.—Heart, position, dimen- sions, force, rhythm, sound (character, situation, and distance). Arteries, pulse at wrist; rate, vol- ume, hardness, laboring, regularity, intermission, dicrotism, etc.; tumors. Veins, enlargement, ten- derness, murmurs. VI. Organs of Respiration.— Respiration generally; frequency, regularity, difficulty, odor of breath. Nares, discharges, odor, action. Epiglottis; Larynx, tenderness, alteration of voice. Cough, its charac- ter and supposed cause. Expectoration, color, odor, tenacity; chemical, microscopical properties. Examination of Thorax.—Form flattened, rounded, asymmetrical; supra and infra-clavicular spaces, etc. Movements; vocal fremitus; intercostal spaces. PRACTITIONER AND PATIENT. 91 Resonance on percussion; changed by posture. Sounds on inspiration, expiration, speaking, cough- ing, succussion. VII. Organs of Secretion and Excretion. — Shin, eruption; sweat, quantity, chemical quality; lo- cality. Kidneys—Pain in micturition ; its seat and direction; pain in the loins. Urine, fre- quency (night or day), quantity, appearance. Microscopic deposits, organic, inorganic. Chemical examination—acidity, specific gravity, albumen, sugar, bile, excess of urea, etc. Bladder, tumors, irritability, etc.,.calculus. Bowels, frequency of action, character of evacua- tions. VIII. Organs of Generation.—(Male), penis, scrotum, testes, cord. (Female), catamenia—color, quantity, frequency, du- ration. Leucorrhoza, or other discharges. Pain—its seat, duration, causes, periodicity. Uterine, pelvic, ovarian enlargements, tenderness, ulcerations. External sores—^-ecfeema, pruritis. IX. Nervous System. — Brain, general intelligence, memory, speech, slowness of manner, headache (where), giddiness, sleep, dreams, fits (one kind or more). Spinal Cord and Nerves.—Pain, alterations in kind or degree of sensibility, in sight (pupils), hearing, smell, taste, touch, numbness; tremors, rigidity, vigors, paralysis. X. Organs of Motion.—Pain, stiffness, swellings, nodes, ulcers, abscesses. 92 DOSES OF MEDICINES. DOSES OF MEDICINES. In addition to the actual quantity of any remedy to be prescribed in individual cases, modifying circumstances must be taken into consideration, such as age, physical condition, etc. It is difficult to limk the effective doses of a medicine within the fixed quantities assigned to it in the various posological tables, such quantities being mentioned as a general guide to the practitioner, beyond which he may sometimes step, according to his own dis- cretion. As will be seen, however, in one of the accom- panying tables (see p. 91), an effort has recently been made to define the maximum doses of the more potent agents. The practice of using caution marks for excessive doses knowingly prescribed, has not yet come into vogue in this country, but it has been suggested by the American Pharmaceutical Association, and other authorities, that such methods of protection and safety should be gener- ally adopted. Wherever desirable, the French metric system is men- tioned in conjunction with that in general use, so that the practitioner may become familiarized with its peculiar construction. Doses for Children. The simple rule, generally applicable, is as follows:— Under twelve years of age diminish the dose of the medicine in the proportion of the age to the age increased by twelve. At one year of age the dose will be___-___= T' < 1 -f- 12 T5 . o At two years.___~ = a '2 + 12 7' DOSES FOR CHILDREN. 93 At three years, __i 3-4-12 5' At six years, 6 + 12 6 Another reliable method of calculating doses for chil- dren is the following r1 The proportionate dose for anf age under adult life is represented by the number of the following birthday divided by 2-1:— The dose for a child of 1 year is ^ = T' " " " 2 years is ^ = i 3 " 24 5 6 __ 24 — 11 " 1 = J-J- 2 4 In prescribing individual remedies for diseases of chil- dren, the practitioner must not, however, be governed blindly by such a table as is here offered. In some in- stances it will be necessary for him to diminish the amounts, in others to increase them, although in very young children extreme caution will be required if the agent is very potent, as in the case of the opiates, anti- mony, etc. Some of the comparatively harmless reme- dies mentioned, such as syrupus rhei aromaticus, oleum ricini, mistura cretse, etc., may be given in rather larger doses than are here assigned to them, or than the ratio above given would seem to warrant. Children tolerate larger proportional doses, also, of the bromides, of quinia, belladonna, cod-liver oil, chlorate of potash, and other re- medies. The closes of opium, antimony, veratrum viride, etc., it will be seen, are decidedly smaller than the ratio there given. Very young children are not as susceptible to the action of mercurials as adults. As a general rule, 1 Dr. R 0. Cowling, Amer. Practitioner, July, 1872. 94 DOSES FOR CHILDREN. the quantities here mentioned are such as will bear repe- tition. After all, the good sense and discretion of the prescriber must in the case of children, even more guard- edly than in that of adults, direct him as to the appropri- ateness of a remedy, and the frequency of its employ- ment. Several years since the Pharmacopoeia of Guy's Hos- pital contained a schedule of a posological table, which forms a useful guide to attain the same end. The maxi- mum or full adult dose is taken as the point of departure for the doses to be given at all ages. The ratios do not correspond exactly with those just given for children, but approximate them sufficiently for all useful purposes:— Maximum dose. 1— One ounce, One drachm, One scruple, Age. 5j 5j 3j 1 month . gr. xxx gr. i'j gr-j 3 months gr. xxx gr. iv gr- j 6 " • gr. xl gr- vj gr- ij 9 " gr. xl gr. vij gr- ij 1 year 3J gr. viij gr- iij 2 years 3iss gr. x gr. iv 3 '< (f gr. xij gr. iv 4 " 3*J gr. xv gr. v 5 " Siiss gr. xviij gr- vj 6 " 3"J gr. xx gr. vij 7 " 5iiiss gr. xxv gr. viij 8 " gss 3ss gr. x 10 " 3ivss gr. xxxv gr. xij 12 " 3V gr. xl gr. xiv 13 " 5vss gr. xl gr. xv 15 " 3'j gr. xlv gr. xvj 18 " 3viss gr. xlv gr. xvij 20 " 3T'J gr. 1 gr. xviij 21 to 45 " c5J 3J gr. xx 50 " 3 vij gr. 1 gr. xviij 60 to 70 " 3?j gr. xlv gr. xvj 80 to 90 " 5^ gr. xl gr. xiv. 100 " 3SS 3ss gr. x DOSES FOR CHILDREN. 95 By way of illustration of the rules here laid down, the following examples, embracing the chief medicines prescribed for young children, may be cited. 'The average dose for the adult is first mentioned as a guide, deduc- tions being made from it to exhibit in a regular series the influence of age on the dose. As the remedies mentioned are such as are almost daily employed, the list will doubt- less be consulted frequently by the practitioner. It will save him the trouble of estimating for himself the quantity to be administered to infants and children, the calculations being carefully made in each instance. It will be ob- served that the ages mentioned range from infancy to four years. After the latter period, the practitioner can readily fix the dose from the data here given, and from comparison with the tables to be hereafter presented (see p. 80). As a rule, the remedies prescribed for young children are soluble in water or syrup, or readily miscible for administration in a palatable form. Should the practitioner desire to convert this table into the phraseology of the metric system, he must bear in mind that 1 gramme = 15.434 grains, that 1 fluidrachm = 3.7 grammes, and 1 minim = .06 grammes, or 6 centi- grammes.1 ! As already explained (p. 31), this varies with the tenuity, etc., of the fluid. 96 DOSES FOR CHILDREN. Doses for Young Children. Article. Adult Under One Two Four dose. one year. year. years. years. Acetum scillae f.3J gtt. iv gtt. vij gtt. X gtt. xvj Aciduin benzoicum gr. xx gr- j gr. iss gr. ivss gr. & gr. iv " carbolicum gr-j gr- ^ gr- tV gr. \ " hydrocyanicum g«. J dilutum gtt. iss gtt- tV gtt- * gtt.£ " nitricum dilutum gtt. X gtt. ss gtt. j gtt. iss gtt. iij " sulphuricum aro- maticum gtt. X gtt. ss 2tt. j gtt. iss gtt. iij either f3i gtt. vij gtt. xij gtt. XX gtt. xxx Alnmen1 gr. xx gr. j gr. ij gr- iij gr. iv Aloes .... Ammonii broniidum . gr. xv gr. | gr. M er. ij gr- iij " carbonas gr. xv gr- i gr- ii gr- ij gr- iij " chloridum . gr. xv gr-f gr- J5 gr- ij gr. iij Antimonii et potassi gr-i « 1 tartras2 (emetic) gr. ij „. 1 ?r- iff gr- i gr. k gr- -eV (diaphoretic) . gr- £ gr- jiff gr- TffU gr- ?V Antimonium sulphura- tum2 gr. ij gr- Tff gr- £ gr. } gr-4 Aqua campliorse . f^ss gtt. XV gtt. XX gtt. xxx f3j " cinnamomi f^ss gtt. XV gtt. XX gtt. xxx f3J " menthae piperitae f^ss gtt. XV gtt. XX gtt. xxx *5J Argeuti nitras gr. ss gr- iff gr- 2J gr- rV g'-- Tff Arsenici iodidum gr- Tff gr- riff g1'- Toff gr- -fa gr- h Assafcetida . ,gr. x gr. ss. gr-j gr. iss gr- ij Bismuthi subnitras gr. xv gr. 4 gr- jl gr- ij gr- iij Carbo ligni 3J gr- iij gr. v gr- vj gr. x Chloral gr. xv gr-i gr- j gr. iss gr- ij Chloroformum jgtt. X gtt. ss gtt-j gr. iss gr. iij Cinchonas pnlvis gr. xxx gr. iss gr. iiss gtt. ivss gtt- vj Creta praeparata . gr. xx g''. j gr- ij gr. ijss gr- iv Cupri sulphas .gr- 4 gr- tV gr- y? gr. Tff gr- T5 " " (emetic) gr. iij gr-£ gr- i gr-4 gr. § Creasoturn . . . gtt. j gtt. A gtt- T\ gtt. 4 ;g". \ Extractum belladonnas gr. \ gr. & gr- ^ gr- iff cr. j1.,- " cinchon33fluidum gtt. xx g«. j gtt. ij gtt. iij gtt. iv " ergotae fluidum . gtt. xx gr-j gtt. ij gtt. iij gtt. iv " nncis vomicae . gr. ss gr- Tff g''- 3i gr- ts ;gr- h " spigeliae et sennae fluidum fgss gtt. XV gtt. XX |f3ss f.-j 1 As an emetic in croup, alum has been given in teaspoonful doses to children. 2 Although the doses are here mentioned, antimonial preparations should not be given to the very young. DOSES FOR CHILDREN. 97 Doses for Young Children—Continued. Article. Adult Under One Two Four dose. one year. year. years. years. Ferri et ammonii citras gr. x gr. ss gr- j gr. iss g1'. ij " hypophosphis . gr. v nr- 4 gr. ss gr-t gr- j " et quiniae citras . gr- iij gr. *■ gr. ss gr- j gr. iss Ferrum redactum Hydrargyri chloridum gr. v gr. ss gr- j gr. iss gr. ij corrosivum1 gr- h gr- *ta gr- Tiff or ! B • lOff g'-. sff " chloridum mite — (purgative) . gr. x gr. ss gr- j gr. iss gr. ij (alterative) . gr- A gr- T5 gr- h gr- -ii gr- jff Hydrargyrum cum creta gr. x gr. ss gr- j gr. iss gr. ij Infusum digitalis f3U gtt. vj gtt. X gtt. XV gtt. xxv Jalapa gr. x gr. ss gr- j gr. ij gr- iij Liquor ammonii aceta- tis . f ;ss gtt. XV gtt. xxv gtt. xl >3J " calcis. 'ii I3S.S hi f3J f'3'j " ferri nitratis rrLx gtt. SS gtt. j gtt. iss gtt. ij " morphiae sulphatis f3J gtt. V gtt. X gtt. XV gtt. XX " potassii aisenitis *uj gtt, ss gtt. j gtt. iss gtt. ij Magnesia 9ij gr. ij gr. v gr. viij gr- xij Magnesiae carbonas 9ij gr. iij gr- vj gr. x gr. xv " sulphas §j gr. xxv gr. xl 3J giss Mistura assafoetidae f:;S9 gtt. XX gtt. xxx '3J f^iss " cretae f.^ss gtt. XX gtt. xxx f5.i t*3'j Morpliiae sulphas gr-i gr. j'o gr- io gr" s\ gr- A Oleuin chenopodii gtt. ij gtt. ij gtt. iv gtt. viij " morrhuae . f§33 utt. XV gtt. XX *3J f3Jss " ricini fcj f^ss f^ss *3J f3J " terebinthinae . Ttlx "ij "Ij mu "I'ij Opium2 gr- j gr. h gr- tV gr-£ gr. | Plumbi acetas gr. ij gr.TV gr-£ gr-i gr- 3 Potassii acetas -r. xl gr- U gr- 'ij gr. v gr. viij " bicarbonas gr. xxx gr. iss gr. iiss gr. iv gr- vj " bitartras 3'j gr. vj gr. x gr. xv gr. xxv " bromidum gr. xx %v. iss gr- iij gr. iv gr- vj " carbonas gr. xx gr- j gr. iss gr. iiss gr. iv " cliloras . gr. xx gr. j gr. iss gr. iiss gr. iv " t citras urr. xx gr. j gr. iss gr. iiss gr. iv " iodidum gr. v gr. \ gr-£ gr- j gr. iss Pnlvis ipecacuanbse compositus2 gr. x gr. ss gr- j gr. iss gr- ij Quinia5 sulphas (tonic) g'-. ij gr- Tff gr- £ gr \ or 1 . o' • 3 (antiperiodic) gr. xv gr. ij gr- iij gr- iij gr. iv 1 Young children have a certain amount of tolerance of mercurial preparations. 2 Opium must be prescribed with the utmost caution to young children. 7 98 DOSES FOR CHILDREN. Doses for Young Children—Continued. Article. Adult Under One Two Kour dose. one year. year. years. years. Rheum gr. x gr-i gr. i gr-j gr- ij Bantoninum gr. iij gr. ss gr. S3 gr. j gr. ij Scammonium gr- x gr. ss gr- j gr. iss gr. ij Senna 3J gr. iij gr. v gr. viij gr. xij Sodii bicarbonas . gr. xv gr. j gr. iss B1-- jJ gr. iij " bromidum . gr. xv gr. j gr. iss gr- ij gr. iij Spigelia 3ij gr. v gr- x gr. xv gr. xx Spiritus ammoniae aro- matic us f3J gtt. vj gtt. X gtt. XV gtt. XX " setheris nitrosi f3J gtt. X gtt. XV gtt. xxv gtt. xl Strychnia . gr- it gr- ih gr- tW gr. jh gr- Tffff Sulphur i'j gr. vj gr. x gr. xv gr. xxv Syrupus ferri iodidi . gtt. XX gtt. j gtt. ij gtt. iij gtt. iv " ipecacuanliae1 •3J gtt. V gtt. vij gtt. xij gtt. xviij " rhei aromaticns . l§ss gtt. XX gtt. xxx t'5ss f3J " sarsaparillae com- positus2 . f;ss gtt. XX gtt. xxx f^ss (3§ " scillae f3ss gtt. ij gtt. iv gtt. y] gtt. X " scillae compositus3 f3«s gtt- ij gtt. iv gtt. vj gtt. X Tinctura cainphorae gtt- xxx gtt. j gtt. ij gtt. iij gtt. v " digitalis gtt. X gtt. ss g". j gtt. iss gtt. ij " ferri chloridi gtt. XX g«. j gtt. iss gtt. ij gtt. iv " gentianae cornpos- ita . f3ij gtt. xij gtt. XX gtt. xxx gtt. xlv " hyoscyami. gtt. xl gtt. ij gtt. iij gtt. V gtt. viij " krameriae . f3J gtt. vj gtt. X gtt. XV gtt. xxv " nucis vomicae gtt. X gtt. ss gtt. j gtt. iss gtt. ij " opii4 . gtt. xxv gtt. ss git. j gtt. ij gr. iv " " camphorata t'3'j gtt. X gtt. xv gtt. xxv gtt. xl " " deodorata . gtt. XX gtt. ss gtt. j gtt. ij gtt. iv " veratri viridis5 . gtt. v gtt. { gtt. ss jgtt. j gtt. iss Vinum antimonii6 *3J gtt. iv gtt. vij gtt. xij . gtt. xviij " ipecacuanhas (emetic) f^ss gtt xxx f3J if 3.i f^iss Zinci oxidum gr. v gr- } gr. ss ,{?'•■ 1 gr. j " sulphas (emetic) gr. x gr. ss gr- j gr. iss gr- ij " " (tonic) . gr- j gr- sff gr- ti gr- £ Sv-l 1 To produce an emetic action the dose must be increased. 2 Chiefly employed as a vehicle. 3 See cautionary remarks under antimonii et potassii tartras. Lnrger doses than are here given are necessary if an emetic action be desired. * See opium for caution in regard to employment of opiates. 5 Veratrum viride should be prescribed to young children with ex- treme caution. 6 The doses are mentioned, Tjut antimonials should not be prescribed to very young children. DOSES BASED ON WEIGHT OF PATIENT. 99 Doses based on the Weight of the Patient. This method of calculating the dose is an unusual one, but it seems to respond tolerably accurately to the test of experiment. In a large number of cases, the results attained will be singularly in unison with those arrived at by the processes already alluded to for young people. As children, however, vary so much in size, and the inconvenience of guessing or of procuring the actual weight may be an obstacle in the way of extreme accu- racy of measurement of the dose, it is more desirable to adhere to the rules already laid down. As a matter of curiosity, it is well to kno.w that, according to this method of calculation, and allowing the average weight of the adult to be 150 pounds, for whom the proper dose is assumed to be 1, the dose of medicine, as a general rule, must be increased or diminished in the proportion of the patient's weight to that number of pounds, a pro- portion represented by a fraction whose numerator is the patient's weight and whose denominator is 150.1 If a child at birth weighs 6 pounds, the approximate dose for it would be t|-q- or -£■%. If it weighs 10 pounds, T}z\ or y1-. A child 2 years old, weighing 20 pounds, would re- quire T'-g^-, or about \ of an adult dose. A child 12 years old, weighing 75 pounds, would re- quire T7S%, or \ of an average dose. A person whose weight is 200 pounds should have yg-jf, or \\ of an average adult dose. The modifications of the average dose demanded by a patient's idiosyncrasy, disease, and other conditions than age or weight, are not, of course, met by this rule. 1 Prof. E. H. Clarke on A New Rule for Doses, Boston Med. and Surg. Journal, Sept. 26, 1872. 100 DOSES OF REMEDIES IN GENERAL. Doses of Remedies in General. In the following list are given the doses of several hundred articles of the Materia Medica. The table has been carefully arranged by the author, and will doubtless be found serviceable to the practitioner. Under the head of " Officinal Preparations," reference is made to the preparations of the U. S. Pharmacopoeia, of which the remedy is an important ingredient. (See Pharmacopoeial Groups) Under the heading "Approximate Metric Dose," is given as nearly as possible the dose of the remedy ac- cording to the metric system, corresponding, in each in- stance, with that given to it under the heading "Dose," according to the system in general use. The metric dose is given in grammes alone, the transposition of which into decigrammes, centigrammes, etc., may be readily made by the reader, if deemed desirable, according to the tables previously given. To avoid the apparent intricacy of the metric system, the approximate dose is alone mentioned. Thus absinthium is credited with a dose of 1.3 to 2.6 grammes, whereas the actual amount is 1.295 to 2.591 grammes. Usually this will be sufficiently explicit, except in the case of potent remedies, such as dio-italinum, where even minute fractions of a gramme would be of consequence. The gramme, it must be re- membered, is equal to 15.434 grains. Liquids are esti- mated according to the rule previously given (p. 31). When the dose of a remedy is not mentioned in the following table, the article is not prescribed alone in- ternally, but in some officinal preparation, or externally. The doses of Tinctures, Syrups, Extracts, Infusions, etc., will be found separately detailed under uPharmaco- pozial Groups." 1 1 Additional New Remedies will be found on p. 336. DOSES OF REMEDIES IN GENERAL. 101 Approximate Name. Dose. metric close. (Grammes.) Officinal preparations. Absinthium gr. xx-xl 1.3-2.6 Acacia Mucilagines, syr- Ac^tuin . f3J-iv 3.7-15.0 Aceta. [upi- Achillea .... gr. xxx 2.0 Ajidum arseniosum jrr 1 1 b1- ffff Tff .002-.006 u benzoicum . gr. x-xxx .65-2.0 Tincturae. (f carbolicum gr- j-ij .06-.13 Aquae, glycerita, ii bromoliydricum . f§ss 2.0 suppositoria, un- dilutum guenta. !< carbon icum Aquae. ii citricum gr. v-xxx .3-2.0 Syrupi. " gallicum gr. ij-v .13-.3 Glycerita. ii hydriodicum di- lutum TU. V-XXX .3-2.0 (I hydiocyanicum dilutum tnj-iss .05-.08 11 lacticum fgss-ij 2.0-7.5 " muriaticum nxv-x .3-. 6 " " dilutum nixx-xl 1.3-2.5 11 nitricum rnjj-v .1-.3 t< " dilutum ITLX-XX .6-1.3 " nitromuriaticum n\,ij-v .1-.3 ii '• dilutum 11\,X-XX .6-1.3 (I phosphoricum di- lutum nix-xl .6-2.5 (( salicylicum gr. v-x .3-.65 ii sulphuricum aro- maticum Ml X-XX .6-1.3 ii sulphuricum di- lutum ni x-xx .6-1.3 ii sulphurosum f3J •3.75 ii tannicum . gr- £-irj .02-.2 Glycerita, supposi-toria, trochisci, unguenta. fi tartaricum 3j-ij 4.0-8.0 Pulveres. ii valerianicnm n\v .3 Aconiti folia . gr- j-ij .06-.13 Extracta. « radix . Emplastra, lini-menta, tincturae. Aconilia . gr- To"o~ffff .0006-.001 ^Ether t'3sH 1.7-3.4 Spiritus. Aletris gr. x .65 Allium .... 3ss-ij 2.0-8.0 Syrupi. Aloe i gr. iij-xv .2-1.0 Pilulse, pulveres, suppositoria, tinc-turae, vina. Aloin . gr. ij-iv .13-.26 Alumen . ! gr. x-xx .65-1.3 102 DOSES OF REMEDIES IN GENERAL. Approximate Name. Dose. metric close. Officinal (Grammes.) preparations. Aluminii et potassii sul- 1 phas .... gr. x-xx .65-1.3 Ammonia Aquae, linimenta, spiritus, tincturae. Ammoniacum . gr. x-xxx .65-2.0 Einplastra, uiis-turae. Ammonii acetas Liquores. " benzoas gr. x-xxx .65-2.0 " bromidum gr. v-xx .3-1.3 " carbazotas gr- j-ij .06-.13 '' carbonas . gr. v-xx .3-1.3 Spiritus. " chloridum gr. v-xxx .3-2.0 " iodidum . gr. j-iij .06-.2 " phosphas . gr. x-xxx .65-2.0 " valerianas gr. ij-x .13-.65 [guenta. Amygdala amara Aquae, syrupi, un- " dulcis Misturae, syrupi. Amyl nitris g". ij-iij .1-.2 Anethi fructus gr. xv-lx 1.0-4.0 Angustura gr. x-xxx .65-2.0 Infusa. Anisum .... gr. xx-xxx 1.3-2.0 Aquae, olea, spiri-tus. Anthemis gr. xxx-lx 2.0-4.0 Infusa. Antimonii et potassii tar- Emplastra, syrupi, tras .... gr- Tff-J .006-.06 unguenta, vina. Antimonii snlphuretnm . gr. ij-x .13-.65 Antimonium sulphuratum gr- i-ij .06-.1 Pilulae. (Emetic dose, gr. v-xx.) Apiol .... gr. ij-v .13-.3 Apocynum androsaemifo- lium .... gr. x -xx .65-1.3 Apocynum cannabinum . gr. v-x .3-.65 Aqua .... Aquae. Aralia nudicaulis gr. xxx 2.o" " spinosa gr. xx-xxx 1.3-2.0 Argenti nitras gr- i-j • 02-.06 " oxidum gr. ss-j .03-.06 Armoracia gr. xxx 2.0 Extracta, emplas-tra, tincturae. Arnica .... gr. v-xx .3-1.3 Liquores. Arsenici iodidum gr- tV .006 Liquores. Arum .... gr. x .65 Asarum .... gr. xx-xxx 1.3-2.0 Asclepias ... gr. xx-lx 1.3-4.0 Assafcetida gr. x .65 Emplastra, mistu-rae, pilula?, sup-positoria, tinc-turae. DOSES OF REMEDIES IN GENERAL. 103 Approximate Name. Dose. metric close. Officinal (Grammes.) preparations. Atropia . . - . &'• CO 30 .001-.002 Atropiae sulphas err -1___1_ a1- ffo 30 .001-.002 Aurautii cortex Confecticnes, syrupi, tinctura?. " flores Aquae, syrupi. Auri cyanidum o-r -i__i .004-008. " iodidum . £1- -1—V .005-.02 Balsainum Peruvianum . f^ss-i 2.5-5.0 " tolutanum gr. x-xxv .65-1.6 Barii chloridum Liquores. Belladonuae folia gr- j-ij .06-.13 Extracta, tincturae, unguenta. radix . Einplastra, sup-positoria. Benzoinum gr. x-xxx .65-2.0 Tincturae, unguen- Bismuthi subcarbonas gr. v-xx .3-1.3 [ta. " subnitras gr. v-xx .3-1.3 " valerianas gr. ss-ij .03-.13 Brayera .... 15.5 Buchu .... gr. xx-xxx 1.3-2.0 Extracta, infusa. Calfeina . g'-. j-ij .06-.13 Calamus .... gr. xx-xl 1.3-2.6 Calcii carbonas praecipi- tata .... gr. x-lx .65-4.0 Calcii chloridum Liquores. " hypophosphis gr. x-xxx .65-2.0 " lactophosphas gr. xx-xl 1.3-2.6 Calumbo gr. x-xxx .65-2.0 Extracta, infusa, tincturae. Calx .... Liquores, linimen- " chlorinata gr. ij-v •13-.3 [ta. Camphora gr. iij-xx .2-1.3 Aquae, linimenta, spiritus, tincturae. " monobromata . gr. ij-v .13-.3 Canella . . . • gr. x-xxx .65-2.0 Pulveres. Cannabis Americana Extracta. ■' Indica Extracta, tincturae. Cantharis gr- j-ij .06-.13 Extracta, cerata, chartae, collodiura, linimenta, tinctu-rae, unguenta. Capsicum gr. v-x .3-.65 Infusa, oleoresinae, Carbo animalis purincata gr- j-v .06-.3 [tincturae. " ligni Cardamomum . 3J~iv 4.0-15.5 Pulveres, tincturae. Carum .... gr. xx-xl 1.3-2.6 Olea, tincturae. Caryophyllum Cascarilla gr. xx-xxx 1.3-2.0 Infusa, olea. Infusa. 104 DOSES OF REMEDIES IN GENERAL. Name. Cassia fistula . " Marilandica Castanea Castoreuin Catechu . Cataria . Cerii oxalas Cetaceum Cetraria . Chenopodium Chimaphila Chiretta . Chloral . Chlorinium Chloroformum purificatum Cimicifuga Cinchona Cinchoniae sulphas . Cinchonidiae sulphas Cinnamomum . Coccus Codeia Colchici radix . " semen Colocynthis Conii folia " fructus " succus Copaiba . Coptis Coriandrum Cornus circinata " Florida " sericea Creasotum Creta praeparata Crocus Croton chloral Cubeba . Dose. 3J-IJ ^ss-iij 3SH gr. x-xxv gr. 3ij gr- x-xxx j-ij gr. xxx-lx gr- xx-xl gr-gr- XX x-xl gtt . x-xx gr. xx-lx gr. xv-lx gr-gr-gr- j-x j-v x-xx gr. j-ij Approximate metric close. (Grammes.) gr- ij-vj gr- ij-vj gr. v-x gr. iij-v rn^xxx-lx gtt. xx-f3j gr. x-xxx gr. xx-lx gr. xx-lx gr. xx-lx gr. xx-lx "Ij gr. x-xl gr. x-xxx gr. v-xv gr- x-3ij 4.0-31.0 2.0-12.0 2.0-4.0 .65-1.6 .65-2.0 8.0 .06-.13 2.0-4.0 1.3-2.6 1.3 .65-2.6 .8-1.6 1.3-4.0 1.0-4.0 .06-.65 .06-.3 .65-1.3 .06-. 13 .13-.4 .13-.4 .3-.65 .2-. 3 1.7-3.4 1.25-3.75 .65-2.0 1.3-4.0 1.3-4.0 1.3-4.0 1.3-4.0 .06 .65-2.6 .65-2.0 .3-1.0 .65-8.0 Officinal preparations Tincturae. Infusa, tinctuiae. Cerata. Decocta. Olea. Decocta, extracta. Aquae. Linimenta, mistu- rae, spiritus. Extracta. Decocta, extracta, infusa, tincturae. Aquae, pulveres, spiritus, tincturae. Tincturae. Extracta, vina. Extracta, tincturae, vina. Extracta, pilulae. Extracta, tincturae. Extracta. Olea, pilulae. Decocta, extracta. Aquae, unguenta. Mi.sturae, trochisci. Extracta, olea, oleo> resinae, tincturae, trochisci. DOSES OF REMEDIES IN GENERAL. 105 Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Cupri sulphas gr. i-ss .O16-.03 (Emetic dose, gr. ij-v.) Cuprum ammoniatum gr. l-ss .016-.03 Cypripedium . gr. xv. 1.0 Daturia .... gr> Toff-oiT .0006-.0013 Digitalis .... gr-j .06 Extracta, infusa, tincturae. Digitalinum B1 • 60 30 .001-.002 Dracontiura gr. x-xx .65-1.3 Dulcamara gr. xxx-3j 2.0-4.0 Decocta, extracta. Elaterin .... gr- tWj .004-.005 Elaterium gr- i-i •016-.03 " Clutterbuck's . gr- »■ .008 Emetia .... gr- tW .005-.01 Ergota .... gr. xx-3j 1.3-4.0 Extracta, vina. Ergotina .... gr- j-ij .06-.13 Erigeron Canadense gr. xxx-5j 2.0-4.0 Extracta, olea. Eucalyptus gr. xxx-gj 2.0-4.0 Eupatorium gr. xx-xxx 1.3-2.0 Infusa. Euphorbia corollata gr. iij-x .2-.65 ipecacuanha . gr. x-xv .65-1.0 Ferri arsenias . gr- xs- .004 " et ammonii citras •. gr. v-x .3-.65 " " sulphas gr. iij-xij .2-.8 " " tartras . gr. x-xxx .65-2.0 " carbonas gr. v-xxx .3-2.0 Liquores, misturae, " bromidum gr. v-xx .3-1.3 pilulae. " chloridum gr. x-xx .65-1.3 Liquores, tincturae. " citras . . . gr. v-xx .3-1.3 Liquores. " ferrocyanidum gr. iij-v .2-. 3 " hypophosphis gr. ij-x .13-.65 Syrupi. " iodidum . gr. j-viij .06-.5 " lactas gr. ij-x .13-.65 " nitras . . Liquores. " oxalas gr. ij-v .13-. 3 " oxidum hydratuui . gr. v-xx .3-1.3 " phosphas gr. v-x .3-.65 " et potassii tartras . gr. x-xxx .65-2.0 " pyrophosphas gr- ij-vj .13-.4 " et quiniae citras gr. v-xv .3-1.0 Einplastra, tro-chisci. " subcarbonas . gr. v-xx .3-1.3 Liquores, misturae. " sulphas . gr- j-v .06-.3 " exsiccata gr. j-iv .06-.26 Pilulae. ?errum .... Pilulae. " redactum . gr. ij-x .13^.65 ?ilix mas 3j-i'j 4.0-12.0 Oleoresinae. ^ceniculum gr. xx-xxx 1.3-2.0 Aquae, olea. 106 DOSES OF REMEDIES IN GENERAL. Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Frasera . ... gr. xxx-3j 2.0-4.0 Galbauum gr. x-xx .65-1.3 Emplastra, pilulae. Galla gr. x-xx .65-1.3 Tincturae, unguen-ta. Pilulae. Garabogia gr. ij-vj .13-.4 Gaultheria Olea. Gelsemium gr. ij-iij .13-. 2 Extracta. Gentiana gr. x-xl .65-2.6 Extracta, infusa, " Catesbaei gr. xv-xxx 1.0-2.0 [tincturae. Geranium gr. xx-xxx 1.3-2.0 Extracta. Geuin gr. xx-gj 1.3-4.0 Gillenia . gr. xx-xxx 1.3-2.0 Glycerina i'5J 5.0 jrlycerita. Glycyrrhiza Extracta, misturae, trochisci. Gossypii radicis cortex . Extracta. Granati fructus cortex gr. xx-xxx 1.3-2.0 '' radicis cortex gr. xx-xxx 1.3-2.0 Guaiaci lignum Pilulae, tinctuiae. " resina . gr. x-xxx .65-2.0 Guarana . gr. xxx-5J 2.0-4.0 Gutta percha . Liquores. Haematoxylon Decocta, extracta. Hedeoma Olea. Heliauthemum 3.1—ij 4.0-8.0 Helleborus gr. iij-xx .2-1.3 Extracta, tincturae. Heuchera gr. v-xx .3-1.3 Hordeum Decocta. Humulus gr. iij-xx .2-1.3 Infusa, tincturae. Hydrargyri chloridum cor- rosivum gr- TW .004-.008 " chloridum mite gr. ss-x .03-.65 Pilulae. " cyanidum gr- tW .004-.016 [ta. " iodidum rubrum . gr- tW .004-.016 Liquores, unguen- " " viride gr- j-iij .06-.2 [ta. " nitras Liquores, unguen- " oxidum fiavum Un guenta. " " rubrum Unguenta. " sulphas flava gr- i-v .016-.3 " sulphuretnm ru- brum gr. v-xxx .3-2.0 Hydrargyrum . Emplastra, pilulae unguenta. " ammoniatum . Ungenta. " cum creta gr. iij-xv .2-1.0 Hydrastis Extracta. Hyoscyami folia gr. v-x .3-.65 Extracta, tincturae. " semen gr. ij-v .13-.3 DOSES OF REMEDIES IN GENERAL. 107 Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Ignatia .... Extracta. Inula .... gr. xx-3j 1.3-4.0 Iodinium Liquores, pilulae, tincturae, unguen-ta. Iodoformuni gr- j-v .06-.3 Ipecacuanha . gr- j-v .06-.3 (Emetic dose, gr. xx-xxx.). Extrac-ta, pulveres, syr-upi, trochisci, vina. Iris versicolor . gr. x-xx .65-1.3 Jalapa .... gr. x-xx .65-1.3 Extracta, pilulae, Jaborandi gr. xl-1 2.6-3.3 pulveres, tinc-turae. Juglans .... gr. x-xxx .65-2.0 Extracta. Jnniperus 3 j-ij 4.0-S.O Infusa, olea, spiri-tus. Kameela .... 3J-iiJ 4.0-12.0 Kino .... gr. x-xxx .65-2.0 Tincturae. Krameria gr. xx-xxx 1.3-2.0 Extracta, infusa, syrupi, tincturae. Lactucarium . gr. v-xv .3-1.0 Syrupi. Lappa .... 3J 4.0 Lavandula Olea, spiritus. Leptandra gr. xx-3j 1.3-4.0 Limon .... Spiritus, syrupi. Linum .... Infusa. Liriodendron . 5ss-ij 2.0-8.0 Lithii carbonas gr. iij-vj .2-.4 " citras • » • gr. v-x .3-.65 Lobelia .... gr. v-xx .3-1.3 Aceta, tincturae. Lupulina gr. v-x .3-.65 Extracta, oleores-inae, tincturae. Magnesia gr. xx-3j 1.3-4.0 Pulveres, trochisci. Magnesii carbonas . gr. xxx-3ij 2.0-8.0 " citras Liquores. " sulphas §ss-j 15.5-31.0 Magnolia gr. xxx-3j 2.0-4.0 Manganesii oxidum ni- grum gr. iij-xx .2-1.3 " sulphas gr. v-xx .3-1.3 Manna .... SHJ 31.0-62.0 Marrubium gr. xxx-3J 2.0-4.0 Mastiche Pilulae. Matico .... gr. xxx-3ij 2.0-8.0 Extracta. Matricaria gr. xxs-3J 2.0-4.0 Mel rosae Mellita. 108 DOSES OF REMEDIES IN GENERAL. Name. Mentha piperita " viridis Mezereum Monarda Morphias acetas " murias " sulphas Moschus . Myristica Myrrha . Narceia . Nectandra Nux vomica Oleum asthereum " amygdalae amarae " cajuputi " chenopodii . " morrhuae " olivae . " origani " pimentae " ricini . " rosmariui " sesami . " succini rectifica turn . " terebinthinae " tiglii . Opium Origanum Pareira . Pepsina . Phosphorus Physostigma . Phytolaccae radix Pimenta . Piper Piperina . Pix Burgundica gr. x „r J,_i. gr- i-£ gr. x-xx gr. x-xxx gr- j-ij gr. ij-v gr. v "U4 Rj-iij nil ij-vj f'3ij-iv t§j "l.j-v TTlij-v fS'J-fJiss TTI ij-v f3ij-iv rn^v-x m,v-fgss gr- j-ij gr. xxx-3j gr. v-x gr- -Wo gr- ij gr. ij-xxx gr. x-xl gr. v-xx gr- j-vj Approximate metric dose. (Grammes.) .65 .008-.03 .008-.03 .008-.03 .65-1.3 .65-2.0 .06-.13 .13-.3 .3 .015-.03 .06-.18' .18-.36 7.5-15.0 30.0 .06-.3 •12-.3 7.5-45.0 .12-.3 7.5-15.0 .3-. 6 .3-15.0 .06 .06-.13 2.0-4.0 .3-.6 .0013-.002 .13 .13-2.0 .6-2.6 .3-1.3 .06-.4 Officinal preparations. Aquae, olea, spiri- tus, trochisci. Aquae, olea, spiri- tus. Extracta, unguen- ta. Olea. Liquores, supposi- toria, trochisci. Pulveres. Pilulae, tincturae. Extracta, tincturae. Spiritus. Aceta, extracta, confectiones, em- plastra, pilulae, pulveres, supp»s- itoria, tincturae. trochisci, vina. Olea. Extracta, infusa. Extracta,. Olea. Oleoresinae. Emplastra. DOSES OF REMEDIES IN GENERAL. 109 Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Pix Canadensis Emplastra. " liquida Glycerita, unguenta infusa Pluinbi acetas gr- j-iij .06-.2 Suppositoria. " carbonas Unguenta. " iodidum §r- HJ .016-.13 Unguenta. " subacetas . Cerata, linimenta, liquores. " oxidum Emplastra. Podophyllinum gr- H .008-.06 Podophyllum . gr. xx 1.3 Extracta. Potassa .... Liquores. Potassii acetas 3J-i* 4.0-15.5 '" arsenis Liquores. " bichromas . er -1-3-B1, 4 4 .016-.05 " bicarbonas gr. x-3j .65-4.0 " bitartras ?;j-3ss 4.0-16.0 Pulveres. " bromidum . gr. v-xx .3-1.3 " carbonas gr. x-xxx .65-2.0 " " pura gr. x-xxx .65-2.0 '" chloras gr. xv-xxx 1.0-2.0 Trochisci. " citras gr. xx-xxx 1.3-2.0 Liquores, misturae. " cyanidum . gr. i .008 '• ferrocyanidum . gr. x-xv. .65-1.0 " hypophosphis gr. x-xxx .65-2.0 " iodidum gr. v-xv .3-1.0 Tincturae, unguen- " nitras gr. x-xxx .65-2.0 [ta. " permanganas Liquores. " et sodii tartras . §ss-j 15.5-31.0 Pulveres. " sulphas Sss-gss 2.0-15.5 Pulveres. " sulphis gr. xx-3j 1.3-4.0 " sulphuretum gr. iij-x .2-.65 " tartras 3J-3J 4.0-31.0 Prinos .... gr. xxx-3j 2.0-4.0 Prunus Virginiana . gr. xxx-3j 2.0-4.0 Extracta, syrupi. infusa, Pyrethrum gr. xxx-^j 2.0-4.0 Quassia .... gr. xx-3j 1.3-4.0 Extracta, tincturae. infusa, Quercus alba . gr. xxx-^j 2.0-4.0 Decocta. " tinctoria gr. xxx-gj 2.0-4.0 Quiniae sulphas gr. ij-xv .13-1.0 Pilulae. " valerianas . gr- j-iij •06-.2 Resina .... Cerata, en resinae. plastra, " jalapae . gr. iv-viij .26-.5 " podophylli . gr- H .008-.06 110 DOSES OF REMEDIES IN GENERAL. Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Rheum .... gr. v-xx .3-1.3 Extracta, infusa, pilulae, pulveres, syrupi, tincturae, viiia. Rosmarinum . Olea. Rosa .... ' ..... Aquae, infusa, con-fectiones, mellita, syrupi, unguenta. Rubia .... gr. xxx. 2.0 Rubus .... gr. xx-xxx 1.3-2.0 Extracta, syrupi. Rumex .... oj-ij 4.0-8.0 Ruta .... gr. xv-xxx 1.0-2.0 Olea. Sabadilla gr. v-xx .3-1.3 Sabbatia .... gr. xxx-5j 2.0-4.0 Sabina .... gr. v-xv .3-1.0 Extracta, cerata, olea. Saccharum Syrupi. Salicina .... gr. ij-v iij •13-.5 Ralix .... gr. xv-3j 1.0-4.0 Salvia .... gr. xx-xxx 1.3-2.0 Infusa. Sanibucus 3J-.5SS 4.0-15.5 Sanguinaria gr. x-xx .65-1.3 Aceta, tincturae. Santonica gr. x-xxx .65-2.0 Santoninum gr. ij-iv .13-.26 Trochisci. Sapo .... Cerata, emplastra, linimenta, pilnla?. Sarsaparilla gr. xxx 2.0 Decocta, extracta, syrupi. Sassafras Mucilagines. olea. Scammonium . gr. v-ax .3-1.3 Scilla .... gr- j-iij .06-.2 Aceta, extracta, pi-lulae, syrupi, tinc-turae. Scoparius gr. x-xv .65-1.0 Scutellaria gr. xxx 3j 2.0-4.0 Senega .... gr. x-xx .65-1.3 Decocta, extracta, syrupi. Senna .... gr. xxx-3ij 2.0-8.0 Extracta, infusa, confectiones, syr-upi, tincturae. Serpentaria gr. x-x::x .65-2.0 Extracta, infusa, tincturae. Simaruba gr. xx-3j 1.3-4.0 Sinapis alba . 5j 4.0 " nigra . 3J 4.0 Chartse. Soda .... Liquores. " chlorinata Liquores. Sodii acetas gr. xx-^ij 1.3-8.0 DOSES OF REMEDIES IN GENERAL. Ill Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Sodii arsenias err i -i b1- 12 4 .005-.016 Liquores. " bicarbonas gr- x-3J .65-4.0 Pulveres, trochisci. " boras gr. xxx-xl 2.0-2.6 Glycerita, mellita. " carbonas gr. x-xxx .65-2.0 Pilulae. " " exsiccata . gr. v-xv .3-1.0 " chloridum gr- xx-gj 1.3-31.0 " hypophosphis gr. x-xxx .65-2.0 " hyposulphis . gr. x-xx .65-1.3 " nitras gr. x-xxx .65-2.0 " phosphas gr. xxx-gj 2.0-31.0 " sulphas . 3** Si 15.5-31.0 " sulphis . gr. x-3j .65-4.0 " salicylas gr- xv-3j 10-4.0 Spigelia .... 3J"iJ 4.0-8.0 Extracta, infusa. Spiraea .... gr. v-xv .3-1.0 Statice .... gr. x-xxx .65-2.0 Stillingia gr. xv-xxx 1.0-2.0 Extracta. Stramonii folia gr- ij .13 Extracta. " semen gr- j .06 Extracta, tincturae, unguenta. Strychnia gr. j—12 .0O2-.005 Strychniae sulphas . er _i___i_ o1- 3 2 12 .002-.005 Styrax .... gr. x-xx .65-1.3 Succinum Olea. Sulphur lotum 3J-iiJ 4.0-12.0 " praecipitatiun 3.HU 4.0-12.0 " sublimatum 3j-iij 4.0-12.0 Unguenta. Sulphuris iodidum . gr- sWff .003-.006 Unguenta. Tabacum Olea, unguenta, vina. Tanacetum gr. xxx-^j 2.0-4.0 Taraxaci succus i3'J-iv 8.0-15.5 Taraxacum Extracta, infusa. Terebinthina . gr- xx -3j 1.3-4.0 Collodium, lini- , menta. Testa praeparata gr. x-s;j .65-4.0 Theina .... gr- j-iij .06-.2 Tolu .... Syrupi, tinctura?. Tormentilla gr. xxx-^j 2.0-4.0 Toxicodendron gr- ss-j .03-.06 Tragacantha . Mucilagines. Triosteum gr. xx-xxx 1.3-2.0 Ulmus .... Mucilagines. Uva ursi .... gr. xx-^j 1.3-4.0 Decocta, extracta. Valeriana gr. xxx-3iss 2.0-6.0 Extracta, infusa, olea, tincturae. Veratria .... gr- tW .004-.008 Unguenta. Veratrum album gr- j -ij .06-.13 112 MAXIMUM DOSES. Approximate Name. Dose. metric dose. Officinal (Grammes.) preparations. Veratrum viride gr-j .06 Extracta, tincturae. Xauthorrhiza . gr. xx-xl 1.3-2.6 Xanthoxylum gr. x-xxx .65-2.0 Zinci acetas gr. Jj-iv .13-.26 " carbonas praecipitata Cerata. " chloridum gr- J .06 Liquores. " oxidum . gr. ij-x .13-. 65 Unguenta. " sulphas . gr- J-iJ .06-.13 (Emetic dose, gr. x-xxx.) " valerianas gr. j-ij .06-.13 Zingiber .... gr. x-xx .65-1.3 Extracta, infusa, oleoresinae, pul-veres, syrupi, tincturae, troch-isci. Maximum Doses. The following table, based on that of the Pharmacopoeia Germanica,1 exhibits the maximum doses of the potent remedial agents mentioned, and beyond which physicians in Germany are not allowed to prescribe unless they add the caution mark (!), thereby indicating that such a large dose is intentionally ordered.2 It must not be forgotten that maximum doses are exceptional ones, not to be pre- scribed without due consideration, as they are generally beyond the ordinary doses to which the practitioner is accustomed. * The table, is arranged in grammes, and their equiva- lent in grains,\)r, in the case of liquids, in minims, etc.:— 1 Dr. Hermann Hager, Commentar zur Pharmacopoeia Germanica, Ber- lin, 1874, ii. 910. 2 Dorvault, IJOfficine, cites a slightly different maximum dose for some of the agents named. It will be noticed that the German doses MAXIMUM DOSES. 113 Total maximum Maximum s ngle dose. dose in 24 hours. Grammes. Grains. Grammes. Grains. Acetum colchici . 2.0 n\,30 6.0 tt\96 Acidum arseniosum . 0.005 i 1 3 0.01 i 6' " carbolicum (crystal.) . 0.05 4 0.15 2} " hydrocyanicum dilnt im . 0.05 m,i 0.20 ni4 Aconitum . 0.004 i 0.03 13 Ammonii bromidum . 3.0 45 10.0 154 " iodidum . 0.5 H 2.5 38.5 Antimonii et potassii tartras . 0.2 3 1.0 15 Apomorphiae murias . 0.015 i 4 0.05 .i i Aqua amygdalae amarae . . 2.0 "130 7.0 m„i05 Argenti nitras . 0.03 6 T3 0.2 3 Arsenici iodidum . . 0.02 1 3 0.05 4 . 0.001 & 0.003 l 2 2 Atropiae sulphas . 0.001 1 0.0.3 1 2 2" Auri et sodii chloridum . . 0.06 9 Tff 0.2 3 Barii chloridum . 0.12 n 1.5 23 Belladonna? folia . . 0.2 3 0.6 9 " radix . . 0.1 H 0.4 6 Bismuthi subnitras . 0.3 4A 1.5 23 are in a number of instances larger than those given by the French authority. Aqua laurocerasi Argenti nitras . Belladonnae radix (pulv.) Colocynthis Digitalis folia Hydrargyri cyanidum Hyoscyami folia Nux vomica Opium Phosphorus Potassii arsenias Potassii cyanidum Scillae radix Sodii arsenias Toxicodendron Veratria Zinci sulphas 8 Grammes. Grains . 2.00 n\,30 . 0.02 i . 0.15 21 . 0.10 1* . 0.20 3 . 0.02 i i . 0.20 3 . 0.10 H . 0.05 3 4 . 0.01 1 ff . 0.005 1 T.T . 0.03 6 T:( . 0.20 3 . 0.005 i T7 . 0.30 H . 0.01 i . 0.1a 2} 114 MAXIMUM DOSES. Total maximum Maximum s ingle dose. dose in 21 hours. Grammes. Grains. Grammes. Grains. Brucia . . 0.1 1* 0.3 4Z Caffeina . . 0.15 2* 0.6 9 Cantharides . . 0.05 a 4 0.15 2i . 4.0 61 8.0 123 Codeinum . 0.05 a 4 0.1 ii Colchicia . 0.005 i T3 0.02 i 3 . 0.001 1 0.003 1 2J Conii herba . 0.3 4£ 2.0 30 Creasotum . 0.05 nil 0.2 ni4 Croton chloral . 1.5 23 5.0 77 Cupri acetas . . 0.1 ii 0.4 6 " sulphas . 0.1 H 0.4 6 " " in divided doaerf as an emetic . . 1.0 15 Cupri et ammonii sulphas . . 0.1 4 0.4 6 Digitalinum . . 0.O05 i 13 0.02 i ff Digitalis folia . 0.3 4i 1.0 15 Ferri iodidum . 0.5 74 3.0 45 Hellebori viridis radix . 0.3 4£ 1.2 18 Hydrargyri cyanidum . 0.02 i 3 0.06 9 IU " chloridum corrosivum . 0.03 6 T3~ 0.1 n " iodidum rub rum . . 0.03 A 0.1 n " " viri ie (flavum) 0.06 9 Tff 0.4 6 " oxidum nigrum . . 0.25 3| 1.0 15 " " rub •urn . .0.03 6 Tff 0.1 n Hyoscyami folia . 0.3 4-t 1.0 15 " semen . 0.3 H 1.2 18 Iodoformum . . 0.3 4i 1.5 23 Lactucarium . . 0.03 6 Tff 1.2 18 Liquor potassii arsenitis . 0.4 Ttl7 2.0 "130 . 0.03 6 Tff 0.12 If Morphiae acetas . 0.03 6 13 0.12 1! " murias . 0.03 6 Tff 0.12 If " sulphas . 0.03 6 Tff 0.12 If Oleum tiglii . . 0.06 nil 0.3 rci4 H 0.5 7-1-'2 Phosphorus . . 0.015 i 4 0.06 9 Tff Plumbi acetas . 0.06 9 Tff 0.4 6 MAXIMUM DOSES. 115 Total maximum Podophyllinum Potassii bromidum " iodidum . Resina jalapae " scammonii. Sabadillae fructus . Santoninum . Stramonii folia " semen . Strychnia1 Strychniae nitras' Syrupus ferri iodidi Toxicodendri folia . Veratri rhizoma Veratria Vinum colchici Zinci acetas . " chloridum " lactas " sulphas . " " in divided an emetic " valeriauas Having thus studied the doses of the various remedial articles in the practitioner's armamentarium, as usually administered through the channel of the stomach, we are now prepared to examine into the posological features characteristic of the same agents when administered through other surfaces or media, such as the skin, air- passages, rectum, vagina, uterus, and urethra, including a reference also to certain local applications, as gargles, eye-washes, etc. These topics will be discussed in con- tinuation of the general subject of Doses. 1 The doses of strychnia and its nitrate seem unusual and excessive (see table of doses, page 90). Maximum single dos ,--------------------x----------------- Grammes. Grains. • 0.1 1$ . 5.0 77 . 2.0 30 . 1.0 15 . 1.0 15 . 0.25 33 • 0.1 1£ . 0.25 3^ . 0.25 3| • 0.01 i . 0.01 ^ . 7.5 rT\,90 . 0.4 6 . 0.3 4£ . 0.005 A . 2.0 ff\,30 . 1.5 23 . 0.015 ^ . 0.06 T% . 0.06 T^ as . 1.2 18 . 0.06 A dose in 24 hours, Grammes. Grains. 0.5 n 15.0 231 8.0 123 3.0 45 3.0 45 1.0 15 0.5 7i 1.0 15 1.0 15 0.03 6 Tff 0.03 6 Tff 30.0 360 1.2 18 1.2 18 ' 0.03 6 T3 6.0 TT[90 3.0 46 0.1 ii 0.3 4i 0.3 4J 0.3 U 116 DOSES FOR SUBCUTANEOUS INJECTIONS. Doses of Medicines administered Hypodermically The severity of the symptoms must be the main guide to the practitioner as to the quantity of the remedial agent he may desire to administer by subcutaneous in' jection. It is expedient, however, that he should be familiar with the doses given by this channel. As a general rule, and when not otherwise mentioned, distilled water is the menstruum employed, and extreme care should be taken that the solution is perfect, free from foreign or irritating substances, neither acid nor alkaline, prepared by the practitioner himself, fresh when used, and filtered. Dr. Joseph G. Eichardson1 has proposed the employment of salicylic acid for the prevention of fungous growths in solutions for hypodermic medication, especially those containing morphia. The chief articles administered in this way are arsenic, atropia, cafFein, conia, ergotine, hydrocyanic acid, mer- curial preparations, morphia, nicotia, physostigma, qui- nia, and strychnia.2 [See also p. 327.] Absenic.—The liquor sodii arseniatis is less irritating than Fowler's eolution; five, ten, or fifteen minims may be injected every alternate day. Arsenious acid has been injected in solution in doses of one to two centigrammes (gr. g-J) with good results. Atropia, Sulphate of.—The following strengths of solutions have been employed: gr. % to f3j, of which u\ v = gr- ?g I gr- ss to f5j, of which "I iiss = gr. ,'g ; gr. j to f3j, of which "lj= gr. ^ 1 N. Y. Medical Record, Sept. 30, 1876. 2 Roberts Bartholow, Manual of Hypodermic Medication, 2d edit., Philada., 1873 ; from which work many of the doses and formulae of the various articles are quoted, and to which the reader is referred for their numerous therapeutic applications. DOSES FOR SUBCUTANEOUS INJECTIONS. 117 A safe subcutaneous dose of sulphate of atropia is gr. ^g. Children are less susceptible than adults, men than women. Atropia and morphia are often given together on account of their antagonistic toxical effects. (See Morphia.) Caffein.—The subcutaneous dose is gr. j, which may be administered as follows :— R. Caffeinse purae, gr. vj ; Spiritus vini rectificati, Aquas destillatae, aa f'5j.—M. Of this solution, "l xx = gr. j, the proper dose. Or the citrate of caffein gr. j may be added to gtt. xxiv of pure glycerine. Conia.—The following formula has been proposed:— R. Coniae, gr. j ; Spiritus vini rectificati, f 3ss; Aquae destillatae, f3iss.—M. Of this solution "ij = gr. T£s, and the hypodermic dose would be "I j-ij. The solution decomposes easily, and should therefore be freshly prepared. Ejrgotix.—This substance may be administered sub- cutaneously as follows:— R. Ergotinae, gr. ij ; Spiritus vini rectificati, Glyceri nae purse, aa f3ss.—M. Of this solution, "Iv =gr. \. A less irritating solution may be made by adding to 3 parts of ergotin, 7.5 parts each of glycerine and dis- tilled water. Hydrocyanic acid (dilute).—A safe dose is "iij, which should not, as a rule, be exceeded. 118 DOSES FOR SUBCUTANEOUS INJECTIONS. Mercury.—Soluble preparations are alone used. Corrosive sublimate is administered in the proportion of a grain to the ounce of distilled water, of which solution, "i x = gr. Vg, a safe and usually sufficient dose. Or, according to Liegeois :l— R. Hydrargyri chloridi corrosivi, gr. iij ; Morphias sulphatis, gr. iss; Aquas destillatae, f'iiij.—M. Of this solution, k\ xv = gr. 3]5, an appropriate quan- tity for a single injection. It may also be given in an unirritating albuminous solution of corrosive sublimate in alkaline chlorides:— R. Hydrargyri chloridi corrosivi, Ammonii chloridi, aa gr. viij; Sodii chloridi, gr. xxx; Aquas destillatae, f^ss.—M. Filter and add to a solution of the white of one egg in water sufficient to make f Jiv. Of this solution, n\v con- tain gr. j-'g of the corrosive chloride of mercury. Lewin2 employs in the treatment of syphilis three different strengths of solutions, gr. ij, iv, and vj to f§j of distilfed water ; the one of medium strength being that usually resorted to. Morphia, gr. TV~1, may be added to relieve the pain attending the application. The smallest subcutaneous dose of corrosive sublimate used by him in these cases is gr. ^ the largest gr. f. The iodide of mercury and sodium is also used where a mercurial is indicated, in the proportion of gr. viij to 1 Bulletin General de Therapeutique, Aug. 30, 1869. • ' 2 Treatment of Syphilis with Subcutaneous Sublimate Injections; Philada., 1873. DOSES FOR SUBCUTANEOUS INJECTIONS. 119 f3j, of which 10 minims, usually a sufficient dose, are equal to gr. \. Morphia.—The acetate may be dissolved with a mini- mum of acetic acid, in hot distilled water, in the propor- tion of gr. v to f5j, of which "ij = gr. TV:. In severe pain, "l ij may be administered.1 Muriate of morphia may be administered in the strength of gr. iv to f'3j, or gr. x to f3ij ; according to Lawson,* a solid preparation requiring heat to dissolve it. Two minims are equivalent to gr. \. The British Pharmaco- poeia has .a formula for its subcutaneous injection, the strength being gr. v to f3j, of which "ij = gr. -f'5. Sulphate of morphia is preferable in the proportion of gr. ij to f3j ; the subcutaneous dose being gr. ^o-l, the smaller dose being the best to commence with. The dose for children, in whom it is seldom employed hypo- dermically, is gr. 3^ to T'0. When morphia and atropia are combined, a larger quantity of the former is borne without inconvenience. A solution may be made, in which r^v = gr. \ of mor- phia and gr. ^'g of atropia. Morphia gr. J may be safely injected with gr. ?'g or ^ of atropia, on account of their mutual antagonism. Nicotia.—This may be prescribed in a solution of gr. \ to f5j of water, of which m, iv = gr. e'D, the proper subcutaneous dose. Physostigma.—The extract is given in the proportion of gr. ij to f3j, of which r\ x = gr. J, the proper dose with which to commence its employment hypodermically. 1 Anstie, Practitioner, July, 1868, p. 37. 2 Sciatica, Lumbago, and Brachialgia, their Nature and Treatment ; London,1872. 120 DOSES OF ATOMIZED FLUIDS. Quinia.—The sulphate may be administered as follows:— R. Quinias sulphatis, 3j ; Acidi sulphurici diluti, "l xl; Aquae destillatas, f§j.—M. Of this solution "I xv-xxx is the dose. A solution of the sulphate of quinia, gr. viij in ether flj, has also been proposed, but this soon decomposes by evaporation of the ether. Strychnia.—The sulphate is used in the proportion of gr. ij to fgj, of which "i v = gr. ,»5 ; or gr. ij to f^ij, of which "ij = gr. gV T'ie maximum dose is gr. 2'7, but a smaller dose, as gr: gV to JB, is safer, and therefore preferable. Doses of Atomized Fluids for Inhalation. In the treatment of certain diseases of the throat and respiratory organs, the introduction of atomized or pul- verized fluids—in other words, of solutions of various medicinal substances in the form of spray—has been highly extolled. It would doubtless be employed more frequently as a remedial process if the practitioner was more generally informed as to the appropriate strength of the solution, which is to be thrown as spray upon the morbid surface. Supposing that he is already in posses- sion of the proper spray-apparatus, the following table will give an idea of the doses in which the remedies may be resorted to :— Acidum carbolicum, ^r. i-ij. " hydrocyanicum dilutum, "IU- " lacticum, n\xxx. " sulphurosum, f^ij -viij. " tannicum, gr. iij-xx. Alumen, gr. v-xxx. " exsiccatum, gr. iij-xx. Ammonii chloridum, gr. v-lx. Aqua laurocerasi, n\v-xx. Argenti nitras, gr. i-x. Cupri sulphas, gr. i-vj. Extractum belladonnae, gr. ^-j. " cannabis Indicae, gr. Hj- " conii, gr. v-x. DOSES FOR GARGLES. 121 Extractumconii fluidum,ttliij-viij. " hyoscyami fluidum, ntiij-x. " opii, gr. ss-v. " " aquosum, gr. \-^. Ferri et ammonii sulphas, gr. iij—vj. " subsulpbas (Monsel's salt), gr. ss-x. " perchloridum.gr. |-ij. " sulphas, gr. i-ij. Glycerina, q. s. Hydrargyri chloridum corrosivum, gr- Te-i- r .. Liquor calcis, 15J-1J. " " saccharatus, f3J-iv. '• ferri subsulphatis, gtt. x-xx. " iodinii compositus, Tn. ij-xv. " picis, fgj-ij. " potassii arsenitis, Ti^iij-xv. " sodae chlorinatae, n\xxx-lx. Morphiae acetas, gr. ^-% sulphas, gr. J _i Oleum terebinthiuue, rnj-v. Plumbi acetas, gr. ij-vj. Potassii bromidum, gr. ij-x. " carbonas, gr. x-^ij. " chloras, gr. v-xv. " iodidum, gr. ij-x. " permanganas, gr. ij -iv. Qniniae sulphas, gr. J-ij. Soda chlorinata, 3ss-j. Sodii boras, gr. v-xx. " chloridum, gr. v-xl. Tinctura cannabis Indicoe, rriv-x. " ferri perchloridi, n\v-xxx. " iodinii, tnjij-xv. " " composita, n\x- XXX. " opii, mjij-xx. Zinci sulphas, gr. iij-x. Doses of Medicines in the form of Gargles. The following list furnishes the practitioner a conve- nient guide to the selection of appropriate local applica- tions in affections of the mouth and throat, in which they are indicated, and suggests the desirable strength of each. No rules are here deemed necessary, as he is supposed to be already familiar with the therapeutic virtues of the remedies to be employed. The quantity specified for each article is for a pint of water, in direct solution, or decoction, etc., according to the degree of solubility : — Acetum, f ^ij—iv. Acidum carbolicum, gr. xl-5'j- " muriaticum, f.^'j- " nitricum, n\xxx-xl " sallcylicum, gr. xl-^j. " sulphuricum. rn_x-xx. " tannicum, gr. XI-31J. Alumen, §ss-j. " exsiccatum, 5'J_"J- Ammoflii chloridum, 3ij-iv. Aqua ammoniae, f .^ss. " c-hlorinii, f.^ij. Calx chlorinata, 3j-iij. Capsicum, 3iij-vj. Catechu, §ss. Chloroformum, f,3j-ij. Creasotum, TT]xl-f3J. Cupri sulphas, gr. xx. Cuprum ammoniatum, gr. xx. Extractum cubebsie fluidum, f ^ss-j. " gallee fluidum, f§ss-j. " granati fluidum, f§ss-j. " krameriae fluidum, f§ss-j. " quercus albee fluidum, toss-j. " xanthoxyli fluidum, f§ss-j. 122 DOSES FOR EYE-WASHES. Gallae, 3ij- Hydrargyri chloridum corrosivum, gr. iv-v. " cyanidum, gr. x. to Oj of barley water. Infusum cinchona coinpositum,q. s. Kino, §ss. Liquor ammonii acetatis, f§ij. " plumbi subacetatis, rn.xxx. " sodee chlorinatae, f§ss-j. Plumbi acetas, 31 j. Potassii chloras, §ss-j. " nitras, §j. " permanganas, gr. xxx~5j. Quercus alba, 3J. Quiniae sulphas, gr. xx-xxx. Salvia, §j. Sodii boras, 5nJ_vJ. " chloras, 5iij-vj " hyposulphis, §iss-ij. " sulphis, ij-ij. Tinctura capsici, f§j. " catechu, fjjj. " cinchonae composita, f gj. " cubebse, f§j. " ferri chloridi, f§ss-j. " galla?, t'5ss-j. " iodinii, l'3ij-iv. " kino, f§ss-j. " krameriae, f.^ss-j. " myrrhae, fgj-ij. Zinci sulphas, gr. xxx~3ij. Many of the above-mentioned solutions may also be appropriately employed as mouth washes in various patho- logical conditions of that cavity. It may be desirable, in order to render them more agreeable for such local ap- plication, to incorporate with them additional flavoring materials, such as mel boracis, etc., or to combine several ingredients in the same prescription. Doses of Medicines for Collyria or Eye-washes. In ophthalmic medication much greater delicacy is of course required in the selection of the appropriate agents and their doses. The following list will facilitate the practitioner in the choice of a remedy and also indicate to him the usual dose in which it is to be prescribed. The solution is in distilled water, preferably rose-water, in a fluidounce of which the quantity specified is to be dissolved, unless otherwise stated :— Acetum, q. s. Acidum hydrocyanicum dilutum, TTlV-X. " tannicum, gr. ij-x. Alumen, gr. ij—viij. " exsiccatum, gr. j-iv. Ammonii chloridum, gr. ij-x. Aqua camphors, f3vj to 131J liquor ammonii acetatis. " rosae, q. s. Argenti nitras, gr. j-iij. Atropiae sulphas, gr. £-ij. Auri chloridum, gr. £. Barii chloridum, gr. x. Cadmii sulphas, gr. j-iij. Calx chlorinata, gr. j-iij. Conia, gtt. j-iij. Creasotnm, gtt. j-iij. Cupri sulphas, gtt. j-iij. Cydonium (in infusion), q. DOSES FOR URETHRAL INJECTIONS. 123 Extractum belladonae, gr. ij-iv. " opii, gr. ij-v. Ferri sulphas, gr. j-iij. Glycerina, q. s. Hydrargyri chloridum corrosivum, gr. ss. Liquor ammonii acetatis,f3ss with f§ss of rose-water. " plumbi subacetatis, rn^x. Morphiae murias, gr. j-ij. " sulphas, gr. j-ij. Plumbi acetas, gr. j-v. Potassii carbonas, gr. ij-vj. " chloras, gr. v- xv. " iodidum, gr. vj-viij. Potassii iodidum, gr. iij ; iodinium, Sassafras medulla (in infusion),q.s. Sodii boras, gr. x-xv. " chloridum, gr. j-v. Strychnia, gr. ij. Tinctura aconiti, Tti^v-xx. " arnicas, rti_v-xxx. Vinum antimonii, f5j. " opii, f 3j. Zinci acetas, gr. j-ij. " iodidum, gr. j-ij. " oxidum, gr. vj-x. " sulphas, gr. ij-x. Doses of Medicines for Injection into the Urethra. The quantity mentioned is intended for solution in a fluidounce of distilled water. Acidum carbolicum, gtt. ss-ij. " hydrocyanicum dilutum, gtt. j-ij. " nitricum, gtt. ij-iij. " tannicum, gr. iij-v. Argenti nitras, gr. ss-x. Copaiba, n\xv; mucilaero acaciae, f3ss ; aqua calcis ad f§j. Creasotum, gtt. ss-ij. Cubeba, gr. xxx. Cupri sulphas, gr. j. Cuprum ammoniatum, gr. ss. Ergota, gr. xxx. Ferri iodidum, gr. ss. Hydrargyri chloridum corrosivum, gr. x (inject f3j). Kino, gr. ij-iv. Liquor calcis, q. s. " plumbi subacetatis, n\x-xv. Morphiae acetas, gr. iss-ij. " sulphas, gr. iss - ij. Opium, gr. iss-ij. Plumbi acetas, gr. v-xx. Potassii chloras, gr. vj-viij. ." sulphuretum, gr. v. Zinci acetas, gr. j-ij. " chloridum, gr. j-ij. " sulphas, gr. iij-x. Doses of Medicines for Injection into the Vagina. The amount mentioned is intended for solution in a pint of water, unless otherwise stated. In gonorrhoea of the female, many of the solutions already mentioned under "Urethral Injections," which may not be repeated in this place, are also applicable, as a general rule, for vaginal injection, but the proportion of the active ingredient, and especially the quantity of solution employed, must be increased. 124 DOSES FOR VAGINAL INJECTIONS. Acidum carbolicum, 3SS_J- " gallicum, gr. XX-3J. li salicylicum, 3J. " tannicum, gr. XX-3J Alumen, 3J_1V- Ammonii cliloridum, 3ij-iv. Aqua chlorinii, f§iv. Argenti nitras, gr. v-xx. Catechu, §ss. Copaiba, l'3vj ; mucilago acacia?, f§iss ; aqua calcis ad Oj. Creasotum, n\,x-f3ss. Cubeba, §ss-j. Cupri sulphas, gr. x-xxx. Cuprum ammoniatum, gr. x. Ergota, §j. Extractum haematoxyli, §j. Ferri iodidum, §ss. Ferri sulphas, gr. xxx-"ij. " et ammonii sulphas, 3J. Galla, §j. Kino, §ss. Krameria, §ss. Liquor ferri subsulphatis, f3ij-iv. " plumbi subacetatis, t'3j—ij. " sodae chlorinata?, f£j. Plumbi acetas, gr. x-xx. Potassii chloras, gj. " nitras, ^ss-j. " permanganas, gr. xx. Quercus alba, ^ss. Sodii hyposulphis, |j-ij. " sulphis, 3'j-iv- Tinctura ferri chloridi, fjss-j. Zinci chloridum, gr. v-vij. " sulphas, gr. 3j —ij. Doses of Medicines in the form of Suppositories. The excipient usually employed in the formation of suppositories is oleum theobromas, or cacoa butter, on account of its possessing the desirable consistence and fusibility for the purpose. Suppositories for young children should not weigh more than five or ten grains; for adults, they may weigh twenty-five or thirty grains. The U. S. Pharmacopoeia recommends thirty grains, the British Pharmacopoeia only fifteen. The usual dose of the active ingredient of the suppository may be from one and a half to two times that of the same medicine admin- istered by the mouth. In city practice the physician usually mentions the quantity of the medicine in his prescription, leaving the exact size of the suppository to the manipulation of the pharmacist; or the latter keeps on hand a full line of ready-made suppositories in anti- cipation of the needs of the practitioner. The general subject of suppositories includes those intended for introduction into the rectum, vagina, uterus and urethra. DOSES FOR RECTAL SUPPOSITORIES. 125 Doses for Rectal Suptpositories. The quantity mentioned of each article is intended to be mixed with an excipient, preferably cacoa butter (oleum theobromae), according to the rules and manipuhV tions familiar to pharmacist and physician.1 Acidum carbolicum, gr. j-iv. Acidum gallicum, gr. v-x. (See Opium.) Acidum taunicum, gr. iij-x. (See Extractum belladonna?, Extrac- tum stramonii, Morphiae sulphas, Opium, Flumbi acetas.) Aloe purificata, gr. ij-x. Aloin, gr. j; sapo, gr. v. Alumen, gr. v-xv. Argenti nitras, gr. j. Assafcetida, gr. v-i tractum ergotae.) Camphora, gr. x. Chloral, gr. v. Creasotum, n\|-ss. Cupri acetas, gr. ij. " sulphas, gr. ij Elaterium, gr. ss. Extractum belladonnae, gr (See Ex- -u- j; j; Extractum belladonna?, gr. extractum opii, gr. ss-ij. Extractum belladonna?, gr. : plumbi acetas, gr. ij-iij. Extractum belladonna?, gr. acidum tannicum, gr. iij. Extractum belladonnae, gr. morphiae sulphas, gr. ss. Extractum conii, gr. ss-ij. " ergotae (Squibb's) ij-x. Extractum ergotae, gr. v ; assafce- tida, gr. v. Extractum hyoscyami, gr. iij-v. (See Opium.) Extractum krameriae, gr. v-x. " nucis vomicae, gr. ss-ij. " opii, gr. j. (See Ex- tractum belladonnae.) 'J gr- Extractum opii aquosum, gr. ^-ij. " rhei, gr. xv. " stramonii, gr. j. Extractum stramonii, gr. j ; plumbi acetas, gr. ij. Extractum stramonii, gr. j ; acidum tannicum, gr. v. Ferri perchloridum, gr. ij. " subsulphas, gr. j-iij. Gall®. (See Opium.) Gambogia, gr. iij—vj. Hydrargyri chloridum mite, gr. v-x. (See Santoniuum.) lodoformum, gr. iij. Ipecacuanha, gr. ij-x. Kino, gr. ij-v. Morphia? acetas, gr. T\-j. " murias, gr. TV-j. " sulphas, gr. TV-J- (See Extractum belladonna?.) Morphiae sulphas, gr. ss; acidum taniiicum, gr. iij. Oleum theobromae. Opium, gr. ^-iv. (See Pulvis ipecacuanha? compositus.) Opium, gr. j; acidum gallicum, gr. ij- Opium, gr. j-ij ; acidum tannicum, gr- ij-v. Opium, gr. j ; extractum hyoscy- ami, gr. ij-iv. Opium, gr. j ; galla, gr. v. Opium, gr. j-ij; plumbi acetas, gr. ij-v. Plumbi acetas, gr. ij-v. (See Opium, Extractum belladonnae, Extractum stramonii.) Plumbi acetas, gr. ij ; acidum tan- nicum, gr. iij. (' For the officinal suppositories, Suppositoria, U. S. Phar., see Phar- macopceial Groups.) 126 DOSES FOR VAGINAL SUPP0S1T0R7ES. Plumbi iodidum, gr. ij. Pulvis ipecacuanha? compositus, gr. j-x. Quinia? sulphas, gr. j-iv. Resina podophylli, gr. -^-j. Sautoniuum. gr. ij-v. Santoninum, gr. ij ; hydrargyri chloridum mite, gr. v. Sapo. Sodii sulphas, 3J. Tinctura assafcetida?, Tl^xl. Unguentum hydrargyri, gr. v. Zinci oxidum, gr. viij-x. Zinci sulphas exsiccata, gr. ij. Doses for Vaginal Suppositories. These conical preparations for the introduction of remedies per vaginam usually weigh about a drachm or more; and are shaped like a minie bullet, but somewhat larger. The quantity mentioned of each article is the proper dose for a suppository :'— Acidum carbolicum, rnjj. " gallicum, gr. x. " salicylicum, gr. v. " tannicum, gr. v-x. " tannicum, gr. vj ; opium, gr- ij- Aconitia, gr. fa. Alumen, gr. xv. " gr. xv ; catechu, gr.xv. Ammonii bromidum, gr. xv. " chloridum, gr. ij-iv. Argenti nitras, gr. j. Atropia, gr. fa " gr- -jV' potassii bromidum, gr. x. " §>r- tV > plumbi iodidum, gr. v. Bismuthi subnitras, gr. xv. Chloral, gr. x-xv. Creasotum, TT\J— ss. Extractum aconiti, gr. iss. Extractum belladonna?, gr. j-ij. " belladonnae, gr. ij ; plumbi iodidum, gr.v. " conii, gr. xv. " hyoscyami, gr. ij-iv. nucis vomicae, gr. ss-ij. " opii, gr. iij. Ferri perchloridum, gr. iij-v. " subsulphas, gr. ij-v. " sulphas, gr. x. Hydrargyri oxidum rubrum, gr. ij. lodinium, gr. ij. Iodoform um, gr. v—x. Matico, gr. x. Morphiae murias, gr. ss-iss. '' sulphas, gr. ss-iss. Morphia? sulphas, gr. j ; acidum tannicum, gr. v-x. Opium, gr. iss-iij. Plumbi acetas, gr. ij—vij. 1 As elsewhere stated, suppositories are usually made with oleum theobromae as the excipient, but Dr. Meadows, in his address before the British Medical Association in 1871, remarks : "Inasmuch as it is no part of the function of the vaginal mucous membrance to digest fats, and as fats without digestion cannot be absorbed, and are apt, more- over, to hinder the absorption of other substances, it is desirable, I think, that we should not use greasy substances of any kind. For this reason I long ago gave up the employment of cacoa butter, and I now invariably use, as the basis of the pessary, gelatin and glycerine, into which we can put any ingredient we wish." Tannic acid, and other sub- stances incompatible with gelatin, cannot, however, be thus administered. DOSES FOR UTERINE SUPPOSITORIES. 127 Plumbi acetas, gr. v ; opium, gr. ij. " iodidum, gr. v-x. " iodidum gr. v ; atropia? sul- phas, gr. fa Potassii chloras, gr. v-xv. " bromidum, gr. x. " perinanganas, gr. iij. Potassii iodidum, gr. v-x. Sodii boras, gr. xv. " carbonas, gr. xv. Unguentum hydrargyri, gr. xx- xxx. Zinci oxidum, gr. xv. " sulphas exsiccata, gr. iij. Vaginal suppositories are also made hollow, of gelatine and glycerine, the medicated ingredient being introduced in the shell, or the powder may be placed in the interior of the hollow suppository. Doses for Uterine Suppositories. Suppositories for introduction into the cervical canal are cylindrical in shape, and about two inches long, having a diameter similar to a No. 9 male catheter. They should weigh about fifteen grains:— Acidium gallicum, gr. j. " gallicum, opium, aa gr. j. " tannicum, gr. j. " tannicum, opium, aa gr. j. Argenti nitras, gr. j. Cupri sulphas, gr. ss. Extractum belladonna}, gr. ij. Extractum opii aquosum, gr. ij. Ferri perchloridum, gr. j. Morphia? murias or sulphas, gr. j. Plumbi acetas, gr. j. Zinci sulphas exsiccata, gr. j. Intra-uterine Pencils have also been devised, made of a combination of gelatin and glycerin, and medicated. They soon dissolve and act directly on the mucous surfaces of the uterus. They resemble a short bougie, about the diameter of a goosequill, sufficiently firm and elastic to be introduced without breaking. Acidum carbolicum, gr. j-iv. Acidum carbolicum, gr. ij. Liq. iodin. comp., gr. ss. Ergotinae, gr. v-viij. | Ext. belladonna? ale, gr. j-ij. Ext. opii aquos., gr. j-ij. Hydrastis Canad., gr. v. Iodoformum, gr. ij-v. Liq. iodinii comp., gr. ij. Morphia? sulphas, gr. ss. Morphia? sulphas, gr. \. Ext. gelsem. fluid, gr. ij. Zinci acetas, gr. ij-iv. Zinci sulphas, gr. i—viij. Zinci sulphas, gr. ij. Acidnm carbolicum, gr. j. Zinci sulphas, gr. ij. Acidum carbolicum, gr. j. Hydrastis Canad.. gr. v. Zinci sulphas, gr. ij. Ext. belladonna?, gr. ss. Iodoformum, gr. ij. Liq. iodinii comp., gr. ss. Morphia? sulphas, gr. ss. Zinci sulphas, gr. ij. Ext. belladonna?, gr. ss. 128 DOSES FOR URETHRAL SUPPOSITORIES. They may be retained in position by a small plug of absorbent cotton in the os. Solid caustic crayons are more powerful than the intra- uterine pencils. They are made of the solid, medicating ingredient, such as alum, sulphate of zinc, etc., moulded into a short crayon, about 1| inch long and T3e inch in diameter. Doses for Urethral Suppositories {Soluble Bougies). This form of treatment of gonorrhoea and gleet con- sists of firm smooth cylinders, three or six inches long, of cacoa butter, or gelatine and glycerine, with the reme- dial agent incorporated in it. Well oiled, it may be in- troduced by the patient into the urethra, preferably at bedtime, and will dissolve in about ten minutes. The bougie may be retained by slips of adhesive plaster.1 Acidum boracicum, gr. i-ij. " gallicum, gr. j. " gallicum, opium, aa gr. j. " tannicum, gr. j. " tannicum, opium, aa gr. j. Argenti nitras, gr. £-j. Bismuthi snbnitras, gr. x. Cupri sulphas, gr. ss. Extractum aconiti, gr. j. " belladonnae, gr. iss—ij. " gelsemii fluidum, gr. v. " krameria?, gr. j. " opii aquosum, gr. iss—ij. Ferri perchloridum, gr. ss-j. Hydrastis Canadensis, gr. v. Iodoformum, gr. j. Morphia? murias or sulphas, gr. ss-j. Plumbi acetas, gr. ss-j. " acetas, gr. ss; bismuthi sub- nitras, gr. x. " acetas gr. j ; extractum opii aquosum, gr. j. Zinci acetas, gr. ss-j. Zinci acetas, gr. ss-j; extractum opii aquosum, gr. j. " chloridum, gr. |-ss. " chloridum, gr. £ ; extractum opii aquosum, gr. j, or ex- tractum belladonna?, gr. j. " salicylas, gr. ss. ' sulphocarbolas, gr. ss. " sulphas, gr. ss-j. " <3iilphas, gr. ss-j ; extractum opii aquosum, gr. j, or ex- tractum belladonna?, gr. j. " sulphas, gr. j ; extractum bel- ladonnae, gr. j ; extractum opii aquosum, gr. j. " sulphas, gr. ss-j; morphi« sulphas, gr. \. sulphas, gr. ss; extractum opii aquosum, gr. j ; ex- tractum matico fluidum, gr. ss. " sulphas, gr. ss-j; acidum car- bolicum, gr. £-ss. Sir Henry Thompson, Lancet, May 12, I860. DOSES FOR EN EM AT A. 129 Doses for Enemata. The following simple rules should guide the practitioner in the employment of enemata:— 1. Unless the remedy thus applied is excessively potent, three times as much of it should be injected per anum as would otherwise be administered by the mouth. 2. When it is desirable to retain the injection, the total amount of fluid should be small, not more than two or three fluidounces, and slowly injected, so that the bowel will not be excited to reject it. On the other hand, a large quantity should be used, as will be presently ob- served, when the object is to produce an evacuation of the bowels. A mucilaginous menstruum may sometimes be necessary, such as starch, barley-water, etc., to cover irri- tating qualities of the drug or to shield the bowel. 3. The appropriate quantity of fluid, at different ages, to be injected for purposes of evacuation, may be briefly stated as follows :— For a very young infant, f^j. For a young child (1 to 6 years of age), for each year an additional f oj. For a child 6 to 15 years of age, varying with age, from fsyj-x. After 16 years of age, from f^x-xvj or more. The quantity mentioned for each article is intended for & pint of water, only when the object of the enema is to produce an evacuation; otherwise, the rule of injecting a very much smaller quantity of fluid must be adhered to. The therapeutic action of each substance, in the form of enema, is appended :— 9 130 DOSES FOR ENEMATA. Acetnm • fgj-iij Astringent. Acidum carbolicum . n\ij-iv Antiseptic and anthel mintic. " tannicum gr. x-xx Astringent. Aloes . . gr. x-xl Purgative and anthel mintic. Alumen . • j?ij-iv Astringent. Amylum ■ §ss Emollient. Anisum (in infusion) . • m Carminative Anthemis (in infusion) • m Carminative. Aqua ammonia? . . f ^ss Stimulant. " camphora? . • f.lj-ij Antispasmodic. Assafoetida . • 3 j-ij Antispasmodic. Belladonna. . gr. xv-xx Antispasmodic. Bismuthi subnitras . gr. xxx-3J Astringent. Calx chlorinata . • 3iJ-ivr Antiseptic. Camphora . gr. xx—xl Antispasmodic. Carum (in infusion) . • m Carminative. Catechu . . . . . gr. xxx-3J Astringent. Chenopodium • 3ss-j Anthelmintic. Creasotum . • T»li j-iij Antiseptic. Ergota . • 3iJ-i'J Extractum cinchona? . gr. xxx Antiperiodic, tonic. " krameria? . . gr. xx Astringent. Fel bovinum • ?J Purgative. Foeniculum (in infusion) • fgj Carminative. Galla .... . gr. xxx-3j Astringent. Kino .... . gr. xxx-3j Astringent. Krameria gr. xx-xl Astringent. Liquor calcis . f§iv-viij Antiseptic. " plumbi subacetatis • nixl-f3j Astringent. " soda? chlorinata? - f§j Antiseptic. Magnesia? sulphas . gj-iss Purgative. Mentha viridis (in infusion ) . f^j-iss Carminative. Mistura assafcetida? • f|ij-iv Antispasmodic. Moschus . gr. xv-xx f§ij-iv in Antispasmodic. ) Oleum lini . Oss ' of water. V Purgative. " morrhua? . . . f^ss-j fgij-iv in Nutritive. ) " oliva? Oss of water. f 1 j-ij in I Purgative. ) " ricini Oss of water. > Purgative. " terebinthinae . • fSiJ-^'J Stimulant, purgative. Plumbi acetas . gr. x-xx Astringent. Potassii bicarbonas • 3JJ Anthelmintic. Quercus alba • 3J gr. x-xx in Astringent. ) Quinra? sulphas , f^iv of water. > Stimulant. DOSES FOR ENEMATA. 131 Salvia (in infusion) . f|j Sapo ..... • 3*3 Sodii boras .... ■ 3'J-iv " chloridum . ■ S'j-iv " hyposulphis 3J '• sulphas . ^j in Oss " sulphis 3J Spigelia .... . gr. xxx Spiritus aetheris compositus f.31'J-ijJ gr. xv-xx f§viij Tinctura assafoetida? . f3'v-f§j " capsici f3j to Oss water. " opii . . . . nixx-f3j to of Carminative. Purgative. Antiseptic. Purgative, Antiseptic. Purgative. Antiseptic. Anthelmintic. Antispasmodic. I Antispasmodic. Antispasmodic. I Stimulant. Antispasmodic. A class of enemata is officinal in the last edition of the British Pharmacopoeia, including the following:— Enema aloes.— R. Aloes, gr. xl; potassii carbonatis, gr. xv ; mucilaginis amyli, fsv. Enema assafcetidse.—R. Assafcetidae, gr. xxx ; aquas des- tillatas, f^iv. Enema magnesise sulphatis.— R. Magnesias sulphatis, sj (avoir.); olei olivas, f.5J ; mucilaginis amyli, f^xv. Enema opii.—R. Tincturae opii, "Ixxx; mucilaginis amyli, fsij. Enema tabaci.—R. Tabaci foliorum, gr. xx ; aquae bul- lientis, f 3 viij. Enema terehinlhinss.—R. Olei terebinthinas, f^j; mu- cilaginis amyli, fsxv. In addition to the articles just enumerated, quite a number of domestic remedies are similarly employed. No definite directions are necessary in regard to propor- tion or the quantity of these to be injected, other than the general rules already laid down. Among these may be mentioned the following:— Alcoholic liquors, barley, beef-tea, chocolate, coffee, flaxseed, gum Arabic, lard, molasses, mutton suet, oat- meal, slippery elm, starch, sugar, tapioca, tea, wines, yelk 132 NUTRITIVE ENEMATA. of egg, and yeast. Their therapeutic action needs no further allusion. When the object of the administration of an enema is its nutritive effect only, in cases in which, for some patho- logical cause, it is impossible for the stomach to receive nourishment, one of the following formulas will be found serviceable •}— Beef-tea and Cream Enema.—Mix together from four to eight ounces of strong beef-tea, an ounce of cream, and half an ounce of brandy or an ounce and a half of port wine, and administer two or three times in the twenty- four hours. Or, mix four or six ounces of beef-tea or restorative soup (see Dietetic Precepts), prepared without acid, one ounce of cream, two teaspoonfuls of brandy, and ten grains of citrate of iron and quinia. If brandy is not indicated, take beef-tea, soup, or milk and eggs beaten together, and thicken with corn flour. Cod-liver Oil and Baric Enema.—Mix four ounces of milk, one ounce of port wine, half an ounce of cod-liver oil, two drachms of tincture of yellow bark, and twenty minims of liquid extract of opium. Administer every twelve hours. Quinine and Solution of Beef Enema.—Take one table- spoonful of brandy, five grains of sulphate of quinia, one teaspoonful of gjycerine, two tablespoonfuls of cream, and from four to eight ounces of restorative soup or beef- tea. Administer every six or eight hours. If the rectum should be irritable, add fifteen to twenty minims of liquid extract of opium. Baths and how to Medicate them. The baths recommended by the practitioner vary in kind and the quantity of the material employed to medi- 1 Tanner, Practice of Medicine, 5th Amer. edit., 1872, p. 1053. BATHS AND HOW TO MEDICATE THEM. 133 cate them, as they vary also in temperature. The sim- plest forms of unmedicated baths, classified chiefly accord- ing to temperature (Fahr.), are the following:— Bath. Cold Cool Temperate Tepid Warm Hot Water. 33° to 65° U5° to 75° 75° to 85° 85° to 92° 92° to 98° 98'' to 112° Vapor. 90° to 100° 100° to 115° 115° to 140° Air. 96° to 106° 106° to 120° 120° to 180° The following formulas will be found of practical value in a variety of cutaneous, hepatic, and other affec- tions.1 Arsenical Bath.—R. Sodii carbonatis, liv; sodii ar- seniatis, gr. xx-xxxv ; aquas calidas, Cong. xxx. Or, R. Sodii chloridi, 3] ; sodii sulphatis, 3] ; sodii car- bonatis, §ij ; sodii arseniatis, gr. lii; aquas calidae, Cong. xxx. Or, R. Potassi sulphureti, ^iv ; sodii arseniatis, gr. xxx -xl; aquas calidas, Cong. xxx. Borax Bath.—R. Sodii boratis, liv; glycerinas, f^iij ; aquas calidas, Cong. xxx. Coniumand Starch Bath.—R. Extracti conii, sj; amyli pulv. ibj ; aquas ferventis, Cong. xxx. Or, the conium may be omitted, and a simple starch bath be employed. Creasote Bath.— R. Creasoti, f3iij; glycerinas. f3iv; aquas ferventis, Cong. xxx. Gelatine Bath.—Dissolve Ibj of gelatine or common glue in a little boiling water, and add twenty gallons of hot water. To make it more efficacious, soak in it ftj-ij of bran confined in a muslin bag. 1 For several important suggestions in this place, the author is in- debted to Tanner's Practice of Medicine, 5th Am. ed., Appendix, p. 1070. 134 BATHS AND HOW TO MEDICATE THEM. Hydrochloric Acid Bath.—See Muriatic acid bath. Hydrosulphureltcd Bath.—See Sulphur bath. Hyposulphite of Sodium Bath.—See Sulphur bath. Iodine Bath.—R. Iodinii, 5j 5 potassii iodidi, 5ss; liquoris potassae, f sij ; aquas calidas, Cong. xxx. Or, R. Potassii iodidi, 3yj; iodinii, 5iij ; aquas calidas, fjxx. To be added to an ordinary bath. Or, R. Potassii iodidi, 9iv; iodinii, 9ij; aquas, f 5x. To be added to an ordinary bath for children. Eon Bath.—R. Ferri iodidi, ^ij—iij : aquas calidas, Cong. xxv. Or, R. Ferri sulphatis, Sss; aquas calidas, Cong. iv. For children. Mercurial Vapor Bath.—The patient is seated on a chair, and covered with an oilcloth lined with flannel, which is supported by a proper framework. Under the chair are placed a copper bath containing water, and a metallic plate on which is put from 60 to 180 grains of bisulphuret of mercury, or of the gray or red oxide. In syphilitic affections of the skin, testes, and bones, five to thirty grains of the green iodide may be used, or twenty grains of the same salt with ninety of the bisulphuret. Spirit-lamps are lighted under the bath and plate, and the patient is thus exposed to the influence of heated air, steam, and mercurial vapor. In ten or fifteen minutes the lamps are to be extinguished, and the patient, gradu- ally cooling, is to be rubbed dry.1 The plan of Mr. Henry Lee is much more simple. A tin case, made by instrument-makers, is used, containing a spirit lamp, and having in the centre, over, the flame, a small tin plate, on which 15 to 30 grains of calomel are placed, and around this a sort of saucer filled with boiling Langston Parker on Syphilis, quoted in Tanner, loc. cit. BATHS AND HOW TO MEDICATE THEM. 135 water. The lamp being lighted, the apparatus is placed under a common cane-bottom chair, on which the patient sits, enveloped, chair and all, in one or more large blan- kets for about twenty minutes, when the water and mer- cury will be found to have disappeared. It is better not to use a towel, as the calomel would be wiped off by it. Muriatic Acid Bath.—R. Acidi muriatici, fsx; aquas, Cong. 1. Mustard Foot Bath.—R. Sinapis pulv. 3*ij-iv; aquas fer- ventis, Cong. iv. Nitromuriatic Acid Bath.—R. Acidi muriatici, p. iij; acidi nitrici, p. ij. Mix carefully and slowly, and after an interval of fifteen minutes, add aquae destillatas, p. v. For a foot bath, add of the above f 3*vj to two or three gallons of water at 98°; or, R. acidi nitrici, f'^ss; acidi hydrochlorici, f'oj ; aquas calidas, Cong. iv. In a wooden bath. For a full bath, add 61 fluidounces of the mixture first named to 5 pints of cold water, and then hot water enough to raise the temperature to 98°. In a wooden bath. Or, R. Acidi nitrici, f^iss; acidi hydrochlorici, f^j-iij ; aquas calidas, Cong. xxx. In a wooden bath. Oak Bark Bath.— R. Quercus contusas, Sbj; aquas calidas, Oij. Boil for half an hour, strain, and add to 3 gallons of warm water. For children. Salt Water Bath..—R. Sodii chloridi, Hbss ; aquas tepidas, Cong. iv. For a sponge bath. Soda Bath.—R. Sodii bicarbonatis, tt>j ; aquas ferventis, Cong. xxx. Sulphur Bath.— R. Potassii sulphureti, |iv; acidi mu- riatici, f3ij ; aquas calidas, Oj. To be poured into an ordi- nary bath. Or, R. Sodii hyposulphitis, |i-iv ; aquas calidas, Cong, j, To be poured into an ordinary bath. 136 PHARMACOPQZIAL GROUPS. Or, R. Potassii sulphureti, §iv; sodii hyposulphitis, .vj; acidi sulphurici, f5j ; aquas calidas, Cong. xxx. Or, R. Potassii sulphureti, siv; aquas calidas, Cong. xxx. PHAKMACOPCEIAL GROUPS, SIMPLIFIED FOR READY REFERENCE. However familiar the practitioner may be with the of- ficinal preparations, from daily experience with the em- ployment of tinctures, extracts, etc., he has, as a rule, only a partial knowledge of their relative doses. The Pharmacopoeia specifies quantities and methods of manu- facture, but is silent on the subject of the doses appropri- ate to each. In addition to the exact composition of each preparation, the practitioner wishes to know in what way he can handle the extract or the solution which the nicety of the pharmaceutist's art has perfected for him. With the view of assisting him in the proper use of the material thus set before him, the following arrangement of the various officinal groups has been made directly from the U. S. Pharmacopoeia. It has not been thought necessary to allude to their therapeutic qualities, with which the practitioner is supposed to be already acquainted.1 1 Should it be desirable to convert the amounts mentioned into the phraseology of the metric system, this must be done according to the rules for solids and liquids already laid down (pp. 29 and 31). PHARMACOPOEIA! GROUPS. 137 Aceta (Vinegars).—Diluted acetic acid is the solvent employed. Name. Strength, etc. Dose. Aeetum destillatum May be substituted for diluted acetic acid in making the other aceta. " lobelia? . §ij to Oj of diluted acetic acid, Tn_xxx-f3j. " opii §iiss " " " nx v-x. " sanguinaria? . §ij uixxx-f3j. " scilla? . 5ij " " " n\ xxx-f ^ij. Aqu Aqua M (Medicated Waters).—These are solutions of es- sential oils and gases in Water. acidi carbolici . Glycerite of carbolic acid fjx in Oj of distilled water, " caibonici . Water impregnated with car- bonic acid, equal to 5 times f.5J-0j- its bulk, Ad lib. ammonia? . 10 per cent, of ammonia, sp. "\x-xx. Also gr. .960, for external use. amygdala? amara? TU.xvj of the oil to Oij of dis- tilled water, fgss. anisi . f3ss of the oil to Oij, f3J- aurantii florum . giij to Oj, distil Oss, f5jss. camphora? o'j to Oij, f§ss. chlorinii Water saturated with chlorine, For external use. cinnnmomi f5*s of the oil to Oij, f§ss-j. creasoti f3J ^ Oj, f3ij- destillata . Usedin making the otheraqua?. fceniculi f3ss of the oil to Oij, f§ss-j. mentha? piperita? f^ss of the oil to Oij, f 3 ss-j. " viridis f.5ss of the oil to Oij, f 3 ss-j. rosae . §xij to Oiv, distil Oij, Used as a ve-hicle. Cerata (Cerates).—These external applications may be briefly mentioned. Their modus operandi and the indications for their use may be learned from their officinal names, the practitioner being of course fa- miliar with the qualities thus suggested. They are— Ceratum, or simple cerate. I Ceratum resina?. cantharidis. " " compositum. " sabinae. cetacei. extracti cantharidis. plumbi subacetatis. saponis. zinci carbonatis. 138 PHARMACOPOZIAL GROUPS. Charts (Papers).—The two officinal preparations of this class are intended as portable substitutes for the or- dinary fly blister and mustard plaster. They are— Charta cantharidis. Charta sinapis. COLLODIA.—CoUodium, or solution of pyroxylon or gun cotton in ether, and two of its preparations are offi- cinal— CoUodium cum cantharide. CoUodium flexile. Confectiones (Confections).—These are medicinal sub- stances mixed in an agreeable form with honey, syrup, etc. Some of them are used as vehicles for other substances. They are— Confectio aromatica. " aurantii corticis. " opii (gr. j in 35.5). Confectio rosae. " sennae. Decocta (Decoctions).—With the exception of decoctum cetrarias, the strength of which is 3*ss to Oj of water, and decoctum sarsaparillas compositum, 3*iss to Oj, the strength of the other decocta is 3j to Oj. These are— Decoctum chimaphila?. " cinchonae liava?. " " rubrae. " cornfis floridae. " dulcamara?. Decoctum haematoxyli. " hordei. " quercus albae. " senegae. " uva? ursi. The dose of each is f§iss-ij. Emplastra (Plasters).—As a general rule the practi- tioner does not desire to know the exact strength of this class of external applications, having confidence that the proper amount of active material has been placed in them to render them effective. Their offi- cinal names will suggest the uses to which they may be applied. They are— PHARMACOPCEIAL GROUPS. 139 Emplastrum hydrargyri. " opii. " picis Burgundica?. " " Canadensis. " " cum cantharide. " plumbi. " resina?. " saponis. Emplastrum aconiti. " ammoniaci. " " cum hydrargyro. " antimonii. " arnica?. " assafoetida?. " belladonna?. " ferri. " galbani compositum. Extracta (Extracts).—The mode of preparation of the different officinal extracts varies greatly in the de- tails, which are chiefly of interest to the pharma- cist. It is therefore deemed advisable to refer here to the doses alone, the minuteness or magnitude of which will be a sufficient guide to the practitioner as to the strength of the extract. Extractum aconiti, gr. ss-j. " arnica?, used in making emplastrum arnica?. " belladonnae, gr. \-\. " " alcoholicum, gv.\—\. " cannabis Americana?, gr. ss-ij. " cannabis Indica?, gr. ss-ij. " cinchona?, gr. x-xx. " colchici aceticum,gr. j-ij. " colocynthidis, gr. v-xxx. " " compositum, gr. x -XX. " conii, gr. ij-vj. " " alcoholicum, gr. j-ij. " digitalis, gr. 4-ss. " dulcamara?, gr. iij — vj. " gentiana?, gr. x-xx. " haematoxyli, gr. x-xx. Extractum hellebori, gr. x-xv. " hyoscyami, gr. ij-vj. " " alcoholicum, gr. j-ij. " ignatia?, gr. ss-j. " jalapa?, gr. x-xv. " juglandis, gr. x-xx. " krameria?, gr. x-xx. " nucis vomica?, gr. ss-j. " opii, gr. ss-j. " physostigniatis, gr. fa-^. " podophyili, gr. v-x. " quassia?, gr. iij—vj. " rhei, gr. x-xx. " senega?, gr. ij-v. " stramonii foliorum,gr. ss -j- " " seminis, " taraxaci, gr. x-^j. " Valerianae, gr. v-x. Extracta fluida (Fluid extracts).—All the fluid ex- tracts of the U. S. Pharmacopoeia, with one exception, contain 16 troyounces of the powdered material to 16 fluidounces of the menstruum. Extractum sarsa- parillas compositum fluidum contains sassafras and mezereon in addition. Extractum spigeliae et sennas fluidum is a mixture of extractum spigeliae fluidum, f^x, with extractum sennas fluidum, f§vj. The pro- 140 PHARMACOPQ.UAL GROUPS. portions in this class of preparations being so defi- nitely and systematically fixed, it will merely be necessary to mention the doses of each. radici Extractum belladonnae flnidum, n\j-ij. " buchu fluidum, Ui^xxv. " calumba? fluidum, f^ss-j. " chimaphila? fluidum, Tljx-xx. " cimicilnga? fluidum, n\x-xx. " cinchonae fluidum, tt\xv-xxx. " colchici radicis fluidum, n(jj- vj- " " seminis fluidum, mjij -vij. " conii fructus fluidum, U^ij-iv. " cornus floridae fluidum, rt^x- XX. " cubebae fluidum, tt\xx. " digitalis fluidum, rr\J-ij. " dulcamara? fluidum, fg j-ij. " ergota? fluidum, tt^xx-xxx. " erigerontis Canadensis fluid- um, TH_v-x. " gelsemii fluidum, *Mjj-v. " j:entiana? fluidum, n\xx-xl. " geranii fluidum, "U|x-xx. " glycyrrhiza? fluidum, f'3j-'v. " gossypii radicis fluidum, n\x- xx. " hydrastis fluidum, "n\iij-v. " hyoscyami fluidum, uiy-x. Extractum ipecacuanha? fluidum, U|V-XV. " krameria? fluidum, Tn_v-xx. " lupulina? fluidum, Ttiy-x. " matico fluidum, Tn.xx-xxx. " mezerei flnidum, Tnjj-iv. " pareira? fluidum, "n^x-xxx. " pruni Vireiniana? fluidum, f3ss-j- " " rhei fluidum, n\xx-xl. " rubi fluidum, u\v-x. " sabina? fluidum. Used exter- nally. " sarsaparilla? compositum fluidum, f 3ss~j- " sarsaparilla? fluidum, f3ss-iv. " si-illa? fluidum, u\v-xx. " senegae fluidum, Uix-xx. " sennae fluidum, f §ss-j. " serpentariae fluidum, Ttix-xx. " spigeliae et sennae fluidum, f3ij-iv. " spigeliae fluidum, f 3ij—iv. " stiliingiae fluidum, u\xxx-lx. " taraxaci fluidum, t'3j-ij. " uvae ursi fluidum, "n^xx-lx. " Valeriana? fluidum, uixxx-f3j. " veratii viridis fluidum, ni v-x. " zingiberis fluidum, uiy-xx. Glycerita (Glycerites).—The solvent powers of glyce- rine are called into requisition in the following officinal preparations. Being externally applied the proportion alone is mentioned in each. ij to Glyceritum acidi carbolici, Oss of glycerine. Glyceritum acidi gallici, Jjij to Oss of glycerine. Glyceritum acidi tannlci, §ij to Oss of glycerine. Glyceritum picis liqnidae, §j to Oj of glycerine, alcohol, and water. Glyceritum sodii boratis, §ij to Oss of glycerine. Infusa (Infusions).—The usual dose of the infusions is f^ij, or a wineglassful, except infusum digitalis, PHARMACOPQZIAL GROUPS. 141 whose dose is f 3ij, and infusum capsici, whose dose is f§ss. The quantity of the active ingredients is alone mentioned. to Infusum lini compositum, Oj. " paieirae, 3J to Oj. " picis liquidae (tar-water), Oj to Oiv. " pruni Virginiana?, ^ss to Oj. " quassia?, 3'j to Oj. " rhei, §ss to Oj. " rosa? compositum, 3SS to Oiiss. " salvia?, §ss to Oj. " senna?, §j to Oj. " serpentaria?, 3SS to Oj. " spigeliae, ^ss to Oj. " tabaci, gj to Oj. " taraxaci, §ij to Oj. " Valeriana?, 3*ss to Oj. " zingiberis, §ss to Oj. Linimenta (Liniments).—The medical uses of the mem- bers of this group are suggested from the officinal names, the effects of each article, when externally applied, being familiar to the physician. They are— Infusum angusturae, §ss to Oj. anthemidis, 3S3 to Oj. buchu, §j to Oj. calumba?, 5SS to Oj. capsici, §ss to Oj. caryophylli, gij to Oj. cascarilla?, §j to Oj. catechu compositum, §s toOj. cinchona? flava?, §j to Oj. " rubra?, §j to Oj digitalis, 3ij to Oj. eupatorii, gj to Oj. gentiana? compositum, §s toOj. humuli, ,^ss to Oj. juniperi, 3J to Oj. krameriae, 3J to Oj. Linimentum aconiti. {' ammonia?. '• calcis. " camphora?. " cantharidis. Linimentum chloroformi. " plumbi subacetatis. " saponis. " terebinthina?. Liquores (Solutions).—The officinal aqueous solutions are given in the following syllabic list. Distilled water is the solvent. Name. Liquor ammonii acetatis " arsenici chloridi " " et hydrargyri iodidi barii chloridi calcii chloridi Strength, etc. Dose. Dilute acetic acid neutralized by carbonate of ammonium. f3'j-f§j. Arsenious acid, gr. iv, muriatic ■ acid, n\viiss, to fgj. inv-x. Iodide of arsenic, red iodide of mercury, aa gr. xxxv to Oss of water. Ttix-xx. H to fgiij- rryv. §j to fgiss. n\xx-xl. 142 PHARMACOPOZIAL GROUPS. Name. Liquor calcis " ferri chloridi . " " citratis " " nitratis " " subsulphatis " " tersulphatis " gutta? percha? . " hydrargyri nitratis " iodinii compositus " magnesii citratis . " morphia? sulphatis " plumbi subacetatis '* plumbi subacetatis dilntus . " potassa? . " potassii arsenitis " " citratis " " permangau- atis . " soda? " " chlorinatae " sodii arseniatis " zinci chloridi . Strength, etc. §j to Oij (saturated solution). Iron, 31 ij ; muriatic acid, ^xviiss, in Oj. §ss in f|j. Iron, §iiss ; nitric acid, §v; in solution f^xxxvj. Sulphate of iron, §xij ; sul- phuric acid, 3;j gr. xl ; nitric acid^j 3v ; in l^xij of solution. Sulphate of iron, ^xij ; sulphu- ric acid, 3xyij > nitric acid, 3xiv ; in Oiss of solution. Gutta percha, ^'ss ! chloro- form, §xvij ; carbonate of lead, §ij. Mercury, §iij ; nitric acid, §v ; distilled water, 13 vj. Iodine, gr. xxiiss : iodide of potassium, gr. xlv ; water, ill- Carbonate of magnesium, gr. cc ; citric acid, gr. cccc; syrup of citric acid, f§ij ; in f|xij of solution. gr. j tofgj. Acetate of lead, §xvj ; oxide of lead, §ixss ; in Oiv of solu- tion. f3'ij of liq. plumbi subace- tatis to Oj. H to Oj. Arsenious acid, gr. iv to f§j. Citric acid, §ss; bicarbonate of potassium, 3VSS > water, Oss. gr. iv to f^j. Carbonate of sodium, §vj 5ij ; lime, §ij ; in Oiss of solution. Chlorinated lime, §xij ; car- bonate of sodium, §xxiv ; in water, Oxij. gr. iv to f§j. Zinc, §vj ; nitric acid, pre- cipitated carbonate of zinc, aa gr. cl ; muriatic acid, q. s. ; water, Oj. Dose. f^ss-j. niij-v. To prepare ferri ci- tras. tt\x-xx. Externally styptic. Used to prepare the ses- quioxide. External use. To prepare citrine ointment. ttjv-x. Half or the whole, of the con- tents of the bottle. <3J-iJ. lor exter- nal use. For exter- nal use. lrix-xx. 1T\V-X. f^ss. Used ex- ternally. rn^x-xx. gtt. x-i3j; also used externally. TTiy. External use. PHARMACOPQZIAL GROUPS. 143 Mellita (Honeys).—The only officinal preparations made with honey, instead of sugar, are— Mel despumatum. Used in the preparation of mel rosa?. Mel sodii boratis. Both are employed as mouth washes, or adjuvants to washes for the oral cavity. MiSTURiE (Mixtures).—The dose of each of the officinal mixtures in the following list is here given ; that of the almond emulsion being ad libitum:— Mistura ammoniaci, f3"ss-j. Mistura creta?, f^j. " amygdala?. " ferri composita, f3*ss-j. assafoetida?, f§ss-iss. " glycyrrhiza? composita, fjss. " chloroformi, f 3ij-iv. " potassii citratis, f^ss. Mucilagines (Mucilages).—These are— Mucilago acacia?. i Mucilago tragacanthse. " sassafras medulla?. | " ulmi. All of these, except mucilage of tragacanth, are em- ployed on account of their demulcent action, ad libitum, and also externally. Oleoresix^e (Oleoresins).—These preparations, formerly called fluid extracts, are solutions of the waxy and resinous constituents of the drug, produced by pass- ing ether through the powdered drug in a covered displacement apparatus. The doses are—^ Oleoresina capsici, employed ex- j Oleoresina lupulinae, gtt. v-x. ternally. " piperis, gtt. j-v. Oleoresina cubeba?, gtt. v-xxx. " zingiberis, gtt. j-v. " filicis, n|v-xv. I Pilula.—Only two pilular masses are officinal under this name— Pilula ferri carbonatis . . gr. x-xx. " saponis composita . gr. j of opium in every gr. v of the mass. gr. v. Pilulae (Pills).—Brief mention is here made of a variety of formulas for pills contained in the Pharmacopoeia. 144 PHARMAC OP GLIAL GROUPS. The proportion of the main ingredients in a single pill is given. It is not considered, therefore, essential to designate the number of pills to be prescribed as a dose. Pilula? aloes, gr. ij. " aloes et assafoetida?, gr. j^ of each. " aloes et mastiches (.Lady Webster's pills), gr. ij aloes, gr. ss raastich. " aloes et myrrha?, gr. ij aloes, gr. j myrrh. " antimonii compositae, gr. ss, each, of calomel and sulphurated antimony, gr. j guaiac. " assafoetida?, gr. iij. " cathartica? composita?, gr. j£ coinp. extract of colocynth; gr. j each of extract of jalap and calomel; gr. \ gamboge. " copaiba?, gr. ivi. " ferri compositae, gr. iss myrrh, gr. | each of carbonate of sodium and sulphate of iron. " ferri iodidi, gr. f f iodine, gr. y57 iron wire, gr. | reduced iron. " galbani compositae, gr. iss each of galbanum and myrrh, gr. ss of assafoetida. " hydrargyri, gr. j mercury in every three grains of the mass. " opii, gr. j. " quinia? sulphatis, gr. j. " rhei, gr. iij. " rhei composita?, gr. ij rhubarb, gr. iss aloes, gr. j myrrh. " scilla? composita?, gr. ss squill, gr. j each of ginger and ammoniac. Pulveres (Powders). Name. Pulvis aloes et canella? (Hiera picra) . - Pulvis aromaticus Pulvis ipecacuanha? com- positus (Dover's powder) Pulvis jalapa? compositus . Pulvis rhei compositus Pulveres effervescentes (soda powders) Pulveres effervescentes aperientes (Seidlitz pow- ders) Strength, etc. 3iv aloes, 3J canella. §j each cinnamon, ginger; §ss each cardamon, nut- meg. gr. lx each ipecacuanha, opium ; sulphate of potas- sa, H- ^ss jalap, §j bitartrate of potassium. §i rliubnrb, §iij magnesia, §ss ginger. Bicarbonate of sodium, gr. xxx; tartaric acid, gr. xxv. Tartrate of sodium and po- tassium, gr. cxx; bicar- bonate of sodium, gr. xl (in one paper) ; tartaric acid, gr. xxxv (in another paper). Dose, etc. gr. x-xx. gr. x-xx. gr. x. gr. xx-3ij. gr. xx-3ij. ") In separate papers, Mix water. \ J 1 j In separate j papers. | Mix in I water. PHARMA COPGHAL GR0UPS. 145 Resins (Resins).—But tliree of these preparations are officinal. Resina jalapa?, gr. v. Resina podophylli (podophylli- uum), gr. i-j. Resina scammonii, gr. v. Spiritus (Spirits).—But few of the following articles of this group are used medicinally, the doses of such being mentioned. Some of them are employed as flavoring agents; others are carminative. Spiritus a?theris compositus, Tn_xxx -t'3J- " aetheris nitrosi, f3ss-j. " ammonia?, U|xxx, also for external use. " ammonia? aromaticus, U|xxx-f3j. " anisi, f3ss-t'5ss. " camphora?, n"Lxx. " chloroformi, i'3j. " cinnamoini, f3J-f§ss. Spiritus juniperi, f'3j. " compositus, t'3j- lavandulae, t3s^-j. " compositus, TTlxl-f3ij. limonis. mentlue piperitae. ~U|v-xx. mentbae viridis, Tn_v-xx. myristica?, f'5j-f§ss. Succi (juices).—Only two of these are officinal— Succus conii, n\xxx-f5j. Succns taraxaci, f3ij-iv. Suppositoria (Suppositories).—It is desirable that the practitioner should know the strength of such of the articles of this group as he wishes to employ. The quantity of the active ingredient in each suppository is therefore mentioned. Suppositorium acidi carbolici, gr. j in eacli. " acidi tannici, gr. ij in each. " aloes, gr. v in each. " assafoetida?, Ttixl of the tincture. " belladonna?, gr. ss. Suppositorium morphiae, gr. ss. opii, gr. j. '• plumbi, gr. iij of the acetate. plumbi etopii.gr. iij of the acetate, and gr. ss of opium. Syrupi (Syrups).—In the following list the proportion of the active ingredient is mentioned only in such syrups as are of practical moment to the prescriber: — 10 146 PHARMACOPCEIAL GROUPS. Name. Strength, etc. Dose, etc. Syrupus.............Used as a vehicle and for making other sy- rups. " acacia?...........f3j-i'j- Chiefly used as a vehicle. " acidi citrici......... " " allii............f 3j—i v. " amygdala?..........f3i-iv. " " aurantii corticis........f3i~ij. " " florum........f'3j-ij- " " ferri iodidi . . f§ij of iodine, 3V °f iron wiie, to f^xx. "n^v-xx. " ipecacuanha? . f^j of fluid extract in Oj. f5j- " krameria? . . fgj of fluid extract in i'3»j. f3i- " lactucarii . . gj in Oj. f 3.j. " limonis...........i Sj —iij. Chiefly used as a vehicle. " pruni virgini- ana? . . . §v of wild cherry to Oj. f5j_iij- " rhei .... f^iij of fluid extract in Oij. f3'j- " " aromaticus giiss of rhubarb, with aromatics, etc., to Ovij. f3j-iv. " rosa? gallica?.........f Sj—iij - Chiefly used as a vehicle. " rubi .... f gviij of fluid extract in Ojss. f^ss. " sarsaparilla? §vj of sarsaparilla, etc., compositus . to Oj. f §ss. " scilla? . . . Oj of acetum scilla? with sugar. f3j. " " compositus § ij each of squill and (hive syrup) seneka, gr. xxiv of tartar emetic in Oiss. f3 j. " senega? . . . §iv to Oss .... t'3j-ij. " tolutanus......... f3j-ij. " zingiberis..........f5J-'V. Chiefly used as a vehicle. Tincture (Tinctures).—The strength and doses of this important group of remedies are given in the follow- ing schedule. As the object is to afford a tangible mode of reference to the practitioner for such articles as he may desire to employ, no attempt at classi- fication, according to therapeutic qualities or phar- maceutical peculiarities, has been made. The men- struum is usually alcohol or diluted alcohol. PHARMACOPGZIAL GROUPS. 147 Name. Strength, etc. Dose. Tii ctura aconiti radicis §vj to Oj. TTI ij-iv. " aloes . §ss to Oj. f§ss-j. " " et myrrha? §iss of each to Oj. f3j-ij- " arnica? . |iij to Oj. Used exter-nally. " assafoetida? . 3'j to Oj. f3*s-j. " aurantii 3'j t0 °J- l'3ss-ij. " belladonna? §'j to Oj. "1X-XV. " benzoini |iij to Oj. f3ss. " benzoini composi ta giss benzoin,3'j aloes, ) . ~. §j storax, §ss tolu. j J f3ss. " calumba? I'j to Oj. f3ij-iv. " cannabis gr. ccclx of extract to Oj. TTJV-XV. " cantharidis. §ss to Oj. Tl^X. " capsici §ss to Oj. f3^-j- " cardamomi 5 J to Oj. t'3J-i'J- " " composita 3vj cardamom, 3'j caraway, 5v cinnamon, 3j cochineal to Oiiss. f3ij-f3ss. " castorei • ?j to Oj. f3ss-ij. " catechu §iss to Oj. f3J-iJ- " cinchona? §iij cinchona flava to Oj. f3j-i^- '; " composita §iv cinchona rubra, §iij bit- (Huxham's tincture) ter-orange peel, gr. ccclx serpentaria to Oiiss. f 5J-iv. '■ cinnamomi fiss to Oj. f3j-ij- " colchici §ij colchicum seed to Oj. Tr\ x-xxx. " conii . 3u to Oj. H|xv-xxx. '; cubeba? 3'j to Oj. f3J-iJ- " digitalis 1 j to Oj. rn,v. " ferri chloridi Oss solution of chloride of iron and Oiss alcobol. nix. " galla? . -?ij to Oj. f3J-i'j. " gentianaecotnposi ta ^j gentian, §ss bitter-orange peel, 3'j cardamom to Oj. f3j-i'j- " guaiaci 3''j to Oj. f3j-ij- " " ammoniata §iij to Oj aromatic spirit of ammonia. f 3j-ij- " hellebori . 3>j to oj. f3ss-j. " humuli §iiss to Oj. f'3j-i'j- " hyoscyami . Vl to Oj. Uixv-f3j. " iodinii 3j to oj. Used exter-nally. " " composita. |ss iodine, §j iodide of po- tassium to Oj. rt\viij-xv. " jalapa? 3'ij to Oj. f3.i-iv. " kino . gr. ccclx to Oss. f3.i-ij- " krameria? . m toOj. '3.HJ- " lobeliae §'j to Oj. f3J-iJ- " lupulinae 3'j to Oj f3.i-ij- " myrrhae §iss to Oj. f3J- " nucis vomicae i\v to Oj. TTlij-x. 148 PH ARM AC OP GLIAL GROUPS. Tino! Name. Strength, etc. Dose. ura opii M t0 0j- , -n , Tl^x-XX. " acetata 3j to fgvj distilled vinegar and ffiv alcohol. »n.x. " camphorata gr. xxx each, opium and ben-zoic acid, gr. xx camphor, f3ss oil of anise, 3J clari- fied honey to Oj. f3J-iv- " deodorata l\\ to Oj. rr\,x-xij. quassia? |j to Oj. '3j-ij- rhei |iss rhubarb, 3'j cardamom toOj. f3u-f3J- " et sennae §i rhubarb, 3ij senna, 3j each of coriander and fennel, etc. > to Oiij. f^ss-ij. sanguinaiia? 3;j to oj. f38S-j. scillae . 3'j to Oj. 1T\ X-XXX. serpent aria? 3'j to Oj. f3J-iJ- stramonii 3o to oj. h\ v-x. tolutana §iss to Oj. f3 rectified spirit colored with alkanet root ^x. Hoffman's Anodyne, Hoffman's Mineral Anodyne Liquor.—Spiritus iEtheris Compositus (Ph. U. S.), composed of ether, etherial oil, and alcohol, is an imitation of a solution made by the celebrated Hoffman in 1732. Hoffman's Pills.—These pills consisted of corrosive sublimate gr. J, with distilled water, and bread crumbs to make a pill. Hooper's Female Pills—Compound pills of aloes, dried or crystallized sulphate of iron, extract of hellebore, myrrh, soap, canella, and ginger. Hope's Mixture.—A mixture of nitrous acid, tincture of opium, and camphor water, used in dysentery, diarrhoea, etc. Husson, Eau Medicinale de.—See Eau Modicinale. Huxham's Tincture of Bark.—Tinctura Cinchon® Composita (Ph. U. S.) is an imitation and also an improvement on the formula of the celebrated English physician. Jackson's Pectoral Lozenges.—A favorite lozenge after a prescription of the late Prof. Samuel Jackson. Each lozenge contains ipecac. powdered gr. fa, sulphuretted antimony gr. fa, muriate of morphia gr. fa, gum arabic, sugar, aud powdered extract of liquorice, each gr. 3.3, tincture of tolu gr. 1£, and oil of sassafras gtt. fa. Jackson's Ammonia Lozenges contain in each muriate of ammonia gr. ss, muriate of morphia gr. fa, powdered elm bark gr. ij, pow- dered gum arabic, powdered sugar, powdered extract of liquorice, each gr. ij^, tincture of tolu gtt. j, oil of partridge-berry gtt. fa. Jackson's Pectoral Syrup.—A prescription of the late Prof. Samuel Jackson, consisting of sassafras pith ,^j, sugar lb. If, gum arabic §j, muriate of morphia gr. viij, water Oj. Teaspoonful a dose. James's Powder —A powder, patented by Dr. James, of England, in the 18th century, which was imitated in the Ph. U. S. under the name Pulvis Antimonialis. CELEBRATED PRESCRIPTIONS OR REMEDIES. 209 Javelle's Water. Eau de Javelle.—A solution prepared from carbon- ate of potassium in the same way that solution of chlorinated soda is prepared from carbonate of sodium. Jesuit's Drops.—Sometimes called Friar's Balsam, Wound Balsam, Balsamum Traumaticum, etc. This is the Tinctura Benzoini Com- posita (Ph. B.). Jesuit's Powder. Jesuit's Bark.—A synonym for powdered cinchona or bark, because one of the most active agents in its introduction was the Cardinal de Lugo. It fell into disuse, but was revived by Sir Robert Talbor; hence it was called Talbor's Powder or the Eng- lish Remedy. Kentish Liniment.—The old name of a liniment of which Linimen- tum Terebinthin® (Ph. U. S.) is an imitation. Kirkland's Neutral Cerate.—A dressing to indolent ulcers, which was afterwards imitated in the Unguentnm Plumbi Compositum (Ph. B.), and composed of prepared chalk, distilled vinegar, aud lead plaster. Labarraque's Solution, Labarraque's Soda Disinjectinq Fluid. Liquor Sod® Chlorinat® (Ph. U. S.). Lady Crespigny's Dinner Pills.—See Lady Webster's Dinner Pills. Lady Haskett's Dinner Pills.—See Lady Webster's Dinner Pills. Lady Webster's Dinner Pills.—Pilul® Aloes et Mastiches of the Ph. U. S. The Pilul® Stomachic® of the Paris Codex, edition of 1758. They have been called also Lady Haskett's and Lady Crespigny's Dinner Pills. Lartique's Gout Pills.—These consist of compound extract of colocynth gr. iv, acetic extract of colchicum gr. |, extract of digitalis gr. \. Ledoyen's Disinfecting Fluid.—A solution of nitrate of lead in water, formerly used as a disinfectant. Liebig's Extract of Beef.—A concentrated preparation of meat, con- taining neither fat nor gelatin, and being rich in nitrogenous prin- ciples. Lisbon Diet Drink.—A celebrated decoction, of which Decoctum Sar- saparill® Compositum of the Ph. U. S. is an imitation. Logan's Plaster.—Made of litharge, carbonate of lead, castile soap, fresh butter, olive oil, and mastic. London Powder.—Same as Vienna Powder. Lugol's Solution.—Liquor Iodinii Compositus (Ph. U. S.) is a substi- tute for that of Lugol, who proposed in a work translate \ into Eng- glish, in 1831, several solutions of iodine ; a concentrated solution of iodine in iodide of potassium, an ioduretted mineral water, and various caustic, rubefacient, and stimulant solutions. Magendie's Solution of Morphia.—A solution of morphia prepared by dissolving 16 grains of sulphate of morphia in f §j of water; the French solution, known as Magendie's, is not so strong, being pre- pared by dissolving 0.8 grain of acetate of morphia in 30 grains of water. 14 210 CELEBRATED PRESCRIPTIONS OR REMEDIES. Maby's Plaster.—A plaster imitated in the Ph. U. S., 1830, in the plaster of the carbonate of leal, and consisting of carbonate of lead, olive oil, yellow wax, lead plaster, and Florentine orris. Marseilles Vinegar.—See Thieves' Vinegar. Marshall's Pills.—Each pill contains one grain each of compound ex- tract of colocynth, blue mass, aloes, Castile soap, and rhubarb. Martin's Cancer Powder.—A remedy for cancer, of which the chief ingredient was arsenious acid. Martin's Haemostatic—Employed in France particularly, and con- sisting of selected pieces of spunk saturated with ferric chloride. Matter of Derosne.—See Derosne. Maynard's Adhesive Liquid.—Collodion was at first so called, after Mr. Maynard, who probably introduced it into surgical practice. McMunn's Elixir.—A celebrated narcotic nostrum, in which opium was the active iugredient, the elixir being of about the strength of laudanum. Mercury of Life.—See Algaroth's Powder. Mettauer's Solution or Aperient.—A laxative infusion, consisting of Aloes Socot. 3V ; Sodii bicarb, ^xj ; Valerian contns. ^j ; Water, Oj ; Comp. spirit of lavender, f3vj- Dose, a dessertspoonful or table- spoonful. Mindererus, Solution of.—A solution of acetate of ammonia was first described by Boerhaave in 1732, and subsequently employed by Minderer or Mindererus, and hence called Spiritus Mindereri. It is officinal (Ph. U. S.), as Liquor Ammoni® Acetatis. Mitchell's Aperient Pills.—These contained aloes gr. j; rhubarb, gr. ij; calomel, gr. ^; tartar emetic, gr. y1^. Mitchell's Tonic Pills.—A favorite prescription of the late Prof. John K. Mitchell, of Philadelphia, consisting of extract of quassia gr. iij; extract of conium, gr. £ ; subcarbonate of iron, gr. £. Monsel's Solution.—The Liquor Ferri Subsulphatis of the U. S. Ph. Mutter's Aromatic Pills.—A prescription for gonorrhoea of the late Prof. Mutter, of Philadelphia, consisting of the oils of copaiva, cu- bebs, and turpentine, each n\j ; magnesia, gr. ij. Mynsicht's Elixir. —See Elixir Vitrioli Mynsichti. Norwood's Tincture.—A saturated tincture of Veratrum viride. Otto's Emmenagogue Pills.—A prescription of the late Dr. J. C. Otto, consisting of dried sulphate of iron, gr. j|; aloes, gr. f-; turpentine gr. j; oil of turpentine, gr. i. Pagliari, Eau de.—See Eau de Binelli. Parrish's Compound Syrup of Phosphates, Chemical Fond.—An excellent tonic prepared by the late Prof. Edward Parrish, each teaspoonful of which contains about 2.^ grs. of phosphate of cal- cium, gr. i of phosphate of iron, with fractions of a grain of phos- phates of sodium and potassium, besides free phosphoric and hydrochloric acids. Paste of Canquoin.—Chloride of zinc pencils, prepared by dissolving chloride of zinc in a small quantity of water, and adding, with con- tiuual trituration, an equal weight of flour. CELEBRATED PRESCRIPTIONS OR REMEDIES. 211 Pearson's Arsenical Solution.—This has a place in the French Codex, and is made by dissolving 1 part of crystallized arseniate of sodium in 600 parts of distilled water. Physick's Medicated Lye.—An alkaline solution, made by digesting hickory ashes and soot in water for 24 hours ; recommended by the late Dr. P. S. Physick for dyspepsia. Pierlot's Solution.—When valerianate of ammonium was first intro- duced as a medicine, M. Pierlot, of Paris, made a solution of uniform strength, which received his name. Plummer's Pills.—Pilul® Antimonii Composit® of the Ph. U. S. Plunket's Caustic.—At one time a well-known remedy for cancer, consi ting of ranunculus acris and ranunculus flammula, arsenious acid, and sulphur, in yolk of egg. Pommade de Gondret.—See Gondret. Portland Powder.—A celebrated remedy for gout, consisting of the roots of aristolochia roiunda and gentiana lutea, the tops and leaves of teucrium chani®drys, and erythr®a centaurium, and the leaves of ajnga cham®pitys. The same, or a similar mixture of powders was known to Ccelius Aureliauus. Quaker's Black Drop.—A celebrated quack medicine of former times, for which Aceturn Opii (Ph. U. S.) is an officinal substitute. It was also called the Lancaster Black Drop. Quevenne's Iron.—The powder of iron reduced by hydrogen from the oxide, was first described by Qnevenne ; hence the name so often applied to it. It is the Ferrum Redactum of the Ph. U. S. Rad cliffs Elixir.—A purgative combination of aloes, cinnamon, zedo- ary, rhubarb, cochineal, syrup of buckthorn, and spirit and water as the solvents, which at one time had a great reputation. Recamier's Caustic.—Chloride of gold gr. vj dissolved iu aqua regia f'§j- Rousseau's Laudanum.—A tincture of opium made with very weak alcohol; composed of white honey, water, opium, and alcohol. Rufus's Pills.—A name formerly given to the Pilul® Aloes et Myrrh® (Ph. U. S.). Sacred Elixir.—An old name for Tinctura Rhei et Aloes (Ph. U. S. 1850). St. John Long's Liniment.—A liniment popularly known by this name consisted of oil of turpentine and acetic acid held in suspen- sion by yolk of egg. Sal Digestivum Sylvii.—A name formerly given to chloride of potas- sium. Sal Polychrestus Glaseri.—An old preparation of sulphate of potassa with sulphur, at one time officinal in the Edinburgh Pharmacopeia. Sal Sedativus Hombergi.—A name formerly given to boric or boracic acid. Salt of Derosne.—See Derosne. Seigrette Salt.—A name formerly given to Rochelle Salts, Potassii et Sodii Tartras of the Ph. U. S. 212 CELEBRATED PRESCRIPTIONS OR REMEDIES. Scudamore's Mixture.—Once a popular remedy for the gout, con- sisting of sulphate of magnesium, mint water, vinegar of colchicum, syrup of saffron, and magnesia. Sels de Boutigny.—Iodide of calomel, proposed by M. Boutigny in 1847 for use in syphilitic, scrofulous, and cancerous affections. Spitta's Lozenges.—An imitation of these lozenges is officinal in the Ph. U. S. under the name Trochisci Cubeb®. Stahl's Aperient Pills.—These consisted of powdered aloes, compound extract of colocynth, iron filings, and mucilage of gum arabic. Sydenham's Laudanum.—Named after the celebrated English physi- cian ; now known as Acetum Opii (Ph. U. S.). Syrup of Cuisinier. Sirop de Cuisinier.—A celebrated French syrup, represented in the Ph. U. S. of 1820 in the formula for Syrupus Sarsaparill®. Talbor's Remedy.—See Jesuit's Pills. Tanjore Pills.—See Asiatic Pills. Thieves' Vinegar.—Sometimes called Marseilles vinegar or Vinegar of the Four Thieves, once supposed to be a prophylactic against the plague and other contagions diseases. It was imitated iu the Acidum Aceticum Aromaticum (Ph. E.). Tully's Powder.—Various formul® have been given, but the following is probably correct: sulphate of morphia 1 part, powdered cam- phor, powdered liquorice root, Euglish precipitated chalk, of each 20 parts. Turlington's Balsam.—The formula adopted by the Philadelphia College of Pharmacy includes alcohol, benzoin, liquid storax, Soco- trine aloes, Peruvian balsam, myrrh, angelica root, balsam of tolu, and extract of liquorice root. Turner's Cerate.—Formerly officinal (Ph. TJ. S.) as Ceratum Cala- min®. Vallet's Pills.—Pilul® Ferri Carbonatis of the Ph. U. S. Vienna Caustic or Vienna Powder.—Officinal (Ph. U. S.) as Potassa cum Calce. A stronger preparation, known in Fiance as Caustique de Filhos, is made by fusing 100 parts of caustic potassa, adding thereto 10 parts of powdered burned lime, and pouring the mass into lead tubes of suitable size to harden. Vienna Draught.—This is the Infusum Senn® Compositum of the German Pharmacopoeia, and contains senna, water, tartrate of sodium and potassium, and manna. Vigo's Plaster.—A mercurial plaster of the French Codex, containing turpentine and gum resins. Vinegar of Four Thieves.—See Thieves' Vinegar. Ward's Paste.—The London Pharmacopoeia gave the following recipe for this well-known remedy for piles: black pepper and elecam- pane §j of each, fennel seeds §iij, honey and sugar §ij each. Dose 5j-'j- Warner's Cordial.—A laxative preparation for which Tinctura Rhei et Senn® (Ph. U. S.) is a substitute. CELEBRATED PRESCRIPTIONS OR REMEDIES. 213 Wistar's Cough Lozenges.—A form of lozenge long popular, in Phila- delphia especially, the Trochisci Glycyrrhiz® et Opii of the Ph. U. S. Zittmann's Decoction.—A preparation of Sarsaparilla popular in Ger- many, especially in obstinate ulcerative affections. The formula of the Prussian Pharmacopoeia is generally adopted. The stronger decoction is made as follows : sarsaparilla §xij, spring water lb. xc. Digest for 24 hours; then introduce, inclosed in a small bag, giss of sugar of alum (powdered alum and whitest sugar equal parts), §ss of calomel, and 3j of cinnabar. Boil to lb. xxx, and near the end of boiling add §ss each of aniseed and fennel seed, §iij of senna, and _^iss of liquorice root, and put aside the liquor. The weak decoction is made by adding to the residue 3 iij of sarsa- parilla and lb. xc of water. Boil to lb. xxx, and near the end add lemon peel, cinnamon, cardamom, and liquorice, of each ^iij. Strain and set aside the liquor. The decoction may be drunk freely. 214 SELECTED PRESCRIPTIONS. SELECTED PRESCRIPTIONS FROM PRACTI- TIONERS' CASE-BOOKS. In illustration of the general principles already laid down as to the doses of medicines, and in continuation of the subject of the applicability of remedial agents to a multitude of morbid conditions, the following prescrip- tions, culled from an immense mass of such material kindly placed at the disposal of the author, will doubt- less prove of practical service. Being the fresh and very recent formulae employed by leading medical men in active professional practice, whose daily experience is but a reflexion and counterpart of that of every other busy practitioner in all portions of the country, such prescriptions offer at once desirable methods of combin- ing reliable medicines and indicate some of the applica- tions of the more modern remedies. They may also, in some instances, by suggesting new trains of thought, aid to lift the mere routinist above the level of a blind adhe- rence to fixed modes of prescribing and dispensing medi- cines. It is desirable, indeed, that even with the formulae now offered, the practitioner should intelligently appre- ciate the motives for making such combinations of various agents in the same prescription, and under no other cir- cumstances adopt any of them in his own practice. No attempt has been made to give anything like complete-^ ness to this merely illustrative collection of scattered formulae. SELECTED PRESCRIPTIONS. 215 Alopecia. 1. R. Olei ricini, f 3vj ; Aqu® aminoni®, f3j ! Tinctur® cantharidis, f §ss ; Aqu® Cologniensis, f§ij ; Aqnam ad f §v. M. S. Apply as a wash. 2. R. Tinctur® cantharidis. f5'j_,v; Spiritus ammoni® aromatici, l'5xv ; Glycerin®, f§j ; Aqu® rosmarini destillat®, f.^xx. M. S. Apply as a wash. Anaemia, Chlorosis, etc. 3. R. Ferri et ammonii citratis, gr. xxx ; Tinctur® calumb®, " nucis vomic®, aa gtt. xxx ; Sacchari albi, £iij ; Aqu®, f.^iij. M. S. A teaspoonful three times a dav. (Tonic for a child 2 years of age.) 4. R. Ferri pyrophosphatis, Quini® sulphatis, aa 5j ', Strychni®, gr. j ; Acidi phosphorici diluti. f5'j ; Syrupi zingiberis, q. s. ; Aquam ad f §iv. M. S. A teaspoonful tliree times daily. 5. R. Hydrargyri chloridi corrosivi, g«-- j; Liquoris arsenici chloridi,f^ss; Tinctur® ferri chloridi, Acidi hydrochlorici diluti, aaf5ij; Syrupi zingiberis, f §iiss ; Aquam ad f §vj. M. S. A tablespoonful in water, after each meal. 6. R. Ferri pulveris, Quini® sulphatis, aa gr. xxv ; Acidi arseniosi, gr. j. M. Divid. in pilulas xxv. S. One three times a day. R. Strychm® sulphatis, gr. ss-j ; Tinctur® ferri chloridi, f 5iij ; Acidi acetici diluti, f^iv ; Liquoris ammonii acetatis, fgiiiss ; Syrupi, Curacoa, aa f §j ; Aquam ad f§x. M. S. A tablespoonful, in water, three times a day. 8. R. Quini® sulphatis, 5j ; Ferri sulphatis, gr. xlv ; Strychni®, gr. j; Acidi arseniosi, gr. iss. M, Divid. in pilulas xxx. S. One before each meal. 9. I£. Ferri carbonatis, 5j 5 Quini® sulphatis, gr. xxx; Strychni®, gr. ss. M. Divid. in pilulas xxx. S. One three times daily. 216 SELECTED PRESCRIPTIONS. 10. R. Tinctur® cinchon® composit®, fgiiss ; " nucis vomic®, f5'ss i Curacoa, f§ij ; Acidi phosphorici diluti, f3•'j• M. S. A dessertspoonful, in solution, after each meal. Asthma. 11. R. vEtheris, f giss ; Tinctur® loheli®, f 5j ; " opii, " stramonii, aa f^ss. M. S. A teaspoonful every hour or two until nausea results. 12. R. Potassii iodidi, gr. xxx; Spiritus ammoni® aromatici, f5^; Tinctur® belladonn®, f 5j; " cinchon® composit®, f,?j; Aquam menth® piperit® ad fgxij. M. S. A wineglassful three times a day. Bronchitis. 13. ft. Spiritus chloroformi, f§ss ; Acidi hydrobromicidilut. f^vj; Syrupi scill®. f §iss ; Aquam ad f.^vj. M. S. A tablespoonful as directed. A sedative cough-mixture.) 14. ;. Morphi® sulphatis, gr. ij-ij; Acidi sulphurici, gtt. ij-ij; M. et adde — Tinctur® serpentari®, f^j; Vini antimonii, " ipecacuanh®, aa f 5'j! Tinctur® anisi, ! 3,i ; Syrupi pruui Virginian®, f = iv. M. S. A teaspoonful pro re natd. 15. R. Morphi® acetati-i, gr. ij; Tinctur® sanguinari®, l'3ijj Vini ipecacuanh®, Extracti pruni Virginiana3 liuidi, aa t'3'S ; Syrupi seneg®, " tolutani, aa f§iss. M. S. A tablespoonful every four hours. 16. R. Potassii chloratis, gr. xl; Acidi sulphurici aromatici, TUxxx ; Syrupi scill®, " pruni Virginian®, aa f§ss; Aqu®, f^iss. M. S. A teaspoonful every two or three hours. 17. R. Antimonii et potassii tartratis, gr. ss; Acaci® pulveris, 5'j ; Liquoris morphi® sulphatis, Syrupi seneg®. " aurantii corticis, Sa f§ss ; Aqu®, f§iv. M. S. A tablespoonful three or four times daily. SELE C TED PRES CRIPTIONS. 217 18. R. Tinctur® lobeli®, f§ss; " opii camphorat®, *>j; Syrupi scill®, f §i?s ; " ipecacuanh®, f5ij ; Acaci®, ^j. M. S. A teaspoonful every three or four hours. R. 19. R. Morphi® acetatis, gr. viij ; Potassii cyanidi, gr. J ; Extracti piuui Virginian®. f.^vj; Syrupi tolutani, f ^ij. M. S. A teaspoonful when cough is troublesome. (An excellent sedative mixture.) 20. R. Ammonii chloridi, 3'j ; Extracti glycyrrhiz®, 3j ; Aceti opii, f^j ; Syrupi aurantii, f^ij ; Aqu® destillat®, f§iv. M. S. A tablespoouful three or four times a day. Burns. 21. R. Iodoformi, 3'j ; Unguenti cetacei, §j ; Extracti conii, 3'ss ; Acidi carbolici, Tti^x. M. S. Apply to the affected surface. 22. R. Liquoris calcis, Glycerin®, aa f^j ; Olei amygdal®, fjij. M. S. Apply locally. Chaps. 23. Zinci oxidi, gr. xl; Acidi tannici, gr. xxx; Glycerin®, fgij ; Tinctur® beiizoini, fgj ; Camphor®, gr. xxx. M. Apply to the affected part. Chilblains. 24. Acidi carbolici, gr. iv; Glycerin®, f 5'ss; Alcoholis (85°), q. s. ad f^vj. M. Apply locally. 25. Cerati simplicis, Olei oliv®, aa f^ij ; Glycerin®, f3'j ; Spiritus camphor®, f 3j. M. Apply locally. Cholera Infantum. 26. R. Acidi sulphurici aromatici, TTlx ; Extracti h®matoxyli, gr. xv ; Curacoa, f 3.1 ; Syrupi, f"3xj. M. S. A teKspoonful every one, two, or three hours, for a child two years old. (See Diarrhoea, etc.) 218 SELECTED PRESCRIPTIONS. Cholera Morbus. 27. R. Chloroformi, Tinctur® opii, " camphor®, Spiritus ammoni® aromatici, aa f 3ij ; Olei cinnamomi, mj ; Spiritus vini Gallici, f3iss. M. S. Half a teaspoonful as re- quired. (See Diarrhoea, etc.) Cold in the Head. 28. R. Morphi® muriatis, gr. ij ; Ac-aci® pulveris, 3ij ; Bismuthi subnitratis, 3vj- M. S. Use this amount as a snuff in from two to four days. Colic, Cramps, etc. 29. R. Chloroformi, Tinctur® opii, " camphor®, Spiritus ammoni® aromatici, aa f5iij ; Olei cinnamomi, rt^iij ; Spiritus vini Gallici, f §ss. M. S. Half a teaspoonful or more as required. 30. R Morphi® sulphatis, gr. j ; Chloroformi, f3'j ; Syrupi zingiberis, fgij. M. S. A teaspoonful every five min- utes until relieved. 31. R. Aqu® camphor®, f gj ; Spiritus ®theris compositi, f5U; Tinctur® cardamomi compo- sit®, f§ss; Spiritus auisi, f3vj ; Olei carui, TT^xij ; Syrupi zingiberis, f3'j ; Aqu® menth® piperita, f^vss. M. S. Half a wineglassful pro re. natd. 32. R. Spiritus ®theris, " chloroformi, aa f3iij ; Tinctur® cardamomi composi- te, {3VJ ; Spiritus myristic®, fgij ; Olei carui, v\ xij ; Mucilaginis tragacanth®, f §iij; Aquam menth® piperit® ad f§viij. M. S. Half a wineglassful as re- quired. Constipation. 33. R. Sodii et potassii tartratis, 5'iss'; Sacchari albi, 3V ; Sodii bicarbonatis, Acidi tartarici, aa 3.1 < Olei limonis, q. s. M. S. A teaspoonful in sweetened water. 34. ft. Resin® podophylli, gr. ij; Extracti hyoscyami, Saponis Castiliensis, a&gr. viij. M. Divid. in pilulas xxiv. S. One at night. SELECTED PRESCRIPTIONS. 219 35. R. Senn® pulveris, Extracti glycyrrhiz®, aa §ss ; Fceniculi seminis, Sulphuris pr®cipitati, aa 5ij ; Sacchari albi, §iss. M. S. One or two teaspoonfuls at bedtime. (The pulvis glycyrrhiz® compo- situs, compound licorice powder, of the Prussian Pharmacopoeia.) 36. R. Ferri sulphatis, .^iij ; Aloes pulveris, 3!j ; Zingiberis pulveris, ^iiss ; Extracti nucis vomic®, gr. xl Confectionis ros®, q. s. M. Divid. in pilulas cxx. S. One three times a day. 37. R. Podophyllini, gr. ij ; Aloes Socotrin®, Extracti nucis vomica, aa gr. xij ; Ferri sulphatis exsiccati, gr. xxx. M. Divid. in pilulas xxiv. S. One three times a day. 38. R. Aloes Socotrin®, Gambogi®, Hydrargyri chloridi mitis, aa gr. xv ; Extracti taraxaci, q. s. M. Divid. in pilulas xv. Diarrhoea. 39. R. Acidi sulphurici aromatici, Tinctur® capsici, aa gtt. xxx ; " opii, " camphor®, aa f 3j ; " zingiberis, f gij ; " cardamomi cotnposi- t®, f^x. M. S. A teaspoonfulin atablespoon- ful of water every hour, or oftener if necessary. Useful to travellers as a preven- tive of diarrhoea from change of water, etc. 40. R. Olei ricini, Ti^xxiv ; Spiritus chloroformi, f 3'ss ; Liquoris morphi® sulphatis, fsj; Acaci® pulveris, 3llSS ! Syrupi, f §ss ; Aquam ad fjfiv. M. S. A small dessertspoonful every hour and a half until the bowels are quieted. 41. R. Sodii bicarbonatis, ^j ; Tinctur® cardamomi compo- sit®, f gj; " camphor®, " opii, aa f §ss ; Syrupi rhei aromatici, f^ss ; Aquam menth® piperit® ad f§iv. M. S. A teaspoonful three or four times a day. 2.20 SELECTED PRESCRIPTIONS. 42. R. Acidi sulphurici aromatici, f3''j; Extracti h®matoxyli, 3'j I Tinctur® opii camphoiat®, f 5ss ; Syrupi zingiberis, q. s. ad f §vj. M. S. A tablespoonful as directed. Diarrhoea (of Infants). 43. R. Bismuthi subcarbonatis, gr. xx ; Cret® pr®parat®, 3j ; Spiritus lavandul® compositi, t'5ij; Tinctur® opii, f[y'] ; " l Aqu® ros®, fjiv. M. S. Mouth wash. Sick Headache. 108. R. s Potassii bromidi, gij ; Extracti belladonn® fluidi, v\ xxx; Aqu® destillat®, 13 ij. M. Half a teaspoonful to a tea- spoonful every three or four hours. Sore Nipples. 109. R. Acidi salicylici, §j ; Sodii boratis, 317 ', Glycerin®, f§iv. M. S. Apply to the breast. 110. R. Plumbi nitratis, gr. xx-xxx, Glycerin®, f$j. M. S. Apply to the breast. 111. R. Acidi tannici, 3j ; Collodii, f§j. M. S. Apply to the breast. 112. R. Iodoformi, 3.j ; Glycerin®, f 3ss-j. M. S. Apply to the breast. 228 SELECTED PRESCRIPTIONS. Sore Throat. 113. R. Acidi carbolici, tt^xx ; " acetici, 3SS \ Mellis, Tinctur® myrrh®, aa f3ij Aquam ad fgvj. M. S. Gargle. Spinal Irritation. 114. Potassii bromidi, §ss ; Extracti valerian® fluidi, f§ij ; Spiritus ammoni® aromatici, f§j; Syrupi, f § j. M. A teaspoonful three or four times daily. Toothache. 115. R. Creasoti, Aqu® ammoni® fortioris, Tinctur® myrrh®, ail f'3j M. S. Apply on very small piece of cotton-wool soaked into the cavity. 116. . Acidi carbolici (sol. sat.). Tinctur® opii, Extracti aconiti fluidi, aa fgj ; Olei menth® piperit®, rr^ xxx. M. S. Apply on cotton to the cavity. 117. R. Creasoti, Chloroformi, aa f 3j ; Vini opii, f'3ij ; Tinctur® benzoini, n\ xxx. M. S. Apply on cotton to the cavity. Ulcers. 118. R. Collodii, f5j ; Olei ricini, Acidi carbolici, aa f 3ss. M- S. Apply locally. The name carbolic collodion has been given to this mixture. 119. . Acidi carbolici, §ss ; Camphor® pulveris, 3SS ; Cerati, § vij. M. S. Apply locally. daily. Vomiting. 120. Acidi hydrocyanici diluti, gtt. xx ; Bismuthi subnitratis, 3j ; Tinctur® gentian® composit®, f5iij : Syrupi zingiberis, f§j ; Spiritus ammoni® aromatici, m; Aqu®, fgij. M. A tablespoonful three times SELECTED PRESCRIPTIONS. 229 121. Chloroformi, f 3'j ; Tinctur® aconiti, fgiss ; " opii camphorat®, f^ss; Aqu® pur®, f^iij. M. . A teaspoonful every hour. 122. R. Bismuthi subnitratis, 3J > Potassii bromidi, 3\ss ; Acidi hydrocyanici diluti, n\xxx; Spiritus chloroformi, fgj ; Mucilaginis tragacanth®, . f§iss ; Aquam ad fgvj. M. S. Two tablespoonfuls every three or four hours. See Nausea.) Vomiting of Pregnancy. 124. Acidi nitrici diluti, " muriatici diluti. aa f 3'j ; Tinctur® gentian® composit®, three f3ss; Aquam ad f^viij. M. S. Two tablespoonfuls times a day. (See Vomiting.) Whooping-cough. 125. R. Chloral, gr. xij; Vini ipecacuanh®, f3.; ; Syrupi aurantii corticis, f3'jl Aqu® menth® piperit®, f §ss. M. S. A teaspoonful every fifteen or twenty minutes. 126. R Potassii bromidi, gr. xxx ; Tinctur® conii, fgj ; Syrupi scill®, f giij ; Aqu®, f gvj. M. S. A tablespoonful every two hours. 123. R. Spiritus pyroxylici rectificati, f3u; Tinctur® cardamomi compo- sit®, f,ij; viij. M. S. A teaspoonful every four hours. 127. Potassii bicarbonatis, 3'j ; " bromidi, §ss ; Syrupi ipecacuanh®, '• tolutani, aa f §j ; Aqu®, f §j. M. A teaspoonful every four or five hours. 230 HYGIENIC TREATMENT OF INFANTS. RULES FOR MANAGEMENT OF INFANTS DURING THE HOT SEASON. The following special rules for the care of young chil- dren during the summer season are those recommended by the Obstetrical Society of Philadelphia to the thought- ful attention of mothers.1 As they are of universal appli- cability in every portion of this country, and embrace in their recommendations so many points on which the prac- titioner is frequently consulted by parents in connection with the hygiene and general management of infants, it is hoped that their reproduction here will be the means of giving them a still more widespread dissemination:— Rule 1.—Bathe the child once a day in tepid water. If it is feeble, sponge it all over twice a day with tepid water, or with tepid water and vinegar. The health of a child depends much upon its cleanliness. Rule 2.—Avoid all tight bandaging. Make the cloth- ing light and cool, and so loose that the child may have free play for its limbs. At night undress it, sponge it, and put on a slip. In the morning remove the slip, bathe the child, and dress it in clean clothes. If this cannot be afforded, thoroughly air the day-clothing by hanging it up during the night. Use clean diapers, and change them often. Never dry a soiled one in the nursery or in the sitting-room, and never use one for a second time without first washing it. 1 A committee of this Society, appointed " to consider the Causes and the Prevention of Infant Mortality during the Summer Months," re- ported these rules March 5, 1874. The committee consisted of Drs. Wil- liam Goodell (Chairman), J. Forsyth Meigs, John L. Ludlow, Albert H. Smith, John S. Parry, and William F. Jenks. HYGIENIC TREATMENT OF INFANTS. 231 Rule 3.—The child should sleep by itself in a cot or a cradle. It should be put to bed at regular hours, and be early taught to go to sleep without being nursed in the arms. Without the advice of a physician, never give it any Spirits, Cordials, Carminatives, Soothing Syrups, or Sleeping Drops. Thousands of children die every year from the use of these poisons. If the child frets and does not sleep, it is either hungry or else ill. If ill, it needs a physician. Never quiet it by candy or by cake; they are the common causes of diarrhoea and of other troubles. Rule 4.—Give the child plenty of fresh air. In the cool of the morning and evening, send it out to the shady sides of broad streets, to the public squares, or to the Park. Make frequent excursions on the rivers. When- ever it seems to suffer from the heat, let it drink freely of ice-water. Keep it out of the room in which washing or cooking is going on. It is excessive heat that destroys the lives of young infants. Rule 5.—Keep your house sweet and clean, cool and well aired. In very hot weather let the windows be open day and night. Do your cooking in the yard, in a shed, in the garret, or in an upper room. Whitewash the walls every spring, and see that the cellar is clear of all rub- bish. Let no slops collect to poison the air. Correct all foul smells by pouring into the sinks and privies Carbolic Acid or Quicklime, or the Chloride of Lime, or a strong solution of Copperas. These articles can be got from the nearest druggist, who will give the needful directions for their use. Make every effort yourself, and ur:_>e your neighbors to keep clean the gutters of your street or of your court. Rule 6.—Breast-milk is the only proper food for infants. If the supply is ample and the child thrives on it,, no other 232 THE NATURAL FOOD OF INFANTS. kind of food should be given—while the hot weather lasts. If the mother has not enough, she must not wean the child, but give it, besides the breast, goat's or cow's milk, as prepared under Rule 8. Nurse the child once in two or three hours during the da}r, and as seldom as possible during the night. Always remove the child from the breast as soon as it has fallen asleep. Avoid giving the breast when you are over-fatigued or over- heated. Rule 7.—If, unfortunately, the child must be brought up by hand, it should be fed on a milk-diet alone—that is, warm milk out of a nursing bottle, as directed under Rule 8. Goat's milk is the best, and, next to it, cow's milk. If the child thrives on this diet, no other kind of food whatever should be given while the hot weather lasts. At all seasons of the year, but especially in summer, there is no safe substitute for milk if the infant has not cut its front teeth.1 Sago, arrow-root, potatoes, corn-flour, 1 The practitioner is reminded that the periods of eruption of the teeth are the following : — First Dentition. As a rule, the teeth of the lower jaw precede those of the upper, ex- cept in the case of the lateral inci Central incisors Lateral incisors First molars . . • Canines . Second molars Second First molars Central incisors Lateral incisors First bicuspids Second bicuspids Canines . Second molars . Third molars . ors. 5th to 8th month. 7th to 9th " . 12th to 16th " . 16th to 20th " . 20th to 36th Dentition. 5 th to 7 th year. . 7th to 8th " 8th to 9th " 9th to 10th " . 10th to 11th . 11th to 12th " . 12th to 13th " . 17th to 21st " DIETETIC TREATMENT OF INFANTS. 233 crackers, bread, every patented food, and every article of diet containing starch, cannot and-must not be depended on as food for very young infants. Creeping or walking children must not be allowed to pick up unwholesome food. Rule 8.—If the milk is known'to be pure, it should have one-third part of hot water added to it, until the child is three months old; after this age the proportion of water should be gradually lessened. Eaeh half pint of this food should be sweetened, either with a heaping dessertspoonful of sugar of milk, or with a teaspoonful of crushed sugar. When the heat of the weather is great, the milk may be given quite cold. Be sure that the milk is unskimmed; have it as fresh as possible, and brought very early in the morning. Before using the pans into which it is to be poured, always scald them with boiling suds. In very hot weather, boil the milk as soon as it comes, and at once put away the vessels holding it in the coolest place in the house—upon ice if it can be afforded, or down a well. Milk, carelessly allowed to stand in a warm room, soon spoils and becomes unfit for food. Rule 9.—If the milk should disagree, a tablespoonful of lime-water1 may be added to each bottleful. When- ever pure milk cannot be got, try the Condensed Milk, which often answers admirably. It is sold by all the leading druggists and grocers, and may be prepared by adding to ten tablespoonfuls of boiling water without sugar, one tablespoonful or more of the milk, according to the age of the child. Should this disagree, a teaspoon- 1 To mdce lime-water, take a handful of quicklime, slake it and put it into a quart bottle full of soft water. Shake the bottle well, and then allow the undissolved portion of the lime to settle. Pour off the clear liquid when needed, replacing it with more water, and after- wards shaking the bottle briskly. 234 DIETETIC TREATMENT OF INFANTS. ful of arrow-root, of sago, or of corn-starch may be cau- tiously added to a pint of the milk, as prepared under Rule 8. If milk in any shape cannot be digested, try, for a few days, pure cream diluted with three-fourths or four-fifths of water—returning to the milk as soon as possible. Rule 10.—The nursing-bottle must be kept perfectly clean; otherwise the milk will turn sour, and the child will be made ill. After each meal, it should be emptied, rinsed out, taken apart, and the nipple and bottle placed in clean water, or in water to which a little soda has been added. It is a good plan to have two nursing-bottles, and to use them by turns. The best kind is the plain bottle with a rubber nipple and no tube. Rule 11.—Do not wean the child just before or during the hot weather; nor, as a rule, until after its second summer. If suckling disagrees with the mother, she must not wean the child, but feed it in part, out of a nursing-bottle, on such food as has been directed. How- ever small the supply of breast-milk, provided that it agrees with the child, the mother should carefully keep it up against sickness; it alone \vill often save the life of a child when everything else fails. When the child is over six months old, the mother may save her strength by giving it one or two meals a day of stale bread and milk, which should be pressed through a sieve and put into a nursing-bottle. When from eight months to a year old, it may have also one meal a day of the yolk of a fresh and rare-boiled egg, or one of beef or mutton- broth into which stale bread has been crumbed. When older than this, it can have a little meat finely minced; but even then milk should be its principal food, and not such food as grown-up people eat. DIETETIC TREATMENT OF INFANTS. 235 To these recommendations may be added the following suggestions for the dietetic treatment of weakly and ema- ciated infants two or three months old, brought up by hand, in whom milk with lime-water excites griping and flatulence, with occasional attacks of vomiting and purg- ing.1 In these cases we can often succeed in rendering' the milk and lime-water digestible by adding an aromatic. Thus, to half a pint of cold milk add a teaspoonful of caraway seeds or chopped cinnamon, inclosed in a small muslin bag, and boil for five minutes. The bag is then withdrawn, and the lime-water, and milk-sugar, are after- wards added as usual. If this do not succeed, one of the diets given below can be tried. The child is to be fed every three hours from a feeding bottle with the following in alternate meals :— 1. One teaspoonful of Liebig's food for infants2 dis- solved in a teacupful of new milk and water (equal parts), with the addition of one tablespoonful of cinnamon-water. 2. A teacupful of fresh whey containing a teaspoonful of cream. If the amount of milk given above cannot be digested, as often happens, the proportion of water used to dilute 1 Eustace Smith, Wasting Diseases of Infants and Children; London, 1870, p. 2S1. 2 Liebig's Food for Infants consists of half an ounce (rather more than a heaped-up tablespoonful) of wheaten-flour, an equal quantity (rather more than a heaped-up dessertspoonful) of malt flour, 7£ grains of bicarbonate of potassium, and an ounce of water well mixed ; to which is added five ounces of fresh milk. The whole is put on a gentle fire, until it begins to thicken, when it must be removed, stirred for several minutes, again heated and stirred till fluid, and then boiled, and passed through a sieve. It is slightly aperient, and, in cases of diarrhoea, pre- pared chalk, gr. xx., may be substituted for the bicarbonate of potas- sium. 236 DIETETIC TREATMENT OF INFANTS. the milk may be increased to two-thirds; or in some of the meals the milk may be altogether omitted, usino- in- stead barley-water, or equal parts of barley-water and weak chicken-broth, in which the Liebig's food can be dissolved. In the above cases Prof. Charles D. Meigs1 recommends the following : A scruple of gelatin (i. e., a square inch of the gelatin cake) is soaked in cold water, and is then boiled for ten or fifteen minutes in half a pint of water until it dissolves. To this, at the termination of the boiling, are added, while stirring, three ounces of milk, and a tea- spoonful of arrow-root, the latter having been previously mixed into a paste with a little cold water. Lastlv, just before removal from the fire, half an ounce of cream is stirred up with the rest, and the whole is sweetened with loaf sugar. Of this food three or four ounces or more can be given every two or three hours from a feeding- bottle. These diets are suitable to all infants suffering from simple atrophy clue to improper feeding. It will, how- ever, be necessary to vary the quantities somewhat ac- cording to age. Thus, a child of six months old will usually be able to take a teaspoonful of Liebig's food for infants, dissolved in milk more or less diluted, for each meal. For a child of the same age, Prof. Meigs's food may be strengthened by increasing the quantity of milk to six or ten ounces, and of cream to one or two ounces. In all these cases of simple atrophy just mentioned, a wet nurse should be provided if possible. 1 J. F. Meigs and W. Pepper on Diseases of Children; Philada., 1877. CASES OF EMERGENCY IN CHILDREN. 237 Brief Rules for Cases of Emergency in Children.1 1. If the child is suddenly attacked with vomiting, purging, and prostration, send for a doctor at once. In the mean time, put the child for a few minutes in a hot bath, then carefully wipe it dry with a warm towel, and wrap it in warm blankets. If its hands and feet are cold, bottles filled with hot water and wrapped in flannel should be laid against them. 2. A mush-poultice, or one made of flaxseed meal, to which one-quarter part of mustard flour has been added, or flannels wrung out of hot vinegar and water, should be placed over the belly. 3. Five drops of brandy in a teaspoonful of water may be given every ten or fifteen minutes; but if the vomit- ing persist, give this brandy in the same quantity of milk and lime-water. 4. If the diarrhoea has just begun, or if it is caused by improper food, a teaspoonful of castor oil, or of the spiced syrup of rhubarb, should be given. 5. If the child has been fed partly on the breast and partly on other food, the mother's milk alone must now be used. If the child has been weaned, it should have its milk-food diluted with lime-water, or should have weak beef-tea, or chicken-water. 6. The child should be allowed to drink cold water freely. 7. The soiled diapers or the discharges should be at once removed from the room, but saved for the physician to examine at his visit. 1 These rules were also suggested by the Committee of the Obstet- rical Society of Philadelphia, previously alluded to (p. 201). 238 THERAPEUTICS OF THE Several dietetic articles especially adapted for young children are described under the head of "Dietetic Pre- parations for the Sick." It is not considered expedient or desirable to isolate them from such a general list, as they are appropriate, in some instances, as auxiliary to the treatment of the adult sick. THERAPEUTICS OF THE BOWEL AFFECTIONS OF CHILDREN.1 All children when suffering from diarrhoea should be kept quiet in a partially darkened room ; and young infants should not be jolted, as is the habit of mothers and nurses, under the idea of amusing them. Young infants, when the diarrhoea is severe, can be kept more easily quiet when laid on a pillow instead of the lap, and should be moved as little as possible even while changing the napkin. The room should be well ventilated—mo- thers usually keeping it too close, under the fear of taking cold; and in the daytime the infant when awake should be carefully carried into the shade in the open air. In severe diarrhoea of young infants also warm applications should be applied to the abdomen. A spice-bag should be made by inclosing between two layers of coarse flan- nel about six inches square, and quilting, cloves, allspice, cinnamon, and aniseed, of each half an ounce, bruised in a mortar. This is to be soaked for a few minutes in equal parts of hot brandy (or other spirits) and water, applied 1 Condensed from an excellent paper by Dr. A. A. Smith, of Bellevue Hospital Medical College, in the N. Y. Medical Record for 1879. BOWEL AFFECTIONS OF CHILDREN. 239 to the abdomen, and renewed when it gets cool. In this way we get the effects of a poultice, and the sedative and antiseptic effects of the spices. Reduction of Temperature.—Great importance is attached to this as an adjuvant. When the rise of temperature is slight, say 102° Fahr. or less, sponging the body with water at about 80° will, if repeated often enough, reduce it to about its normal condition ; but in all cases when the rise is above 102° a form of the wet pack should be resorted to. For this, having placed the child on a bed, cover it from the axillse to the ankles (leaving the arms and feet uncovered) by means of a small folded sheet, on which water of the desired temperature is poured by means of a pitcher. The first application should be made by the practitioner himself, in order to allay the fears of the friends excited by the cries of the child, and to ex- hibit to them the wonderful power this means possesses of reducing temperature, calming the restlessness and irritability of the child, and inducing sleep. The tem- perature of the water may at first be 90°, and gradually reduced until it is brought down to 80° in a few minutes; or even lower when the temperature of the body is very high or rapidly rises again after reduction. It should be reduced to 99°, and usually sinks lower still when the child is taken out of the pack. According to whether this reduction to 99° is obtained, the child may be left in the pack twenty or thirty minutes, longer or shorter; and when removed should be put into a thin blanket and co- vered up, and allowed to sleep. In very severe cases, when the temperature rises to 105°, or higher, the cold may have to be applied every hour or two, and then the child need not be removed, even for days, from a bed conveniently adapted for this procedure, termed a "Kib- be's cot." 240 THERAPEUTICS OF THE Too Frequent Nursing as a Cause of Diarrhoea.—Irregu- lar and too frequent nursing are a frequent cause of diar- rhoea, and by attention to this point it may be often cured. A child under four months will, as a rule, have two and sometimes three, evacuations daily, and this is within the range of health. Many cases of diarrhoea are met with in which there is but little constitutional disturbance. There is frequency of stools, but the appearance of these is not unhealthy. Bismuth, three grains every two or three hours, will cure such cases. Preternatural Acidity in the digestive organs produces diarrhoea, which is accompanied by considerable pain, the passage of small cheesy-looking masses into the stools, the odor of which is acid, and sometimes offensive, and the reaction decidedly acid. A teaspoonful of lime-water in two of milk three times a clay, or chalk, may be given with good effect; and an occasional laxative is indicated for the removal of any of the cheesy masses that may be acting as irritants, or the laxative may be given at the commencement when the existence of any irritant is sus- pected. A good formula is pulv. rhei gr. xv, sod. bicarb. gr. xxv, aq. m. pip. f^ij. A drachm is a dose for an in- fant between one and four months of age. Dentition as a Cause of Diarrhoea. — Lancing the gums is here especially indicated, and it is far better to err in lancing them too soon than to fail to do so when neces- sary. A child having from ten to twelve stools a day has often been relieved by lancing the gums, without any other treatment. It is in these cases that the bromides prove so effectual. Of a mixture consisting of sod. brom. 3ss, mucil. acaciae, aquae, aa ad foij, a drachm may be given every three hours to a child between six months and a year. The bromide diminishes the reflex disturb- ance caused by the dentition, and the mucilage is soothing to the irritated intestinal membrane. BOWEL AFFECTIONS OF CHILDREN. 241 Errors in Diet as a Cause of Diarrhoea.—Another cause of diarrhceal troubles is the giving of all sorts of diet too early. There is a desire to make the child strong and grow more rapidly. Meat, vegetables, and farinaceous articles in abundance are given to children even eight or ten months old. A child under eight months ought to have no other diet than milk, and even up to two years milk should be its main diet. Human milk is the best during the first year, or until weaning; but often from necessity the child is brought up on the bottle. During the first eight months cow's milk diluted one-fourth with barley-water, makes the best diet. The ground or crushed barley should be boiled with water of sufficient quantity, so that when cold it is about as thick as thin cream. The milk should be grven about blood-warm and a little sweet- ened. What place should condensed milk be given in the feeding of children ? I should give it a place on the shelf at the grocer's. I have tried the condensed milk with children thoroughly, and have seen it tried in the practice of others, and must protest against its use. Chil- dren fed on condensed milk, although they may thrive well apparently, yet when they fall ill show very little resisting power, and, particularly when they fall ill of diarrhoea, they weaken very rapidly and the diarrhoea is apt to be obstinate. There are exceptional cases in which it may be used, and some cases in which it is desirable to use it for a short time. When bottle-fed children suffer from diarrhoea it is well to boil the milk and make the barley-water thinner and give more of it, say one-third barley-water to two-thirds boiled milk. I have found thoroughly cooked wheat flour an admirable food for children with diarrhoea. Have it prepared in this way: Put about two pounds of flour in a muslin bag, tie a string around the top of it, and suspend it in a kettle of water 16 242 THERAPEUTICS OF THE and boil it for five hours ; then let it get cold. Take off the bag, cut off the outside dough and grate it. Thicken boiled milk with this to about the consistency of a thin gruel, or about thick enough for it to pass through the rubber nipple of a nursing-bottle. All food for children should be thoroughly cooked. Still more is this to be observed when they are ill of diarrhoea. As a rule, feed children suffering with acute diarrhoea just as little food as will satisfy their hunger, and often a little cold water will relieve their thirst and lessen the desire for food. Avoid alcoholic stimulants unless there is exhaustion. Champagne iced may be given in small quantities, if there is obstinate vomiting. Flatulent Diarrhoea.—There is a flatulent diarrhoea which occurs in young children and giVes much trouble. The movements are frequent but very small, and the flatulence is sufficient to keep the child awake at nights. I have found the following prescription an excellent one in such cases:— $. Magnes. calcin. gj. Spts. amm. aromat. n\xl. Tinct. asafcet. 3J* Anisette f3vJ- Aq. cinnamomi, q. s., ad f§iv. M. Sig. f3J every half hour until relieved, to a child from tliree weeks to four months old. Two or three doses will usually relieve. Diarrhoea Dependent on Non-digestion of Sugar.—There is a diarrhoea which occurs in the summer, characterized by frequency of discharges; the movements are green, aceompanied with pain, and in many cases the stomach is so irritable that vomiting is a troublesome symptom. Probably the diarrhoea is due to non-digestion of sugar. In connection with such cases I would like to call your attention to kumyss or fermented milk. In this prepara- tion the milk has already taken the first step in digestion. BOWEL AFFECTIONS OF CHILDREN. 243 There is or ought to be no sugar itl it; the casein is in a fixed condition, and consequently cannot undergo the changes of coagulation and putrefaction, and there is a small quantity of alcohol, but it is in such a combination that it is easily assimilated. The kumyss is charged with carbonic acid gas, but children do not take it readily with the gas in. It may be gotten rid of by taking the kumyss out of the bottle and pouring it from one pitcher to ano- ther a few times. A small quantity may be kept out for immediate use, and the remainder put back into the bot- tle, the bottle corked and put into a cool place. Some- times children who are unable to retain anything else, can take a teaspoonful of kumyss at a time and digest it, and frequently without any medicinal treatment will re- cover under its use. Twelve hours is as long as it can be kept safely, after once uncorking it. The child need take no other food while it is taking the kumyss. It is itself food and drink. It is sour, and mothers are tempted to sweeten it to make it palatable. Of course it should never be sweetened, and should never be given within two hours after any other form of milk, and should be given cold. After the first repugnance to it children take it quite readily; even children as young as six or eight months can be made to like it by taking advantage of their thirst and giving it at first in small quantities. Ku- myss may be used in many forms of diarrhoea because of its eas}'' digestion. Dysenteric Diarrhoea.—There is another form of diar- rhoea quite common in summer, characterized by what are known as dysenteric discharges—that is, quite fre- quent evacuations and straining, as in dysentery, and the evacuations are about the consistence of pudding, or thin jelly, and are usually of a pinkish color. This pinkish color is due to the admixture of blood and mucus with 244 THERAPEUTICS OF THE the substance that passes the bowels. I have found small doses of castor oil and opium, given in mucilage, an excellent combination in such cases, as in the following prescription:— I£. 01. ricini 3j. Sacch. lactis £ss. Tinct. opii camph. TTixxxij to f3iss. Mucilag. acacise, Aquae purse, aa q. s. ad f|j. M. Sig. fgj every 2 or 3 hours. Give the paregoric according to the age of the child. For a child under a year, four to eight drops. For child of one to two years, ten drops. Don't forget the general suggestions in regard to diet in all cases of diarrhoea. It is well sometimes in these cases to give starch-water ene- mata. If the enemata are given, the paregoric may be left out of the castor oil mixture, and laudanum may be put in the enema. One or two drops of laudanum with one to three tablespoonfuls of starch-water may be given, according to the age of the child. The starch-water should be made about as thick as thin cream, and given tepid. It may be repeated every three to six hours, ac- cording to the severity of the attack. Inflammatory Disorders.—There is a large class of sum- mer diarrhoeas included under the term of inflammatory disorders. They are accompanied with great pain; fre- quency of movements; there may or may not be a small quantity of blood passed with the movements, more or less increase of temperature, with disturbance of the nervous system, and there may or rnny not be gastric irritability. The indications are to reduce the tempera- ture, manage the diet according to the directions I have. given you, surround the child by the best possible hy- giene, put the warm applications over the abdomen, and give internally a combination of opium and camphor. BOWEL AFFECTIONS OF CHILDREN. 245 Tully's powder, which consists of morphine, camphor, and prepared chalk, makes a good combination. The dose for an adult is the same as Dover's powder. Ten grains contain one-sixth of a grain of morphine and a ■ little over three grains, of camphor. A child three to six months old may be given an eighth of a grain every two to six hours, according to the severity of the attack and the control the powder has over it. A child six to eigh- teen months may be given one-sixth to one-fourth of a grain in the same way. After the acute symptoms have been controlled there remains in many cases a tendency to looseness of the bowels, with very little constitutional disturbance. Stop the Tully's and give the following:— $. Ac. sulph. dil. Ti^xxiv. Salicin. gr. xxiv. Glycerinae fo^j- M. Sig. f3j t. d. Do not give it within a half-hour of the taking of milk. The sulphuric acid has a tonic and astringent effect, and the salicin, besides its tonic effect, acts also as an anti- fermentative. Cholera Infantum.—And now, as to the treatment of a disorder of children, which is the dread of all physicians, especially young ones, and justly so, for it is a formidable disease. I look upon cholera infantum as a disorder of the nervous system, and the disturbances of the aliment- ary canal as only the local manifestations of a constitu- tional disorder. It occurs from great heat, but it has always seemed to me that in addition to great heat there was some other element. I have noticed that cases are much more frequent when, besides great heat, there were certain atmospheric influences which depress the nervous system greatly. "Dog days," as they are called, are very fruitful in the production of cholera infantum. Among 246 THERAPEUTICS OF THE the poor, great heat, poorly ventilated rooms, poor hy- giene in all its forms and with all its attendants, improper food, particularly bottle food, favor the development of the disease. I recognize two varieties of cholera infant- um, and divide them, according to their manifestations, into congestive and exhaustive. In the congestive form there is redness of the surface of the body, especially about the face and head; redness of the conjunctiva, great elevation of temperature, the pulse rapid and full, the nervous symptoms marked, twitching of the muscles, and frequently convulsions; the vomiting and purging vio- lent, the matters vomited and passed being very thin and of enormous quantity. All of these symptoms come on very rapidly, differing in this respect from other forms of diarrhoea. The two special indications are to reduce the temperature and control the nervous manifestations. Apply cold according to the directions I have given you. Give hypodermic injections of quinine and morphine. Give to a child of six months one grain of quinine and about 2^ of a grain of morphine every four or six hours, according to the indication. For each additional six months of age an additional half grain of quinine and an additional jjj of a grain of morphine. To simplify the matter I will give the prescriptions of the solutions of quinine and morphine:— R. Morph. sulph. gr. ss. Aqua? destillat. f^j. M. Sig. Triv by hypodermic injection for a child six months old. R. Quinia? sulph. ^j. Ac. sulph. dil. q. s. Acid, carbol. cryst. gr. v. Aquse destillat. f§j. M. Sig. n\viij by hypodermic injection for a child six months old. Usually the stomach is so irritable that medicines and food are both vomited. After the temperature is reduced and the nervous system is rested, small quantities of food BOWEL AFFECTIONS OF CHILDREN. 247 can be given. Small pieces of ice may be given to allay thirst. In the other variety, the exhaustive form of the disease, there is paleness of the surface of the body; little or no elevation of temperature; indeed, the temperature in some cases is below normal; the pulse is rapid and feeble; the nervous symptoms, although present, are not as marked as in the other variety. The vomiting and purg- ing are violent, the child sometimes getting rid of more fluid in a few hours than it has taken in days. The ema- ciation is very rapid and great. The indications for treat- ment are to check this enormous loss of fluid and sustain the patient. Our main reliance must be on opium and alkalies and stimulants, with the general directions I have given you in the beginning of the lecture. Opium in small doses, in addition to the other effects claimed for it, is a cardiac stimulant, thus meeting one of the chief indications in this disease. A combination of tinctura opii camphorata and mistura cretae may be prescribed with advantage in such cases. Sometimes nothing is retained by the stomach. In such cases, it is necessary for us to give the opium hypoder- mically. Give the ^^ grain morphine as directed in the other variety of the disease, but do not give the quinine. Alcoholic stimulants should be given. Brandy is the best. Give five drops of brandy in a teaspoonful of water, every hour, to a child of six months, if there is great exhaustion. This quantity may be increased or dimin- ished according to the indications. In some cases of cholera infantum a child becomes suddenly much more exhausted, pulse becomes more rapid, extremities are cold, perspiration comes out freely, and the child seems to be going into collapse. An enema of hot water will sometimes revive such a child wonderfully. Let a good 248 BOWEL AFFECTIONS OF CHILDREN. quantity of hot water be used, say half a pint, and hold a towel to the anus afterward, in order to have the water retained as long as possible. Along with this give inter- nally spirits of camphor, from six to ten drops. It may be put in with the brandy, and the two given together for a few hours. In any case of diarrhoea, where these symp- toms of great exhaustion occur with the coldness of the extremities, the hot water enemata may be given. Beef-Tea.—The very common habit of giving beef-tea in the diarrhoea of children, prompts me to say a word in regard to its use. Of course, it is given with a view to sustain the strength of the child, but I have found that almost invariably it acts as an irritant and aggravates the disease. Sometimes it seems to pass the bowels in the same form in which it was taken. In any case of acute diarrhoea I would advise you not to give beef-tea. Opium.—I believe that opium is given too indiscrimi- nately in the diarrhoeas of children. It has its uses, and is an orthodox remedy in such disorders, but it is given very frequently when other remedies would do quite as well and much better, and would produce none of the ill effects of opium. Good nursing; removal of causes; keeping the patient quiet; regulation of the diet: improving'the hygiene; reducing the temperature; removing the causes of dis- turbance of the nervous system, will, in the great majority of the cases of diarrhoea in children, do away with the necessity for medicines. DIAGNOSIS OF UTERINE INFLAMMATIONS. 249 DIAGNOSTIC SYLLABUS OF UTERINE INFLAMMATIONS. The usual means of diagnosis may be thus arranged to show at a glance what they reveal: — Means of Diagnosis of Uterine Diseases.1 Oen'l symptoms. Touch. Speculum. Probe. 1. Pain: Reveals: 1. Reveals color of 1. Reveals capacity Locality and 1. Perviousness of va- mucous mem- of uterus. character. ginal canal. brane of vagi- 2. Existence of Amount. 2. Location, size, den- nal tract and foreign sity, and tender- cervix, and growths. 2. Leucorrhcaa : ness of cervix. condition of os. 3. Shows devi- Character. 3. Os open or vice 2. Nature of leu- ations of Amount. versa, soft or vice corrhcaa. course of canal, Constancy. versa, smooth or 3. Declares atrophy and differenti- rough, moist or or hypertrophy ates them from 3. Menstruation: dry, enlarged or of cervix. tumors. Regularity. elongated or atro- i. Reveals nature 4. Indicates endo- Amount. phied. of mucus, abra- metritis. Pain. i. 5. Presence or absence of hardness or tu-mefaction of recto-vaginal or cysto-vaginal spaces; also nature of the same. State of ovaries and pelvic areolar tis-sue determined l>y lateral and upward pressure. sions and " ul-cerations." By Conjoined Manip- illation. 6. Volume, shape, sen-sitiveness of ute-rus, ovaries, broad ligaments, and bladder. By Rectal Touch, double and single : 7. Condition of poste-rior wall of uterus. Having thus learned what general information may be obtained by the different means of diagnosis employed in uterine affections, we may now make the application of it to the specific varieties of uterine inflammation. The arrangement in a syllabic group is well calculated to fix in the mind the various symptoms of each affection as thus diagnostically revealed. 1 Prof. J. H. Etheridge, M.D., Chicago Med. Journal and Examiner Sept. 1876, p. 812. 250 DIAGNOSIS OF UTERINE INFLAMMATIONS. Diagnostic Syllabus of Varieties of Means OF 1. Metritis. 2. Cervicitis. Diagno-sis. Acute. (Very rare.) Chronic. Acute. Chronic. 1. Gene- a. Violent pelvic a. Dull, heavy, See a. Pain in back ral pain, accompanied dragging pain in Acute and loins. symp- with rectal, vesical, pelvis, increased by Metri- b. Pressure on toms. and uterine tenes- locomotion. tis. bladder or rectum. mus, and sometimes b. Defecation and c. Painful and with nausea and coition painful. sometimes profuse vomiting. c. Menses accom- menstruation. b. Pressure over panied with pain, d. Difficulty of abdomen reveals which begins several locomotion. great sensitiveness. days previous. d. Pain in mammae during and before menstruation. c. Darkening of areolae of the breast. / Nausea and vomiting. g. Great nervous disturbance. h. Pressure on rectum with haemor-rhoids and tenes-mus. i. Pressure on bladder with vesical tenesmus. e. Nervous disor-ders. J. Pain during sexual intercourse. g. Dyspepsia, headache, general lassitude, and de-bility. 2. Touch. a. Vagina hot and a. Enlargement. a. Uterus low dry, unless from co- b. Tenderness. down. existing endometri- b. Cervix large, tis there be purulent swollen, and pain- discharge. ful, and os may ad- b. Organ low in mit finger. pelvis, os enlarged, c. Usually tender- cervix swollen, pres- ness. sure on cervix very painful. c. Painful tender- ness most apparent upon rectal touch and conjoined ma- nipulation. 3. Specu- a. Usually pro- Nothing revealed Confirms signs lum. duces too much pain to be used. specially. evinced by touch. 4. Probe. a. Produces intol- a. Usually reveals Reveals great sen- erable pain, and can- some flexion or ver- sitiveness before not usually be re- sion, tenderness. reaching os inter- sorted to. num, but nothing beyond that. DIAGNOSIS OF UTERINE INFLAMMATIONS. 251 Inflammation of the Uterus.1 3. Endometritis. 4. Endocervicitis. Acute. Chronic. Acute. Chronic. See a. Leucorrhoea a. Dragging weight a. Dragging sensation in the Acute streaked, glairy, and pain in pelvis, pelvis. Endo- and bloody. pain in back, groin, b. Pain in back and loins •cervi- b. Menstrual dis- and thighs. increased by exercise. citis. orders. b. Rectal and vesical c. Profuse, irritating leucor- c. Pain in back, tenesmus. rhoea, like boiled starch. groins, and hypo- c. Purulentdischarge d. Menses too scanty or vice gastrium. sometimes bloody versa,100 frequent or vice versa. d. Nervous dis- after 3 or 4 days. e. Nervous, irascible, orders. d. Tympanitis and moody, or even hysterical. e. Tympanitis. tender abdomen. /. Digestion impaired, ulti- /. Symptoms of mately spanaemia, sometimes pregnancy. nausea, etc. g. Sterility. a. Conjoined ma- a. Vagina hot and a. Os in normal position, nipulation reveals dry, or covered with may be enlarged, lips puffy, or tenderness of fun- above discharge. may be roughened. dus. b. Os gaping, cervix b. Pain results from placing swollen and tender, the finger under the cervix body slightly enlarged, and pressing upwards. whole organ lower in pelvis than normal. ' a. Reveals no- a. Cervix puffy, a. Long, stringy, tough, te- thing special. swollen, and red, fluid nacious mucus, difficult to re- exuding from os either move, exuding from os. clear, albuminous b. Cervix not usually en- looking, muco-pus, or larged, may be puffy acd stringy, and tenacious. swollen and very red, as it ulcerated, due to removal of investing epithelium. a. Patulous os a. Great tenderness a. Meets with obstruction internum. throughout whole or- at os internum. b. Uterine cavity gan, and removal fol- b. Does not produce pain by prolonged. lowed by a few drops striking against the walls of c. Tenderness. of blood. the fundus, nor is its removal Withdrawal fol- followed by blood or mucus. lowed by blood. i Prof. J. H. Etheridge, M D., loc. cit. DIAGNOSTIC TABLE OF THE PRINCIPAL FEVERS. DIAGNOSTIC TABLE OF Mode of inva- sion. Charac'eristic symptoms, Skin eruption. Typhoid Fever. Typhus Fever. Relapsing Fever. Scarlatina. Often very gradualjGenerally well Generally remark- and ill-defined ; marked, and may ably sudden; patient cannot fix, be very sudden; i severe rigor; date; no marked rigors ; may be only diarrhoea for some time. Marked frontal headache, but other head symp toms not promi- nent, or only come on at a lato period ; abdominal symp- toms, viz., pain and tenderness, especially in right iliac fossa ; tympa nitis ; gurgling in right iliac region ; diarrhoex, with pc culiar stools ; not uncommonly intes- tinal hemorrhage enlarged spleen ; no particular pros tration ; epistaxis not uncommon: tongue peculiar at first; pulse liable to great variations. 7th to 12th day; generally confined to abdomen, chest, and back ; comes out in successive crops, each lastinv 2 to 5 days ; con- sists of minute rose-colored spots, slightly raised, disappearing on pressure ; only a few visible at the same time ; con- tinue to appear until 2Sth or 30th day, or even later ; sudamina not un- common. usually marked rigors ; speedy prostration and high fever. Groat depression and prostration dingy and muddy aspect of counte- nance, with dusky flush on cheeks, and dull, heavy expression; early and marked head symptoms, and low, nervous phe- nomena ; rapid tendency to ty- phoid condition; pupils often much contracted. 4th or 5th day usu- ally ; first about back of wrists, ax- illa;, or epigastri- um ; spreads rap- idly over the body and limbs, but rarely seen on neck or face ; en- tire eruption out in from 1 to 3 days ; consists of: a, ir- regular, dusky-red subcuticular mott- ling ; b, macula; or mulberry spots, deepening in color. and soon not fad- ing on pressure ; disappear from 14th to 21st day; skin gives off pe- culiar odor; suda- mina less common than in typhoid. great weakness. Sharp frontal head- ache ; severo pains in back and limbs ; pains in epigastri- um and hypochon- driac regions; bilious vomiting, with retching ; enlargement of liver and Epleen : peculiar aspect of countenance ; no marked nervous symptoms usually; much debility, but not prostration ; pulse very fre- quent at an early period ; epistaxis and other hem»r- rhages common. No specific erup- tion ; sudamina may appear at cri- sis ; oftentime des- quamation of cuti cle after crisis. Usually distinct; chilliness, but not severo rigors ; rapid pyrexia ; may be nervous phenomena, such as convulsions or coma. High pyrexia; flushed face ; sore throat, of variable intensity, but al- ways marked; vomiting ; '' straw- berry" tongue; uo prominent head symptoms usually; pulse very fre- quent, generally strong and full. 2d day usually; first on neck and upper part of the chest; spreads rapidly to face, and over trunk and limbs; consists of a rash, beginning as mi- nute points, coa- lescing to form patches or to cover entire surface; color more or less bright red ; no ele- vation generally; roaches height 4th to 5th day, then gradually fades to 9 th or 10th day, followed by marked desqua- mation ; often puf- finess of face, etc.; much itching aud tingling, with burning sensation; sudamina common. 1 F. T. Eoberts, Theory and Practice DIAGNOSTIC TABLE OF THE PRINCIPAL FEVERS. 253 THE PRINCIPAL FEVERS.1 Smallpox. Rather sudden, and generally marked; chilliness or rigors; occasionally convul- Moderate pyrexia ; catarrhal phenomena, viz., coryza, etc.; only slight sore throat, it any; more or less ca- tarrh of respiratory passages, extending to bronchi, and increas ing during eruptive stage. 4th day generally ; first on face, especially on forehead, then spreads to trunk and limbs, often in three distinct crops on successive days ; consists of mi- nute red points at out- set, soon enlarging to distinct papules, which tend to form crescentic or semi- lunar patches ; color darker than that of scarlatina; declines in same order }n about 12 hours, followed by slight desquamation ; reddish or coppery dis- coloration may remain for some time; much itching. Generally sudden ; often repeated and strong rigors ; rapid pyrexia. High pyrexia; uneasi uess or pain in epigas- trium ; nausea and much vomiting; severe pain in buck; much debility and sense of illness ; fever rapidly abates when eruption appears, followed by secondary fever; often symptoms pointing to implication of mucous surfaces ; erythema- tous or measly rash may appear, especially in certain parts. 3d or beginning of 4th day; first on face, espe cially on forehead ; spreads over body and limbs in a day or two, often in successive crops ; consists of "pjcks" going through stages of: a, small, bright-red spot; b, hard, shot-like pimple ; c, vesicle, be coming umbilicated ; d, pustule, reaching maturation about Sth day; e, scab, which leaves reddish-brown stain on separation, or a pit. Hard, inflamed areola forms ; very va- riable mode of arrange- ment and number; swelling of face, etc. ; intense itching ; dis- agreeable odor given off; eruption may be on mucous surfaces. Varicella. Not marked. Slight pyrexia, without special symptoms, or may be no symptoms at all. Within 24 or 3G hours ; first about the shoul- ders and chest, ex- lends over body and limbs, may be many on scalp, but generally few on face ; corner out in successive crops for 4 or 5 nights; first, bright rsis. Great dyspnoea, and very hurried breath- ing, especially in the tubercular form. Often very high, espe- cially in the tubercu- lar form, but no regu- larity in temperature. Severe prostration and weakness, with pro- fuse perspiration and rapid wasting. In the tubercular form ex- treme adynamia. of consolidation scattered spots with rales. Both lungs are usually in volved in irregularly scat tered patches. When the disease follows extensive pulmon- ary collapse, there may be a peculiar pyramidal form of dulness No crisis, and course often prolonged. fremitus; succeeded by signs of fluid, viz., side often enlarged; move ments interfered with; diminished vocal fremi- tus ; dulness occasionally movable; weak or sup- pressed breathing and vocal resonance; ego- phony sometimes; and displacement of organs : finally, signs of absorp- tion, with redux friction- sound or fremitus. Usu- ally on one side. No crisis, and course very variable. bronchitis ; followed by consolidation, soft- ening, or excavations in different parts, es- pecially towards the bases. In the tuber- cular form frequently scattered rales con- stitute the only phy- sical signs. Generally very rapid course, and fatal ter- mination. of Medicine. Philadelphia, 1880. 260 DIAGNOSTIC TABLE OF SYMPTOMS DIAGNOSTIC TABLE OF SYMPTOMS Symptoms. Acute Laryngitis. Chronic Laryngitis. Tubercular Laryn-gitis. Subjective— Voice. . . Hoarse, sometimes Hoarse, faltering, Hoarseness of pe- aphonic. easily fatigued. culiar character; aphonic in later stages. Respiration . Not embarrassed Not embarrassed. Hurried; embar- except when ce rassed in later dema is present, stages. then dyspnoea. Cough . . Dry and hard ; la- Hacking, with Painful; amount ter moist. starchy expecto- and character de- ration. pending upon the lung implicated. Deglutition . Usually painful. Not interfered Difficult and pain- with. ful. Pain . . . Feeling of con- Feeling of fulness. Only in degluti- striction and tion and phona- acute pain. tion. Physical— Color . . . Uniformly intense Partially increas- Grayish red. red. ed. Form and tex- Swelling iu oede- Abrasions. Swelling of mu- ture . . ma. cous membrane, ulcers, and pyri-form swelling of arytenoid cartil-ages. Position . . Unaltered. Unaltered. Usually no dis-placement. External Pharynx implica- Pharynx implica- Pharynx involved ted. ted. —physical signs of lung disease. Cause . . . Exposure to draft. Impure air; abuse Same as of lung Imbedded foreign of voice. affection. bodies or corro- sive substances. Prognosis . . Favorable except Favorable. Unfavorable. in oedema. i Carl Seller, Handbook of Diagnosis and Treatment OF DISEASES OF THE LARYNX. 261 OF DISEASES OF THE LARYNX1 Syphilitic Laryn- gitis. Hoarse, seldom aphonic. Not usually em barrassed. Slightly hacking. Unimpaired, un less epiglottis 01 arytenoids are ulcerated. Absent. Benign Growths. Malignant Growths Variable, from slight hoarseness to aphonia. Embarrassment depends upon situation of growth. Not severe; occa- sional expectora- tion of parts of growth. Impaired when growth is situ- ated on epiglottis or ary-epiglottic fold. Absent. Brick-red in sym- Variable with na metrical patches, tnre of the > growth. Ulcerations and Variable; no ul. specific neo- cers. plasms. Unaltered exceptj Normal parts when changed byj seldom changed cicatrices of ul- cers. Pharynx, velum, None. and skin impli- cated. Variable. Quickened and paroxysmal. Not severe; occa- sional expectora- tion of parts of growth. Difficult and pain (ul. Severe. Livid. Depends upon size and nature of the growth; large ulcers. Primary sore. Favorable. Uncertain. Depends upon size and position cf growth. Displacement infiltration. by Functional Dis- eases. Aphonic in bi- lateral paraly- sis ; hoarse in other forms of paralysis. Embarrassed in paralysis of ab- ductor. Paroxysmal in spasmodic af- fections. Not generally affected. Not usually pre- sent. Glauds implicated —cancerous ca- chexia. Primary cancer in other parts. Unfavorable. Normal. Form of glottis changed. No displace- ment. Other org his may be affect- ed. Ceiebr'l disease, hysteria, aiute and chronic laryngitis. Favorable when cerebral dis- ease is absent of Diseases of the Throat, &c. Philadelphia, 1879. 262 DIAGNOSTIC TABLE OF SYMPTOMS OF DIAGNOSTIC TABLE OF SYMPTOMS OF Symptoms. Subjective— ' Voice. . . Respiration . Cough Deglutition . Pain . . . Physical— Color . . Form and tex- ture . . External Cause Prognosis . Acute Pharyngitis. Usually hoarse, with thick artic- ulation. Not interfered with, except when tonsils are touching each other. Hacking; later moist. Difficult and pain- ful if tonsils and glands are im- plicated. Severe lancinat- ing. General redness of mucous mem- brane. Exposure to cold. Chronic Pharyngitis. Dry, but slight, white, stringy expectoration. Sense of dryness and burning. Generally dimin- ished, with prominent veins. Mucous mem- brane dry and shining. Bad air, alcohol- ism, masturba- tion. Syphilitic Pharyngitis. Variable. Difficult accord- ing to position of ulcers. Usually absent. Brick-red, sym- metrical patches. More or less deep ulcers on phar- ynx, velum, and tonsils. Skin implicated. Primary sore. Favorable. Favorable. Favorable. Not changed. Larynx impli- cated. None. Normal, unless larynx is impli cated, then hoarse and easily fatigued. Not interfered with. formal, or slight- ly hoarse; artic- ulation nasal if velum or uvula is ulcerated. 'Jot affected. Not affected. i Seiler, DISEASES OF THE NASO-PHARYNX. 263 DISEASES OF THE NASO-PHARYNX.1 Granular Pharyngitis. Tonsillitis. Nasal Polypi. Post-nasal Catarrh. Usually hoarse Normal; articu- Normal; articu- Normal; articu- from laryngeal lation thick. lation nasal. lation more or implication; ar- less nasal. ticulation nor- mal. Not affected. Affected only in Respiration Respiration severe cases. through nose through nose more or less ob- affected, espe- structed. cially in re-cumbent posi-tion. Often severe and Slight. Absent. Slight, with ex- dry, with little pectoration of expectoration. thick, tena-cious mucus. Not affected. Almost impossi-ble and very painful. Not affected. Not affected. Sense of dryness Severe. Usually absent. Frontal head- and fulness. ache ; sense of dryness in nose and pharynx. Usually paler Tonsils appear General hyper- Paler than nor- than normal. livid. semia of nasal mucous mem-brane. al. Red nodules and Great tumefaction Depends upon Tumefaction of prominent veins of the glands. character of pol- mucous mem- on surface of ypus. brane , shallow pharynx resem- ulcers. bling granula- tion. None. Implication of Stoppage of nose ; Stoppage of cervical and dryness of mouth nose, often submaxillary and pharynx ; watery dis- glands. bleeding from charge ; slight nose. depression of bridge of nose. Abuse of voice ; Exposure to cold. Uncertain. Vitiated air and gastric derange- changeable cli- ment. mate. Favorable. Favorable in most cases. Favorable. Favorable. op. cit. 264 DIAGNOSIS OF TUMORS OF THE GROIN. DIAGNOSTIC SYLLABUS OF TUMORS OF THE GROIN.1 Diagnosis of Inguinal Tumors. Hernia.—Impulse on coughing; reducible with gur- gle ; clear on percussion if intestine; feels like intestine, or knotty, if omentum. Hydrocele of Cord.—Impulse on coughing; appa- rently reducible; dull on percussion; elastic feel, like small elongated bag of fluid. Iliac Abscess.—Impulse on coughing; non-reducible; dull on percussion ; elastic, and possibly fluctuating. Lymphadenoma.—No impulse on coughing; non-re- ducible; dull on percussion; hard, well-defined, not tender unless inflamed. Testis.—No impulse on coughing; non-reducible; dull on percussion; obscurely elastic, and characteristically painful. Diagnosis of Femoral Tumors. Hernia.—Impulse on coughing; reducible with gur- gle ; clear on percussion if intestinal; feels like intestine, or knotty, if omentum. Psoas Abscess.—Impulse on coughing; irreducible; dull on percussion; elastic or fluctuating. Fatty Tumor.—No impulse; irreducible; dull; lobu- lated. 1 Extract from a lecture by Christopher Heath, F.R.C.S., in Medical Times and Gazette of London. DIAGNOSIS OF TUMORS OF THE GROIN. 2G5 Cyst in Canal, or Lymphadenoma.—No impulse; irreducible; too small for percussion; hard and ill-de- fined. Reducible Scrotal Tumors. Hernia.—Impulse on coughing; percussion clear if intestinal, dull if omental; ring and inguinal canal occu- pied, spermatic cord obscured; intestine to be felt, and returned with gurgle, and remains up till effort is made; opaque; any age. Congenital Hydrocele.—No impulse unless com- bined with hernia ; percussion dull; ring and canal clear; fluid to be felt, and readily returned when patient lies down, and reappears slowly when he stands up; translu- cent; childhood. Varicocele.—Impulse on coughing when large; per- cussion dull; ring occupied by enlarged spermatic cord ; feels like a bag of worms when small, but like intestine when large—can be reduced by pressure, and fills again while pressure is made on ring; opaque; young adult, and on left side. Irreducible Scrotal Tumors. Hernia. — Sausage-shape; intestine clear, omentum dull; intestinal or knotty; opaque; sudden. Hydrocele.—Pyriform ; dull on percussion ; elastic or fluctuating; translucent; chronic. Hematocele.—Globular; dull on percussion; tense or doughy ; opaque; sudden. Sarcocele.—Irregular; dull on percussion; more or less induration ; opaque; chronic. Strangulated Hernia.—Suddenly produced, or, if present before strangulated thus ; pain in groin and about abdomen, with considerable constitutional depression and 266 DIAGNOSIS OF TUMORS OF THE GROIN. anxiety of face; tumor tense, and giving the sensation of intestine when manipulated—skin normal; impulse on coughing to be felt along the groin, in which there is more fulness than usual, but ceases abruptly at the point of. strangulation; percussion over tumor gives a clear sound unless the protrusion is omental; vomiting proba- bly present, continuous, and eventually stercoraceous. Hematocele.—Suddenly produced by some external violence; pain in scrotum and constitutional disturbance, slight after the first few minutes; tumor tense and heavy, globular in shape, and not translucent—skin often bruised; no impulse in groin, whicli is perfectly normal; percus- sion gives a dull note; vomiting immediately following the accident, but not continued. Orchitis.—Developed a few hours after a blow or fol- lowing gonorrhoea; pain in scrotum and along the cord to the loins—feverish disturbance of system; tumor ex- cessively tender to the touch—cord thickened—skin red- dened ; no impulse on coughing; percussion gives a dull note; nausea and faintness, but seldom vomiting. CALCULATION OF DATE OF LABOR. 267 OBSTETRIC MEMORANDA. Under this head may be mentioned several items of practical interest to the obstetrician, such as the method of calculating the date of labor, the various presentations and positions, and the measurements of the pelvis' and icetal head. Calculation of the Date of Labor. The following carefully-prepared table is a valuable aid to the obstetrician in fixing an approximate date for the termination of pregnancy. The duration of human pregnancy is about 275 days. As labor occurs in the larger proportion of cases between 270 and 290 days from the last menstruation, it is usual to reckon either from the first or last day of this period, taking as the mean 280 days, or a little over nine calendar months. For this approximate calculation, the first day of the menstrual period may be used as being more readily ascertained. The table presents at a glance the beginning and end of 280 days for every day of the year. Find the date of menstruation in the upper line of the horizontal row, and the figure below, with the corresponding month, will indicate 280 days. In leap year, if the period of preg- nancy includes February, the time for labor will be one day earlier than that given in the table.1 i 1 This table, with explanatory remarks, was prepared by W. W. Ely, M.D., of Rochester, N. Y., for the Medical Register of New York, New Jersey, and Connecticut, Dr. A. K. M. Purdy, Editor, N. Y. 1S76. The Duration of Pregnancy. Jan. . Oct. . 1 8 2 9 3 10 4 11 5 12 6 13 7 14 8 15 9 16 '0 17 11 18 12 19 13 20 14 21 15 22 16 23 17 24 18 25 19 2j 20 27 21 28 29 23 30 24 31 25 1 20 2 27 3 28 4 29 5 30 0 31 7 Nov. Fob. . Nov. . 1 8 1 6 2 9 2 7 3 10 4 11 5 12 0 13 7 14 8 15 9 10 10 17 11 18 12 1!) 13 20 14 21 15 22 16 23 17 24 18 25 19 26 20 27 21 28 22 29 23 30 24 I 25 2 26 3 27 4 28 5 Dec. March Dec. . 3 8 4 9 5 10 0 11 7 12 8 13 9 14 10 15 11 16 12 17 13 18 14 19 15 20 10 21 17 22 IS 2i 19 24 20 25 20 25 20 24 21 26 22 27 23 28 24 29 25 30 26 31 27 1 28 2 29 3 30 4 31 5 Jan. April. Jan. . 1 6 1 5 2 7 3 8 4 9 5 10 6 11 7 12 8 13 9 14 10 15 11 16 12 17 13 18 U 19 20 16 21 17 22 18 23 19 21 21 2j 22 27 23 28 23 27 24 29 24 28 2) 30 26 31 27 1 28 2 29 3 30 4 31 7 Feb. May . Feb. . 2 6 3 7 4 8 5 9 6 10 7 11 8 12 9 13 10 14 11 15 12 10 13 17 14 18 15 19 16 20 17 21 18 22 19 23 21 25 22 26 25 1 20 2 27 3 28 4 29 5 30 0 March. April. May. June. July. Aug. Sept. Oct. June . March 1 8 1 7 1 8 1 8 2 9 2 8 3 10 3 9 4 11 4 10 5 12 5 11 5 12 6 13 6 12 6 13 7 14 7 13 8 15 8 It 9 10 9 15 ■o 17 11 18 12 19 13 20 14 21 15 22 16 23 17 L4 18 25 19 26 20 27 21 28 21 27 22 29 22 28 23 30 23 29 24 31 25 1 26 2 27 3 28 4 29 5 30 0 © July . April . 10 16 11 17 12 18 13 9 14 20 1,3 21 16 22 17 2! 18 24 19 25 20 26 24 30 25 1 20 2 27 3 28 4 28 4 29 5 29 5 29 6 30 u CO u 30 7 31 7 1 Ana;. . May . 2 9 3 10 4 n 7 14 8 15 9 16 10 17 11 18 "2 19 13 20 14 21 15 21 16 17 21 18 25 19 26 °0 27 21 28 22 29 23 30 24 31 25 1 2d 2 27 3 Sept. . June . 2 9 3 10 4 n 5 12 6 13 7 14 8 15 9 16 10 17 11 18 12 19 13 20 13 20 14 21 14 21 15 22 10 23 17 21 IS 25 19 26 20 27 21 28 22 29 23 30 21 1 25 26 3 27 4 28 4 28 4 Oct. . July . 1 8 o 9 3 10 4 11 5 12 0 13 7 14 8 15 9 16 10 17 11 18 12 19 15 22 16 23 17 21 18 25 19 26 20 27 21 28 22 29 23 39 21 31 25 1 26 2 27 3 29 5 30 6 31 7 C5 o Nov. . Aug. . 1 8 2 9 3 10 4 11 5 12 6 13 7 14 8 15 9 16 10 17 11 18 12 19 13 20 14 21 15 22 16 23 17 21 18 25 19 26 20 27 21 28 22 29 23 30 2t 31 25 1 26 2 27 3 28 4 29 5 30 6 __ 31 7 Dec. . Sept. . 1 7 8 3 9 4 10 5 11 6 12 7 13 8 14 9 15 10 10 H 17 12 18 19 14 L0 15 21 16 22 17 23 18 21 19 25 •20 20 21 27 28 23 29 24 30 25 1 20 27 3 28 4 29 5 30 6 DIAMETERS OF THE PELVIS. 269 Diameters of the Female Pelvis. The diameters of the pelvis may be stated as follows :l— Anteroposterior, taken at the brim, from the upper part of the posterior surface of the symphysis pubis to the 'centre of the promontory of the sacrum ; in the cavity, from the centre of the symphysis pubis to a corresponding point in the body of the third piece of the sacrum ; and at the outlet, from the lower extremities of the symphysis pubis to the tip of the coccyx. Oblique, taken at the brim, from the sacro-iliac joint on either side to a point of the brim opposite the ilio-pecti- neal eminence (that starting from the right sacro-iliac joint being called the right oblique, that from the left the left oblique); in the cavity, a similar measurement at the same level as the conjugate; while at the outlet, an oblique diameter is not usually measured. Transverse, taken at the brim, from a point midway between the sacro-iliac joint and the ilio-pectineal emi- nence ; in the cavity, from corresponding points in the same plane as the conjugate and oblique diameters; and at the outlet, from the centre of the inner border of one ischial tuberosity to the other. The average measurements are the following :— Antero-posterior. Oblique. Transverse. Brim .... 4.25 inches. 4.8 inches. 5.2 inches. Cavity . . .4.7 " 5.2 " 4.75 " Outlet ... 5.0 * — 4.2 " ^ ' Tbe facts here detailed are extracted from the recent work of Dr. W. S. Playfair, of London, on the Science and Practice of Midwifery, Philadelphia, 1876, p. 33, etc, 270 DIAMETERS OF THE FOZTAL SKULL. Diameters of the Festal Skull. These are measured from corresponding points opposite each other, and may be briefly stated as follows: — Occipito-mental, from the occipital protuberance to the point of the chin, 5.25" to 5.50". Occipito-frental, from the occiput to the centre of the forehead, 4.50" to 5". Sid)-occipito-bregmatic, from a point midway between the occipital protuberance and the margin of the foramen magnum to the centre of the anterior fontanelle, 3.25". Cervico-bregmatic, from the anterior margin of the fora- men magnum to the centre of the anterior fontanelle, 3.75". Transverse or bi-parietal, between the parietal protuber- ances, 3.75" to 4." Bi-temporal, between the ears, 3.50". Fronto-mental, from the apex of the forehead to the chin, 3.25". Presentations and Positions of the Foetus. Head Presentations.—The positions of the foetal head after it has entered the brim, are— First, or left occipito-colyloid. The occiput points to the left foramen ovale, the sinciput to the right sacro-iliac synchondrosis, and the long diameter of the head lies in the right oblique diameter of the pelvis. Second, or right occipito-cotyloid. The occiput points to the right foramen ovale, the forehead to the left sacro- iliac synchondrosis, and the long diameter of the head lies in the left oblique diameter of the pelvis. Third, or right occipito-sacro-iliac. The occiput points to the right sacro-iliac synchondrosis, the forehead to the PRESENTATIONS AND POSITIONS OF THE FOETUS. 271 left foramen ovale, and the long diameter of the head lies in the right oblique diameter of the pelvis. (This posi- tion is the reverse of the first.) Fourth, or left occipito-sacro-iliac. The occiput points to the left sacro-iliac synchondrosis, the forehead to the right foramen ovale, and the long diameter of the head lies in tne left oblique diameter of the pelvis. (This position is the reverse of the second.) Pelvic Presentations.—The positions of breech pre- sentations may be divided as follows:— First, or left sacro-anterior (corresponding to the first position of the vertex). The sacrum of the child points to the left foramen ovale of the mother. Second, or right sacro-anterior (corresponding to the second vertex position). The sacrum of the child points to the right foramen ovale of the mother. Third, or right sacro-poslerior (corresponding to the third vertex position). The sacrum of the child points to the right sacro-ilac synchondrosis of the mother. Fourth, or I ft sacro-posterior (corresponding to the fourth vertex position). The sacrum of the child points to the left sacro-iliac synchondrosis of the mother/ Face Presentations.—The positions, classified accord- ing to the part of the pelvis to which the chin points, may be stated as follows :— First. The chin points to the right sacro iliac synchon- drosis, the forehead to the left foramen ovale, the long diameter of the face lies in the right oblique diameter of the pelvis. (This corresponds to the first vertex position.) Second. The chin points to the left sacro-iliac synchon- drosis, the forehead to the right foramen ovale, and the long diameter of the face lies in the left oblique diameter 272 PRESENTATIONS AND POSITIONS OF THE FOZTUS. of the pelvis. (This is the conversion of the second ver- tex position.) Third. The forehead points to the right sacro-iliac syn- chondrosis, the chin to the left foramen ovale, and the long diameter of the face lies in the right oblique dia- meter of the pelvis. (This is the conversion of the third vertex position.) Fourth. The forehead points to the left sacro-iliac synchondrosis, the chin to the right foramen ovale, and the long diameter of the face lies in the left oblique dia- meter of the pelvis. (This is the conversion of the fourth vertex position.) Shoulder Presentations.—These include two divi- sions, those in which the back of the child looks to the abdomen of the mother, and those in which the back of the child is turned towrards the spine of the mother. Each of these is subdivided into two classes, according as the head of the child is placed in the right or left iliac fossa. In dorso-anterior positions, if the head lie in the left iliac fossa, the right shoulder of the child presents; if in the right iliac fossa, the left. In dorso-posterior positions, if the head lie in the left iliac fossa, the left shoulder pre- sents; if in the right, the right. RULES FOR EXAMINATION OF THE URINE. 273 BRIEF RULES FOR CLINICAL EXAMINATION OF THE URINE. The following rules for the examination of a specimen of urine will be found of value to the practitioner as a guide to the proper method of investigating the abnormal conditions of that fluid.1 1. Color.—Whether pale from being dilute, dark from being concentrated, dark or greenish from presence of bile, smoky from blood. 2. Smell.—Fragrant from the existence of cystin, or sugar, etc., or fetid from alkalinity. 3. Quantity passed in twenty-four hours, to be mea- sured; observe whether there is excess or diminution. 4. Specific Gravity.—Take the specific gravity, if pos- sible, of the mixed urine. Normal sp. gr. 1020. If high, suspect sugar; if low, suspect albumen. 5. Reaction.—If acid, is it normally so or not? If ex- cessively acid, examine for crystals of uric acid. If alkaline, ascertain whether the alkali is fixed or volatile. 6. Heat.—Heat a portion in a test-tube. If a precipi- tate appear, it may be albumen or phosphates. Add a drop or two of nitric or hydrochloric acid. If precipitate dissolve, phosphates; if not, albumen. If a deposit disap- pear on heating, we have urates. If it do not disappear, add a drop of nitric acid. If now dissolved, we have phosphates; if not, cystin. 7. Bile.—Test for bile pigment and bile acids, if neces- sary. 1 Arranged acd condensed from J. Hughes Bennett's Text-Book of Physiology, pp. 478-485 ; Philadelphia, 1873. 18* 274 TESTS FOR ALBUMEN IN THE URINE. 8. Sugar.—Test for sugar, if necessary. 9. Chlorides.—Add a drop of nitric acid, and then nitrate of silver, until a precipitate ceases to form. Thus estimate the average of chlorides. Microscope.—Examine for blood, pus, cystin, oxalate of lime, leucin, tyrosin, tube casts, etc. Mode of Detection of Abnormal Constituents of the Urine. The abnormal constituents of the urine are the follow- ing: albumen, bile acids and pigment, acetic, lactic, and butyric acids, fat, sugar, kiestein, leucin, tyrosin, allan- toin, sulphuretted hydrogen. Albumen.—1. Heat.—If the urine be alkaline to test- paper, or neutral, add a few drops of acetic or nitric acid • if very acid, neutralize with a little dilute ammonia. Boil a small quantity in a test-tube. If albumen be pre- sent, urine becomes turbid if the heat exceeds 154° Fahr.; if albumen abundant, distinct coagulation occurs. If the urine before examination is too acid or too alkaline, coagulation will be prevented by the union of the albu- men with the acid or the alkali respectively. In some varieties of urine, boiling produces a precipitate of earthy phosphates, which dissolve on the addition of a little dilute nitric acid. 2. Nitric Acid.—This acid produces white turbidity when albumen is present in small quantity; distinct coagulation, if in large quantity. If soluble nitrate of nlbumen is formed, no coagulation occurs; if nitrate of urea be precipitated, the microscope will detect it. If the patient has been taking copaiva, cubebs, or other oleagi- nous or oleo-resinous medicines, the urine may be turbid, but the turbidity does not sink, but remains for hours suspended in the fluid. TESTS FOR SUGAR IN THE URINE. 275 It is better to employ both heat and nitric acid than either alone. 3. Ferrocyanide of Potassium.—Add to a well-filtered urine, acidulated with acetic acid, a weak solution of the ferrocyanide (gr. v to fij); a white precipitate occurs, but if there is much mucus in the urine, the test is not serviceable. Sugar.—Sugar, in excess in the urine is grape sugar, often termed diabetic sugar. The urine in diabetes is usually light-colored, froths readily when poured from vessel to vessel, and has a high specific gravity. To ob- tain the sugar, evaporate the urine to syrupy consistence, and allow the sugar to crystallize out. Separate from it the urea and extractive matters by absolute alcohol, and add to the residue spirits of wine to dissolve the sugar, which is allowed to separate, and the crystalline masses are then purified from alcohol by repeated re-crystalliza- tions from water. The tests for sugar in the urine are the following:— 1. Moore's Test with Caustic Potash.—Add to the urine an equal bulk of solution of caustic potash, and boil. If sugar be present, a dark sherry color will be obtained ; if in large quantity, a dark purple, sometimes almost black. The caustic potash, unless freshly prepared, may be contaminated with lead of glass bottle, producing a sulphide of lead when added to urine. 2. Trommels Test with Sulphate of Copper and Caustic Potash.—This test depends on the fact that diabetic sugar has the property of reducing cupric to cuprous oxide; but an excess of urates or the protein compounds occa- sionally present in urine unfortunately have the same property. We may be sure that diabetic sugar is present if cupric oxide be thus reduced in the cold. The process is to add to the urine a few drops of solution of sulphate 276 TESTS FOR SUGAR IN THE URINE. of copper; to this add a little caustic potash. A greenish- blue precipitate of hydrated cupric oxide results, which is dissolved in an excess of the caustic potash, forming a blue liquid. Heat this by applying the flame of a lamp to the upper stratum; if sugar be present, a yellow, or orange, or red precipitate of cuprous oxide will be formed, in marked contrast to the blue liquid at the bot- tom of the test-tube. . 3. Fen-ling's Test with Potassio-cupric Tartrate.—This compound is made by dissolving 34.65 grammes of pure crystallized sulphate of copper in about 160 grammes of water. This solution is gradually poured into a solution of 173 grammes of pure crystallized double tartrate of potash and soda, treated with from 600 to 700 grammes of caustic potash of 1.12 sp. gr. The clear mixture is then diluted up to a litre. When a few drops of this potassio-cupric tartrate solution are added to the urine, and the upper stratum boiled, the cupric oxide in the alkaline tartrate is reduced to the cuprous oxide, if sugar be present, as in Trommer's test. Ten cubic centimetres of the alkaline solution are reduced by exactly 0.05 gramme of diabetic sugar. Fehling's solution is, how- ever, liable to decomposition, even if kept for only a week, and sometimes gives uncertain results. 4. Boucher's Test with Nitrate of Bismuth.—Add to the urine an equal volume of a solution of one part of crys- tallized carbonate of soda to three parts of water, and afterwards a little trisnitrate of bismuth, and boil. If sugar be present, the white powder will become dark, the oxide of bismuth being reduced by the sugar. Any albumen in the urine should first be got rid of by boiling and filtration, otherwise the sulphur of the albumen may form the black sulphide of bismuth. 5. Dichloride of Tin Test.—Moisten a few strips of me- TESTS FOR BILE IN THE URINE. 277 rino in a solution of stannous chloride, and dry in a water-bath. On moistening one of these strips with diabetic urine, and holding it near the fire, a brownish- black color results. 6. Fermentation Test.—Ordinary yeast is mixed with water, and a long test-tube filled with the suspected urine, to which some of the yeast has been added. Invert the tube over a saucer containing the urine under examination, so that no air may enter, and set the whole aside in a warm place. Sugar, if present, will be decomposed into carbonic acid and alcohol, and the gas will collect in the upper part of the tube. Or the carbonic acid may be conducted off by a fine tube into lime-water, which be- comes turbid from the formation of insoluble carbonate of lime. Bile.—Urine containing bile has a peculiar greenish- black color. The tests are the following :— 1. NoeVs Test.—Immerse a strip of blotting paper for a few minutes in the fluid, dry, and add a drop of nitric acid containing a little nitrous acid. If bile be present, a violet color results, changing to red or yellow. 2. Pettenkofer's Test for Bile Acids.—Add to the liquid, in a test-tube, a little powdered white sugar, or its equiv- alent of syrup. Then pour in of strong sulphuric acid (very gradually) rather more than half the bulk of the liquid. The temperature is thus gradually raised to the proper point, and a deep purplish-crimson color appears. This test frequently fails in the examination of the urine. 3. Nitric Acid Test.—Place a drop of the fluid on a white porcelain plate, add carefully a drop or two of strong nitric acid, and at the point of contact of the fluid with the acid there will be a play of colors, passing from red to green, pink, blue, violet, and yellow. The green 278 TESTS FOR LACTIC ACID IN THE URINE. tinge, though often evanescent, indicates the presence of bile. 4. Oxide of Silver Test.—Boil the fluid with an ammo- niacal solution of silver oxide. Acidulate the filtrate with a few drops of hydrochloric acid. If biliverdin be present, a purple color will be produced, owing to the formation of an artificial compound, bilipurpin. 5. MarechaVs Test.—This is employed as follows: Place about 3j of the urine in a test-tube, and allow one or two drops of tincture of iodine to trickle down the side of the tube, held nearly horizontally, so that the two fluids may touch, but not mix. If bile pigment be present, a fine green color will almost immediately be developed below the red iodine layer. By holding the test-tube up against a white cloud, or a white surface, in a good light, the three zones of color will be distinctly visible.1 Lactic Acid.—This acid is rarely present in the urine, but may be detected by evaporating fresh urine nearly to dryness, and treating the residue with a solution of oxalic acid in alcohol. Oxalates are precipitated; lactic acid remains in solution, which is digested with litharge, eva- porated to dryness, and an alcoholic solution of lactate of lead obtained, which is decomposed by sulphuretted hydrogen, the sulphide of lead filtered off, and the fluid evaporated to a syrup. The syrup is then shaken up with ether, the ethereal solution evaporated, and the lactic acid dissolved in water. The aqueous solution is then boiled with zinc oxide, and the crystals of lactate of zinc are allowed to separate. Of the other abnormal constituents, FAT, in the form of oil globules, usually associated with fatty casts, may indicate an advanced condition of Bright's disease.— 1 Dr. W. G. Smith, Dub. Journ. Med. Science, Dec. 1876, in Amer. Journ. Med. Sciences, April, 1877, 531. EXAMINATION OF URINARY DEPOSITS. 279 Chyle gives a white appearance to the urine, from the abundance of fatty molecules it contains; albumen is sometimes present when it coagulates on cooling. Possi- bly there may be abnormal communication between the lacteal system and the ureters or kidneys.—Kiestein, a granular albuminous matter, occurs in the urine of preg- nant women, forming with crystals of triple phosphate and fat globules a fat-like scum on the surface.—Acetic and butyric acids are found only in decomposing urine, and are not important.—Sulphuretted hydrogen is rarely found in urine, but may be detected by blackening a piece of paper dipped in a solution of acetate of lead and held over it.—Allantoin is only a temporary and occa- sional constituent, in young children especially.—Leucin occurs in hepatic cases, and is detected by microscopic examination. It is usually seen in roundish yellowish- colored balls, made up of masses of small needle-like crystals.—Tyrosin occurs under similar conditions, and is similarly detected, consisting of stellate groups of long silky needles, not in balls or colored, as with leucin. Examination of the Sediments of Urine. Urinary deposits may be divided into three classes: 1. Those which occur in acid or alkaline urine, namely, uric acid, urates, phosphates, oxalates, and cystin. 2. In al- kaline urine only, namely, the ammoniaco-magnesian, or triple phosphate, phosphate of lime, and urate of ammo- nia. 3. Organized deposits, namely, mucus, blood, pus, tube casts, spermatozoids, torulaB, sarcinae, bacteria, vibri- ones, etc. I. Deposits found occasionally in Acid or Alkaline Urine, usually in the former. Uric acid.—Yellow, reddish, or brown sediment; little masses of crystals, assuming various forms, as lozenge- 280 EXAMINATION OF URINARY DEPOSITS. shaped rhombs, rectangular tables or prisms, dumb-bell and spindle or barrel-shaped crystals. Urates.—These appear when the urine is cold, if the salts are present in excess, the urates being much more soluble in hot water than in cold. Consequently every deposit which disappears on heating consists of urates. They usually form a heavy precipitate at the bottom of the glass, with an ill-defined upper border; and are white or deeply tinted by the coloring matter of the urine. They have been termed " lateritious deposit," " brick-dust de- posit," " critical deposit," and " purpurates." Urate of soda is amorphous in urine, but prepared arti- ficially by acting with uric acid on sodium phosphate, it forms acicular crystals. Urate of ammonia appears as an amorphous granular sediment, or in the form of brown round balls covered with spines. Urate of lime is a white amorphous powder, of rare occurrence. Phosphates.—In acid urine they appear as a cloudy precipitate, at once soluble in a drop of nitric or hydro- chloric acids. Oxalate of lime may be detected by its characteristic octahedral or dumb-bell crystals. It is not a distinct sediment, but exists as isolated crystals entangled in the mucous cloud with which it is usually associated. Cystin.—This occasionally exists as a sediment mixed _ with amorphous urates. Under the microscope it is seen in transparent, colorless, six-sided plates. If it occurs in large quantity along with urates or phosphates, or both, it may be distinguished from them by heating and adding acetic acid-; the heating dissolving the urates, and the acid the phosphates, but neither have any effect on the cystin. EXAMINATION OF URINARY DEPOSITS. 281 II. Deposits found occasionally in Alkaline Urine only. When, from any cause urine becomes alkaline, from the decomposition of urea into carbonate of ammonia, the earthy phosphates (of lime and magnesia), which are soluble only in a slightly acid fluid, are at once thrown down ; the phosphate of lime remains unchanged, but the ammonia unites with the phosphate of magnesia and forms a precipitate of ammoniaco-phosphate of magnesia, or triple phosphate.1 The deposits of this class are all dissolved on adding a few drops of nitric or hydrochloric acid. Ammoniacomagnesian, or Triple Phosphate.—It usually occurs in six-sided crystals, some elongated, others nearly square, some with sharp angles, others with broad facets. In very alkaline urine, they appear as feathery crystals. Phosphate of Lime.—Usually an amorphous white powder; occasionally, aggregated into rosette-like crys- tals. Urate of Ammonia and Urate of Lime, already re- ferred to, may also be present; the former always in alkaline, rarely in acid urine; the latter occasionally in alkaline urine. III. Organized Deposits. Mucus.—The cloudy transparent flocculi seen in urine, when left at rest, consist of mucus entangling various forms of epithelial cells, derived from the urinary pas- sages. The supernatant liquid being carefully poured off, and acetic acid added to the mucus, it coagulates, forming delicate molecular fibres. 1 Nenbauer and Vogel. Guide to Qualitative and Quantitative Analysis of the Urine. (New Sydenham Society's Publications.) 4th ed., p. 56. 282 EXAMINATION OF URINARY DEPOSITS. Blood.—Urine containing blood has a peculiar smoky color, and always contains a trace of albumen. Under the microscope, the blood-corpuscles are usually colorless, have lost their biconcave form, and are globular from imbibition of water. Pus.—If there be a thickish yellow deposit at the bot- tom of the vessel, of a stringy consistence, it usually consists of mucus containing pus. The supernatant fluid being poured off, an equal bulk of caustic potash is added to the deposit, which at once gelatinizes, becom- ing so thick and tough that it cannot be poured from the test-tube. When pus is present in small quantity, pus- corpuscles can readily be detected by the microscope. Tube Casts.—These are either: 1. Fibrinous casts, often containing blood-disks. 2. Desquamative casts, containing epithelial casts. 3. Granular or fatty casts, containing numerous oil-globules, free, or in the epithe- lial cells. 4. Hyaline or waxy casts, solid and transpa- rent, or containing epithelial cells, granules, and free nuclei. These bodies ma}r be detected by allowing any sediment to fall to the bottom of a conical glass, remov- ing a small portion of it with a fine pipette, placing a drop on a slide, covering it with a thin glass, and exam- ining it with a power of 250 diam. linear. Spekmatozoids, Torul^e, Sarcix^;, Bacteria, Yibri- ONES, etc.,occasionally found in urine, may be readily detected by their characteristic microscopical appearance. ANTIDOTES TO POISONS. 283 POISONS, THEIR NATURE AND TREATMENT. A condensed table of poisons, presenting, at a glance, the prominent symptoms and the most available remedies or antidotes, is sure to prove, sooner or later, of practical and immediate utility. After all, the general principles of treatment only can be indicated in such an outline portrait of the effects of toxical agents; the details must be left to the intelligence, aptness, and presence of mind of the practitioner. Whenever it may be possible to ap- ply a direct chemical antidote, no time should be lost in its speedy employment. Of late years the antagonizing physiological action of various powerful remedies has also been invoked in cases of poisoning, and in a number of medical journals favorable results have been reported, where reliance had been successfully placed in this class of physiological opposites. Thus atropia, which dilates the pupil, has in a toxical overdose been combated by morphia, which contracts it; and a small dose of atropia administered hypodermically, say -g\ to ^ of a grain, until its characteristic effects are induced, is a physiolo- gical antidote to physostigmia, the active principle of Calabar bean. Watchful care must be taken, however, so far as quantity is concerned, lest in substituting one intensely potent agent for another the character of the poison may alone be changed, and the patient be left in equal peril. In cases in which no such chemical or phy- siological antidotal power is available, general principles of treatment must guide the practitioner in the employ- ment of emetics, counter-irritants, etc. The following classification, modified from that of 284 CLASSIFICATION OF POISONS. Taylor,1 is based on the modus operandi of poisons on the human system in its normal or healthy state:—■ Classification of Poisons. f Order 1. Irritants pro- f „. , f Non-metallic. Case I. per. | (Metallic. \ Order 2. Irritants pro- \ y t w Irritants. ducing remote specific | b [ effects. |^ Animal. ( r\ i -i n vi I Narcotics.2 Order 1. Cerebral, -s . ., .. , I. Anaesthetics.3 Class II. | Order 2. Spinal, or -j Tetanies.4 Neurotics. (Deliriants.5 [ Order 3. Cerebro-spinal. \ Depressants.6 ( Asthenics.7 By way of illustration, the following explanation may be made:— Irritants exert their action on the mucous membrane of the alimentary canal. They cause great pain in the abdomen, acrid and burning taste on swallowing, nausea, vomiting, purging, cramps, and sometimes bloody evacu- ations. Some irritants are corrosive, and act immedi- ately. Death may ensue from collapse, from convulsions, from intense inflammation, or stricture of the oesophagus. The symptoms of irritant poisoning are not unlike those attendant on some of the diseases of the gastro-intestinal apparatus, as colic, gastritis, enteritis, cholera, etc. Neurotics act specially on the cerebro-spinal system, producing drowsiness, headache, giddiness, coma, deliri- um, and occasionally convulsions, and at times an irri- tant action on the alimentary canal. The subdivision into spinal, cerebral, and cerebro-spinal neurotics indicates 1 Manual of Toxicology, by Dr. John J. Reese ; Phila., 1874. 2 As opium and alcohol. 3 As ether, chloroform, and alcohol. 4 As nux vomica, strychnia, brucia, etc. 6 As belladonna, stramonium, hyoscyamus, solanum. 6 As coninm, tobacco, lobelia, aconite, Calabar bean. 7 As hydrocyanic acid, oil of bitter almonds, digitalis, cocculus indi- cus, etc. THE TREATMENT OF POISONING. 285 the mode of action of each. Self-evident also is the method of subdivision of the latter into deliriants, depress- ants, and asthenics, the latter producing death by shock. The symptoms may resemble those of apoplexy, epilepsy, and ursemic poisoning, or insidious cerebro-spinal diseases, which at times burst unexpectedly and with full force on ■ the patient. The Treatment of Poisoning. The treatment of poisoning is briefly and concisely de- tailed in the following statement, prepared for the ready reference of the practitioner. The list of articles is ar- ranged alphabetically for convenience, the class to which each belongs being mentioned. He should, in the ab- sence of any information as to specific chemical or phy- siological antidote or remedy, treat the case on general principles; in other words, evacuate the stomach by emetics or the stomach pump; resort to the use of ca- thartics, if they seem to be indicated, stimulants, diluents, oleaginous substances, external friction, artificial respira- tion, etc., according to the urgency of the symptoms. A General Antidote for Poisons has been suggested by Jeannel for use in poisoning by various powerful agents, as arsenic, zinc, digitaline, etc., the preparations of which are rendered completely insoluble by it:— Solution of sulphate of iron (sp.gr. 1.45), 2 J oz. i Water, 20 oz. Calcined magnesia, 2 oz. Washed animal charcoal, 1 oz. The ingredients are kept separate, the solution of the sul- phate in one vessel, the magnesia and charcoal in another, with some water. When needed for use, the solution of the sulphate is poured into the other vessel, and violently agitated. The mixture should be administered in doses of from one and a half ounces to three ounces. 286 READY REFERENCE TABLE OF POISONS. Atropia. Cerebro- spinal neurotic Barium, salts Irritant. of. Belladonna Cerebro- (and Atro- spinal pia). neurotic Class. Irritant. Cerebro- spinal neurotic. Cerebral neurotic, Irritant. Irritant. Irritant. Irritant. Cerebral neurotic. Irritant. Irritant. Irritant. Treatment. Free vomiting, followed by exhibition of alka- line carbonates, chalk, or magnesia. Active emetics or stomach-pump. Stimulation externally and internally. Finely-powdered animal charcoal, or tannin and astringent in- fusions. Digitalis considered a physiological antidote. Stomach-pump; cold affusion; inhalation of vapor of ammonia ; use of electro-magnetic apparatus. General treatment for irritant poisons. See Potassa. Mild vegetable acids, as dilute vinegar or lemon-juice; olive oil; milk may be given copiously ; stomach-pump should not be used. Inhalation of vapor of acetic acid. Same treatment as for chloroform poisoning. Free vomiting with warm mucilaginous drinks, or stomach-pump. The proper antidote is tannin, as in tincture or infusion of cinchona, infusion of green tea, or of galls. Opium, and internal and external stimulation, may be em- ployed subsequently. See Arsenious acid. In the absence of vomiting prompt emesis by sulphate of zinc or warm mustard ami water. Warm demulcent drinks. Antidote : Hydra- ted sesquioxide of iron, in a moist state, in tablespoonful doses, followed by castor oil. (The hydrate may be extemporaneously pre- pared by adding aqua ammoniae to dilute tinctura ferri chloridi.) Freshly-precipitated hydrate of magnesia has also been employed. Antidote not reliable if the arsenic has been taken in form of powder. See Belladonna. Sulphate of soda or of magnesia ; emetics or stomach-pump. Prompt emetic or stomach-pump. No reliable chemical antidote : tannin and animal char- coal have been employed. Physiological anti- dote, morphia, which may be administered subcutaneously. Jaborandi lias also been Suggested. READY REFERENCE TABLE OF POISONS. 287 Class. Bismuth, Irritant. subnitrate of. Bromine. j Irritant. Brucia. Spinal neurotic Calabar bean Cerebro- (and Phy- j spinal sostigmia). neurotic Camphor. Irritant. Cantharides. Irritant. Carbolic Irritant. acid. Treatment. Chloral. Chloroform. Chromium, compounds of. Citric acid. Cerebral neurotic, Cerebral neurotic Irritant. Irritant. Cocculus In- Cerebro- dicus. ! spinal neurotic. Colchicum. Irritant. Conium (and Cerebro- Conia). I spinal I neurotic. Copper, pre- Irritant. parations of. Corrosive Irritant. sublimate. Albumen, milk, sugar, mucilaginous drinks. General treatment for irritant poisons. Same treatment as for poisoning by nux vomica. Free emesis. Physiological antidote, atropia, cautiously administered hypodermically. Emetics, stimulants, wine, opium. Free emesis to be encouraged with warm de- mulcent drinks; castor oil; demulcent in- jections. Early use of the stomach-pump. Olive oil; saturated solution of saccharate of lime has been recommended as an antidote. Stomach-pump ; stomach well washed out with tea or coffee. General treatment same as for opium poisoning, or poisoning by chloroform vapor. In poisoning by liquid chloroform, stomach- pump and emetics. General treatment of poisoning by the vapor same as that hereafter mentioned for ether. Reverse the patient, as recommended by Nelaton. Emetics; carbonates of magnesia or chalk in milk, albumen, or water. Free vomiting, followed by exhibition of alka- line carbonates, chalk, or magnesia. Emetics, mucilaginous drinks, stimulants. Prompt emesis, castor oil, demulcents, opium, and stimulants. Prompt emesis by mustard and water. Active stimulation, externally and internally. Free vomiting should be aided by warm muci- laginous drinks, stomach-pump if necessary. Antidote, white of eggs, freely administered, forming insoluble albuminate; or milk, form- ing insoluble caseate of copper. Free vomiting aided by warm, diluent drinks ; stomach-pump may produce perforation. An- tidote, white of egiiS, mixed with water and given copiously, forming insoluble compound; white of one egg neutralizes four grains of corrosive sublimate. Gluten, or wheat flour paste, or milk, also employed. 288 READY REFERENCE TABLE OF POISONS. Poison. Creasote. Croton oil. Curara. Dafuria. Digitalis(and Digitaline). Elaterium. Ether, vapor of. Gelsemium. Gold, prepa- rations of. Hydrochloric acid. Hydrocyanic acid. Hyoscyamus (and Hyos- cyamia). lodin^. Iron, chloride and sul- phate of. Lead, acetate, subacetate, and carbon- ate of. Lobelia. Mercury and its prepara- tions. Methylene, bichlo- ride of. Class. Irritant. Irritant. Spinal neurotic. Cerebro- spinal neurotic. Cerebro- spinal neurotic. Irritant. Cerebral neurotic. Irritant. Irritant. Irritant. Cerebro- spinal neurotic. Cerebro- spinal neurotic, Irritant. Irritant. Irritant. Cerebro- spinal neurotic, Irritant. Cerebral neurotic Treatment. Emetics or stomach-pump; demulcent and mucilaginous drinks. Same general treatment as for other irritant poisons, to counteract excessive vomiting and purging. Opium, stimulants, etc. Same general treatment as that mentioned for poisoning by nux vomica. See Stramonium. Free use of emetics; vegetable infusions con- taining tannic acid render the active principle insoluble. General treatment for irritant poisons. Withdraw the cause ; cold affusion ; exposure to current of air ; artificial respiration. General treatment for irritant poisons. Sulphate of iron ; mucilaginous drinks. See Muriatic acid. Being rapidly fatal, treatment must be instan- taneous. Cold affusion ; cautious inhalation of ammonia and chlorine vapors ; stimulation externally and internally. Mixture of proto- sulphate and sesquisulphate of iron, followed by solution of carbonate of potassium, to pro- duce insoluble Prussian blue, has been pro- posed as a chemical antidote. Same general treatment as for poisoning by belladonna. Starch or flour in water. Magnesia, copious diluent drinks. Sulphate of zinc, producing free emesis, and forming insoluble sulphate of lead. Milk and white of egg, given copiously, form insoluble compounds. Solutions of sulphate of mag- nesia or of soda, freely administered, act as antidotes and cathartics ; or castor oil. Emetics, purgatives, stimulants. See Corrosive sublimate. Same treatment as for poisoning by chloroform vapor. READY REFERENCE TABLE OF POISONS. 289 Class. 19 Cerebral neurotic, Irritant. Cerebro- spinal neurotic. Cerebral neurotic. Irritant. Spinal neurotic Cerebro- spinal neurotic Cerebral neurotic Irritant. Treatment. Irritant. See Opium. Solution of alkaline carbonates in water or milk; magnesia or chalk suspended in milk; soapsuds ; scrapings frorii whitewashed walls (in the absence of other articles], oily emul- sions, gruel, and milk in large quantities; free use of barley water. See Tobacco. Same general treatment as for poisoning by chloroform vapor. Same treatment as already detailed for poison- ing by muriatic acid. Dilute solution of car- bonate of sodium, or fluid magnesia, with water, and demulcents may be given. See Strychnia. Same treatment as for hydrocyanic acid poison- ing. Direct emetics, as large doses of sulphate of zinc, repeated if necessary, or mustard and warm water, or stomach-pump. Persevere until no smell of opium remains. For the narcotic effect of the drug, affusion with cold water, walking the patient, arousing him by shak- ing and shouting ; flagellations ; afterwards strong coffee. If unsuccessful, electro-magnet- ism, applied between upper part of spine and chest. Artificial respiration as a last resort. As antidotes, tannic acid and iodated iodide of potassium, not reliable if employed alone. Physiological antidote, solution of atropia or tincture of belladonna. Avoid the use of alkalies or their carbonates, as they will form poisonous salts with the oxalic acid. Give chalk or magnesia, or its carbonate, suspended in water or milk, form- ing insoluble and inert earthy oxalates; or saccharated solution of lime. After-treatment, mucilaginous drinks, lime-water, and oil; warmth and stimulants. Free vomiting, with sulphate of copper, espe- cially ; albuminous and mucilaginous drinks, in which hydrate of magnesia is suspended. Oil, being a solvent of phosphorus, should be avoided. Old oil of turpentine (containing oxygen), oxygenated water, oxygen inhala- tions, animal charcoal, have been employed as antidotes. Intravenous injection of oxygen is also recommended. Avoid animal fat in diet. 290 READY REFERENCE TABLE OF POISONS. Class. Cerebro- spinal neurotic Irritant. Irritant. Cerebro- spinal neurotic, Irritant. Irritant. Irritant. Cerebro- spinal neurotic. Irritant. Irritant. Irritant. Cerebro- spinal neurotic. Spinal neurotic. Treatment. Irritant. Irritant. Irritant. See Calabar bean. Mild vegetable acids, as dilute vinegar or le- mon-juice; demulcent drinks; olive oil, in large quantities, produces a soap. Milk may be copiously administered. Stomach-pump should not be used. Same treatment as for the nitrate. Dilute solution of bicarbonate of potassium reduces bitartrate to harmless neutral tartrate. Weak solution of sulphate of iron converts it into Prussian blue. Treatment similar to that for hydrocyanic acid. General treatment for irritant poisons. No known antidote; stomach-pump; free vomiting, and copious mucilaginous drinks; stimulants, opium, camphor, etc., if great depression exists. Warm dilute drinks to produce emesis ; hydrate of magnesia, or weak solution of carbonate of ammonium; stomach-pump. See Hydrocyanic acid. General treatment for irritant poisons. Albumen, milk. If nitrate of silver, the chlo- ride of sodium. Same treatment as for poisoning by compounds of potassium. Same treatment as for poisoning by belladonna. Morphia should be administered subcutane- ously until contraction of the pupils results. Prompt emesis by stomach-pump, or mustard and warm water, or mixture of ipecacuanha and sulphate of zinc. Inhalation of chloroform continuously employed may relieve tetanic rigidity. Bromide of potassium, in very large doses, a physiological antidote. Hydrate of chloral, nitrite of amyl, atropia have also been employed. Same treatment as for poisoning by muriatic acid. Solution of carbonate of sodium in milk and water. (Used in dyeing.) Relieved by calcined mag- nesia and milk, or fluid magnesia. Same treatment as for poisoning by citric acid or oxalic acid. READY REFERENCE TABLE OF POISONS. 291 Poison. Class. Treatment. Tartar eme- Irritant. See Antimony. tic. Tin, prepara- Irritant. General treatment for irritant poisons. tions of. Tobacco (and Cerebro- Stomach-pump or emetics ; injections per anum. Nicotia). spinal neurotic. Veratrum Irritant. Rapid emesis, stimulants, with laudanum or (and Vera- some other opiate. Tannin has been proposed tria). as an antidote. Zinc, chloride Irritant. Free emesis, copious warm mucilaginous drinks, of. or stomach-pump, albumen given liberally. Opium, if necessary. Zinc, sul- Irritant. Tepid water with milk and albumen ; infusions phate of. containing tannic acid. Stomach-pump. Emol-lient enemata. There is a number of so-called vegetable irritants, such as aloes, scammony, jalap, etc., which may give rise to toxical symptoms. Their effects should be treated on general principles, such as the employment of emetics, diluents, castor oil, opium, fomentations, etc. The same remarks apply also to the various articles of diet, such as fish, meat, etc., which occasionally produce similar effects. Irritant gases, as chlorine, nitrous acid, or sulphurous acid vapor, etc., may act as poisons, and their effects should be treated by removal of the patient from the causes, cold affusion, etc. The numerous poisonous fungi, which may be taken into the stomach, may also produce symp- toms, which may require treatment on the previously- mentioned general principles. Bites of venomous reptiles require a special treatment; the wound may be sucked with impunity ; the limb above this point having a ligature placed around it, or com- pressed ; the part involved excised or cauterized with the iron, nitric acid, etc. The injection of liquor ammoniae into the vein has also been advised. Stimulants, as am- monia or brandy, should also be freely given. The greater part of the local treatment here detailed would also be applicable in cases resulting from*the bites of rabid animals. 292 READY REFERENCE TABLE OF ANTIDOTES. READY REFERENCE TABLE OF ANTIDOTES.1 General Remarks.—An emetic is unnecessary when the pois- oned patient lias already vomited freely. Antidotes for Unless otherwise stated, the figures denote grammes. 1. Aconitia. R. Cupri sulph. ... 1.0 Aquas dest. . . . 40.0 Dissolve. S.—Emetic; give half, and balance, if necessary, in five minutes. Then: R. Acid. tann. . . 4.0 Aqua? dest. . . . 200.0 Syr. simpl. . . . 50.0 M. S.—Tablespoonful every five min- utes. 2. Alcohol Intoxication. R. Pepsini .... 2.0 Aquas dest. . . . 200.0 Acid. mur. . . . 1.00 M. D. S.—Teaspoonful every five min- utes. Or R. Aquae ammon. . . . gtt. 10 Aquae dest. . . . 150.0 Syr. simpl. . . . 20.0 M. S.—Take at once. 3. Alkali Carbonates and Caustic Alkalies. R. Acidi tartaric. . . . 10.0 Aquae font. . . . 1000.0 M. S.—Drink a tumblerful at once; then every five minutes a dessertspoon- ful of almond oil, with five tablespoon- fuls of the tartaric acid solution. (This is sufficient for 100 grams of a 5 per cent, solution of alkali.) 4. Ammonia. R. Acid. acet. concent. . S.—For smelliug. R. Acet. crud. Aquae dest. Syr. simp. 10.0 20.0 200.0 20.0 M. S.- utes. -Tablespoonful every five min- . Aceti crudi Aquae dest. S.—Iuhale warm. . 50.0 . 200.0 (Cold washing.) 5. Anilin Preparation. R. Cupri sulph. ... 1.0 Aquae dest. . . . 40.0 S.—Emetic ; half to be taken at once, and the other half in five minutes, if necessary. fy. Magn. ust. in aq.2 . . 200.0 D. S.—Tablespoonful every half hour. 6. Antimonial Preparations and Tartar Emetic. R. Acid, tannic. ... 3.0 Aquae dest. . . . 140.0 Syr. althajae . . . 60.0 M. S.—Tablespoonful every five min- utes. 1 By Dr. Th. Schlosser. Translated from "Ztschr. d. Allg. Oest. Apotli. Ver.," 1880, Nos. 1 and 2, by Louis von Cotzliausen, rii.G., in "Amer. Journ. of Pharmacy,'" Marcli, 1880. 2 1$.. Magnesias.....OJ- Aquae......0vJ- READY REFERENCE TABLE OF ANTIDOTES. 293 7. Arsenic Preparations. R. Magn. ust. in aq.' . . 200.0 D. S.—One-third to be taken at once, then a tablespoonful every five minutes. 8. Atropia. R. Fol. jaborandi . . . 10.0 Fiat infus. ad colat. . . 200.0 S.—Take half at once, then every half hour a tablespoonful with a tablespoon- ful of wine. R. Pilocarpin. mur. . . 0.05 Aquae dest. . . . 2.00 S.—Inject hypodermically. 9. Baryta. Treat like lead salts. 10. Belladonna. Treat like atropia. 11. Bites by Dogs and Cats. R. Potassae .... 1.0 Aquae dest. . . . 500.0 M. S.—Wash the wound, and keep open with linen dipped into it, until a physician arrives. 12. Bite of Snakes. See bites by dogs. R. Aquae amnion. . . . gtt. 30 Aquae dest. . . . 150.0 Syr. simp. . . . 30.0 M. S.—Tablespoonful every five min- utes. 13. Bromine. R. Magn. ust. in aqua1 . . 200.0 S.—Take one-third at once, then a tablespoonful every quarter of an hour. 14. Brucia. Treat like strychnia. 1 See foot-note, p. 292. 15. Cannabis Indica. Treat like morphia. 16. Cuntharidin. R. Cupri sulph. . . . 1.0 Aquae dest. . . . 40.0 M. S.—Emetic ; take one-half imme- diately, and the balance in five minutes, if necessary. Then: R. Camph.....3.0 Muc. g. arabic . . . q. s. Mixt. gummos. . . . 300.0 Tr. opii .... gtt. 10 M. S.—Tablespoonful eveiy five to ten minutes. 17. Carbolic Acid. Use the same emetic as for anilin. Then: R. Magn. ust. in aqua2 . . 200.0 S.—Take one-half at once, then every quarter of an hour a tablespoonful alter- nately with Mixt. oleos. . . . 200.0 S.—Tablespoonful every quarter of an hour. 18. Carbonic Oxide and Carbonic Acid Gas. R. Aquae ammon. . . . 40.0 S.—For smelling. (Cold ablutions.) R. Extr. ergotae . . . 0.30 Aquae dest. . . . 50.0 S.—Dessertspoonful every quarter of an hour. 19. Caustic Alkalies. See alkali carbonates. 20. Caustic Lime and Calcium Salts. fy. Magnes. sulph. . . . 20.0 Aquae dest. . . . 100.0 Syr. simpl. . . . 40.0 Dissolve. S. Take at once. 294 READY REFERENCE TABLE OF ANTIDOTES. Then: R. 01. amygd. dulc. . 20.0 Pulv. gum acaciae . 10.0 Aquae dest. . 15.0 Syr. simpl. . 100.0 M. D. S.—Two dessertspoon 'uls every quarter hour. 21. Chloral Hydrate. R. Atrop. sulph. . . milligram. 2 quae dest. . . . 35.0 M. S.—Give in two doses, in the course of half an hour. (Instead of atropia, tincturs of belladonna 2.0 may be iven in the same manner). 22. Chlorine Vapors. R. Aquae laurocerasi • . . 10.0 iEtheris, Alcohol, 90 per cent. aa 30.0 S.—For smelling and inhaling. 20.0 R. Spir. nitr. dulc. . Syr. althaeae, Aquae dest. . . aa 40.0 M. S.—A tablespoonful every five or ten minutes. 23. Chloroform. R. Aquae animon. . . . 50.0 S. —For smelling. (Cold douche and ice applied to the head.) R. Two Seidlitz powders. S.—Give one. If very bad, give R. Cupr. sulph. ... 1.0 Aquae dest. . . . 40.0 S.—Emetic; give one-half, and, if ne- cessary, the other half five minutes later. 24. Chromic Acid and Chromates. R. Pulv. ferri ... 5.0 Linct. oleos.,1 Syr. simp. . . . aa 50.0 M. S.—Shake well, and take a dessert- spoonful every five minutes, and then two tablespoonfuls of water. 25. Codeia. See morphia. 26. Colchicia. See aconitia. 27. Conia. R. Strych. nitrat. . . . 0.01 Aquae dest. . . . 100.0 Tr opii .... gtt. 30 M. S. — Two dessertspoonfuls every quarter of an hour, until one-third is taken ; then every half hour, until the second one-third is consumed; then every hour. 28. Copper Money Swallowed To children : R. Hydrom. infant.^ D. S.—Give at once. To adults: R. Aq. laxat. Vienn.3 Sodii sulph. cryst. D. S.—Take at once. 20.0 50.0 10.0 1 Linctus Oleosus. fy. Acacias pulv......p. j. Aquae amygd. amar. dilut. 01. amygdal. express. . . aa p. ij. Syrupi althaeas.....p. iij. M. 2 Hydromel Infantum is composed of VI enna draught, 3 p.; Syrup of manna, 1 p. 3 See footnote, p. 295. READY REFERENCE TABLE OF ANTIDOTES. 29") 29. Copper Salts. fy. Pulv. ferri . . 14 0 Flor. sulph. lot. . . 8.0 Syr. simpl. . . . 60.0 M. D. S.—Shake well, and give a des- sertspoonful every five minutes, alter- nating with R. Magn. ust. in aq.' . . 200.0 Mix with white of 4 eggs and add Aquae dest. . . . 200.0 Syr. simpl. . . . 80.0 S.—Half a teacupful every five min- utes. 30. Creasote. 10.0 20.0 280.0 R. Pulv. acaciae 01. amygd. dulc. Aquae dest. m . Ft. emulsio. D. S.—Take one-fourth at once, then half a teacupful every ten minutes. 31. Curare. R. Strychn. nitr. Aquas dest. M. S.—Inject. 0.05 5.0 32. Cyanide of Potassium and Prussic Acid. R. Cupri sulph. ... 2.0 Aquae dest. . . . 28.0 Dissolve. S. — Emetic ; tablespoonful at once, thefbalance in five minutes. (Cold wa- ter ought to be applied.) 33. Digitalis. Like morphia. 34. Ergot. Like sausage poison. 1 See footnote, p. 292. 35. Excessive Etherization. Vf.. Aquae ammon. . . . gtt. 15 Aquae dest. S.—To be taken at one dose. 20.0 I£. Aquae ammonias . . 30.0 S.—For smelling. (Cold water must be freely applied and fresh air.) 36. Fungi. Like morphia. 37. Gratiola. Like aconitia. 38. Helleboius. See aconitia. 39. Hyoscyamus. See morphia. 40. Iodini. R. Amyl. .... 5.0 Mix by triturating with a little water ; then pour on Aquae fervidae . . . 100.0 and add Magn. ust. in aqua' . . 100.0 S.—Tablespoonful every five minutes. 41. Lactucarium. As morphia. 42. Lead Salts. R. Aquas laxat.2 . . . 50.0 Magnes. sulph. . . . 30.0 Aquas ferv. . . . 100.0 M. S.—Give in two doses, within ten minutes. 43. Lime. See caustic lime. 1 See footnote, p. 292. 2 Aqua laxativa Viennensis is nearly iden- tical with infus. sennas comp. Ph. Germ. In- fuse senna 6 p. in hot water 48 p. for half an hour, strain, and add manna 8 p. 296 READY REFERENCE TABLE OF ANTIDOTES. 44. Mercury Salts. . See copper salts. 45. Mineral Acids. ty. Magn. ust. in aq.1 . 200.0 D. S.—Take one-half at once ; then a tablespoonful every five minutes, alter- nating with two tablespoonfuls of the following:— R. 01. amygd. dulc. . . 20.0 Pulv. acacias . . . 10.0 Aquas dest. . . . 200.0 Syr. simp. . . . 1C0.0 Fiat emuls. 46. Morphia. R. Cupri sulph. ... 1.0 Aquas dest. . . . 40.0 M. D. S.—Emetic; give one-half, and, if necessary, the balance in five minutes. Besides: R. Coffeae tostae . . . 50.0 F. infusum ad colatur. . 200.0 Acidi tannici . . . 4.Q Syr. simpl. . . . 50.0 S.—Teaspoonful every five minutes. 47. Muscarin. See chloral hydrate. Or R. Atrop. sulph. . . . 0.01 Aquae dest. . . . 5.0 S.—Use as an injection. 48. Nicotina. In case of nausea in consequence of smoking. R. Aceti crudi . . . 50.0 Aquae dest. . . . 200.0 Syr. simpl. . . . 50.0 M. S. — One-half at once, and then a tablespoonful every five minutes. In case of poisoning. See morphia. R. Acidi tannici ... 4.0 Aquas dest. . . . 200.0 Syr. simpl. . . . 50.0 M. D. S. — Tablespoonful every live minutes. 49. Oxalic Acid and Oxalates. R. Calcii carb. pulv. . . 50.0 Aquas dest. . . . 200.0 M. D. S. — One-half at once; then every ten minutes a tablespoonful. Half an hour later take R. Aquae laxat. Vienn.1 . . 50.0 Sodii sulph. cryst. 10.0 Dissolve. S.—Take at once. 50. Opium. Treat like morphia. 51. Paris quadrifolia. Like morphia. 52. Petroleum, or Volatile Oils. R. Mixt. oleos. . . . 1000.0 S.—Drink continually. 53. Phosphorus. R. Cupri sulph. ... 1.0 Aquas dest. . . . 40.0 Solve. D. S.—Emetic ; give one-half, and, if necessary, the balance in five minutes. Then: R. 01. terebinth, vetusti . 30.0 (the older the better), beat with the white of 2 eggs, and add Aquae menth. pip. . . 250.0 Syr. simpl. . . . 50.0 Fiat emulsio. 1 See footnote, p. 292. 1 See footnote, p. 295. READY REFERENCE TABLE OF ANTIDOTES. 297 S.—Shake well, and give one table- spoonful every half hour, until one- fourth of the mixture has been given; then one tablespoonful every hour. In doubtful cases of poisoning with phosphorus give R. Magn. ust. iu aqua . . 20.0 Aquas chlori . . . 120.0 M. D. 54. Phosphorus Burns. R. Argenti nitr. fus. . . 2.0 Aquas dest. . . . 20.0 Solve. S.—Apply with a camel-hair brush, and use as a wash. 5"). Prussic Acid. See cyanide of potassium. 56. Pulsatilla. Treat like aconitia. 57. Sabina. See morphia. 58. Santonin. R. Cupri sulph. . . . 1.0 Aquae dest. . . .40.0 S. — Emetic; give one-half at once, and, if necessary, the balance in five minutes. 59. Sausage Poison, or Spoiled Meat. R. Cupri sulph. ... 1.0 Aquae dest. . . . 40.0 S. D. S. — Emetic; give one-half at once, and, if necessary, the balance in five minutes. Then give: R. iEtheris pur. ... 2.0 Aquas dest. . . . 150.0 Tr. opii .... gtt. .10 Syr. capill. vener. . . 20.0 S.—Tablespoonful every half hour. 60. Silver Preparations. R. Sodii chlorid. . . .20.0 Aquas comm. . . . 300.0 M. D. S.—Give one-half at once, and then a tablespoonful every half hour. Between the doses give : R. Mixtures oleosae, Mixturae gummosae, . aa, 150.0 M. S.—Two tablespoonfuls every half hour. 61. Spoiled Meat. See sausage poison. 62. Stings by Insects. R. Aquas ammon. . . . 20.0 S.—Apply externally. 63. Stramonium. Like opium. Then: R. Morph. mur. . . . 0.10 Aquas dest. . . . 10.0 Inject hypodermically. 64. Strycftnia. R. Acidi tannici . . . 3.0 Aquae dest. . . . 140.0 Syr. althasae . . . 60.0 M. D. S. — Tablespoonful every five minutes. R. Chloral, hydrat. . . 4.0 Aquas dest. . . . 100.0 Solve. S.—Tablespoonful every half hour. 65. Sulphuretted Hydrogen. fy. Spir. astheris comp. . . 30.0 S.—Give ten drops every five minutes in a dessertspoonful of water. R. Spir. asth. nitrosi . . 50.0 S.—Pour on a cloth, and apply to nostrils. 298 READY REFERENCE TABLE OF ANTIDOTES. R. Calc. hypochlor. uaic. nypochlor. . . 40.0 S.—For smelling. (Fresh air ; wash with vinegar.) 66. Tartar Emetic. See antimonial preparations. 67. Tin Salts. R. Pulv. ipecac. ... 2.0 Aquae dest. . . . 100.0 Syr. simpl. . . . 20.0 M. D. S.—Emetic; to be taken in two doses inside of quarter of an hour. Then: R. Magn. ust. in aqua1 . . 200.0 S.—Take one-third at once, then a ta- blespoonful every five minutes, besides plenty of milk. 68. Veratria. Treat like morphia. 69. Volatile Oils. See petroleum. 70. Zinc Salts. R. Acidi tannici . . . 4.0 Aquas dest. . . . 140.0 Syr. althaeas . . 60 0 D. S.—Tablespoonful every five min- utes. i See footnote, p. 292. RESTORATION OF THE APPARENTLY DROWNED. 299 directions for restoring the appa- rently DROWNED.1 The leading principles of the following directions for the restoration of the apparently dead from drowning are founded on those of the late Dr. Marshall Hall, combined with those of Dr. H. E. Silvester, and are the result of extensive inquiries which were made by the Royal Na- tional Life-Boat Institution of England, amongst medical men, medical bodies, and coroners throughout the king- dom. These directions have been extensively circulated by the Institution throughout the United Kingdom and in the Colonies. They are also in use in the British navy, in the Coastguard service, and at all the stations of the British army, both at home and abroad. The actual condition in drowning is due to the same cause as in death by hanging—the non-entrance of air into the lungs. If repeated attempts at breathing be made while the patient is in the water, air will escape from the chest, and water may pass into the air-passages, but this intrusion of water is no necessary condition of drowning. Hence no attempts need be made, as our fore- fathers taught, to remove the water from the chest, by rolling the body face downwards on a barrel, etc. The points to be aimed at are—first and immediately the Restoration of Breathing; and, secondly, after breathing is restored, the Promotion of Warmth and Circulation. The efforts to restore breathing must be commenced immediately and energetically, and persevered in for one 1 Good Health, July, 1869. 300 RESTORATION OF THE APPARENTLY DROWNED. or two hours, or until a medical man has pronounced that life is extinct. Efforts to promote warmth and cir- culation, beyond removing the wet clothes and drying the skin, must not be made until the first appearance of na- tural breathing; for if circulation of the blood be induced before breathing has recommenced, the restoration to life will be endangered. Send immediately for medical assistance, blankets, and dry clothing, but proceed to treat the patient instantly on the spot, in the open air, with the face downward, whe- ther on shore or afloat, exposing the face, neck, and chest to the wind, except in severe weather, and removing all tight clothing from the neck and chest, especially the braces. Cautions.—Prevent unnecessary crowding of persons around the body, especially if in an apartment. Avoid rough usage, and do not allow the body to remain on the back unless the tongue is secured. Under no cir- cumstances hold the body up by the feet. On no account place the body in a warm bath unless under medical direction, and even then it should only be em- ployed as a momentary excitant. To Restore Breathing. Dr. Marshall HalVs Method. To Clear the Throat.—Place the patient on the floor or ground with the face downwards, and one of the arms under the forehead, in which position all fluids will more readily escape by the mouth, and the tongue itself will fall forward, leaving the entrance into the windpipe free. Assist this operation by wiping and cleansing the mouth. If satisfactory breathing commences, use the treatment described below to promote warmth. If there be only DR. MARSHALL HALVS METHOD. 301 slight breathing, or no breathing, or if the breathing fail, then— To Excite Breathing.—Turn the patient well and in- stantly on the side, supporting the head, and excite the nostrils with snuff, hartshorn, and smelling salts, or tickle the throat with a feather, etc., if they are at hand. Rub the chest and face warm, and dash cold water, or cold and hot water alternately on them. If there be no suc- cess, lose not a moment, but instantly— 302 RESTORATION OF THE APPARENTLY DROWNED. To Imitate Breathing (see Figs. 1 and 2).—Replace the patient on the face, raising and supporting the chest well on a folded coat or other article of dress. Turn the body very gently on the side and a little beyond, and then briskly on the face, back again, repeating these measures cautiously, efficiently, and perseveringly, about fifteen times in the minute, or once every four or five seconds, occasionally varying the side. On each occasion that the body is replaced on the face, make uniform but efficient i DR. SILVESTER'S METHOD. 303 pressure with brisk movement, on the back between and below the shoulder blades or bones on each side, removing the pressure immediately before turning the body on the side. By placing the patient on the chest, the weight of the body forces the air out; when turned on the side this pressure is removed, and air enters the chest. The first measure increases the expiration—the second commences in- spiration. The result is respiration or natural breathing; and, if not too late, restoration to life. During the whole of the operations let one person at- tend solely to the movements of the head and of the arm placed under it. Whilst the above operations are being proceeded with, dry the hands and feet, and as soon as dry clothing or blankets can be procured, strip the body, and cover or gradually reclothe it, but taking care not to interfere with the efforts to restore breathing. Dr. Silvester's Method. Should the efforts just described not prove successful in the course of from two to five minutes, proceed to im- itate breathing by Dr. Silvester's method, as follows: Place the patient on the back on a flat surface, inclined a little upwards from the feet; raise and support the head and shoulders on a small firm cushion or folded article of dress placed under the shoulder-blades. Cleanse the mouth and nostrils, draw forward the patient's tongue, and keep it projecting beyond the lips; an elastic band over the tongue and under the chin will answer this pur- pose, or a piece of string or tape may be tied around them, or by raising the lower jaw, the teeth may be made to retain the tongue in that position. Remove all tight clothing from about the neck and chest, especially the braces. 304 RESTORATION OF THE APPARENTLY DROWNED. To Imitate the Movements of Breathing.—Standing at the patient's head, grasp the arms just above the elbows, and draw the arms gently and steadily upwards above the head, and keep them stretched upwards for two seconds. By this means air is drawn into the lungs. Then turn down the patient's arms, and press them gently and firmly for two seconds against the sides of the chest. By'this means air is pressed out of the lungs. (See Figs. 3 and 4.) Re- peat these measures alternately, deliberately, and perse- veringly, about fifteen times in a minute, until a sponta- THE AFTER-TREATMENT. 305 neous effort to respire is perceived, immediately upon which cease to imitate the movements of breathing, and proceed to induce circulation and warmth. Treatment after Natural Breathing- has been Restored. To Promote Warmth and Circulation. Wrap the patient in dry blankets; commence rubbing the limbs upwards, with firm grasping pressure and en- ergy, using handkerchiefs, flannels, etc. By this measure the blood is propelled along the veins towards the heart. The 20 306 RESTORATION OF THE APPARENTLY DROWNED. friction must be continued under the blanket or over the dry clothing. Promote the warmth of the body by the application of hot flannels, bottles, or bladders of hot water, heated bricks, etc., to the pit of the stomach, the armpits, between the thighs, and to the soles of the feet. If the patient has been carried to a house after respiration has been restored, be careful to let the air play freely about the room. On the restoration of life, a teaspoonful of warm water should be given ; and then, if the power of swallowing have returned, small quantities of wine, warm brandy and water, or coffee, should be administered. The patient should be kept in bed, and a disposition to sleep encour- aged. The above treatment should be persevered in for some hours, as it is an erroneous opinion that persons are irre- coverable because life does not soon make its appearance, persons having been restored after persevering for many hours. The appearances, which generally accompany death are entire cessation of breathing and of the heart's action; the eyelids are generally half closed; the pupils dilated; the jaws clenched; the fingers semi-contracted; the tongue approaches to the under edges of the lips, and these, as well as the nostrils, are covered with a frothy mucus; coldness and pallor of surface increase. PRINCIPLES OF DISINFECTION. 307 DISINFECTANTS AND THEIR PRACTICAL APPLICATION. The employment of this class of agents has become so much more general in recent times, that it is deemed desirable and expedient here to embody some of the practical conclusions arrived at by scientific and other authorities on the subject. A knowledge of the means of prevention of the spread of malignant or infectious disease in communities is undoubtedly of greater import- ance than their cure in individual cases. The Principles of Disinfection.1 Fresh air and pure water, constant ventilation, warm clothing, good food, and thorough cleansing, are natural means of preventing and destroying the causes of infection and disease. But there may be infected or foul places and things, and there are times of special necessity or sudden danger from the presence of infectious epidemic disea.-e, which require the instant arrest or destruction of the infection and all its removable causes ; this is disinfection. The clothing from persons with smallpox, scarlatina, or typhus, and even the air in the sick-rooms of such patients, is infectious; and the sick with typhoid fever or cholera discharge excremental matters which possess in- fective properties that should be immediately destroyed. 1 The valuable recommendations contained in the following pages, many of which are almost inaccessible to the general practitioner through any other channel than that now offered, have been carefully collated from the admirable chapter on the subject in the Annual Re- port of the Board of Health of New York for 1873, and from other trust- worthy sources, with numerous additions by the author. 308 PRINCIPLES OF DISINFECTION. In this memorandum the words infection and disinfec- tion are employed just as they are understood, as referring to the preventable causes that are concerned in repropa- gating specific kinds of disease; these causes are:— 1. The specific infectious property or contagious sub- stance of any one of the pestilential disorders. 2. The local impurities and moisture in the house and grounds where the outbreaks of disease have occurred or are liable to occur. 3. The foul exhalations and atmospheric impurities which injure health or help to propagate pestilential epidemics. Experience has proved that it is possible, by certain chemical agencies (such as are or will be hereafter de- scribed), wholly to destroy or prevent the operation of the specific infection or contagion of any disease; but to do this, it is necessary that precise rules should be observed in applying the disinfectants; and, as regards cholera and typhoid fever, it is especially important that the infective discharges from the sick should be disinfected as soon as voided from the body, and that whatever clothing or sur- faces may have been soiled by such discharges should be disinfected as soon as practicable. The fact should also be borne in mind by all persons who have charge of in- fected things, that the infective property or virus of some diseases, and of cholera especially, is capable of rapid increase in filthy places and in a foul, damp atmosphere. Therefore, the cleansing and disinfection of such places should, if possible, precede the arrival or outbreak of any such pestilence. Every unclean and damp place about dwelling houses, warehouses, factories, places of assem- blage, passenger vessels, railway depots, and hotels, should be made and kept perfectly clean and dry. All drains, necessaries, and water-closets, should be kept as clean as PRINCIPLES OF DISINFECTION. 309 possible, and should be thoroughly purified before cholera comes into the neighborhood. Such cleansing and disin- fection give the surest protection against pestilential epi- demics. It must be borne in mind, however, that although the so-called disinfectants are very useful when properly applied, they are not, by any means, infallible preven- tives of disease. Dr. Baxter,1 from careful experiments, arrives at the fol- lowing opposite conclusions in regard to disinfectants: No virulent liquid can be considered disinfected by carbolic acid unless it contains at least two per cent, by weight of the pure acid. When disinfectants are mixed with a liquid it is very important to be sure that they are thoroughly incorporated with it, and that no solid matters capable of shielding contagion from immediate contact with its destroyer be overlooked. Aerial disinfection, as commonly practised in the sick-room, is either useless or positively objectionable, owing to the false sense of secu- rity it is calculated to produce. To make the air of a room smell strongly of carbolic acid by scattering car- bolic powder about the floor, or of chlorine, by placing a tray of chloride of lime in a corner, is, so far as the de- struction of specific contagion is concerned, an utterly futile proceeding. According to his views the practical result of these experiments goes to prove (1) that dry heat, when it can be applied, is probably the most effi- cient of all disinfectants ; (2) that the old plan of stopping up crevices and fumigating with sulphur and charcoal is more efficacious than any other proceeding with more modern disinfectants; (3) that the use of carbolic vapor for disinfecting purposes should be abandoned, owing to the relative feebleness and uncertainty of its action. 1 Med. Times and Gazette, July 29, 1876. 310 DISINFECTANTS IN COMMON USE. Disinfectants in Common Use. There are three important classes of disinfectants, each having specific uses as mentioned above. Some of tliese purifying agents accomplish only one object, others ac- complish two or more objects; some may be advan- tageously combined ; others are incompatible with each other, and must not be used together. Class I. Positive Disinfectants that quickly destroy or completely restrain every contagious and infectious virus. This class comprises the caustic acids, the acid salts of metals (soluble oxide salts), such as sulphate of iron, sul- phate of zinc, etc.; carbolic and cresylic (impure carbolic) acids; which not only destroy every communicable virus of disease, but also prevent those kinds of fermentation and decay that aid in propagating epidemics. Frost destroys some infections, but preserves many others, while boiling or high steam heat destroys all contagious matter. It will be observed that no one of these agents, singly, is applicable to everything and every place that may re- quire disinfection. Class II. Antiseptics, comprising chemical agents that arrest or wholly prevent fermentation and decay. This is a large class, and embraces carbolic and sali- cylic acids, and most of the agents of the first class ; but not every antiseptic substance or gas (common salt or chlorine, for example) can absolutely prevent the fatal operation of epidemic infections. Class III. Deodorants, absorbents, etc., comprising all the chemicals that deodorize or destroy putrid exhalations, or that absorb moisture and gases. Charcoal, quicklime, and chlorine are good examples of this group. Each of these three classes, and each disinfecting HOW TO USE DISINFECTANTS. 311 agent, has its proper uses, and, as it is frequently im- portant that these threefold means of disinfection should be applied at once to a given place or source of disease, the chemical properties of the several agents must be regarded. For example, it should be remembered that chlorine and the common alkaline compounds do not destroy the cholera infection ; also, the fact that, if per- manganate salts, carbolic acid, and chlorine be used together, or if the first two of them be mixed, they will simply destroy each other, and leave the infection unde- stroyed. Volatile Disinfectants.—Carbolic acid on any surfaces from which it will evaporate, or from which it may be vaporized by steam-heat, and the sulphurous acid fumes, are examples of disinfectants belonging both to the first and the second class. Bromine and nitrous acid have similar powers, but should be used only by medical officers. Of the volatile deodorants in Class III., chlorine is the chief, and though useful for certain purposes in the other classes (I. and II.), if intensely concentrated, it is prin- cipally useful to destroy other gases and temporarily to arrest decay. It seems not to have power to destroy the infectious property of cholera, smallpox, and the cattle-plague, while the vapor, as well as the strong solution of carbolic acid, is believed by some to have the power of arresting the infectious activity of all of them. This view, however, as already stated, is not universally accepted. How to Use Disinfectants. Brief mention may now be made of the proper methods of using some of the most important of the above agents. The methods of disinfection which are here described 312 HOW TO USE DISINFECTANTS. are preferred simply because they are effectual, safe, easily applied, and not expensive. They have been thoroughly tested, and are in accordance with the latest experience. 1. Quicklime.—To absorb moisture and putrid fluids, use fresh stone-lime finely broken; sprinkle it on the place to be dried, and in damp rooms place a number of plates or pans filled with the lime-powder; whitewash with pure lime, and not with kalsomine. 2. Charcoal Powder.—To absorb the putrid gases, the coal must be dry and fresh, and should be combined with lime; this compound is the calx-powder, as sold in the shops. 3. Chloride of Lime.—To give off chlorine, to destroy putrid effluvia, and to stop putrefaction, use it as lime is used; and if in cellars or close rooms the chlorine gas is wanted, pour strong vinegar or diluted sulphuric acid upon plates of chloride of lime occasionally, and add more of the chloride. 4. Stdphate of Iron {Copperas) and Carbolic Acid.—To disinfect necessaries, cesspools, drains, and sewers, and especially the vessels, grounds, or places in which the discharges from the sick with cholera and diarrhceal dis- eases are evacuated, dissolve eight or ten pounds of sul- phate of iron in five gallons of water, and add a pint of fluid carbolic acid (if it can be had); stir or agitate it briskly, to make a complete solution. The uses of this solution in infectious diseases will be given hereafter. 5. Permanganate of Potassium.—To be used in disinfect- ing clothing and towels from patients sick with cholera, scarlatina, typhus or typhoid fevers, during the night, or when such articles cannot be instantly boiled: throw the soiled articles immediately into a tub of water in which there has been dissolved an ounce of the permanganate HO W TO USE DISINFECTANTS. 313 salt to every three gallons of water. Boil the clothing as soon as it is removed from this colored solution, or boil them in it. The permanganate salts must not be used with the carbolic or coal-tar disinfectants. It is also best that chlorine and the chlorides should not be used at the same time or in contact with the latter class of substances. 6. Sulphate of Zinc.—The Weimar Conference recom- mended that sulphate of zinc should be used precisely as we use permanganate of potassium. The zinc solutions need to be much stronger than those of the perman- ganate: use at least two ounces of sulphate of zinc to one gallon of water. It must be remembered that, if any of these solutions are very strong, they would destroy clothing. At the best, they are but temporary substi- tutes for disinfection by boiling. 7. Carbolic Acid {Fluid).—This may be diluted at the rate of from forty to one hundred parts of water to one of the fluid acid. Use this solution for the same purpose as copperas is used; also, to sprinkle upon any kind of garbage or decaying matter, and on foul surfaces, or in drains. When used to disinfect clothing, carbolic acid of a pure quality should be thoroughly mixed with its own quantity of strong vinegar, and next be dissolved in one hundred times its own quantity of water before the clothing is immersed in it. This mixture with vinegar insures such complete solution of the carbolic acid, that the clothing will not be burned by undissolved drops of acid when disinfected in the carbolic-water. This weak solution (one part to one hundred) will not injure com- mon clothing, but the acid must be of good quality and free from tarry matter. The clothing, etc., will long retain the offensive odor of the acid, except in articles 314 HOW TO USE DISINFECTANTS. that can be immediately washed out in a strong solution of soap and soda. If it should be desirable to destroy certain articles and their infection together, without fire, then saturate them with the acid, or use it diluted in ten to thirty times its own quantity of water. The disinfecting and antiseptic power of good carbolic acid is so great that one part of it to one hundred parts of water is sufficient for ordinary disinfecting solutions. For ordinary purposes in disin- fecting clothing, the zinc solution is preferable to that of carbolic acid. For drains, sewers, foul heaps, stables, necessaries, and cesspools, the cheap "dead oil" of coal tar, or the crude carbolic acid, answers every purpose when freely applied. Coal-tar itself is available as a disinfectant or antiseptic paint for the walls of stables, necessary-vaults, and drains. By mixing with sawdust or dry lime, coal-tar or crude carbolic acid may be used on foul grounds or heaps of refuse. The carbolic and cresylic " acids" are derived from coal-tar. Chemically considered, they are alcohols, and not acids. In market they are called bj^ the first name —carbolic acid—and are frequently much adulterated or very impure in consequence of the naphthaline and tarry matters that dissolve in thvs kind of alcohol. The im- purities do not dissolve in water. Coal-tar and the "dead oil" of coal tar derive their disinfecting power from the "carbolic acid," of which the tar contains two or three per cent., and the dead oil contains five to twelve per cent. The impurities and adulterations of the crude " acids" make it desirable for sanitary officers to know the percentage of crystallizable acid in the carbolic fluids or disinfecting powder they use. Crude carbolic acid, con- taining fifty per cent, its weight crystallizable, is not HOW TO USE DISINFECTANTS. 315 expensive, and is a good disinfectant for grounds, drains, or the air of a foul place in which cholera or any pesti- lential disease exists. Dilute or thoroughly agitate the acid in forty to one hundred parts water, and completely saturate the grounds, the surfaces, and foul things in the infected neighborhood. Streets, court-yards, drains, and sewers may be quickly and effectually disinfected in this manner. The sprinkling of streets and gutters with a cheap solution of the acid has proved very useful in damp, hot weather. Add sulphate of iron whenever it is practicable. 8. Other Disinfectants, such as the solutions of Sesqui- chloride of Iron, or of Chloride of Zinc, are effectual in neces- saries and drains, and upon foul surfaces and offensive materials. These metallic chlorides, combined with a twentieth part of carbolic acid, are most valuable disin- fectants. A solution of Iodine, gr. ij, and Iodide of Potas- sium, gr. xx, in f^iv of water, kept in an open vessel at a high temperature, has been employed as a disinfectant in scarlatina. Carbolates of lime and carbolic powders do not contain sufficient carbolic acid to render them important. 9. Boiling or High-steam Heat.—Whenever foulcloth- ing and infected things can be boiled, or have a boiling heat steadily applied and kept up for an hour, this is one of the simplest and best modes of disinfection. But, until such high heat is actually applied to the infected things, some one of the disinfecting solutions must be used. A common steam tub (in a laundry, or elsewhere), with a tight cover, is a good disinfecting vat; but the temperature must be kept boiling-point. Solution of Nitrate of Lead is another excellent disin- fectant. 316 PLACES TO BE DISINFECTED. Places that must be Disinfected, and how to Disinfect them. Water-closets, necessaries, close-stools, bed-pans, etc.—For general disinfection use either of the substances, 4 or 7, as described in the numbered sections of the foregoing directions. Cellars, vaults, stables, or any damp or offensive places.— Use 1, 2, 3, 4, or 7, in any manner suited to the objects to be attained, as described in these directions. Sick-rooms, bedrooms, and closets.—Ventilate and keep clean, and use substances described in sections 1, 2, or 3, according to directions. To disinfect water-closets, necessaries, waste-pipes, and all kinds of drains and foul places in houses, stables, and yards, and especially in any drain or sewer that is liable to become offensive, use a strong solution of copperas {sul- phate of iron) alone—in the proportion of two or three pounds to a gallon of water—or combined with carbolic acid. This solution may be made by mixing eight pounds of dry copperas and a pint of fluid carbolic acid in five gallons of water, and stirring the mixture briskly. To keep necessaries and water-closets from becoming infected or offensive, pour a pint of this solution into every water- closet, pan, or necessary-seat morning and evening, or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid. Garbage and garbage-tubs should be daily disinfected with this fluid. Public urinals should be kept clean with a constant current of water; chloride of lime may be sprinkled on the pavement near by, the chlorine of which decom- poses the ammonia of the urine as formed. Where dis- infectant irrigation is necessary, a sprinkling mixture employed for disinfecting streets and gutters will be effi- cient, the proportions of which are as follows: 40 gallons of the ferrous chlorate liquor (formed by the action of PLACES TO BE DISINFECTED. 317 muriatic acid and iron on tin clippings), 4 gallons of impure carbolic acid, 83 per cent, strength, to 300 gal- lons of water. To disinfect masses of filth in necessaries, sewers, or drains, gradually pour in the solution, hour by hour, until every part of the mass or foul surface has been thoroughly dis- infected. To every cubic foot of filth give a pint or more of this strong solution. To every necessary and water- closet allow at the rate of one pint of this solution, to be poured daily, at evening, for every four persons that use the same. This practice to be kept up while the hot weather lasts. If these rules be made general in all private dwellings, not only will the house-drains of such dwellings be dis- infected, but the benefit will extend even to the public sewers. The seats and floors of all water-closets in private houses, at ferry-houses, at hotels and lodging houses, on steamboats, and rail-cars, should be frequently washed with a solution of one ounce of carbolic acid in each gallon of water. To disinfect dwellings, hospital ivards, prisons, or any locality infected will contagious germs, metallic salts are of little benefit. Charcoal absorbs but a small portion of the mephitic gas; indeed, in such cases, the object is not so much to destroy the odors of decomposition as the infected germs, and so prevent further propagation. Fumigations of chlorine, sulphurous acid, and the vapors or spray of carbolic acid are particularly beneficial, and cannot well be replaced by any other agent. The fumiga- tions should be practised until all animal odor disappears.1 To disinfect sewers, stables, gutters, foul ditches, filthy ground, slimy surfaces of drying ponds, etc., or other place ' Dr. S. 0. Vander Poel, Trans, of State Med. Soc. of N. Y., 1875, 235. 318 PLACES TO BE DISINFECTED. where there are great surfaces or masses of putrid mat- ter; use the "heavy oil of coal-tar," or some one of the strongest disinfecting powders that are made from coal- tar. Heavy oil, or coal-tar, used with copperas, or used alone, is the most effectual and the cheapest disinfectant for this class of nuisances. The inside walls of foul stables, vaults, cellars, open gutters, and all such places, can be quickly and permanently disinfected by occa- sionally laying upon tliese surfaces a coating of the " heavy oil," or of the crude coal-tar. Sewers and all foul drains can be kept perfectly disin- fected by pouring into them, at as many places as pos- sible, a small quantity of the "heavy oil," or a quantity of the strongest solution of sulphate or sesquichloride of iron mixed with a twentieth part as much crude carbolic acid, and well stirred together. Wherever it is proper to use a powder that does not dissolve, as upon filthy heaps, and in larger drains or cesspools, stables, cellars, and the like, carbolic acid or coal-tar powders are effectual. And for use in a larger way, upon filthy masses, and drying, stagnant or foul pools, a powerful disinfectant may be made by mixing one part (by measure) of " heavy oil" with five parts of quick- lime and ten parts of sawdust, to use by covering the foul places with this mixture. To disinfect a necessary or a quantity of earth that is con- taminated with Cholera-excrement, or liable to be infected.— Use the mixed carbolic and copperas solution, saturated strength, as follows: To every cubic foot of soil or filth give two or three pints of the strong solution. To every necessary and water-closet allowed at the rate of one pint of this solution, to be poured in daily, at evening, for every four persons on the premises ; this practice to be kept up while cholera is in the district or country. THINGS TO BE DISINFECTED. 319 This method of systematic disinfection would be useful in every household; but when cholera is present in any city or country, such thorough application of this means of protection cannot be safely neglected in any city to which persons may come from towns where cholera is epi- demic. Sanitary chemists advise that the estimated quantity of these water-closet and sewer disinfectants required for each person daily, in the presence of cholera, should be one half an ounce of sulphate of iron and one half a drachm or one half a teaspoonful of carbolic acid. Things to be Disinfected. 1. Beds, bedding, and upholstered stuffs. — Expose to sunlight and ventilation freely and frequently. If actu- ally infected, thoroughly moisten every part with a strong solution of carbolic acid or permanganate of potassium. 2. Soiled clothing, etc., from the sick with Gholer a or any Contagious Disease.—Use a solution of permanganate of potassium or carbolic acid, precisely as previously di- rected, and as soon as the soiled articles are -removed from the patient; or place them in a tub containing eight ounces sulphate of zinc, three ounces carbolic acid, and three gallons of water, for one hour, and then put them in boiling water; or the clothing may be thoroughly steeped, before boiling, in a solution of two ounces of chloride of lime in a gallon of water. Or immerse them at once in boiling water. In any case of infectious dis- ease, the clothing must be boiled previous to washing or drying. Infected clothing must be thrown into the water at boiling heat. The boiling should be kept up for an hour. Wo' ^en goods must be treated differently. They must be exposed for some time to the fumes of sulphur, and 320 THINGS TO BE DISINFECTED. afterwards freely exposed to the action of the sun and wind. 3. Carpets, sofas, lounges, mattresses, floors, etc., infected by Cholera-excrement, or by Smallpox, Scarlatina, and other Contagions, should be treated as follows:—■ First. Thoroughly moisten every infected hing with one of the carbolic or permanganate solutions. Second. Rules for Fumigation.—To give still greater completeness to the disinfection required for an infected apartment and thick woollen stuffs, carpets, etc., to which boiling heat cannot be applied, fumigate with sulphurous acid, thus: Arrange to vacate room for twelve hours; close every window and aperture, and, upon an iron pip- kin, or kettle with legs, burn a few ounces of sulphur; the quantity required for effectual work will depend upon cubical space of the apartment, and there should be enough to burn rapidly until want of oxygen in the air shall extinguish the flame. Instantly after kindling it every person must withdraw from the place, and the room must remain closed for the succeeding eight hours. After this time the windows should be thrown open, and when the fumes have disappeared, all the woodwork and walls should be thoroughly washed with soft soap and water, to which carbolic acid has been added (one pint of the common liquid to three or four gallons of water), and the paper from the walls stripped off. In whitewashed rooms the walls should be scraped, and then washed with hot lime, to which carbolic acid has been added. The windows should then be kept open for thirty-six or forty- eight hours. If any other kind of fumigation is resorted to (as that by chlorine, bromine, or nitrous acids), a sani- tary officer or a chemist should superintend the process. Fumigation should be resorted to in dwelling-houses only by official orders or permission, or under the personal RULES FOR INFECTIOUS DISEASES. 321 superintendence of a competent medical man, as the disinfecting gases are very poisonous. 4. Finally, let fresh air and sunlight purify every place they can reach. Open and dry all cellars and vaults, and keep the grounds and surfaces about dwellings as dry and clean as possible. Use fresh lime or the "calx- powder" freely upon wet or offensive surfaces. Flush the water closets and drains .daily before throwing in the disinfectants as directed. Domestic and personal clean- liness should be everywhere observed. There are no sub- stitutes for pure air and water. - (Rules for Disinfecting Impure Drinking-water will be detailed on another page.) DIRECTIONS FOR PREVENTING THE SPREAD OF INFECTIOUS DISEASES.1 I. When a case of infectious disease occurs in a house, immediate notice thereof should be given to the proper officer of health, and medical advice at once procured. The following precautions should be taken :— 1. Isolate the person affected as much as possible from the other inmates of the house. This is most readily effected by at once removing him to an upper room, if circum- 1 These rules are an embodiment of the excellent paper published in the Sanitarian, Jan. 1877, from the pen of J. M. Maclagan,M.D., Medical Officer of Health for Hexham and Haltwhistle Unions Rural Sanitary Districts, England, and are applicable to smallpox, scarlet fever, mea- sles, typhus fever, enteric fever, whooping cough, diphtheria, etc. Ad- ditions have been made to these directions to still further increase their efficiency. 21 3.'2 RULES FOR INFECTIOUS DISEASES. stances permit. The room should be large and airy, and means of ventilating it at once adopted. If the sick can- not thus be separated from all other persons, the Board of Health will send the patient to hospital. Persons with smallpox must not be moved from one house to another, or to hospital, except by permission of the Board of Health. 2. Before removing the patient the following prepara- tions ought to be made in the room : All superfluous cur- tains, carpets, woollen articles, unnecessary clothing, bedding, etc.—in short, everything likely to retain infection—should be at once removed. 3. The patient's bed ought to be so placed as to allow of a free current of air around it, but not so as to place it in a draught. 4. The room must be kept well ventilated, under the physi- cian's direction, by means either of a fire (when required) or of an open fireplace and chimney, and of windows opening to the external air. By means of the latter ven- tilation is effectually procured, so as to avoid draughts, in the following manner: Raise the lower sash of the win- dow three or four inches, then procure apiece of wood made to fit accurately into the lower opening, and place it there. By these means free outward and inward currents of air —without causing any draughts—are obtained through the vacant space between the two sashes. When a win- dow is merely opened from the upper or lower sash, draughts are invariably caused. 5. Placing a small sheet of oil-cloth, mackintosh, or other waterproof material, beneath the upper blanket on which the patient is to rest, effectually prevents the bed from being soiled by any discharges, etc. II. 1. After removal of the patient to the room in which he is to remain, the outside of the door and door-posts RULES FOR INFECTIOUS DISEASES. 323 should be completely covered by a sheet kept constantly wetted with some disinfecting solution. A piece of muslin, one foot square, should be dipped in the same solution and suspended constantly in the sick-room. 2. The room must be kept scrupulously clean. Before being swept, which should be done daily, if possible, the floor should be sprinkled with some disinfecting powder, or with a weak solution of a disinfecting fluid. 3. Vessels containing disinfecting fluids should be placed in the room for the reception of all bed and body linen, towels, handkerchiefs, etc., immediately on being removed from the patient, and on no account should they be washed along with other household articles. 4. Disinfectants, as already mentioned, should also be placed in all the chamber utensils used by the patient, and, after use, more disinfecting fluid should be added, and the whole contents, if possible, should be immediately buried deeply in the ground, at a distance from any drain, well, or watercourse. On no account should they be thrown on any ash-pit, dunghill, or into any cesspool. The vessel, after being thoroughly emptied, must be cleansed with boiling water. No chamber vessel should be allowed to remain in the room after having been used. 5. All plates, cups, glasses, etc., which have been used by the patient, should be rinsed with some disinfectant before being washed; and on no account should any ves- sels used in the sick-room be washed along with other things, unless previously thoroughly disinfected. 6. Attendants on the sick should be chosen, if possible, from those who have already had the disease. They should not wear woollen dresses, but only those made of washing materials. It is advisable not to use handker- chiefs about the patient, but soft rags for cleansing the nostrils and mouth, to be immediately thereafter burned. 324 RULES FOR INFECTIOUS DISEASES. 7. Basins containing water, to which some disinfectant has been added, should be at hand for the benefit of the attendants on the sick, who should not be sparing of their use. 8. No article of food or drink from the sick-room should be consumed by other persons. 9. "Visitors to the sick-room, except in the case of clergymen and medical men, should be peremptorily for- bidden ; and they, when necessarily present, should, on leaving, wash their hands in water to which a disinfectant has been added, and should have as little immediate com- munication with others as possible. III. When a death from infectious disease occurs, the body should be wrapped in a clean sheet, and at once placed in a coffin and sprinkled with some disinfecting fluid, such as a carbolic solution, or powder, such as chlo- ride of lime, etc., and buried with the least p)ossible delay. On no account whatever should it be alloivecl to remain in a room occupied by living persons. IV. 1. On the termination of a case of infectious disease, either when the patient is pronounced free from infection, or, in the event of death, after removal of the body, the sick- room and its contents should be thoroughly cleansed and disinfected. The ceilings and side walls of the sick-room, after removal of the patient, should be thoroughly cleansed and lime-washed; and the wood-work and floor thoroughly scrubbed with soap and water. Or, if pre- vious fumigation be thought desirable, it may be prac- tised according to directions given on a preceding page. 2. The bed and bedclothes, and all wearing apparel used by the attendants or patient, should be thoroughly disinfected before removal from the sick-room. Beds, pillows, and thick stuffs, after being soaked in disinfecting fluid, must be placed on the roof, or in an RULES FOR INFECTIOUS DISEASES. 325 empty room, to dry. They must not be placed in the yard or in the hall-ways. All straw beds and refuse stuff must be burned. , V. 1. In houses where a case of infectious disease occurs, no washing, tailoring, dressmaking, nor any similar occupation, ought to be carried on. 2. No milk or food of any kind should be supplied from infected houses. Milk has frequently been found to be a fruitful medium for conveying disease, either from having been placed in infected air, from which it has absorbed the poison, or from milk pails having been washed, or the milk adulterated, with water containing the infection. Great care should therefore be taken as to the source of the household milk supply. 3. Children from infected houses should not be allowed to attend schools, and all persons from infected houses should have as little communication as possible with others, either in private houses or in public places, such as rail- ways, omnibuses, puhlic-houses, churches, etc. 4. Any accumulation of filth or refuse of any kind should be at once removed from or about the premises, and disinfectants freely used. If this cannot be done by the persons themselves, immediate notice should be given to the sanitary authorities. 5. Open and thoroughly ventilate cellars, garrets, closets, sleeping-rooms, and all other apartments, and keep them clean and dry. Observe the utmost cleanli- ness in basements, areas, and grounds about the house. 6. The existence of nuisances of any kind and where- soever situated should also be at once reported. In the event of sewer gas, continued offensive odors, or constant sickness occurring in a house, proper workmen should be obtained in order to see if any structural defects exist in 326 RULES FOR INFECTIOUS DISEASES. sinks, drains, water-closets, necessaries, etc. If such should exist, disinfection merely will be of no avail. Directions to Persons in charge of the Unburied Dead from Infectious Disease.1 Cleansing.—In cleansing the surface of the corpse, espe- cially the parts most soiled by discharges, use the solution of chlorinated soda (Labarraque's solution, of the shops), a pint to two quarts of hot water. A solution of chloride of lime, made by straining or decanting a gallon of water into which a pound of that substance has been thrown, answers the same purpose. This cleansing is required for the whole person in every case of death from cholera, fever, scarlatina, or smallpox. Cloths, sponges, etc., em- ployed about the dead must be instantly burned or boiled. Disinfection.—Fill a large wad of cotton or fine shav- ings with two pounds of coal-tar powder, or chloride of lime, and place it beneath the hips; and, in cases of cholera, place much more of this kind'of absorbent mate- rial beneath the corpse, to absorb and disinfect the purged fluids that may flow. Directions in the Family.—Whatever disease has caused the death, order every garment and cloth that was used upon the dead person, and in cholera and infectious fevers, whatever was about the person or was soiled during sick- ness, to be immediately boiled, or, until boiled, to be kept in one of the disinfecting solutions. Ventilate every room and closet upon the floor where a death has occurred from an infectious disease. Keep windows and fireplaces open for several days. Burials.—The dead of cholera should be interred as soon as practicable, and always within thirty-six hours after death. 1 From the report of New York Board of Health for 1873. HOW TV USE THE HYPODERMIC SYRINGE. 827 DIRECTIONS AS TO THE USE OF THE HYPO- DERMIC SYRINGE IN DISEASES IN WHICH IT IS APPLICABLE1 Physicians of the present day carry in a pocket-case more active elements of prompt medication than used to be packed in a*good-sized pair of saddlebags of a quarter century ago; and these modern condensed preparations for subcutaneous injection, as we all know, in many re- spects supersede the old-fashioned way of administering medicines. In cases of unconsciousness, delirium, strangulation, or other condition in which the patient cannot or will not swallow, the proper remedy, in nicely graduated quan- tity, injected hypodermically, answers just as well as if taken into the stomach; and, in many cases, even when the patient can take remedies in the usual way, hypo- dermics respond more promptly and favorably than other plans of treatment. We give the following list as embodying the principal conditions in which hypodermics have been employed:— Abortion has.been caused by hypodermics of pilocarpine. This should insure caution. Arrest of Perspiration. Pilocarpine, the alkaloid of jabo- randi, will cause more or less profuse sweating, according to amount injected beneath the skin. Bubo has been aborted by injecting carbolic acid into the centre of the swelling.. Carcinoma. Acetic acid one part to three of water, in- jected into the cancer, has proved successful in shrivelling the tumor, and obviating an operation. 1 Quoted from the National Medical Review, 1879. 328 HOW TO USE THE HYPODERMIC SYRINGE. Cerebral Apoplexy has been successfully treated by sub- cutaneous injections of ergotiue in the arm. Chloroform-poisoning. One-tenth grain of digitaline, hypodermically, followed an hour afterward with one- tenth grain of atropia in similar manner, has been sue- successful. Chorea. Curare, in hypodermics of from one-tenth to one-twentieth of a grain daily, has been found valuable in this disease. Congestive Chills. Ten drops of tinct. belladonna, hypo- dermically, every fifteen minutes, until the pulse became distinguishable, succeeded where the patient was uncon- scious and unable to swallow, followed by hypodermics of quinine, brandy, or whiskey. Croup. Sulphate of atropia, one per cent, solution, has proved successful in a desperate case, injected in the neck on level with pneumogastric. Three drops, repeated after four hours. Dysentery. Morphia, hypodermically, in one-third grain doses, has been found more rapid in relieving tenesmus than any other opiate. Epilepsy. Curare, in solution, seven grains in twenty- five minims water, with two drops hydrochloric acid. About once a week inject about eight drops beneath the skin. It has cured cases of several years' standing within two months. Eczema. Arseniate of soda, hypodermically, in solu- tions of one-fifth, one-half, and one per cent., commencing with ten mimims of the weaker and gradually increasing, is recommended. Erectile Tumors have been successfully treated by in- jections of perchloride of iron and chloride of sodium in solution, the tumor to be surrounded by a ring. Erysipelas. Carbolic acid, three per cent, solution, eight HOW TO USE THE HYPODERMIC SYRINGE. 329 or ten injections at the same time, so as to surround and cover the inflamed regions ; also, salicylic acid in the same manner. Foreign Body in (Esophagus. Threatened strangulation from impaction of gullet has been promptly relieved by inducing vomiting. Apomorphia, one-tenth grain, hypo- dermically. Emetina is also suggested in same way. Goitre has been successfully treated by subcutaneous injections of ergotine, one-third, gradually increased to one grain. Haemoptysis. Sclerotinic acid, substitute for ergotine, five per cent, solution injected in the neck or arm. Hemorrhages. Hoamoptysis, haematemesis, and uterine hemorrhages have all been arrested by hypodermics of ergotine. If pain, add morphia. Hernia is more easily reduced by giving a hypodermic of morphia with or without atropia. Hiccough. In an obstinate case, resisting all other means, three-eighths grain of chlorohydrate of pilocar- pine, hypodermically, quickly proved successful. Hydrophobia. Much amelioration of the symptoms has followed hypodermics of curare. Infantile Convulsions. Morphia, subcutaneously, with inhalations of five drops of nitrite of amyl immediately following, have proved successful. Membranous Croup. Equal parts of water and sol. ferri perchlor. injected into the trachea, piercing the needle through just below the thyroid cartilage .this dissolves the membrane, and assists its expectoration, and is thus a substitute for tracheotomy. Nasal Polypus. Carbolic acid, one part; glycerine, four parts; twenty drops sunk into tumor by means of hypo- dermic syringe effectually dissipated polypus in case reported. 330 HOW TO USE THE HYPODERMIC SYRINGE. Night-sweats. Atropia has given good results in injec- tions of about one-fortieth of a grain at bedtime. Nocturnal Enuresis. Two very small doses of the nitrate of strychnia, injected in the vicinity of the rectum at suitable intervals, have proved successful. Obstruction of the Bowels. Aloin has been used with success, subcutaneously, to move the bowels. Opium-poisoning. Quite rapid recovery is reported to have followed warm hypodermics of fluid extract coffee in thirty minim doses. Caffeine citrate and sulphate of atropia are also considered antidotes to opium. Puerperal Convulsions. Chloral, subcutaneously, has been pronounced better than when swallowed. Puerperal Eclampsia. Veratrum viride, two to four drops of the tincture, subcutaneously, as required to keep the pulse down to about sixty. Pilocarpine, two per cent. solution, is also recommended. Retention of Urine from paralysis of the bladder, ac- companying typhus, variola, and hydrocephalus, has been promptly overcome by hypodermics of e.rgot in the fossa behind the great trochanter. Skin Diseases caused by Animalculse. Sulphuric, car- bolic, salicylic, or sclerotinic acids, hypodermically, as in erysipelas. Snake-bites. Ammonia, brandy, carbolic or salicylic acids are all recommended, hypodermically, in case of snake-poison, and have been injected with benefit directly into a vein. Strychnia-poisoning. Caffeine, one grain, hypodermic; alcohol in the same way is also suggested; chloral injec- tions are also mentioned. Surgical Shock. Quinine, six grains, hypodermically, with one-third grain of morphia. Suspension of Salivary Secretion. Pilocarpine, used as heretofore explained, excites salivation. HOW TO USE A GALVANIC BATTERY. 331 Syphilis has been treated by solutions of some of the mercurials, injected locall}'. Tetanus. Chloral hydrate is recommended in connec- tion with chloroformization, alternating it with other anodynes and antispasmodics. Trichinosis. Tincture of ergot and ergotine have effected speedy cures, hypodermically, into muscles affected. Tumors. Just before removal, hypodermic of half grain of morphia, with a thirty-sixth grain of atropia, directly into the growth. Ununited Fractures. Glacial acetic acid, five to ten minims, between ends of the bones, with hypodermic syringe. Iodine has also succeeded, used in same way. Urticaria. Saturated solution of bisulphite of soda in- jected directly into the part affected. HOW TO USE A GALVANIC BATTERY IN MEDICINE AND SURGERY.1 Varieties of Electricity.—Wre make use of three vari- eties of electricity in medicine:— Firstly, of static or friction electricity, the electricity of glass and amber, appropriately called from its early investigator, Franklinism. Secondly, of the electricity of chemical action, Gal- vanism, or better, Voltaism, the " Constant Current." Un- less artificially interrupted, the electricity flows contin- uously until the battery is exhausted, just as a stream of water flows from an ordinary water pipe; and 1 Condensed from a Discourse on Electro-therapeutics, by II. Tibbits, M.D., London, 1877. With so many instruments in the market, it is obviously impossible to enter into the details of individual batteries. 332 HOW TO USE A GALVANIC BATTERY. Thirdly, of Faradism, the induced currents of momen- tary duration which are generated or "induced" in a coil of wire by the action upon it, under certain circum- stances, of a magnet or of a voltaic current. There is no steady flow of electricity, but instantaneous currents only. These are repeated many times in a second, and they flow in alternate directions, as in the magneto-elec- tric machine. It may be well to call to mind for a moment that elec- tricity per se is not a panacea, but simply a remedy, most valuable, it is true, but only in appropriate cases, and in suitable doses; and that it produces very opposite effects, not only according to its variety, but according to its method of administration. The galvanic current, applied with intermissions—that is, by moving the conductors during the application—differs altogether in its effects from the very same current applied as a constant current, that is, without intermissions, or with immovable conductors; and Faradism, or the induced current, differs again, in toto, from either of these. Static electricity, though sometimes of the utmost value, has certain inconveniences in its application, and is little used by specialists. Electrical Instruments.—A clear comprehension of the mechanism of batteries is essential to their pleasant and successful use, and to the easy detection and rectification of faults in their working. Insufficient information upon these points goes far to explain why it is still too common for the medical practitioner (as quoted by Golding Bird, nearly thirty years ago), to consider that when his fiat has gone forth ''let the patient be electrified," he has done all that is necessary, while the patient usually car- ries out his mandate by the purchase of a rotary mag- neto-electric machine, using it according to the directions 110W TO USE A GALVANIC BATTERY. 333 of its maker, who is generally about as well fitted to teach its application in disease as is the maker of an am- putating knife to operate with it! In electrization the source of electricity is furnished by a cell or cells with contained elements and chemicals. Until quite recently, it was impossible to get a portable cell that remained always in order, and ready for use; from an early period of my electrical experience I have suffered much from batteries—from instruments " striking work" at the most inconvenient moment—from spilling of corrosive acid upon fingers and clothing; but the in- vention of the "Leclanche" cell has done away with all these petty annoyances. The " Leclanche" cell consists of a zinc plate inserted in powdered sal-ammoniac and a carbon plate inserted in powdered peroxide of manganese, in a porous cell; and, although it is requisite for this sal-ammoniac to be in a semi-fluid condition, and it will not admit of being left turned quite upside down, it does not suffer from being accidentally overturned, if replaced immediately. Le- clanche cells are remarkable for their constancy and per- sistency in action, and they will remain, with ordinary work, in full efficiency for many months, and can then be readily recharged. They are the only cells that do not require some arrangement by which the elements are either lowered into the exciting fluid, or this is raised to them; and they are necessarily free from the chance of destruction by their elements being inadvertently left in this fluid—a frequent accident with other batteries. The Application of Electricity.—I shall use the term " electrization" in all remarks applicable equally to Vol- taism and Faradism. Electrization may be applied generally and locally; it may be arrested in the skin without stimulating the sub- 334 HOW TO USE A GALVANIC BATTERY. jacent organs ; or, on the contrary, it may be caused to penetrate the skin, and made to concentrate its power on deeply-seated muscles or nerves. The skin itself is a non-conductor of electricity, and if it be carefully dried and powdered with some absorbent powder, the dry me- tallic conductors of an electrical instrument, in moderate action, applied to it, will produce only sparks and crack- ling, but no physiological phenomena. The electricity does not penetrate the skin. If the dry conductors are re- placed by well moistened sponges, there will be produced neither sparks nor crackling, but very variable pheno- mena of contractility or sensibility, according as the electricity acts upon a muscle, a nerve, or an osseous surface; and this brings us to the consideration of con- ductors. Different kinds of Rheophores.—The varieties of conduc- tors are infinite. The most essential are well-moistened sponges contained in cylinders; metallic disks covered with wet work-leather; the same metallic disks, pol- ished, and not covered with leather; and a brush of metallic wire; all having conveniently shaped handles: and, of course, some form of conducting cord or wire between these conductors and the poles of the instrument. I have had endless trouble with conducting cords, which are always liable to get out of order, and cause interrup- tion in the current; and I strongly advise that nothing should be used but very thin copper wire, coated with gutta-percha, in the same way as that known as "telegraph wire." This is perfectly insulated, sufficiently pliable for all practical purposes, is inexpensive, does not kink, will fit any sort of rheophore, and if the end breaks, all that is ne- cessary is to scrape off with a pocket-knife the coating for about a couple of inches from the broken end. For use, where the rheophores remain immovable during the HOW TO USE A GALVANIC BATTERY. 335 whole time of application, the ordinary telegraph wire is more convenient, and from its much greater diameter will wear much longer; but it is not sufficiently flexible for other purposes. Most sponge holders are made much too long in the cylinder, the proper dimensions for general use being about IJ X 1^ inch, and the sponge should be large enough to fit the cylinder tightly, or it will be apt to slip out, and when not in use it should be taken out of the holder and kept in water until required again. Conductors, with fixed sponges, although convenient, soon become fouled, and interrupt the current, unless the sponges are frequently renewed. The disk rheophore covered with wash-leather is very generally useful, and by using- the edge it may be made to answer, in the majority of cases, for a pointed conductor. It has also an advantage over the sponge of allowing firm pressure to be made without the inconvenience of water being squeezed out. Methods of Applying Electricity.—The voltaic current is applied as a "constant" and as an "interrupted voltaic" current. In the "constant" voltaic current, the conduc- tors are maintained immovable upon the skin ; or the feet or hands, as the case may be, are immersed in tepid water, with which the conducting wires of the battery are in contact, and the current is allowed to pass during the time required. The tension of voltaic electricity is so low that salt is needed to render the water a good con- ductor. In the " interrupted voltaic current," the current is interrupted by gliding over the skin one or both rheophores, or keeping one rheophore stationary, and lifting and reapplying the second at intervals of about one to two seconds. Radcliffe's Positive Charge.—This is an application of positive voltaic electricity, originated by Dr.Radcliffe. The patient and the battery must both be insulated, the passage 336 HOW TO USE A GALVANIC BATTERY. must be constant, and a wire, termed a " ground wrire," must be carried from the negative pole of the battery or from the negative rheophore to the earth ; that is, there must be two wires from the negative pole, one to be applied as well as the positive to the patient, and the other taken " to tearh." This latter may conveniently be attached to a me- tallic chandelier, or gas pipe, which always gives direct metallic conduction to the ground. With careful insula- tion, the negative electricity passes away by this wire, and while the current circulates, the patient continues "charged" with positive electricity. A sheet of gutta- percha, about four feet square by half an inch thick, will answer admirably to insulate the patient, and the acces- sories. It is often convenient, in making this application, to insert the hand or foot of the patient, as the case may be, in a vessel containing tepid salt and water, in which is immersed the wire from one pole; while the sponge from the other pole is held applied to some part of the body, the operator taking care not to touch the patient, or the insulation would be destroyed; but to hold the sponge holder by its insulating handle only; or a second limb is immersed with the wire from the second pole in another vessel of salt and water. Administered thus, this is especially an " electric bath" of positive electricity. Direct Muscular Electrization, termed by the German school " intra-muscular," consists, as the name implies, in electrizing a muscle by placing the rheophores on the muscle itself; and is accomplished by placing well-moist- ened rheophores on points of the akin corresponding to the muscle it is desired to act upon. The rheophores must be applied over the fleshy body of the muscle, and not over its tendons; and they should be applied in succes- sion to all points of its surface, and the thicker the sub- stance of the muscle, the more intense must be the HOW TO USE A GALVANIC BATTERY. 337 current, because a weak current will only produce exci- tation of the superficial layers. Using Faradism, it is a good rule to promenade, as it were, the two rheophores, held in the same hand, in lines along and across the mus- cle, or group of muscles, keeping them stationary on every point of the muscle for about thirty seconds, and let- ting the entire application vary from five to fifteen min- utes, according to therapeutic requirements. Using interrupted voltaism, it is better to maintain the positive rheophore stationary, and to " paint," as it were, the en- tire muscle with the negative glided in lines from the positive. With constant voltaism both rheophores must be held immovable. Indirect Muscular Electrization, termed by the German school "extra-muscular," consists in causing muscular contraction by acting upon the special nerve trunk and branches, instead of by placing the rheophores upon the muscle itself. When it is desired to act exclusively upon the nerve, it is convenient to place a broad conductor, such as a sponge contained in a cylinder, upon some little sensitive part of the body—such as the sternum— and to apply a fine-pointed conductor to the most super- ficial point of the nerve it is desired to act upon; but in practice it is often better to place the larger conductor upon the muscle itself. Electrization of Central Organs of Nervous System.—The voltaic current is the only form of electricity which exerts any special action on the central nervous s}rstem. To affect the brain, well-moistened sponges may be applied to each mastoid process, to each temple, or to the frontal and occipital protuberances. The sponges must be held immovable. To galvanize the superior cervical ganglion of the sympathetic, one electrode, of small size, must be deeply pressed into the auriculo-maxillary fossa, and the 22 338 HOW TO USE A GALVANIC BATTERY. other with a good-sized sponge applied over the sixth or seventh cervical vertebra, or to the manubrium sterni, close to the border of the sterno-mastoid. The spinal cord may be electrized by keeping one sponge—usually the positive—stationary, and moving the other up and down by the sides of the vertebrae, or one pole may be applied to the spine, and the other held to a nerve or muscle. Cutaneous Faradization.—When it is desired to act only upon the skin, faradization is invariably made use of. The solid metallic disks, but polished, and without lea- ther, may be applied by their metallic surfaces to the skin, and either kept stationary or moved over it with greater or less rapidity, in proportion to the degree of irritation it is required to produce; or the wire-brush may be substi- tuted for one of the disks, and moved over the skin, the other disk being held stationary. The skin should be carefully dried and sprinkled with some absorbent pow- der, such as starch or violet powder. Electrization of Internal Organs.—The rectum and mus- cles of the anus may be electrized by introducing into the rectum the rectal rheophore, a metallic stem insu- lated by gum elastic, and moving it over the internal surface, bringing it also into contact with the levator and sphincter ani. A well-moistened sponge connected with the other pole may be applied to the abdominal muscles or to the neighborhood of the anus. The rec- tum must be first freed from fecal matter. The bladder is most readily electrized by the intro- duction into the rectum of the rectal rheophore, and into the bladder—previously emptied—of a curved metallic sound insulated by an elastic catheter to within an inch of its vesical extremity. This sound must be brought into contact successively with all points of the neck of the bladder. HOW TO USE A GALVANIC BATTERY. 339 The uterus may be electrized by the introduction of the rectal rheophore, connected with one pole, to the os uteri, and by the application of two sponges from the other pole, one to the abdominal parietes, the other to the lumbar region. The larynx may be electrized externally by one sponge to the nape of the neck, and the second to the exterior of the larynx; or, internally, a sponge to the neck as before, and the introduction by the aid of the laryngoscope of a small bit of sponge at the end of a curved metallic stem, insulated by a gum elastic catheter, the current not being allowed to pass until it is seen by the laryngeal mirror that the sponge is in the desired position. The male genital organs may be electrized by moist rheophores to the scrotum over the testicle. Electrization of the Organs of the Senses.—The retina may be electrized by a moistened conductor to the closed eye, and the second to the temple or to the mastoid pro- cess of the same side. The auditory nerve by one con- ductor tipped with sponge, and inserted to the bottom of the meatus, the second being held in the hand of the opposite side; or the meatus may be filled with tepid water, and a metallic wire traversing the axis of a vul- canite tube may be immersed in the water, the second conductor being a well-moistened sponge to the nape of the neck. The olfactory nerve by sponge to neck, and movement over all points of the nasal mucous membrane of a metallic sound, insulated except at its extremity. The nerves of taste by sponge to the neck, and move- ment of the second conductor over the base and borders of the tongue. Electro-diagnosis. — Electricity will assist us only in those conditions in which there is altered muscular con- tractility, or cutaneous or muscular sensibility, or both. 340 HOW TO USE A GALVANIC BATTERY. Healthy nerves and muscles respond to the electric stimulus whatever variety of electricity is employed; but in disease this reaction may be increased or dimin- ished, or altogether absent. The irritability of a muscle is tested by ascertaining the lowest power which will cause its contraction. Supposing the case to be one of hemiplegia, say of the left side, having found the lowest power causing contraction of any one of the healthy muscles of the right side, we apply that same power to identical points of the corresponding muscle of the dps- eased side, and note whether there is contraction. If there is, we decrease the power of the current, and if contraction still occurs there is increased irritability, and vice versa. It is essential that on both sides there should be exact similarity in the application ; and this is especially important with the voltaic current, for healthy muscles and nerves answer more readily to it when it flows down the limb—i.e., with positive pole above and negative below—than when it flows up, and consequently a reversal of the poles will influence the result. In test- ing a case cf paraplegia where there is equal disease on both sides, we must be guided by a knowledge of the strength of current usually required to bring about con- traction. In a case of hemiplegia it will be found almost inva- riably that irritability to both varieties of electricity is normal in the muscles. This proves the integrity of the muscular tissue—if the muscle also responds to indirect excitation by its motor nerve, we know, in addition, that the conducting power of the nerve is uninjured, and that the spinal cord has preserved its integrity at the spot where the nerve is given off. The disease is in the brain. If we find irritability diminished—more than that slight diminution from disuse which is restored by two or three HOW TO USE A GALVANIC BATTERY. 341 faradizations—there is disease of cord, or nerve, or mus- cular tissue, and the disease, as a rule, will be in direct proportion to the amount of diminished irritability. The reaction to the interrupted voltaic current will generally correspond to that to faradism ; but in some cases in which response to faradism is abolished, the reaction to a slowly interrupted voltaic current is not only preserved, but greatly increased. In these cases the nerve will re- act to neither current; and the increased irritability is due to the muscular tissue, without the agency of nerve, and it exists only in peripheral and never in central lesion. By this differential reaction we may diagnose periphe- ral from central paralysis; for example, paralysis of the facial nerve from facial hemiplegia, paralysis of the ex- tensors of the wrist and fingers, due to lead poisoning, from commencing muscular atrophy, or from rheumatic paralysis, progressive muscular atrophy from paralysis from section of a nerve, essential infantile paralysis from other varieties of paralysis—all important questions as affecting treatment. In paralysis from disease of the cord there is almost invariably diminution of reaction in the affected muscles to all varieties of electricity, and the possession of normal irritability will often help us in the diagnosis of cases of emotional paraplegia. The condition of muscular irri- tability will largely aid us to distinguish between real and pretended disease; and finally, its entire abolition in all the muscles of the body, is conclusive proof of death. Increased irritability points to increased vascularity, irritative lesion of brain or cord, or both, but in such cases we seldom require the aid of electricity to complete our diagnosis. Electro-therapeutics.—I propose to refer very briefly to the general principles regulating the application of elec- 342 HOW TO USE A GALVANIC BATTERY. tricity in medicine, and to instance a few of the special forms of disease in which its administration would seem to be imperatively demanded. The influence of faradism in those cases in which it does not produce muscular contraction, is chiefly stimu- lant; where it does produce contraction it acts in addi- tion as an artificial gymnast, imitating natural muscular action in a way quite impossible to any agency but elec- tricity. It is in cases where there is muscular response to it, but not to the will, that faradism is often of immense service, and it can then be replaced by no other remedy known to medicine. In these cases, too, its dosage is important, that the weakened muscles may not be ex- hausted. The interrupted voltaic current is similar in its action upon muscle to faradism, but this is complicated by chemical and electrolytic effects upon the animal tissues, and by certain special influences upon the central nervous system. It is of great value in the treatment of those cases of loss of power in which the paralyzed muscles, whose response to faradism is wholly lost, contract under the influence of a slowly interrupted voltaic current. The Constant Voltaic Current, the "Constant Current" of which we have all heard so much, differs toto coelo from the above, for it consists not of any voltaic current from any voltaic battery, but of a current from that form of battery which supplies one, not only continuous but one which does not vary appreciably in power during the application; and not only so, but of this current so applied to the patient by the operator, that its flow through that part of the patient's body to which it is directed shall be as continuous as the stream of the cur- rent from the battery to the conductors. Unless thus applied, it is not a constant current, and its therapeutic HOW TO USE A GALVANIC BATTERY. 343 application will be unsatisfactory. The effects of the constant current thus applied are chiefly sedative, resto- rative, or refreshing, and absorbent or resolvent. It has great power in relieving pain, and it is sometimes unap- proached in this power by any other remedy. None of its therapeutic results is more firmly established; and were it in no other respect of use, its services here would entitle it to the foremost rank as a remedy. a. For Relief of Pain.—It is of the greatest benefit in neuralgia. The sponges should be so applied as to include the affected nerve in their circuit; the number of cells should be the highest number that the patient can bear without pain, and care should be taken not only to main- tain the conductors quite immovable upon the body, but to avoid shock by abruptly shutting the electricity off or on; two cells should be commenced with, and the current so gradually increased, that no shock is felt, and at the end of the application it must be as gradually decreased, for it must be remembered that an abrupt removal of the sponges would give a shock. The length of application from five to ten minutes, and the frequency usually once or twice daily; but I have met with the best results in obstinate cases by applying the current as frequently as the paroxysms of pain recurred. Dr. Althaus considers that the positive pole should always be applied to the seat of pain; the negative pole is more irritating than the positive, and on this account the latter is better borne. It is, however, the constancy of the application that is of primary importance. I generally place the negative pole with a large sponge upon the spine over the origin of the nerve affected, and apply the positive pole to the painful spot; and if there are more spots than one, to them all in succession. It is seldom that relief is not afforded, even if cure do not result. The number of cells must 344 HOW TO USE A GALVANIC BATTERY. be determined according to the region affected. In the face, about five to ten will generally be sufficient; and the application must be discontinued upon the occurrence of the slightest giddiness. b. Galvanization of the Cerebral Hemispheres is very beneficial in true migraine (sick headache), two to three cells to each temple, or to each mastoid process. c. In Angina Pectoris, one pole to spine, and the other to the region of the heart. Dr. Anstie and Dr. Russell Reynolds both quote successful cases. d. The Pains of Muscular Rheumatism may almost inva- riably be removed or .mitigated by cutaneous faradization, and so rapidly, as in many cases to appear marvellous. The current should be strictly limited to the skin. e. In Rheumatic Gout, the voltaic current has been found of the greatest use by Althaus. He directs the positive pole to the cervical spine, and the negative to the pit of stomach,'the sponges being of large size, and a mild cur- rent allowed to flow for from three to five minutes. This frequently causes sleep. Pain may be relieved by a small conductor from the positive pole to the painful spot, the negative with a large sponge being held in the neighbor- hood. Length of application, one to five minutes. /. In Cerebral Paralysis.—It is probable that in some cases of cerebral paralysis, where the clot or softening is of limited extent, the process of reparation in the brain may be promoted by the use of the constant current; but too much caution cannot be exercised in its application. Peripheral faradization is seldom advisable until some three or four months after the attack. Faradization should then be used of a strength just sufficient to bring the muscles into full contraction. In those cases in which the paralyzed muscles are cold, blue, flaccid, and ill-nou- rished, and where a generally ansemic type predominates, HOW TO USE A GALVANIC BATTERY. 345 the muscles should be well sponged with the voltaic cur- rent (the positive pole being held stationary upon the origin of the muscle, and the negative being evenly "painted" as it were over its entire surface), alternately with faradization. Applications to be made daily, or every other day, for from five minutes to fifteen minutes. g. Spinal Paralysis. — In spinal paralysis, we must be guided by a consideration of the nature of the disease, and the condition of the cord, muscles, and nerves. The evidence of the good resulting from central electrization of the cord is much greater than can be adduced in sup- port of similar treatment of the brain. Such applications, when powerless to cure, not unfrequently relieve some of the most distressing symptoms. Peripheral faradization must not be employed during the early period of active mischief in the cord; but in the persisting localized paralysis following upon myelitis it is often of the greatest service, especially in relieving symptoms of paralysis of the bladder and rectum. The dribbling of urine, which is so troublesome in some paraplegic cases, may be frequently relieved, and the condition of the sufferer made much more tolerable. The interrupted voltaic current should always be given a trial where faradization fails—one pole to the lumbar spine, and the other to the pubes; length of application about five minutes; interruptions three or four times a minute. Application, twice daily. In traumatic paralysis, in local palsies, such as mercu- rial and lead palsy, in all peripheral palsies, and notably in facial paralysis, in rheumatic and in all forms of atro- phic paralysis, and in some varieties of ocular paralysis, some one or other of the different forms of electricity will be essential to the most successful treatment. Central applications of the voltaic current must be made 346 HOW TO USE A GALVANIC BATTERY. according to therapeutic requirements, and the methods already described; but the general rule, applicable to all localized muscular electrization, is to test the muscles with the faradic and the interrupted voltaic current, and to electrize them with that current to which they most readily respond. h. Locomotor Ataxy.—In locomotor ataxy, the constant current applied to the spine has, in one case under my care, resulted in perfect recovery, and in many others it has relieved many of the symptoms. In the case referred to, the ataxy had existed for eighteen months, the gait being most characteristic, and the patient unable to walk without assistance. There was also considerable anaes- thesia. The current from fifteen to twenty cells was applied to the spine by large sponges (the sponge-holders being five inches in diameter), the positive sponge to the nape of the neck, and the negative sponge to the lower lumbar vertebras, both sponges held immovable, for ten minutes upon going to bed and getting up in the morn- ing, followed by five minutes' faradization to the legs and feet with the wire brush. The patient had improved in one month, could walk without assistance in three, and was apparently quite well in eight. i. Spasmodic Diseases. — In spasmodic diseases, electri- city should always be given a trial. In ivriter's cramp, which consists essentially of a paroxysm of spasm when- ever the sufferer is called upon to execute some special movement, but in which there is no true paralysis, Dr. Poore has very successfully applied the refreshing and restorative effects of the voltaic current, by localizing it in the nerves of the affected muscles, and exercising these muscles during the passage of the current, by various gym- nastic movements. I have been successful in two cases by faradization of the antagonists of the suffering muscles, HOW TO USE A GALVANIC BATTERY. 347 united with the localization in the muscles themselves of "Radcliffe's Positive Charge" for fifteen minutes daily; and similar treatment was most beneficial in a case of torticollis in a young lady twenty years of age. In her case, the spasm was almost constant, had existed for twelve months, and had resisted every kind of treatment, includ- ing hypodermic injections of morphia, and the wearing of a mechanical apparatus. There was some wasting of the sterno-mastoid and trapezius on the right side, and the corresponding muscles of the left side exhibited increased irritability to all forms of electricity, and were the seat of pain and wellnigh constant clonic spasm. The voltaic current from fifteen cells was localized in these muscles, by stationary sponges, for fifteen minutes night and morning, and at the same time the antagonist muscles were well faradized. j. Infantile Paralysis. — In "essential infantile paral- ysis," the physiological treatment of the affected mus- cles should become the routine treatment invariably directed by the practitioner, and that within a week of the outset of the disease. In infantile paralysis premonitory symptoms are often absent or but slight, and not seldom the child is put to bed well, and found in the morning to have lost the use of one or more of its limbs; but the visceral muscles are never affected, and the paralysis is motor only, sensation being unaltered. The paralyzed muscles soon suffer in their nutrition, the limb affected is found to be much colder than its fellow; find, tested by electricity, there is complete abolition of farado-contractility, but marked increase to the inter- rupted voltaic current. If proper treatment is adopted in time, and before muscular degeneration and atrophy have advanced too far, the greater number of cases of infantile paralysis admit of cure. The case must be 348 HOW TO USE A GALVANIC BATTERY. treated, at first, upon general principles, but localized treatment should be had recourse to as soon as possible, and before the muscles themselves begin to atrophy, or to be impaired in their nutrition. The reaction to electricity of the weakened muscles should be tested, and each muscle should be daily electrized for a few minutes with that current to which it responds, and of a strength just suffi- cient to produce muscular contraction. If the precaution is taken of commencing with only moistened sponges (no current being allowed to pass), and then gradually inur- ing them to the strange sensation, children betray, as a rule, but slight signs of pain, and I have even seen the operation amuse them. In addition to electrization, the paralyzed limbs should be immersed in water, as hot as can be borne, for a quarter of an hour twice a day, and should afterwards be well rubbed and shampooed; or they may be sponged in very hot water, and then shampooed. In the intervals of treatment the temperature of the af- fected muscles should be maintained at as high a degree as possible; and if the leg is affected, a stocking of pure silk should be constantly worn, day and night, in addition to the ordinary clothing ; if the arm, a silken sleeve; or, if necessary, ordinary chamois leather, as a cheap substi- tute for silk, one for day and one for night wear. When any amount of voluntary power has been restored by elec- tricity, the child must be encouraged to use the limb, and practise various movements. Passive movements are of equal importance; and the mother or nurse must be taught to frequently exercise the paralyzed muscles to the fullest extent of their normal movements—e. g., if the extensors of the hand and fingers are paralyzed, the hand and fingers should be flexed and extended completely by the nurse at intervals of a few seconds, for some min- utes, and so on with all the paralyzed muscles in succes- HOW TO USE A GALVANIC BATTERY. 349 sion. If the above directions are patiently and faithfully carried out, there are very few cases, indeed, if there be any, in which we need fear deformity, and this never until the child begins to walk. If, however, we then observe distortion commencing, the weakened muscles will require mechanical support; but great care must be taken that this support 'is in no wise allowed to supersede the healthy exercise of the muscles. Essential infantile paralysis is always a tedious disease, and it is unfortunate that it is generally when all kinds of treatment have been vainly exhausted that electricity is appealed to as a forlorn hope. In these chronic cases, a satisfactory result can only be expected after long perseverance; but there appears to be scarcely any limit to the time in which even complete recovery is possible, provided that the paralyzed muscles retain their electro- contractility, and so show that they have not degenerated. The question arises, How far is it advisable for the medical practitioner who prescribes electricity to sanction its admin- istration by the patients themselves? The most explicit directions will often be misunderstood, or fail in being correctly carried out; and yet we are compelled, in cer- tain cases, to do our best in instructing some one attendant of the patient how to carry out the treatment, making her do this a few times in our presence, and looking sharply after Iter afterwards, and, in addition, explaining every- thing as fully as possible to her mistress. Moreover, we must not lose sight of the fact that, with electricity as with other remedies, the skill of the physician is shown in determining how, when, and in what dose to administer it, and his judgment in selecting those cases in which its administration may be wisely committed to others. Electricity in Surgery.—Surgery also owes much to elec- tricity, for in addition to its indebtedness for the galvanic 350 HOW TO USE A GALVANIC BATTERY. cautery, the dispersion of tumors by the electrolytic or chemical action of electricity is making daily progress, and will probably before very long become a recognized part of ordinary therapeutics. The galvanic cautery is an application of the power possessed by the voltaic cur- rent of raising a conducting wire to a red or white heat. For this purpose, ordinary medical batteries are altogether useless, special batteries possessing elements of large sur- face being required. Electrolysis.—In electrolysis medical batteries are used, and it is chiefly applicable to tumors or growths which from their nature or situation are difficult or impossible to be removed by the knife. One or more needles con- nected with a voltaic battery in action are inserted into the tumor, and it is subjected to the disintegrating influ- ence of the current of electricity. There is no hemor- rhage, and after the dispersion of small tumors there is frequently no visible scar. The number of needles must of course vary with the size of the tumor; for a very small one, one needle is sufficient, but for a growth of say an inch in breadth, two or three will be required; and in subcutaneous tumors, where it is desired to avoid injury to the skin, the needles should be insulated by gum elastic, or vulcanite, to within a quarter of an inch of their points. Local anaesthesia of some kind will usually be required; and it may often be sufficiently produced by painting the part with a mixture of one part of carbolic acid to two parts of sulphuric ether. The pain and the fear of the operation will thus be reduced to a minimum. Where only one needle is used, it is generally better to connect it with the negative pole, a large sponge from the positive pole being applied in the neighborhood of the tumor. Where more needles than one are inserted, they should be connected with both HOW TO USE A GALVANIC BATTERY. 351 poles. These are the most generally useful needles, and holders with eyelet holes may be made for the attach- ment of conducting wires which render the operator independent of special conducting cords, for with a coil . of insulated wire and a pocket knife he can fit up his needles in a few minutes in any way best adapted to his proposed operation. a. Electrolysis has been successfully employed in seve- ral cases of aneurism. Where pressure and ligature admit of application, it is hardly necessary to say that the pre- ference should be given to them; but many internal aneu- risms, and especially aortic aneurisms, cannot be thus treated, and in such cases the question of electro-puncture should be carefully considered, and, when called for, it should not be too long delayed. Two fine, sharp, and carefully insulated needles, one connected with each pole, should be introduced into the aneurismal sac, and the current allowed to pass for from half an hour to an hour, the needles carefully withdrawn, and their punctures covered with a bit of lint soaked in collodion or styptic colloid. Authorities are divided as to the kinds of aneu- rism calculated for electro-puncture, but there is no-doubt that an aneurism pressing on the parietes, but not hav- ing actually perforated them, is the best adapted for this treatment, and that it is contra-indicated where the sac is of large size, or where large trunks issue from it. b. The treatment of malignant tumors by electrolysis is yet sub judice, but the evidence in its favor has recently , much accumulated. If future experience should demon- strate that localization of the galvanic current exerts a more powerful destroying or retarding influence upon disease germs than local treatment by caustics, a much more hopeful future will be afforded to sufferers from malignant disease. HOW TO APPLY TRUSSES. THE APPLICATION OF TRUSSES TO HERNIA.1 Hernia may be treated with a great amount of success by proper care and mechanical restraint. We will first consider what may be accomplished in inguinal hernia by trusses in the way of cure, the kind of truss to be applied, and the sort of apparatus which is either of no use or positively injurious, and therefore to be avoided. I. Inguinal Hernia. The Pad.—There are two parts of the truss for sep- arate consideration. The chief and most important part is the pad. All trusses for reducible hernia are provided with some sort of pad, whatever may be their principle of mechanical action. The object of this pad is to press upon the opening through which the rupture passes, to keep the bowel or omentum from getting into the canal, aud, if possible, to prevent it from slipping down into the scrotum, even if it passes the internal or deep abdom- inal ring. Objections to Conical Pads.—Some shapes of pads are very objectionable in principle. One, for example, is so conical as to be almost bluntly pointed. Put this on a weak place, and what ensues ? There is a hole beneath the integuments, which are spread over that hole, cover- ing it in. The conical or acute truss-pad presses these superficial tissues into the hole, in much the same way as when you put a cork into a bottle, with a piece of leather over it. It thus spreads the tissues out, stretches and weakens them, and, at the same time, dilates the tendinous aperture of the superficial ring. The injurious effect of wearing continuously trusses of this kind, or their various 1 Condensed from Clinical Lecture by John Wood, F.R.C.S., etc., Prof, of Clinical Surgery at King's College, London. HOW TO APPLY TRUSSES. 353 modifications, all of which have the same radical vice, is increased in some by a powerful spiral spring placed inside the conical pad, so that they press the tissues still more powerfully into the hernial opening. The move- ments of a patient who wears such a truss cause a constant working of this spring, and a boring motion into the aperture is produced, like the twisting of a cork into the neck of a bottle. Moreover, in a case of rupture you have, not a resisting bottle-neck, but an elastic and val- vular opening, which yields to the pressure. You are continually obliged, therefore, to increase the size of your cork-like pad, so as to fully occupy the hole, and sustain the rupture. The aperture regularly increases, and the rupture, when it does come down, constantly becomes larger, and more liable to become scrotal, until at length it gets so large and unmanageable that no truss will keep it up. It has been asserted that, as a fact, the projecting con- ical pad only buries itself in the subcutaneous tissues, and does not project between the pillars of the ring. But this seems a purely arbitrary assumption, and one certainly contrary to the results of observation in cases which have been subject to such pressure for a length of time. If there be no pressure exerted by the point of the cone, what effect can it have in restraining the rupture at all ? If it has any effect at all upon the inguinal canal, that effect must be in accordance with the shape of the im- pinging surface. A conical wedge-like pressure cannot be transformed into a flat pressure by skin and fat, which are almost as yielding as water. And what occurs in the numerous cases in which the skin is thin and delicate, and the fat almost entirely absent? A rounded surface must press on all sides in a direction perpendicular to the sur- face which presses. It must tend, therefore, to thrust 23 354 HOW TO APPLY TRUSSES. outwards the pillars of the ring, and to stretch and weaken the intercolumnar fascia, as verified by a post- mortem examination in numerous cases where a truss had been worn. In fact, a conical surface fitting into a slip- pery and elastic opening, rather favors the escape of the hernia between its sloping sides and the edges of the aper- ture, as soon as the rupture acquires sufficient power to lift up the truss-pad a little; and if it becomes displaced laterally, the hernia immediately slips down the inclined plane. Sometimes in such a case the instrument maker, finding the rupture to slip down into the canal, and wish- ing to stop it in its descent, prolongs his truss-pad down- ward into a sort of tail, and makes it bigger and bigger, until at length he pushes aside the scrotum, and may bring the pad down into the perineum. Such arrange- ments are exceedingly uncomfortable to the patient, and if a rupture gets down the canal so far as to need such a secondary pad, it is certain to pass on into the scrotum ; you cannot stop it. The most important indication, therefore, is to prevent the rupture from entering the canal at all; to shut up the internal ring altogether. Best Forms of Pad.—The pads are fastened on to the retaining apparatus in a variety of ways. Some are made so as to be adjusting, with the idea of following the rup- ture in the various twistings of its course and emergence. After long experience, I have come to the conclusion that nothing useful can be done by such pads as these, unless the patient is constantly on the watch to adapt the pad to the shil'tings of the rupture. This, I need not remark, can scarcely be done in society, or in the streets, or in various situations where the stress of a rupture may come. The best way is to have your pad so fixed that it pre- vents the rupture from getting into the canal at all. The kind of pad I myself recommend—what I chiefly insist HOW TO APPLY TRUSSES. 355 upon—is, first, that the bearing of the surface of the pad shall be flat, that it shall not press in the tissues or in- vaginate them into the canal between the pillars of the external abdominal ring, and thus stretch, fray, and weak- en the intercolumnar fascia which ought to restrain the rupture from coming down. The edge, of course, must be rounded off to prevent it cutting. We get, therefore, to this kind of flat-bottomed-boat shape according in out- line with that of the inguinal canal in its diseased condi- tion ; that is an oblique oval. In oblique inguinal hernia in the female a flat oval pad, without any break in its outline, answers very well indeed. In the male, however, there is a peculiarity in the anatomical arrangement of the parts. The spermatic cord passes out of the super- ficial abdominal opening external to the spine of the pubis, crossing or lying over the outer pillar of the ring. If the truss-pad produces a pressure upon the cord, it not only makes the patient uncomfortable and the pad more liable to shift and slip about, but also may cause swelling of the testicle, hydrocele, varicocele, and ultimately atrophy; while the chafing of the pad against the pubis leads to the formation of excoriations, sores, and even abscesses. In order to avoid this, we make in the truss a chink or slit in the pad. This gives the pad a sort of oblique horseshoe shape. If properly put on, the shorter end lies upon Poupart's ligament immediately outside and above the spine of the pubis; the longer end lies on the inner pillar, and the round end covers the deep hernial opening of the external ring. The cord, being very mov- able, will adjust itself to the pad and slip into the part where there is the least pressure, i. e., into the chink left between the two points of the pad. If you hope to get the inguinal canal closed up, and the sac obliterated by a radical cure, it is better to have 356 HOW TO APPLY TRUSSES. the pressure hard and firm; and the best material for the pad is the substance called "vulcanite;" it does not ab- sorb the perspiration, is perfectly smooth and hard, and, if proper care is taken to keep the surface clean and dry, will not chafe or give rise to sores. The next best sub- stances are boxwood and ivory, which however, absorb the perspiration to a somewhat greater extent. Experi- ence of these trusses in hot climates has been unanimously in favor of the hard vulcanite over any other substance for truss pads. Leathern or parchment coverings become putrid, foul, and hard, under the effect of constant ab- sorption of cutaneous excretions, and get so nasty that sensitive and cleanly patients cannot bear to wear them. In other cases, where you do not go into a radical cure so much as for making a patient comfortable, then water and air pads, made up of india-rubber upon a metal frame, are exceedingly comfortable and useful. Some patients cannot bear any other than this soft pressure. They are of the same general shape and principle, but the surface is more yielding, and the pressure is soft; they cannot press into the hernial apertures as hard conical pads do, and the pressure, being fluid, is equal in all directions. Retaining Apparatus.—The nature of the apparatus for fixing and keeping on the pad and restraining the rupture is also of great importance. The rupture requires pres- sure to retain it, and, as a rule, you do no good at all unless there is a side-spring. There have been various ways devised of applying this retaining apparatus. One way which the patients sometimes choose, and which seems to recommend itself to them by its simplicity, is having a strap round the body, and an understrap across the perineum. Now it is exceedingly difficult to wear a band round the waist so tight as not to give way to pres- HOW TO APPLY TRUSSES. 357 sure at one point, and so to yield before the rupture. Even if you could make it tight enough, the patient could not wear it, the tightness would be so great. You may take it, as a rule, that these straps round the pelvis, when a patient is exerting himself and contracting his abdominal muscles, are of no use in keeping in a rupture. Where there is real need of pressure, nearly all truss- makers have recourse to some form of the side-spring. Some have the spring passing only round one-half of the body, with a pad behind, on the sacrum. This pad is always flat or oval, and slightly concave, and is larger and thinner than that placed on the rupture. It is held in its place by a strap that goes round the opposite side of the body, and frequently by an understrap across the perineum. Some have the spring put on the same side as the rupture; but in one of the best forms the spring is put on the opposite side, so that it reaches across the front of the abdomen, and is longer than those which are put on the same side as the rupture. The rupture pad projects more than the posterior one, and works upon a ball-and- socket joint. The spring is longer than is necessary to go only half round the body; it reaches over to the op- posite side, and the support it gives depends upon the fact of its pushing upwards and towards the ruptured side. Other half-round springs depend upon the power they possess of pressing or pulling upwards and outwards towards the same side, in opposition to the descent of the rupture. Sometimes it is necessary to wear a perineal baud which buttons in front. Generally speaking, this may be dispensed with after the truss has accommodated itself to the shape of the body, which, after a time, all trusses do to some extent. The warmth and motion of the body will make even the spring accommodate itself somewhat to the shape of the body. 358 HOW TO APPLY TRUSSES. The Spring.—With regard to the bend of the spring, there are one or two matters of very great importance. In the first place, the spring should go round the body at a level midway between the projection of the tro- chanter and the anterior superior iliac spine. There it lies on the tensor vaginae femoris and gluteal muscles, and does not work over bony surfaces. That is the level at which the measurement for a strap should be taken when you have to send for a truss to a maker. But I may here remark that it is never satisfactory to send measurements without the maker seeing the patient. The maker wants, in addition, to comprehend the shape of the back and set on of the pelvis as well as the mere dimensions. So that, if possible, you ought to bring the maker and patient together. Other plans do not usually succeed. The spring should point down far enough to get to the opening, and the pad should be placed upon the opening. The spring requires to be bent down a good deal more for crural than for inguinal hernia. For cru- ral hernia the side-spring should be made like the handle of an old-fashioned pistol. That end of the spring which bears the pad should project well, so as to give a proper degree of backward pressure; and if you look at the sur- face of the spring you will see that it is somewhat twisted on its own axis, so as to give an outward and upward pressure as well as a backward pressure. This gives the right direction in which to keep the hernia in the abdomen when it tends to pass into the canal. The round part of the horse-shoe pad presses upon the internal ring, and the ends press upon the pillar of the external ring. The chink is to lodge the cord, which is thus held as. if embraced by the fingers employed in reducing and keep- ing in the rupture. Thus the rupture is prevented from coming through the internal ring, while the pillars of the HOW TO APPLY TRUSSES. 359 superficial opening are prevented from separating, and so allowing the rupture to pass out. The length of the spring from the point where it comes round the hips should be duly proportioned to the patient's formation. In these horseshoe pads there are holes and screws by which the pad can be shifted a little to adjust this properly. If the spring be too long at this part the pad presses against the outer edge of the rectus muscle. The inner border of the pad should be parallel to the outer border of this muscle, and the outer border should lie upon Poupart's ligament. If the spring be too long it pushes the pad further on to the muscle which bears off the pressure from the hernial cause during the contrac- tion of the muscle, permitting the rupture to escape below and outside the pad. If, on the other hand, you have the spring too short, the rupture will escape between the rectus and the pad. II. Direct Inguinal Hernia.—A direct inguinal hernia passes thrpugh the triangle of Hesselbach, in- closed between the epigastric artery, the edge of the rec- tus, and Poupart's ligament. That is the area you have to protect; and it can best be done by a flat-rounded or oblately-oval pad fitting close between the edges of the rectus and Poupart's ligament, reaching well down to the crest of the pubis, and provided with a slight notch below for the passage of the cord. To keep the pad from shifting upwards, and from pressing unduly upon the pubis, care is required in adjusting the action of the side-spring. It is as well to wear at first an under or per- ineal strap, until the pad and spring have adjusted them- selves to the shape of the abdomen. In corpulent persons a considerable upward slope may be also given to the surface of the pad, to make it lie parallel with the slope of the abdomen, and to prevent the upper edge from 360 HOW TO APPLY TRUSSES'. pressing unduly into the flesh. In thin persons, with lean flanks, the tendency is always for the pad to slide upwards into the hollow formed by the abdomen. This can be met sometimes by keeping the surface of the pad quite flat, so as to lie perfectly level upon the surface of the groin. You may, however, in the course of time, in the same patient find a marked alteration in the slope of the abdo- men from an increase in the abdominal volume, as well as in the thickness of the superficial fat, altering entirely the conditions of the rupture and the requirements of the pad and spring. In some instances this may occur in a very short time. On the other hand, a patient, from illness or active work, may get rapidly thin, and require a readjustment from this cause. To meet and manage these conditions, is one of the niceties of truss-making. It is sometimes difficult to get the exact twist, and even when you have got it right, the condition of the patient may change, and you may have to alter the spring accord- ingly. The problem to solve may be put geometrically; it is requisite to obtain the angle of inclination of the abdo- men to a transverse vertical plane, taken at the most prominent part of the inguinal region, and containing the side of a right-angled triangle of which the posterior wall of the inguinal canal is the hypothenuse, and the horizontal level of the upper margin of the pubis is the base. If you do not have the pad-surface inclined enough, the rupture comes down under its lower border, and if you twist it too much, you get the same edge pressing in so as to inconvenience the patient, and allow the rupture to enter the upper part of the canal. It is this slipping over and under on one side or the other that constitutes the troublesome part of the treatment of ruptures by trusses. You do not often find patients who have suffi- HOW TO APPLY TRUSSES. 361 cient mechanical knowledge, or who take sufficient pains, to aid the efforts of the instrument-maker by skilful adjustment of the pad after a careful return of the rup- ture. This is one cause why so few cures are effected in this way. I recommend, as a rule, the all-round spring cov- ering over both hips, instead of the one-sided spring; but in certain cases half-round spring, fitted to the opposite side of the hips, and pushing towards the ruptured part, may be advantageous; the horseshoe form of pad, how- ever, may be used quite as well with this form of spring. Irreducible Hernia.—In old cases of irreducible hernia you meet with another difficulty; you cannot reduce the hernia entirely, and all you can do is to prevent more of the intestines from coming down. In such cases the bowel may be exposed to ail sorts of injury, besides con- stituting a deformity of a somewhat conspicuous charac- ter. To remedy this you must have a suspensory or bag truss made of stout jean, or some unyielding material, which will keep a constant pressure upon the contents. If the irreducible portion consist of omentum only, you must also have some pressure over the inguinal canal to prevent the bowel from following the omentum. Such combinations are sometimes exceedingly difficult to carry out. In a case of this kind one of the best arrangements is a truss-pad shaped to the form of the rupture, com- posed of a frame of stout wire, well padded, and stretch- ing between the wire framework a bag of stout jean, or of some slightly-elastic material, sufficiently resisting, into which the hernia is received. The wire framework, pressing all round the irreducible rupture, keeps it well in hand and under control. All you can do in such cases is simply to make your patient as comfortable as circum- stances will allow, and to prevent injury to the irredu- cible rupture. 362 HOW TO APPLY TRUSSES. III. Crural Hernia.—In crural hernia we have con- ditions entirely different. The inner opening is consti- tuted by the crural ring, a horizontal aperture with a slight inclination forward. In front it is bounded by Poupart's ligament, on the inner side by Gimbernat's ligament, and on the outer side by the femoral vein and artery. These are structures which vary somewhat in tension. Relaxation of the muscles of the abdomen has a great effect upon Poupart's ligament. But the greater part of the surrounding structures are composed of un- yielding ligamentous tissue, so that there is not that con- traction and relaxation that is present in inguinal hernia. A little below there is another opening, called the saphe- nous opening, directed forwards, and a little inwards, and almost vertically, but with a slight inclination downward. Lying in front of the passage between these two open- ings is the upper part .of the process of Burns's or femoral ligament (Hey's), which extends from half to three-quar- ters of an inch downwards from Poupart's ligament, with which it is continuous above, to the margin of the saphenous opening. It is this part to which the pressure of a truss should be applied in crural rupture, when it will protect both crural ring or upper, and the saphenous opening or lower, aperture of the crural canal. Immediately outside the canal are the femoral vein and artery, which must not be pressed on by the truss, and below is the saphena vein, which it is also important not to compress. When a femoral rupture gets fairly through the saphe- nous opening, it turns upward and outward round the edge of the falciform process, and lies over the femoral vessels and upon Poupart's ligament. In order effectively to deal with this rupture, you must altogether prevent it coming through the crural ring into the canal before it HOW TO APPLY TRUSSES. 363 makes the upward and outward turn, so as to lie upon Poupart's ligament. If you fail in this, then your truss pressing the rupture against the falciform process of Burns thereby injures the bowel, and does harm rather than good, and the patient would be safer and better without a truss at all. The truss-pad for crural hernia must protect the crural ring by pressure over Poupart's ligament, and it must also press upon and fill the saphenous opening. It must not press downward, so as to obstruct the saphenous vein. The pad will be apt to slip, so as to miss the crural canal altogether, and, by irritating the inguinal glands, may cause trouble. The best form of truss-pad for this hernia is one which I may thus describe: The outline is an egg-shape, with the small end downwards; it is adapted to the saphenous opening, but rather longer, so as to press upon Poupart's ligament with its broad end above, and the side-spring is fixed exactly in the centre. It slopes off below, so as to avoid pressing upon the saphenous vein, and forms a rounded projection above, so as to fall into the fold of the groin upon Poupart's ligament when the patient sits down. It is thus adapted for keeping in position; for the truss-pad which most adapts itself to the form of the surface will stop in its place the best. In the truss for femoral hernia, the pad end of the spring is bent downwards in a large curve to permit the patient's thigh to bend freely and without obstruction in sitting. You ought not to be content with seeing your patient stand when you fit on a truss; you must make him sit down on a low seat, and then stand, walk about, and jump from a stool, and see if that dislodges the truss. If the truss does not hurt him, but keeps the hernia up, under those conditions, you may conclude it will do for 364 HOW TO APPLY TRUSSES. all the ordinary purposes of life. The commencement of a radical cure by truss pressure always dates from the last time the bowel or omentum came into the sac of a rupture. Hence the importance of the patient preventing the hernia from ever coming down. If it come down even once, he has to begin de novo from that point to pro- duce the obliteration of the canal. Hence a patient who wishes to get rid, at the earliest possible period, of a dis- agreeable and troublesome deformity, must wear his truss on all occasions, night and day; he must never assume the erect posture without it; and if he bathes, he must have a bathing truss, for sometimes in the gymnastic movements which generally attend upon a cold bath the rupture may come down. IV. Umbilical Hernia.—Umbilical rupture is ex- ceedingly common in children, and in them it is usually curable. It comes through a natural opening which is left for the umbilical vessels up to the time of birth, and which it is the tendency of nature to close up sooner or later. That tendency is very strong, and the only thing that prevents it is the bowel constantly coming into the sac. If you can, in a child, manage to prevent this, you cure the hernia; and that is generally the case when the improved apparatus of the present day is carefully at- tended to. But there are some cases where the child is not tractable, and from pain and fretfulness is often cry- ing and screaming; then you get the rupture distended violently and constantly. Again, if the nurse is not soothing and careful you seldom get the rupture cured. The ordinary rough-and-ready and often very successful fashion of treating umbilical hernia is covering a flat piece of metal, say, one of the old-fashioned copper coins, a penny-piece, with plaster, with the sticky side outwards, putting it on the projection, and strapping it across the abdomen with broad straps of adhesive plaster. HOW TO APPLY TRUSSES. 365 In some of the older books on this subject you will find recommended a convex cork plugging up the aper- ture, like the neck of a bottle; but elastic apertures of vital tissue cannot be blocked up in that way, while the cork tends to make matters worse by dilating the aper- ture, and thus keeping open the rupture. Therefore that is one of the things to be avoided. It does not keep in the rupture, because it will slip out at the side of the cork. A flat surface, rather larger than the aper- ture, is what you ought to have. A flat penny-piece, or bit of lead of the same shape and size, may be backed up by a thicker piece of wood or cork, and the strapping may be put across. In this way a very good and easy apparatus is made, if the patient cannot afford to have a proper apparatus; but it involves the necessity of a tedious process of taking off sticking plaster, which is sometimes not done in the gentlest way, and thus sets up a crying bout, and brings the bowel out of the aperture. All this is inconvenient. When you are called upon to do this, you must press the parietes of the abdomen together with your finger and thumb, so as to close the umbilical hole before you take off the pad and strapping, and take care the bowel does not slip out. A capital invention is a very ingenious adaptation of elastic India-rubber, arranged in two compartments, dis- tended with air, and communicating by a small aperture; a central one, globular in shape, and an outer ring. The former presses upon the umbilical opening, and the outer upon neighboring tissues forming its boundaries, and so prevents the umbilical hernia from coming out under a cough or cry impulse. This central portion acts like the penny-piece, with the additional advantage of becoming tightly distended by the air from the surrounding ring cushion forced through the small aperture of communi- 366 HOW TO APPLY TRUSSES. cation by the impulse of the abdominal muscles. The whole is held on by an elastic band round the body, and can be distended after fixing by blowing through a little stop-tap. By this means, the moment the bowel has a tendency to escape through the hernial aperture, it is met and forced back again by the dilating globe. By this means some very capital cures may be produced in chil- dren. In adults, also, in whom it is much more difficult to produce a radical cure, this apparatus is very useful and comfortable. The chief reason why in adults you do not get a radical cure of umbilical hernia is because it is generally accompanied by abdominal obesity and laxity, the stomach too becoming at intervals much dis- tended with food and flatulence, and the mesenteries being enlarged by an accumulation of fat. In such persons you must be content, even in any kind of hernia, with ame- lioration of their condition rather than cure. But in young persons you may frequently succeed in effecting a cure by the aid of a proper instrument. If, in young persons, a hernia of the inguinal or umbilical variety resists the cure by careful mechanical restraint, then it becomes a question whether you cannot safely and greatly increase the chance of a cure by an operation, which keeps out the bowel for a sufficient length of time for the open- ing to contract and close. Rules for the Wearing of Trusses.—The truss should be constantly worn, except when the body is in the horizontal position. It should always be adjusted in the recumbent position, never when standing upright. The spring should be opened sufficiently to go round the right leg; it should then be placed round the left leg, and after- wards drawn up into its place, and the pads adjusted in their proper position after the rupture has been per- fectly reduced. The object of this is to prevent the breaking, or gradual weakening of the spring. HOW TO USE THE CLINICAL THERMOMETER. 367 A duplicate truss is recommended in all cases, not only for renewal of cover, or in case of injury to the original truss, but for the great additional comfort of a " change." As the truss forms part of the attire, it must be so considered; the inconvenience of wearing one pair of boots or shoes from the time they are new to the time they become worn out, is sufficiently obvious; a new truss is as irksome to wear, and should be brought grad- ually into regular use. A bathing truss is always recommended, it being al- most impossible to retain the rupture with the hand during swimming, bathing, or ablution. A sleeping truss is sometimes recommended. A soft pad attached to a soft band round the body is usually sufficient. The principle that a rupture should, under all circumstances, be kept up, should always be borne in mind; and the importance of these simple directions can hardly be too strorigly insisted upon. HOW TO USE THE CLINICAL THERMOMETER.1 The value of the thermometer in the investigation of disease is at present so generally recognized in theory, that it is unnecessary to enter into any discussion on this subject; at the same time it is needful to impress upon all the extreme importance of employing this instrument in daily practice, because there can be no doubt that even now many do not use it to the extent which it deserves. Neither is it requisite to give any detailed description of the instrument. All that need be said is that the ther- mometer should be sensitive and accurate; of a sufficient i F. T. Roberts, Theory and Practice of Medicine, Phila., 1880. 368 HOW TO USE THE CLINICAL THERMOMETER. range; self-registering; and of a convenient size to be carried in the waistcoat pocket. These conditions are fulfilled in the clinical thermometers, which are sold in most respectable instrument shops. Special instruments are employed for taking surface temperatures. Mode of Use.—The regions usually employed for tak- ing the temperature by rrreans of the clinical thermometer, are the axilla, the inner side of the upper part of the thigh, the mouth, rectum, or vagina. Sometimes it is requisite to determine and to compare local temperatures. The instrument must be kept in close contact with the surface, and completely covered. When the temperature is taken in either axilla, which is the most convenient place in most cases, the patient should lie on the same side, and press the arm firmly to the side; or it may be occasionally necessary to strap the thermometer to the surface by means of plaster. The mouth does not afford accurate results, but it may conveniently be made use of to give approximate information, the thermometer being placed under the tongue, and the mouth firmly closed. With regard to the time required for the instrument to be retained in its position, there is a difference of opinion. With proper precautions, five minutes is usually sufficient, especially if "two observations at intervals of one or two minutes give exactly the same result" (Aitken). To be strictly accurate, however, many think that the mercury ought to remain stationary for five minutes. Baumler gives, in order to be scientifically correct—for the rectum three to six minutes; mouth, nine to eleven minutes; axilla, eleven to twenty-four minutes. It is desirable, if possible, that the individual upon whom the observation is made, should have been at rest in bed for at least an hour previously. Not unfrequently, however, the thermometer has to be employed without HOW TO USE THE CLINICAL THERMOMETER. 369 any such preparation. The intervals at which the temp- erature should be taken will vary according to the nature of the case. Often, only one observation is required. In most instances twice a day is sufficient, viz., in the morn- ing and evening, and in many, once daily is enough. Sometimes, however, it is most important to note the temperature at very frequent intervals, or even to allow the thermometer to remain constantly applied. Should this be needful, it is advisable to teach the nurse or some other intelligent person how to use the instrument, by whom it might also be employed, if any unusual symp- toms should arise. In all febrile cases it is requisite to have recourse to the thermometer until convalescence has been firmly established, for reasons to be presently indi- cated. In using the thermometer, the points to be observed are: 1. degree of heat, as indicated by the end of the index most distant from the bulb of the instrument. 2. The rapidity with which the mercury rises, this being in propor- tion to the height of the temperature. It is often impor- tant to take a note at the same time of the frequency of the pulsa, and respirations ; and, in some cases, to make a quantitative analysis of the urine, in order to determine whether there is a relation between the temperature and, the amount of urea, uric acid, and other waste products discharged. All these observations should be recorded on proper forms, of which several have been planned, the temperature being indicated by angular lines or curves. It may be mentioned here that Fahrenheit's scale is the one followed in this paper. Temperature in Health and Chief Modifying Influences.— In the axilla the temperature in health averages about 98.4° F. It may range, however, from 97.3° to 99.5°, or even 100° ; but if it goes beyond this in either direction, 24 370 HOW TO USE THE CLINICAL THERMOMETER. and remains persistently above or below the normal, there is something wrong. The chief circumstances which in- fluence the temperature in health, are as follows: 1. The part of the body in which it is taken. It is higher in in- ternal parts, such as the rectum or back of the mouth, than in external parts; in sheltered regions of the body than in those which are exposed; over the trunk than over the limbs. 2. Age. The temperature, according to most observers, is higher in children and young persons than in adults. It is also said to rise in old age. 3. Time of the day. During the day the temperature rises until evening, and then falls slowly till early morning, when it again ascends. In this way there is a variation of about 1.5° during the twenty-four hours in adults, but the range is greater in children. 4. Climate and exposure to heat or cold. In the tropics the average temperature is a little higher than in temperate or cold climates, and it may reach 99.5°, or even 100° F. Long exposure to great heat or cold will also influence it to a slight degree. 5. Food and drink. After a full meal the temperature at first falls, but it rises as digestion proceeds. Fasting low- ers the temperature. Alcohol seems to cause a speedy fall, but this is only temporary, and a considerable quan- tity is required in order to influence the temperature materially. Certain articles of diet in daily use produce some effect, such as tea and coffee. 6. Exercise increases the temperature, especially that of the extremities, pro- vided it is not sufficient to induce greit fatigue. 7. Pro- longed study and other forms of mental effort cause a slight depression. 8. Professor A. B. Garrod has found that the temperature rises on stripping off the clothes, and exposing the surface of the body, and the difference is greater in proportion to the coldness of the surround- ing air. When the temperature of the air is above 70° HOW TO USE THE CLINICAL THERMOMETER. 371 F., there is a slight fall, but a rise to the previous tem- perature soon takes place. The chief source of the animal heat is almost universally believed to be the chemical and vital changes in the food and tissues, especially the muscular tissue, which are con- stantly going on in the body, the heat thus produced being diminished by evaporation from its surface, while the circulating blood renders the temperature tolerably uniform throughout the system. The influence of tire nervous system upon temperature has been already con- sidered. Dr. Beale believes that the conversion of non- living into living material is the cause of the production of heat. Uses of the Thermometer in Disease. — In the great majority of cases disease tends to raise the temperature to an abnormal height, there being more or less pyrexia ; and it is for the purpose of accurately determining the degree of this increased bodily heat that the thermometer is chiefly employed. Occasionally the animal heat sinks below the normal, or it may be unequal in different parts of the body; but these deviations are not nearly of so much consequence as a general rule. At present, it is only intended to sum up concisely the circumstances under which the thermometer may prove serviceable. The peculiarities which individual diseases present as re- gards temperature present a distinct field of study. The information afforded by the thermometer may give valuable assistance in: 1. Diagnosis; 2. Prognosis; 3. Treatment. 1. In Diagnosis.—Much help is constantly derived from the thermometer with respect to diagnosis, and the fol- lowing remarks may serve to gather up the circumstances under which it is thus useful, a. In many cases which present themselves in ordinary practice, where symptoms 372 HOW TO USE THE CLINICAL THERMOMETER. exist which might or might not belong to the premonitory stage of some acute illness, all doubt may at once be cleared up by taking the temperature. Thus we have frequently found in the out-patient room that, when symp- toms suggestive of scarlatina or smallpox were complained of, by the help of the thermometer we have been enabled to negative the supposition of either of these diseases being present, or, on the other hand, to corroborate such a suspicion. In short, the instrument enables us at once to determine whether pyrexia is present or not, as well as its degree, and thus becomes a most valuable aid to the practitioner, which he should ever keep in mind. b. Oc- casionally by one, or at most two observations, it is pos- sible to ascertain positively the nature of a fever. For instance, if the temperature suddenly rises to 104° or 106° F., the patient having been quite well on the pre- vious day, he is probably suffering from some form of malarial fever; and this is certain, if the temperature falls rapidly, so that it becomes normal in a few hours, c. Many febrile disorders are now known to have tolerably regular and uniform ranges of temperature throughout their entire course, and to present peculiar diurnal and nocturnal variations, the temperature being, as in health, generally higher by night than by day. It is therefore essential to become acquainted with this portion of the natural his- tory of each of these affections, and to employ the ther- mometer regularly in investigating them, so that they may be thus distinguished from each other, and from all complaints which may simulate them. d. The habitual use of "the thermometer may lead to the discovery of dis- ease when there is no obvious sign of its existence, for the fact -of a patient presenting a temperature above the normal should always call for a more minute examina- tion, which would probably lead to a satisfactory diag- HOW TO USE THE CLINICAL THERMOMETER. 373 nosis. This has been frequently observed by those who employ the thermometer in lunatic asylums, who have thus detected phthisis in insane patients, when they could not otherwise have suspected it. e. Complications occur- ring during the progress of fevers, or during the period of convalescence, as well as relapises, are indicated either by a disturbance of the typical range, by delayed defer- vescence, or by a rise in temperature, after it has once subsided, and either of these deviations may be the first thing observed. Hence the necessity of taking a daily note of the temperature, until the patient has perfectly recovered. /. In certain diseases the thermometer gives information as to the activity of the progress of a morbid process; for instance, in pulmonary phthisis. Further, it ma}' occasionally help in distinguishing between differ- ent forms of this complaint. Again, in, connection with haemoptysis, the thermometer is useful in indicating in- flammation which may be set up by blood extravasated into the respiratory organs. The same remark applies to the effects of an apoplectic clot in the brain, g. Inequality of temperature in different parts is sometimes of aid in diagnosing paralysis, or other nervous disorders. Of late attention has been particularly drawn to the value of comparing local temperatures in the diagnosis of brain affections and of pulmonary phthisis. A word of caution is necessary with regard to children. In these subjects, the temperature may run up rapidly to a considerable height, when there is nothing particular the matter, and therefore care must be taken not to jump to a hasty diagnosis of some serious disease, simply be- cause the thermometer indicates much bodily heat. It often falls with equal rapidity. 2. In Prognosis.—The temperature may be of use in assisting towards a prognosis, either in itself, from its re- 374 HOW TO USE THE CLINICAL THERMOMETER. lation to the pulse, respirations, or amount of excreta, or from its association with other symptoms, a. The degree of heat observed during the early period of a febrile dis- ease, especially when taken in conjunction with the pro- minent symptoms, will often give a good idea as to whether the particular case under observation is likely to be a severe one or not. If the temperature is at all high, it shows that a sharp attack may be anticipated, and that complications resulting from the presence of products of decomposition in the blood are liable to arise; there- fore a guarded prognosis should be given, b. A very high temperature, especially when it exhibits a tendency to a continuous and rapid rise, is extremely dangerous, espe- cially if the excretions are deficient, c. A sudden change in the temperature may be premonitory of some coming event, even for some days before this actually occurs. Thus a marked fall in cases of typhoid fever not uncom- monly precedes hemorrhage from the bowels, and gives warning of its approach, d. If the temperature does not increase, or if it falls from morning to evening, this is a favorable sign; if it is higher in the morning than on the previous evening, this shows that the disease is advancing, and the prognosis is consequently more grave, e. In many pyrexial diseases the fever usually subsides on cer- tain days, often by crisis; if in a particular case the expected fall takes place, and defervescence goes on reg- ularly and continuously, the prognosis is favorable, if the contrary happens, or if the decline of the fever is irreg- ular, an unfavorable course is indicated. /. Should the temperature decline rapidly in certain acute febrile affec-. tions, such as pneumonia or typhus fever, while the pulse and respirations increase in frequency, and the other symptoms show no signs of improvement, but on the other hand become worse, the prognosis is very serious. A very low temperature is in itself an evil omen. HOW TO USE THE CLINICAL THERMOMETER. 375 It must be remembered that accidental circumstances may temporarily modify the temperature in disease as in health, such as food, exercise, excitement, etc. It may be increased by sources of irritation, e. g., retained urine or feces, on the removal of which irritants it is often markedly reduced. Defervescence may proceed so far that the animal heat is brought below the normal, some- times considerably. After convalescence from severe continued fevers, the temperature often remains low for some time. The same condition is also observed during the apyrexial periods of intermittent fever and in the remissions of the remittent variety. 3. In Treatment.—The value of the thermometer, as affording indications for treatment, may be gathered from the remarks already made, and it will be only necessary to give two or three illustrations. A very high and ascending temperature calls for prompt recourse to the use of cold. In ague, after this disease has apparently sub- sided, it is found that the temperature still rises at the usual intervals, and until this has become quite normal for two or three days, treatment must not be discontinued. During convalescence from fevers an increase of the bodily heat may be due to something wrong in the diet, or in the use of medicines, and such an event should lead to careful inquiry on all matters which might tend to raise the temperature, so that appropriate measures might be adopted to remove the source of disturbance. 376 HOW TO REMOVE SPOTS OF BLOOD, MUCUS, ETC. HOW TO REMOVE SPOTS OF BLOOD, MUCUS, ETC. Nature of the Spots or Stains. On White Goods. On Colored Goods. On Silk Goods. Blood and albumin- ous spots.......... Mucus, iiiucilage; sugar, jelly....... Mechanically at- tached particles... Fats................ Oil colors, varnish resin .............. Stearine............ Vegetable colors red wine, fruits red ink........... Alizarine inks..... Simply washing out with lukewarm water. From woollen goods of tenrb colors, blood-spots may be removed by rubbiug with the inner sido of crust of bread. Rust, and spots of ink made of nut galls............. Lime, lye, and al kaliesin general. Acids, vinegar, sour wine, must, acid fruits, etc....... Beating, brushiug, and allowing water to fall Irom an elevation upon the wrong side of the goods. Washing out with Boapra"h,ngJ °U\ with \y*ew*™ or iVa 0"ai' Soap and water ; or, if woollen or lye. goods, spirits of hartshorn. Oil of turpentine, alcohol, benzine, and then soap. Benzine, ether, spir- its of hartshorn, magnesia, chalk, clay, yolk of eggs. Benzine, ether, and soap, very careful- ly and in a very weak solution. Strong, alcohol. 0„,„,___, „„___„___. .Washing out with lukewarm Sulphurous vapor or hot . s , . -. . r„u,„_;____r„t„_ water and soap, or spirits of chlorine water. Tartaric acid—the older the spot the more con- centrated. Hot oxalic acid, dilute hydrochloric acid, and then tin filings, or so- lution of oxalic acid in a tin spoon. Rust may also be removed by soaking the stains in a weak solution of lin chloride, and rinsing immediately with much water. Simply washing. Simply washing ; in the case of fruit, also with hot chlorine water. Tannin substances. fruit or green nut- shells, leather.... Tar, wagon grease as also fat, resin, c irbonaceous par tides, aud wood vinegar........... Superficial loss ot substance by scorching......... Bleaching lye, hot chlo- rine water, concentrat ed tartaric acid. Soap, with oil of tur pentine, varied with the action of fallin water. Rub over thoroughly with a pad dipped in hot chlorine water. hartshorn. If the color permits, dilute tartaric acid. Citric acid to be tried ; or, in non-colored woollen goods, dilute chloric acid. As with the preced- ing articles, but very cautiously. As before, but with great precaution. Nothing can be done without increasing the evil. Much-diluted citric acid, drop for drop upon the moistened spot, to be spread around by the finger. According lo the delicacy of the material and the color, more or less diluted spirits of hartshorn, to be spread around on the spot moistened, drop for drop, with the tip of the finger. Yellow spots pro- duced by nitric acid may be removed from brown or black woollen goods only while fresh, by repeated dipping in a concentrated solution of permanganate of potassium, and then washing with water. Chlorine water, diluted according to the delicacy and color'of the material, applied with a rag, and drop for drop on. the spot moistened, alternately applied and then rinsed off. Hog's lard to be rubbed on, then soaped and allowed to remain qui''tly,then washed alternate- ly with water and oil of tur- pentine. Whenever possible, coloring over, or raising up the nap. As in the preceding, but more carefully, and instead of tur- pentine, benzine and a continued current of water falling from a height, and only upon the reversed side of the spot. Nothing can done. be STAINED SECTIONS OF ANIMAL TISSUES. 377 HOW TO PREPARE STAINED SECTIONS OF ANIMAL TISSUES.1 The staining of tissues by the more simple tinging agents, as carmine, logwood, and the anilin dyes, etc., is so easy, that it has always been a matter of marvel to me that, of the thousands of slides one sees (I refer now- only to those of stained animal preparations), scarcely any are ever stained so as to show the structures to their best advantage; indeed, most of them are utterly useless. The causes of this failure in producing good and use- ful stains are several, and in many cases may be due even to the condition of the material when it first comes into our hands; therefore, though this paper is nominally devoted to stains and staining, I shall treat of— 1. Material. 2. Methods of preserving and of hardening it. 3. Cutting of the sections. 4. Tinging agents. 5. Method of staining; and 6. Suggest a few points to which sufficient attention is not generally given in the mounting of the sections, after all the other processes have been satisfactorily completed. The Material. This, in all cases, should be as fresh as possible, and I am confident-that much of the want of success in staining is due, not so much to inattention to the details of the staining process itself, as to a want of care in having the material quite fresh. It should always be borne in mind that, though for the knowledge of human histology it is advisable to study it from tissues obtained from the human subject, still it 1 Read before the Quekett Microscopical Club by J. W. Groves, May 23, 1879, and published in the Amer. Journal of Microscopy, Feb. 1880. 378 STAINED SECTIONS OF ANIMAL TISSUES, is so difficult to procure these in good condition—to many people even an impossibility—that for general pur- poses it is far better to utilize similar structures or organs from the lower animals. Though these may differ in some more or less important details, they do in the main furnish all that, for ordinary purposes, we require to know of the similar structures in man. Decomposition rapidly .sets in, sufficiently to impair, if not to neutralize, the subsequent process; therefore, ex- cept with certain morbid structures which can only be obtained from the post-mortem room, all normal mate- rial, and, where possible, that also which is morbid, should be placed in a preservative fluid, there to be hard- ened or softened as the case may be, either directly after the death of the animal, or immediately after its removal from the living body. Preservatives. These may be divided into two classes: 1st, those which simply prevent further alteration, and 2d, those which, in addition to preserving, at the same time cause hardening, softening, etc., as set forth in the following table :■— Canada Balsam. Glycerine. Goadby's Fluid. Dammar Solution. Glycerine and Carbolic Acid (15.1). . Glycerine Jelly, etc. f Alcohol. | Chromic Acid (1-eighth percent, sol'n). a. Simply \ Bichromateof Potash (2 per cent.sol'n). " Ammonia (ditto). I. Muller's Fluid, etc. r Picric Acid (sat. solution). Osmic Acid (1-2 p. c. solution). Gold Chloride (\ p. c. solution). Alcohol and Carmine, etc. Chromic Acid (1-eighth p. c. sol'n) and L subsequent immersion in glycerine. 1. Simple Preservatives. I. Those which also harden. b. Which color also. AND HOW TO PREPARE THEM. 379 3. Those which also f For Mineral Salts—Acids. soften. ( " Animal Matters—Alkalies. 4. Those which harden ") ome jx i n o - , ^jarom|c Aci,j Solution and Nitric Acid. ten others at the | same time. J In the preceding table are enumerated the more ordi- nary and useful preservatives, each of which will be pre- sently noticed separately ; though, firstly, I wish to draw your attention to three facts in connection with them, which are of the greatest importance, and to the want of a due regard to which may be ascribed a second cause of failure in procuring good stains, to say nothing of their also being the cause of want of success in cutting thin sections. These facts are, first, that it is necessary to be careful to employ that strength of the hardening or softening fluid which is most suitable for the tissues to be acted upon. What these strengths should be, it would be impossible to tell for every case, but I will give those which are most usually employed, and, for further details, must refer you to that useful work, " Practical Histology," by Mr. E. A. Schafer. The second fact is, that small pieces of material and a large bulk of the fluid must always be employed; say half a pint of fluid for pieces equal to one cubic inch. The third fact is, that the fluid (even though that may be alcohol) should be changed frequently. How fre- quently this change should be made can only be learned by experience; but for all aqueous solutions it is well to make the first change after a few hours, then every day or two. Of the hardening agents, chromic acid comes first. This should be used in solutions of various strengths, but pro- vided they are frequently changed, it is better to err on the side of their being too weak than too strong, for in the 380 STAINED SECTIONS OF ANIMAL TISSUES, latter case, the tissues become friable, and crumble away before the knife or razor; besides, it is utterly impossible to stain them properly. The most useful strengths are \ or \ per cent, aqueous solutions; but before immersing the material in these, it is well to place in it a 2 per cent. solution of bichromate of potash or bichromate of ammo- nia, for some eight or twelve hours, as they have a greater penetrative power than the simple chromic acid solution, and thus cause the masses to be more evenly hardened. It. should be remembered that chromic acid solutions have a tendency to bleach tissues already stained or injected with carmine solutions. Bichromate of potash and bichromate of ammonia.—Either of these may be used in a 2 per cent, solution; the latter being the more generally useful.1 Alcohol.—This is perhaps the most generally useful fluid for those who have not much time to devote to the subject, as with it there is less chance of the material spoiling; moreover, tissues hardened by its means give the best results with most of the staining fluids. Alcohol should be used rather weak at first, then stronger, till the material is hard enough to cut, except when the freezing microtome is to be employed. Mullens solution is another most useful hardening agent, especially for the retina and other nerve struc- tures. Material should be kept in it from three to six weeks. Its composition is— Bichromate of potash, 25 grammes, or 2| parts. Sulphate of sodium, 10 grammes, or 1 part. Water, 1000 c.c, J 00 parts. The method of hardening tissues by drying them is 1 Material hardened by immersion in solutions of chromic acid, bi- chromate of potash, or bichromate of ammonia, should be removed to alcohol at the end of about ten days, or it will become brittle. AND HOW TO PREPARE THEM. 381 open to many objections, among which may be mentioned the alteration of structures, and the difficulty of obtain- ing thin sections; for, cut them as thin as may be, they will swell when rendered moist again by the subsequent processes. Softening fluids are usually only required for structures which are naturally hard, due to the impregnation of lime salts, as bone and teeth. For these, acids are required, but as it is generally desirable to retain in situ the soft parts connected with them, it is advisable to use, as a softener of the inorganic matter, some fluid which will at the same time harden all the soft or organic parts. For this purpose a fluid consisting of Chromic acid, 1 gramme, Nitric acid, 2 c.c. (this added last), Water, 200 c.c, is, perhaps, the best. In making it, care should be taken that the chromic acid and water be first mixed, and the nitric acid added subsequently. It is better to immerse specimens containing lime salts in a one-eighth per cent. aqueous solution of chromic acid, or a two per cent. sol. of pot. bichrom. for a few days before placing them in this mixture, as by that means the soft parts become more perfectly hardened. A few agents, at the same time that they harden, impart a color to the tissues; thus material which has been soaked in chromic acid acquires a green tinge when placed in glycerine. This, though handy for certain purposes, is not generally useful. Osmic acid, on the other hand, hardens, and, at the same time, imparts a useful color, for it selects all fatty matters and tinges them black. After the material has been par- tially hardened in a one-tenth to one per cent, aqueous solution of this acid, the process may be completed in alcohol, though, if left in acid solution for 12 to 48 hours, 382 STAINED SECTIONS OF ANIMAL TISSUES, it will be quite hard enough. When hard, it should be placed in distilled water for a day or two, and the sec tions should be mounted in a saturated solution of acetate of potash (Schultze). Gold chloride hardens and stains at the same time, but as its powers of penetration are very small, it is chiefly used as a coloring agent. Picric acid has considerable properties of hardening tis- sues, whilst it renders them of a bright primrose yellow, but as it is extremely soluble in both alcohol and water, it wants great care in use, if it is desired to retain much of the color. Ranvier states that a concentrated solution will produce excellent results in 24 hours ; neither shrink- ing nor coagulation of the albumen occurring, lime salts being removed at the same time. Finally, one of the hardening agents, capable of fur- nishing better results than any other, is the freezing method, which has fallen into disrepute with some, because they have considered it inapplicable to tissues just re- moved from the animal. When thus applied, they have almost invariably failed, not to obtain thin sections (for these can be cut as thin as may be desired), but to mani- pulate them when cut, as they tear most readily in every subsequent process, and, when finely mounted, it is found that naught is left but the tattered fragments of what should have been a good preparation. The freezing method undoubtedly enables us to put up specimens sooner than any other, but before they are frozen they must be exposed for some few hours (say 5 to 24) to the action of one of the hardening agents already mentioned, so as to partially coagulate the fibrin and albumen, and thus enable the sections to be put through the after processes without injuiy. The fresh material should be first placed in: a. A \ p. c. AND HOW TO PREPARE THEM. 383 aqueous solution of chromic acid; or b. A two p. c. aqueous solution of bichromate of potash; or c. A two p.c. aqueous solution of bichromate of ammonia; or d. In alcohol solution for 8 or 12 hours. It should then be washed in clean water to remove the hardening agent, when it is ready for freezing. With this it is necessary to pound the ice into small pieces, and to mix it thor- oughly with an equal quantity of salt; it is moreover necessary to have a free exit for the dissolved mixture. • With material that has been wholly hardened by chro- mic acid, alcohol, or some other of the reagents above mentioned, the mass must be imbedded in some material for the purpose of supporting the structures, as well as in some cases of affording a wider surface upon which to rest the razor. For cutting sections by hand, the best imbedding mate- rials are :— 1. Olive oil and white wax in equal parts; or 2. Cacao butter: while in machines with hollow cylinders, or for use without any machine, either those of elder pith or of carrot may be employed. In cutting sections, by whatever process may be pre- ferred, care should be taken :— 1st. That the razor is in perfect condition, and that its surface be kept thoroughly moist—with water if the freez- ing method be adopted, or with spirit when any other mode of hardening is used. 2d. That each section as it is cut be floated into water or spirit, instead of allowing several sections to accumu- late on the razor, as they thereby get torn, or otherwise injured. Stains. The next subject we have to consider is that of stains, and how to use them. 3S4 STAINED SECTIONS OF ANIMAL TISSUES, The following is a are classified accordi table in which the most useful stains ng to their qualities, or method of use:— A. General stains. 2r,d ■ .5 so ® - s B. Selective J f^ c 2 "3* stains. Carmine with excess of Ammonia. Eosin (Dreschfeld). Molybdate Qf Ammonia. (This requires the action of light.) Carmine (Beale's). Borax Carmine (Golding Bird). Logwood (Golding Bird). Logwood Acid Solution (Schafer). Indigo Carmine (Tiersch). Anilin Blue (Heideuhain). Picric Acid. Gold Chloride. Silver Nitrate. Osmic Acid. Chloride of Palladium. Molybdate of Ammonia and Carmine. Picro-carmine (Schafer). Chloride of Palladium and Carmine. Carmine and Indigo Carmine. Logwood and Anilin Blue. Gold Chloride and Logwood. Silver Nitrate and Logwood. Silver Nitrate and Gold Chloride. Osmic Acid. Picric Acid. Gold Chloride. Alcohol -f- Borax Carmine. Alcohol -j- Guiding Bird's Logwood. Alcohol -f- Eosin. With regard to these, I will give some general rules applicable to most, and then proceed to notice each sep- arately. In staining, it is a general rule of almost universal ap- plication that the fluid should be weak and the quantity large in proportion to the number of sections, or to the mass, as the case may be. A section which has been in a fluid so weak that 24 or 48 hours, or even more, have been required to produce the requisite depth of color, is almost always better stained than one which has been in C. Which will stain in the mass and harden at the same time. AND HOW TO PREPARE THEM. 385 fluid which will produce the same tint in a shorter time, for the following reason : that a fluid commences to stain a tissue directly it comes in contact with it. Now from this it follows that the surfaces of the section are stained much sooner, and consequently more deeply than the intervening portions; and if the fluid is strong, this difference will be great. Again, to produce the best results, the sections should be as thin as possible, 1. because they take the stain more perfectly; 2. because the thinner they are, the less thick- ness of colored structures the light has to penetrate before reaching the lenses of the objective; besides, it enables the deeper structures to be more readily examined with high powers. Those colors are preferable which are cool and pleasant to the eye, i. e., those which contain least red and yellow. Provided the staining is perfect, and sufficient to show all the detail of which it is capable, the paler it is the better:— 1. Because in the examination with the microscope, less light is required, and consequently a continuous pro- tracted observation is less fatiguing to the sight. 2. The eye is not so immediately attracted by points and streaks of bright color, thereby running the risk of passing over unnoticed, details of structure of equal im- portance, but which do not obtrude themselves before us with the same glaring pertinacity. Finally, it ma}'- be remarked that it is better to use dis- tilled in preference to ordinary water in all processes con- nected with staining. With some—as Logwood, Gold Chloride, and Silver Nitrate—this is of the utmost impor- tance. Those stains which color all tissues alike, are of little use unless employed as a ground to bring out details 25 386 STAINED SECTIONS OF ANIMAL TISSUE* which would be left untouched by a selective stain, which can afterwards be used, and then their value cannot be overrated. Thus molybdate of ammonia produces a mo.st delightfully cool blue gray general stain, which in no way interferes with the subsequent use of carmine, when all the nuclei appear pink on a pleasant neutral-tint ground. To obtain this, a five per cent, neutral aqueous solution of the molybdate should be used. The stain is complete in 24 hours, at an ordinary temperature, and under the ac- tion of light. Specimens thus colored become brown by supplementary expesure to the action of tannic acid (1-15) or pyrogallic acid (20 per cent.). Another general stain is a strongly ammoniacal solution of carmine, but this is of little use, and is best avoided. Eosin, again, is a general stain, which may be used either before or after the sections have been colored with log- wood. One part of eosin should be used with 1000 of water. Many of the other stains, too, which are them- selves selective, may be used with others which have a still stronger selective power, and thus for the time ap- pear to be merely general stains. In this way may be used—Carmine and Logwood, Carmine and Silver Nitrate, Logwood and Silver Nitrate, Logwood and Gold Chlo- ride, and some others. Selective Stains.—Of these none is more useful or more pleasant to work with than logwood; but it is not so com-' monly used as carmine, because many find it difficult to prepare, and others do not succeed in its use, in conse- quence, I fancy, of hardening their material in fluids containing chromic acid or bichromates of too great strength. There are two useful formulae for the preparation of logwood solutions— AND HOW TO PREPARE THEM. 387 1. Kleinenberg's modified by Golding Bird is easy to use; while the older it is the better are the results ob- tained with it. It is prepared thus : Make saturated solu- tions of alum and calcium chloride, in proof spirit; mix in the proportions of eight of the former to one of the latter; pound a small piece of ext. haematoxyli (the older the* better); add to it the mixed solution, and agitate; after two days decant, when it may be used at once, though better after keeping. A watch-glass should be filled with water, and a few drops of this solution added, till the fluid acquires a mauve tint. Into this the sec- tions may be placed, and should remain for 24 hours or more. The second is Schafer^s Acid Logwood Solution, which is especially useful for certain structures, as tendon cells, etc., which could not be so well shown by neutral or alka- line solutions. It is thus prepared : A one per cent. solution of acetic acid is colored by the addition of 1.3 of its volume of logwood solution. The Anilin Dyes, whether in aqueous or alcoholic solu- tion, give good results. The best are:— Rosanilin or Magenta 1 grain, to ounce of Alcohol; red. Acetate of Mauvein 4 grains, Alcohol 1 ounce, Nitric acid, 1 minim; blue. Anilin Black 2 grains, Water 1 ounce; gray black. Nicholson's Soluble Blue 1-6 grain, Alcohol 1 ounce, Nitric Acid 2 minims; blue. These, as other stains, should be used weak; but the chief point to be careful about is that, after the sections are stained they should be passed through alcohol and oil of cloves as rapidly as possible, otherwise the color will be dissolved out before they reach the balsam. Heidenhain, speaking of the use of Anilin Dyes, says:— 388 STAINED SECTIONS OF ANIMAL TISSUES, " The sections, upon removal from alcohol, should remain for a day in a four per cent, neutral aqueous solution, in a moist place, and then be immediately mounted in gly- cerine and cemented." Some of the Anilin Dyes are but sparingly soluble in alcohol, whereas they dissolve readily in water. Their color, as a rule, is increased by acetic acid, but removed by ammonia. There are, however, some exceptions. The use of benzole for cleaning instead of clove oil fixes the colors better, but has a tendency to produce shrinking in some structures. The indigo carmine solution, introduced by Tiersch, is a good and useful blue stain, especially for sections of brain and spinal cord which have been hardened in chromic acid, and it possesses one very convenient quality, viz., that, if the sections are too deeply stained, the excess of color may be removed by the action of a saturated solu- tion of oxalic acid in alcohol. This reducing process, however, should not be relied on more than is absolutely necessary. It is prepared thus:— Oxalic Acid, 1 part. Distilled Water, 22 to 30 parts. Indigo Carmine, as much as the solution will take up. Sections should be immersed in this, diluted with alco- hol, from 12 to 48 hours, to produce a good color. Carmine, first used by Gerlach, is a most useful tinging agent, and if preparations are not colored too deeply, it is not disagreeable to the eye. Beale's ammoniacal solution is very good, and so is Goil- ing Bird's borax carmine solution, which possesses consid- erable powers of penetration, so that small masses (about the size of a pea) may be colored with it before being sectioned ; and if it is diluted with six times its bulk of alcohol, they may be hardened at the same time, and will be ready for cutting in about 10 days. AND HOW TO PREPARE THEM. 3S:i Sections stained with the ammoniacal carmine should be washed, and then put into water slightly acidulated with glacial acetic acid (2 minims to the ounce), so as to fix the carmine. BeaWs fluid is thus prepared :— Carmine, 10 grains. Liq. Amm. Fort. 30 minims. Glycerine, 2 oz. Distilled Water, 2 oz. Sp. Vini Rect. £ oz. Dissolve the carmine in ammonia, boil for a few sec- onds, add the water, filter; finally, add the glycerine and spirit, and keep in a stoppered bottle. Beale says, "Let the excess of ammonia pass off;" but this is unnecessary, as the excess is very slight.. Beale's stain, reduced with eleven times its bulk of water, produces good results in from 12 to 48 hours. The borax carmine is thus prepared :— 1. Carmine, \ drachm. 2. Borax, 2 drachms. 3. Distilled Water, 4 oz. Place 1 and 2 dry in a mortar, and mix; then dissolve in warm water for 24 hours; after which pour off the su- pernatant fluid, and the solution is ready for use. The acid carmine fluid of Schweiggerseidel is also useful in some cases, though Schafer's acid logwood, already noticed, is preferable. So far we have had to do only with stains that change but little, if at all. Those which we now come to, how- ever, do change materially, i.e., get rapidly darker and more opaque, till they reach a stage when they are utterly useless. They differ from all the others, with the exception of molybdate of ammonia, in the fact that the action of light is necessary to produce the color. Nitrate of silver, which was introduced by Reckling- hausen, is used in a half per cent, aqueous solution. Spe- 390 STAINED SECTIONS OF ANIMAL TISSUES, cimens to be acted upon should be dipped in distilled water to remove any trace of sodium chloride, and then steeped in the silver solution for some two or three min- utes, after which they should be washed in ordinary water till it ceases to turn milky; then placed in glycerine and exposed to the action of light, until they assume a dark brown color, when they may be mounted in glycerine or glycerine jelly. By means of this stain the endothelial cells of the lym- phatics, bloodvessels, etc., and the nodes of Iianvier in medullated nerves, are rendered evident. They may sub- sequently be stained with logwood, carmine, or chloride of gold. Many methods have-been adopted for staining with gold chloride. I may mention three: Dr. Klein's, Dr. C. Bastian's, and Mr. Schafer's. 1. Dr. Klein's method for showing the nerves in the cornea is as follows: Remove the cornea within 15 min- utes of death ; place it in a half per cent, chloride of gold solution for half an hour to an hour and a half or more; wash in distilled water, and expose to the light for a few days, the water being occasionally changed. Then place in glycerine and distilled water, in the proportion of one to two; subsequently place it in water, and brush gently with a sable pencil to remove any precipitate, when it may be mounted in glycerine. The cornea should now be of a gray violet tint. Dr. Charlton Bastian's method is as follows: Place the sections or portions of tissue in gold chloride, 1 part; distilled water, 2000 parts, acidulated with strong hydro- chloric acid (drop 1 to water 2| oz.). Let them remain protected from light for an hour, then remove and place them in acidulated water, half the strength of the above, and then transfer to a watch glass containing equal parts AND HOW TO PREPARE THEM 391 of formic acid, and alcohol (90 p. c). They should be stained in about half an hour. Or, if it is desired to produce the stain more rapidly, use chloride of palladium, 1 part, water of palladium, 500 paits, where they should remain five or ten minutes; then wash in acidulated water, transfer to the formic acid and alcohol, as before, and mount. Mr. Schafer's method is the use of the double chloride of gold and potassium. 1. Place the fresh tissue in bi- chromate of ammonia (1-2 per cent, in water) solution for fifteen or twenty days. 2. Dip the sections, after being cut, into water, 1000 parts, double chloride of gold and potassium, 1 part. 3. Wash in hydrochloric acid, 1-2 parts, water, 3000 parts. 4. Then immerse for ten min- utes in hydrochloric acid, 1 part, 60 p. c. solution of alcohol, 1000 parts; transfer to absolute alcohol; clear with oil of cloves; mount in balsam or dammar. In staining with gold chloride or silver nitrate, Mr. Schafer has found that, if the material after immersion in these stains be dipped into alcohol, the reduction of the metals is thereby greatly facilitated. Osmic acid, which was first used by Schultze, is useful for the demonstration of fatty matters, which are thereby colored black; it is also valuable for some nerve prepa- rations, but it is very irritating to the mucous membranes of the experimenter, and should be used with care. Spe- cimens should be allowed to remain in a 1-2 per cent. aqueous solution of the acid from a quarter to twenty-four hours, when the stains will be complete;, but if it is de- sired to harden also by its means, they should remain in it for some days. Osmic acid does not penetrate deeply, therefore small portions should be selected for its action. Chloride of palladium, also introduced by Schultze, is used to stain and harden the retina, crystalline lens, etc., 392 STAINED SECTIONS OF ANIMAL TISSUES, and other tissues, but cornified fat and connective tissues remain uncolored. Dissolve: Chloride of palladium, 1 part, in water of palladium, 1000 parts. An ounce of this solution will harden a piece of tissue, the size of a bean, in two or three days, staining it at the same time a brown or straw color. Specimens may be mounted in glycerine at once, or may be further stained with car- mine. Before proceeding to the double stains, it will be well to mention Schafer's silver nitrate and gelatine solution for demonstrating lung epithelium. Take of gelatine 10 grms., soak in cold water, dissolve, and add warm water to 100 c.c. Dissolve a decigramme of nitrate of silver in a little distilled water, and add to the gelatine solution. Inject this with a glass syringe into the lung until disten- sion is pretty complete. Leave it to rest in a cool place until the gelatine has set; then cut sections as thin as possible, place them on a slide with glycerine, and expose to light until ready for examination. Of the double stains I will specially notice only those where the double color is produced by a single process. Of those in which the one color is first employed, and then the other, I will simply state which is to be used first, as all further particulars have been already given. Those which are used in a single fluid are picro-car- mine, carmine and indigo carmine, anilin blue, and ani- lin red. Picro-carmine, which was first employed by Ranvier, has been used and prepared in several ways, but perhaps the best is Schafer's, viz.: 1. Add to a saturated solution of picric acid in water a strong solution of carmine in ammonia to saturation. 2. Evaporate the mixture to one- fifth its bulk over a water bath, allow to cool, filter from deposit and evaporate to dryness, when picro-carmine is AND HOW TO PREPARE THEM. 393 left as a crystalline powder of red-ochre color. Sections should be stained in a 1 per cent, aqueous solution, re- quiring ten minutes for a good result; they should then be washed with distilled water, and mounted in glycerine. If it be desired to preserve them in balsam, after staining, transfer direct to alcohol methylated, then to absolute alcohol, after which they may be cleared in oil of cloves or benzole, and then mounted. Carmine and indigo carmine, adopted by Merbel, give a blue and red stain, and are said to be extremely selec- tive. To prepare the Red Fluid, take: Carmine J oz., borax 2 drachms, water, distilled, 4 oz. For the Blue Fluid, take: Indigo carmine 2 drachms, borax 2 drachms, water, distilled, 4 oz. Mix each in a mortar, and allow to stand, then pour off the supernatant fluid. 1. If the sections have been hardened in chromic acid, picric acrid, or a bichromate, they should be washed in water till no tinge appears. 2. Place them in alcohol, then 3. For fifteen or twenty minutes, in the two fluids mixed in equal parts, after which 4. Wash them in a saturated aqueous solution of oxalic acid, where they should remain a rather shorter time than in the staining fluids. 5. When sufficiently bleached, wash them in water, to get rid of oxalic acid, then 6. They may be passed through spirit and oil of cloves, and be mounted as usual in balsam. For Staining Blue and Red by Means of Anilin Dyes the best method is that which Mr. Gilburt recommends for staining plant sections. Dissolve : For Red, \ gr. Magenta crystals, in 1 oz. Alcohol. For Blue : Then 1-6 gr. Nichol- 394 STAINED SECTIONS OF ANIMAL TISSUES, son's soluble pure blue, in 1 oz. alcohol, to which have been added 2 minims nitric acid. Both solutions should then be filtered. Use 2 minims of the blue to 7 minims of the magenta, and thoroughly mix. Place the section in the mixture for about one minute, then remove to ab- solute alcohol, from that of oil of cloves or benzole, and finally mount in balsam and benzole. To fix the magenta, it is usually necessary to pass the sections through benzole. Cements, etc. For balsam or glycerine jelly mounts, almost any var- nish will do; but for fluids or glycerine it is necessary to have one that is tough, and most likely to prevent leak- age; for this purpose, the following answer very well:— 1. Mastic and Bismuth.—Dissolve gum mastic in chloro- form, and thicken with nitrate of bismuth. The solution of mastic should be nearly saturated. 2. Oxide of Zinc, Dammar, and Drying Oil.—Rub up: Oxide of zinc, well ground, 2 oz., with drying oil to consistence of thick paint. Then add an equal part of gum dammar, dissolved in benzole, to thickness of syrup. Strain through close-meshed muslin. Keep in well corked bottles, and, if necessary, thin with benzoline. 3. Mr. Kitto?i,s Cement.—White lead in powder, red lead in powder, litharge powder, equal parts. Grind together with a little turpentine until thoroughly incor- porated, and then mix with gold size. The mixture should be thin enough to use with a brush, and in use one coat should be allowed to dry before applying another. The mixture may be kept in a bottle, but no more cement should be made {i. e., should be mixed with gold size) than required for immediate use, as it sets quickly aud becomes unworkable. AND HOW TO PREPARE THEM. 395 Certain precautions are necessary to be observed in var- nishing fluid or glycerine preparations; they are— 1. Use no more glycerine or fluid than is just necessary to fill up the space beneath the cover. 2. If the medium should escape beyond the cover glass, soak it up with a piece of blotting paper, being careful not to press the cover, or the cement will run in after- wards. 3. Wash the slide round the cover and the edge of the cover glass also, if necessary, with a sable pencil; then run a ring of cement on the slide just beyond the edge of the cover, a second round the edge of the cover, and a third bridging over the space between the two. 4. Three or four coats should thus be put on, taking care on each occasion that the previous coat is dry. Of preservative mounting media, the most useful are bal- sam, glycerine, and glycerine jelly. Canada balsam should be exposed to heat until it be- comes quite brittle, allowed to cool, then it should be dis- solved in benzole till as thin as glycerine, and should always be used cold. Glycerine.—Specimens Avhich have been hardened in chromic acid or bichromates may be mounted in pure glycerine alone ; but if thej' have been hardened in spirit, glycerine and carbolic acid (in the proportion of glycer- ine 15 parts to carbolic acid 1 part) is better, as it is less refractive, and prevents the sections becoming granular. For carmine-stained preparations it is well to add a trace of acetic acid to the glycerine (2 minims to th.e ounce). Glycerine jelly is a good medium, as it offers the advan- tages of glycerine without the chance of leaking, but it is rather difficult to prepare, and therefore had better be 393 STAINED SECTIONS OF ANIMAL TISSUES. bought. A jelly composed of glycerine, gelatine, equal parts, is very useful; the glycerine should be warmed, and the gelatine (Nelson's) be allowed to dissolve in it. Acetate of potash in a saturated solution is used for some preparations, but is liable to leak. The same may be said of Goadby's fluid. Summary. To summarize the whole of this paper:—■ 1. Let the material be quite fresh. 2. Take care that the hardening or softening fluid is not too strong. Use a large bulk of fluid in proportion to the material. Change the fluid frequently. If freez- ing be employed, take care that the specimen is thoroughly frozen. 3. Always use a sharp razor. Take it with one diag- onal sweep through the material. Make the sections as thin as possible, and remove each one as soon as cut, for if sections accumulate on the knife or razor, they are sure to get torn. 4. Do not be in a hurry to stain, but remember that a weak coloring solution permeates the section better, and produces the best results; and that the thinner the sec- tion is, the better it will take the stains. 5. Always use glass slips and covers free from scratches and bubbles, and chemically clean. Never use any but extra thin circular covers, so that the specimens may be used with high powers. Always use cold preservatives, except in the case of glycerine jelly, and never use warmth to hasten the drying of balsam or dammar, but run a ring of cement round the cover. 6. Label the specimens correctly, and keep them on the flat and in the dark. DIETETIC RULES AND PRECEPTS. (397) DIGESTIBILITY OF ALIMENTARY SUBSTANCES. Few practitioners have made a careful study of aliments, considered individually or in their relations to one ano- ther. Even the relative composition of the various arti- cles of food is to most of them an unknown quantity; and yet nothing is more important to the medical attend- ant on the sick than the knowledge judiciously applied of the principles of dietetics. With a proper appreciation of the amount of albuminous, starchy, saccharine, or oleaginous matters in each article of diet which his pa- tient may employ, he will be much more competent to suggest the appropriate course to be pursued as supple- mentary to a rational medical treatment. The following tables will at once give an insight into the digestibilit}' of a large number of articles of food in common use, showing the various grades of easy, mode- rately easy, or difficult digestion; a comparison between animal and vegetable aliments in these respects; the elementary composition of the chief articles, etc. Composition of Various Articles of Food (in 100 parts).1 Water. 1 Albumen, etc. Starch. Sugar. Fat. Salts. Bread 37 8.1 47.4 3.6 1.6 2.3 Biscuit . 8 15.6 73.4 1.3 1.7 Wheat flour . 15 10.8 66.3 4.2 2.0 1.7 Barley meal . 15 6.3 69.4 4.9 2.4 2.0 Oatmeal 15 12.6 58.4 5.4 5.6 3.0 Rye meal 15 8.0 69.5 3.7 2.0 1.8 Indian corn meal . 14 11.1 64.7 0.4 8.1 1.7 Rice 13 6.3 79.1 0.4 0.7 0.5 1 From estimates by Letheby and Parkes, in Treatise on Food and Dietetics, by F. W. Pavy, p. 427, Phila., 1874. (399) 400 DIGESTIBILITY OF ALIMENTARY SUBSTANCES. Water Albumen, etc. Starch. Sugar Fat. Salts. Peas 15 23.0 55.4 2.0 2.1 2.5 Arrowroot 18 82.0 Potatoes 75 2.1 18.8 3.2 0.2 0.7 Carrots . 83 1.3 8.4 6.1 0.2 1.0 Parsnips 82 1 1 v9.6 5.8 0.5 1.0 Turnips . 91 1.2 5.1 2.1 0.6 Cabbage 91 2.0 5.8 0.5 0.7 Sugar 5 ...... 95.0 Treacle . 23 ...... 77.0 New milk 86 4.1 ...... 5.2 3.9 0.8 Cream . 66 2.7 ...... 2.8 26.7 1.8 Skim milk 88 4.0 ...... 5.4 1.8 0.8 Buttermilk 88 4.1 ...... 6.4 0.7 0 8 Cheese . 36.8 33.5 24.3 5.4 Cheddar chee^ >e 36 28.4 31.1 4.5 Skim cheese 44 44.8 6.3 4.9 Lean beef 72 19.3 3.6 5.1 Fat beef. 51 14.8 29.8 4.4 Lean mutton 72 18.3 4.9 4.8 Fat mutton 53 12.4 31.1 3.5 Veal 63 16.5 15.8 4.7 Fat pork 39 9.8 48.9 2.3 Green bacon 24 7.1 66.8 2.1 Dried bacon 15 8.8 73.3 2.9 Ox liver 74 18.9 4.1 3.0 Tripe . 68 13.2 16.4 2.4 Cooked meat, roast, no dripping being lost; boiled meat assumed to be the same . 54 27.6 15.45 2.95 Poultry . 74 21.0 3.8 1.2 White fish 78 18.1 2.9 1.0 Eels 75 9.9 13.8 1.3 Salmon . 77 16.1 5.5 1.4 Entire egg 74 14.0 10.5 1.5 White of egg. 78 20.4 1.6 Yolk of egg . 52 16.0 30.7 1.3 Butter arid fat 15 83.0 2.0 Beer and porter 91 0.1 8.7 0.2 Another useful but less scientific classification of ali- mentary substances, is that which arranges them into the three groups mentioned in the following summary, according to their relative digestibility. The practitioner, DIGESTIBILITY OF ALIMENTARY SUBSTANCES. 401 in special cases, where more minute information is needed, may supplement this table by data derived from works particularly devoted to dietetics.1 Easy of Digestion. Mutton. Venison. Hare. Sweetbread. Turkey. Chicken. Partridge. Pheasant. Grouse. Beef-tea. Mutton broth. Milk. Turbot. Haddock. Flounder. Sole. Fresh fish generally. Roasted oysters. Stale bread. Rice. Tapioca. Sago. Arrowroot. Asparagus. Sea kale. French beans. Cauliflower. Baked apples. Oranges. Grapes. Strawberries. Peaches. Toast-water. Black tea. Sherry. Claret. Ale. Moderately Digestible. Beef. Lamb. Rabbit. Young pigeon. Duck. Wild waterfowl. Woodcock. Snipe. Soups. Eggs. Butter. Turtle. Cod. Pike. Trout. Raw or stewed oysters Potatoes. Beets. Turnips. Cabbage. Spinach. Artichoke. Lettuce. Celery. Apples. Apricots. Currants. Raspberries. Bread. Farinaceous puddings. Jelly. Marmalade. Rhubarb plant. Cooked fruits. Cocoa. Coffee. Porter. Hard to Digest. Pork. Veal. Goose. Liver. Heart. Brain. Salt meat. Sausage. Hashes. Mackerel. Eels. Salmon. Herring. Halibut. Salt fish. Lobster. Crabs. Shrimps. Muscles. Oil. Melted butter. Raw eggs. Cheese. Fresh bread. Muffins. Buttered toast. Pastry. Cakes. Custards. Nuts, pears, plums. Cherries, pineapples. Cucumbers, onions. Carrots, parsnips. Peas,beans, mushrooms. Pickles. Chocolate. Champagne. The following tables, exhibiting the relative digesti- bility of animal and of vegetable substances, are self- explanatory, the mode of cooking of each article being 1 Dr. H. Hartshome's Essentials of the Principles and Practice of Medicine, p. 224, Phila. 1874. 26 402 DIGESTIBILITY OF ANIMAL SUBSTANCES. given, as well as the time necessary for chymification. These facts are so constantly essential to the well-being of the patient, and to satisfactory treatment by the practi- tioner, that but little further comment is necessary. Relative Digestibility of Animal Substances.1 Article of diet. How prepared. Time of chymification. Pigs feet (soused).....Boiled lh 0™ Tripe ".....Boiled 1 0 Eggs (whipped) ..... Raw 1 30 Salmon trout ...... Boiled 1 30 Venison steak ...... Broiled 1 30 Brains ....... Boiled 1 45 Ox liver.......Broiled 2 0 Codfish (cured dry)..... Boiled 2 0 Eggs.......Roasted 2 15 Turkey.......Boiled 2 25 Gelatiu.......Boiled 2 30 Goose...... . Roasted 2 30 Pig (sucking)......Roasted 2 30 Lamb.......Broiled 2 30 Chicken.......Fricasseed 2 45 Beef.......Boiled 2 45 Beef.......Roasted 3 0 Mutton.......Boiled 3 0 Mutton....... Roasted 3 15 Oysters.......Stewed 3 30 Cheese.......Raw 3 30 Eggs.......Hard boiled 3 30 Eggs.......Fried 3 30 Beef....... Fried 4 0 Fowls.......Boiled 4 0 Fowls.......Roasted 4 0 Ducks.......Roasted 4 0 Cartilage.......Boiled 4 15 Pork.......Roasted 5 15 Tendon . . . . . . Boiled 5 30 A similar tabular arrangement of vegetable aliments may also be made. 1 H. Letheby, Lectures on Food, 2d edition, London, 1872, p. 56. DIETETIC PREPARATIONS FOR THE SICK. 403 Relative Digestibility of Vegetable Substances.' Article of diet. How prepared. Time of chymitication. Rice.......Boiled lh 0m Apples (sweet and mellow) . . . Raw 1 30 Sago.......Boiled 1 45 Tapioca.......Boiled 2 0 Barley.......Boiled 2 0 Apples (sour and mellow) . . . Raw 2 0 Cabbage with vinegar .... Raw 2 0 Beans.......Boiled 2 30 Spongecake . . . . . Baked 2 30 Parsnips ....... Boiled 2 30 Potatoes ....... Roasted 2 30 Potatoes.......Baked 2 33 Apple dumpling.....Boiled 3 0 Indian corn cake ..... Baked 3 0 Indian corn bread ..... Baked 3 15 Carrot....... Boiled 3 15 Wheaten bread ..... Baked 3 30 Potatoes.......Boiled 3 30 Turnips.......Boiled 3 30 Beets.......Boiled 3 45 Cabbage.......Boiled 4 0 DIETETIC PREPARATIONS FOR THE SICK. The practitioner is frequently appealed to for instruc- tions, not only as to the nature of the diet appropriate for his patient, but also as to the precise manner in which it should be prepared, to be at once palatable, nutritious, and continuously serviceable. Not having familiarized himself with the simplest principles of cookery, he is sometimes at a loss to know what suggestion to make, or what advice to offer, in order to insure the greatest attain- able perfection of culinary effort. At any moment he may be called upon for his views as to the best methods of preparing even the most ordinary dietetic articles for ' Letheby, op. cit., p. 58. 404 DIETETIC PREPARATIONS FOR THE SICK. the sick-room, such as beef-tea, mutton broth, flaxseed tea, etc.; and he should also be able to suggest, in con- valescence, the use of other substances, that may form an essential feature in the recovery of his patient. With the view of assisting the practitioner in this channel, which is too frequently left to the unskilled and uninstructed, the following useful recipes and sug- gestions are offered. An alphabetical arrangement is adopted, rather than any systematic attempt at classifica- tion, so that the practitioner may at once find the article when most needed.1 It will be, of course, his duty to decide which of these articles are adapted for patients who may be seriously sick, as distinguished from those which may be taken, almost with impunity, by conva- lescents. Almond Emulsion. Beat an ounce and a quarter of blanched sweet almonds with five drachms of white sugar in a porcelain mortar into a smooth pulp, gradually adding a quart of soft water, and stirring actively until the whole is mixed. Strain through linen. An agreeable demulcent drink. Alum Whey. Add a quarter of an ounce of powdered alum to a pint of boiling milk, and strain; flavor with sugar and nut- meg, if desired. A useful astringent drink. 1 Some of the palatable preparations here given are obtained from manuscript recipes of excellent housekepers. Others are derived from works on dietetics, especially that of Pavy, already referred to ; from Florence S. Lees's "Handbook for Hospital Sisters;" and from several standard works on cookery, whose object is to give the most reliable information on this subject. The most desirable recipes from a large mass of such material have been selected for insertion here. DIETETIC PREPARA TIONS FOR THE SICK. Apple Barley "Water. Add half a pound of apples, cut in slices, with the skin on and the pips removed, to a pint of barley water. Add sliced lemon, boil gently until done, and pass through a colander. A cooling drink in febrile affections. Apple Water. Carefully roast three good tart apples, preserve the juice, put in a quart pitcher, pour on it about a quart of boiling water, cover, and drink when cold. An agreeable drink may also be made by baking an apple over which a teaspoonful of brown sugar has been sprinkled, adding toast water (see p. 297) to it when browned, and flavoring with orange or lemon-peel A pleasant drink in fevers, etc. Arrowroot. Mix two teaspoonfuls of arrowroot with three table- spoonfuls of cold water, and pour on them half a pint of boiling water, keeping it well stirred. If the water be merely warm, the arrowroot must afterwards be boiled until it thickens. Add sugar, and flavor with lemon- peel or nutmeg, or add sherry or brandy if required. If milk is used instead of water, wine must be omitted, as it will curdle the milk. A nutritive preparation for convalescents especially. Arrowroot Pudding. Mix a tablespoonful of arrowroot with cold water, put it over the fire in a porcelain-lined saucepan, add a pint of boiling milk, stirring constantly, and one egg well beaten with a tablespoonful of white sugar; let it boil for five or ten minutes. If a baked pudding is preferred, 406 DIETETIC PREPARATIONS FOR THE SICK. it may be mixed in the same way and baked in a mode- rately quick oven for twenty or thirty minutes. May be taken in the early periods of convalescence. Arrowroot Water. Mix well in a pan three ounces of arrowroot, two of white sugar, peel of half a lemon, quarter of a teaspoonful of salt, two quarts of water; set on the fire and boil for a few minutes. Use either hot or cold. A nutritious drink in diarrhoea, fevers, etc. Barley Gruel. Wash two ounces of pearl barley, boil in a quart of water till reduced to a pint; strain, add a little sugar and three wrineglassfuls of port wine, or milk if the wine be contraindicated, and heat it up before using. For convalescents and anaemic patients. Barley Soup. Add a pint of boiling water and a small quantity of salt and sugar to half a cupful of good washed pearl barley, put into an earthenware pot with a piece of butter about the size of a nut, and a piece of fine cinnamon. Cook over a slow fire until soft, strain through a fine hair sieve. Stir the beaten yolk of an egg into the soup. Add more boiling water v/hile cooking if necessary. Barley Water. Wash two ounces of pearl barley well with cold water, throwing away the washings. Boil with a pint and a half of water for twenty minutes in a covered vessel and strain. Sweeten and flavor with lemon-peel or lemon juice. Another agreeable formula—for a compound barley water—is to put two ounces of pearl barley well washed DIETETIC PREPARATIONS FOR THE SICK. 407 in cold water into half a pint of boiling water; let it stand for five minutes, pour it off, add three pints of boiling water, a little salt, half a dozen nice figs sliced, a handful of cut raisins, and a small stick of liquorice; let this simmer for fifty minutes, strain, and add a little sweetening if necessary. A diluent and moderately nutritious drink. Barley Wine (Aromatic). Boil a quart of barley water down to a third; add while hot a pint of sherry, a drachm of tincture of cin- namon, and an ounce of refined sugar. To a convalescent, a wineglassful may be given two or three times daily. Beef Broth. Take a pound of lean beef, some sweet herbs, put in a saucepan with two quarts of water, simmer to one quart. Let it stand until cold, skim off the fat carefully; if small particles should remain, lay a piece of clean blotting- paper on the broth, in order to remove them. A simple restorative after acute disease. Beef, Raw. Take half a pound of juicy beef, free from any fat; mince it very finely; then rub it into a smooth pulp either in a mortar or with an ordinary potato masher, and press it through a fine sieve. Spread a little out upon a plate and sprinkle over it some salt, or some sugar if the child prefers it. Give it alone or spread upon a buttered slice of stale bread. This is an excellent food for children with dysentery, and also for adults. 408 DIETETIC PREPARATIONS FOR THE SICK. Another formula for its preparation is recommended in France:—1 The fat should be removed (one reason being that it may contain cysticercus). The best part is the rump steak. The fibres are here best suited for rasping in longitudinal direction. This is the best mode of prepar- ing it, as chopping removes from the meat most of its juice, and does not give such good division. The rasping is done with a sharp knife-blade—the sharper the better. The piece of meat should be pretty thick, and of lozenge shape; the rasping can be done on all the facings, in the natural direction of the muscular fibre. The meat is generally reduced to the form of a pill or bolus, which is rolled in powdered sugar on crumbs of bread. If it cannot be taken thus, it may be given under the mask of cold bouillon. One of the best methods is to prepare a thin porridge of tapioca; let it cool until it cannot cook the meat in the least. Then the meat, finely rasped, is introduced into a small quantity of the cold soup till the mixture is complete, having the aspect and consistence of a fine soup of tomatoes. Next the tapioca porridge is gradually poured on this soup, the mixture being con-' stantly stirred. Beef Tea. It should be borne in mind that prolonged boiling or simmering produces a broth instead of a tea, destroying the flavor and nutrient power. All that is needed is to heat the cold infusion to about 170° Fahr., which is just "sufficient to coagulate the albumen and coloring matter, and thus deprive the product of its character of rawness.2 Being so important a dietetic agent, several formulas are given for its manufacture. 1 New Remedies, 1876. * Pavy, op. cit. DIETETIC PREPARATIONS FOR THE SICK. 409 The most agreeable and nutritive form of beef-tea is made as follows:— 1. Mince finely one pound of lean beef, and pour upon it, in a preserve jar, or other suitable vessel, ope pint of cold water. Stir, and allow the two to stand for about an hour, that the goodness of the meat may be dissolved out. Next, stand the preserve jar or other vessel in a saucepan of water, and place the saucepan over the fire or a gas-stove, and allow the water in it to gently boil for an hour. Remove the jar, and pour its contents on a strainer. The beef tea which runs through contains a quantity of fine sediment, which is to be drunk with the liquid, after being flavored with salt at discretion. 2. Liebig's Beef-tea.—On half a pound of raw lean beef (or chicken, etc.), finely minced, pour, in a glass or earthenware vessel, three-quarters of a pint of water containing three or four drops of muriatic acid, and half a saltspoonful of salt; stir well together and allow it to stand lor an hour. Strain through a hair-sieve and rinse the residue with a quarter of a pint of water. The result is the juice of the meat with uncoagulated albumen, and muscle fibrin, which has been dissolved by the agency of the acid. It is to be taken cold, or, if warmed, must not be heated beyond 120° Fahr. No cooking will have been employed. Although much richer in nutritive material and more invigorating than ordinary beef-tea, the raw-meat color, smell, and taste, are to many an ob- jection to its use.1 (See Restorative Soup, p. 291.) 3. Take one pound of juicy lean beef—say a piece from the shoulder or the round—and mince it. Put it 1 Pavy, op. cit. 410 DIETETIC PREPARATIONS FOR THE SICK. with its juice into an earthen vessel containing a pint of tepid water, and let the whole stand for one hour. Then slowly heat it to the boiling-point, and let it boil for three minutes. Strain the liquid through a colander, and stir in a little salt. If preferred, a little .pepper or allspice may be added. Recommended for children by the Philadelphia Obstet- rical Society. 4. Take a pound of lean, juicy beef, being sure to re- move all skin and fat, cut in small squares, and place in a porcelain-lined saucepan with a pint of cold water. After soaking for an hour, put it over a slow fire and let it simmer for two or three hours, carefully skimming it occasionally, then boil quickly for a few minutes, when it may be strained and served. Salt and pepper may be added if desired. Biscuit Jelly. Pour a quart of boiling water over a two-ounce bis- cuit, boil until reduced one-half, strain, and stir in a little wine and half a pound of white sugar, simmer until re- duced to half a pint, and set aside to cool. Useful in debilitated conditions of the digestive organs. Blanc Mange. Pour half a pint of cool water on half an ounce of isinglass, put it near the fire to simmer until perfectly dissolved. In the mean time whip one pint of cream with rather less than three ounces of sugar to a stiff froth, flavoring with extract of lemon or vanilla. When the isinglass is quite soft and while lukewarm, pour the cream slowly in, beating constantly until stiff enough to drop from the spoon. Pour in moulds. Milk may be substi- tuted for the water. DIETETIC PREPARATIONS FOR THE SICK. 411 Bran Loaf. Boil two quarts of wheat bran in sufficient water to well cover it, for five minutes, strain through a sieve, then add fresh water and boil ten minutes, strain through a sieve a second time, then pour cold water over it until the water runs through perfectly clear. Press the bran tightly in a cloth, making it as dry as possible, then spread thinly on a dish and put in a slow oven for several hours or over-night, and when dry and crisp it will be ready to grind. Grind very fine in a mill and sift through a fine wire sieve (a brush may be needed to pass it through). The bran must be soft and fine. Take three ounces of this bran powder, three eggs, an ounce and a half of butter, and a small teacupful of milk. Warm the butter in part of the milk, and mix the eggs well with the other por- tion, add a little nutmeg, and stir all well together. Just before putting in the oven stir in half a drachm of bicarbonate of sodium and three teaspoonfuls of hydro- chloric acid. Bake in a well-buttered pan for an hour or more. Valuable in the dietetic treatment of diabetes. Bran-Flour Jelly. Take half a pint of bran flour, moisten it with cold water, then stir it into a quart of boiling water, let it boil slowly for half an hour, stirring it almost constantly to prevent scorching, then pour through a coarse sieve into a mould; when cold turn it out, and eat with milk or cream, with a little sugar if desired. Brandy and Egg Mixture. (See Egg Brandy.) 412 DIETETIC PREPARATIONS FOR THE SICK. Bread Jelly. Toast lightly three or four slices of stale bread, remov- ing the crust before toasting. Have ready in a porcelain- lined saucepan three pints of boiling water, lay the bread in it, along with the half of a small lemon thinly sliced; boil until it jellies, then strain and sweeten to the taste. A useful food for infants about the period of weaning, for children suffering from acute affections, etc. Bread and Milk. Even the simplest dishes may be spoiled by not being properly cooked. Cut stale bread into small square pieces, put in a dish, let the milk boil, at which point pour it over the bread. Cover the dish closely for about ten minutes, when the bread will be well soaked and ready for use. Bread Panada. (See Panada, Bread.) Calves'-Feet Jelly. Take four calves' feet, wash and clean them carefully and put them in a saucepan with three quarts of cold water and a little salt; boil them down until reduced to half the quantity, then strain through a colander. When quite cold remove all the fat carefully, then put this jelly into a perfectly clean saucepan, adding sugar and sherry or Madeira wine to the taste, the rind of two fresh lemons peeled thinly, with their juice, and a small wineglassful of best brandy; let these simmer thoroughly for five minutes, then add the whites of five eggs beaten up with their shells, and stir constantly until it boils; let it boil slowly for twenty minutes, when it may be set aside ten or fifteen minutes to settle, after which it can be poured DIETETIC PREPARATIONS FOR THE SICK. 413 through a strainer ar jelly bag into moulds. It need not be stirred after it begins to boil, being careful not to have it over too strong a fire. A valuable article in convalescence. Carrageen Moss. (See Irish Moss.) Caudle. Mix two spoonfuls of oatmeal in a quart of water, with a little lemon-peel thinly sliced; let it boil half an hour, stirring frequently, then strain and add sugar to the taste, a glass of white wine, and a little grated nutmeg. A slightly stimulating and nutritious drink. Chicken Broth. Clean carefully a chicken weighing about one pound— an old one is the best for the purpose—if too heavy, take half, crack the bones in several places, add a little salt and put over the fire in a saucepan with a quart of water ; a spoonful of rice may be added; boil very slowly for two hours, skimming it well and keeping the vessel tightly covered. Just before using, a little chopped parsley may be added. Chicken Jelly. After washing and cleaning a chicken break all the bones, put it into a stone jar closely covered, set the jar into a kettle of boiling water, keep it boiling three hours, strain, and season with salt and a very little mace, if desired. Replace the chicken in the jar, and boil again; it will produce as much jelly as before. Chicken Panada. Boil a chicken in a quart of water until nearly done, then take off the skin, cut the meat off when cold, and 414 DIETETIC PREPARATIONS FOR THE SICK. put into a marble mortar if convenient; if not, roll it with a rolling pin and mix to a paste with a little of the water it was boiled in; season with salt and a little grated nut- meg; simmer gently for a few minutes to the desired con sistence. It should be such as can be easily drunk, though reasonably thick. A very nourishing article of diet in small bulk. Chicken Tea. Take the thigh and leg of a chicken, put in a covered saucepan with a pint of cold water, set it over the fire to simmer for twenty minutes, skim it well, add a little salt, and strain it when it is ready for use. A piece of toast bread cut in small pieces, with some of the boiling tea poured over it, is quite nutritious and palatable. Cracker Panada. (See Panada, Cracker?) Crackers, Soaked. (See Toast, French) Cream of Tartar Water (Imperial). Pour a pint of boiling water over the thin peel of half a lemon, cover closely, let it stand for five minutes, then stir in a teaspoonful of cream of tartar; when quite cold sweeten to the taste. A refrigerant and diuretic drink. Cream of Tartar Whey. Stir a large teaspoonful of cream of tartar into a pint of boiling milk, and strain. A refrigerant and diuretic drink, made more palatable by the addition of sugar. DIETETIC PREPARATIONS FOR THE SICK. 415 Egg Brandy. Rub the yolks of two eggs with half an ounce of loaf sugar, and add four ounces each of brandy and cinnamon water. A restorative and stimulant in doses of half a wine- glassful to a wineglassful, in the sinking stage of typhus and other adynamic fevers. Egg Broth. Take a tablespoonful of white sugar and the yolk of one egg, beat them well together, then pour on it, stir- ring constantly, half a pint of boiling sweet milk or water; add a tablespoonful of best brandy and a little grated nutmeg. A still more nutritious broth may be made by stewing two ounces of well-washed pearl sago in half a pint of water, until it is tender and very thick; mixing with it the yolks of four fresh eggs, well beaten with half a pint of good boiling cream; mix the whole carefully into a quart of boiling beef-tea. Useful in lingering convalescence, after acute disease. Egg Flip. Beat well together the yolks of four fresh eggs and the whites of two with two tablespoonfuls of white sugar, pour in boiling water, a little at a time until you have added a quart, finally throw in two tumblers of cognac brandy and one of old Jamaica rum. Wine may be used if preferred. Egg Nogg. Take the yellow of four eggs and three tablespoonfuls of pulverized sugar, and beat them to a cream, add a little nutmeg and beat well together; then mix in two ounces 416 DIETETIC PREPARATIONS FOR THE SICK. of the best brandy and half a wineglass of Madeira wine; when this is well mixed, stir in a pint and a half of rich milk; have ready the whites of the eggs beaten to a stiff froth, and beat them in the mixture—when it is ready for use. This preparation is not likely to cause headache, and is nourishing to the debilitated or consumptive. Flaxseed Tea. Pour a pint of boiling water over an ounce of whole flaxseed and quarter of an ounce of bruised liquorice root; cover lightly, digest for three or four hours near a fire, and strain through linen. Flavor with lemon if necessary. A demulcent drink in pulmonary and urinary affections. Flour Ball, or Flour, Boiled. Take one quart of good flour; tie it up in a pudding- bag so tightly as to make a firm, solid mass; put it into a pot of boiling water early in the morning, and let it boil until bedtime. Then take it out and let it dry. In the morning, peel off from the surface and throw away the thin rind of dough, and, with a nutmeg-grater, grate down the hard dry mass into a powder. Of this from one to three teaspoonfuls may be used, by first rubbing it into a paste with a little milk, then adding it to about a pint of milk, and, finally, by bringing the whole to just the boiling point. It must be given through a nursing- bottle. Useful in irritability of the stomach and bowels, and in dysentery and diarrhoea. Recommended for children by a committee of the Obstetrical Society of Philadel- phia. An excellent food for children who are costive may be DIETETIC PREPARATIONS FOR THE SICK. 417 made by using bran-meal or unbolted flour instead of the white flour, preparing it as above directed. Flour Caudle. Mix a tablespoonful of flour with about five table- spoonfuls of water; set on the fire an equal quantity of new milk, slightly sweetened, and let it boil; pour it gradually over the flour and water; let them boil together for twenty minutes, constantly stirring. Useful for infants with weak condition of the bowels. Fruit Drinks. Cherries, currants, or raspberries may be used. Put the fruit in a jar and set in a saucepan of water over the fire, let the water boil slowly until the fruit in the jar is well broken, giving out its juice freely; then pour through a strainer or jelly-bag, slightly pressing the fruit. This juice sweetened and iced makes a pleasant cooling drink. Goat's Milk (Artificial). Boil an ounce of fresh suet, cut into small pieces, and tied in a roomy muslin bag, in a quart of milk, in which is dissolved a quarter of an ounce of white sugar candy. Useful in the emaciation of scrofula and phthisis, and for infants raised with a spoon. Gruel. Mix a small tablespoonful of fine oatmeal or groats in two tablespoonfuls of cold water, add a pint of boiling water and a little salt, boil thirty minutes, stirring fre- quently. Sugar and nutmeg may be used, as also a small piece of butter. Or, mix two spoonfuls of oatmeal in a little milk, stir this into a pint of boiling water. Simmer thirty minutes, 27 418 DIETETIC PREPARATIONS FOR THE SICK. stirring frequently; strain, and add a little wine or brandy. Gruel may also be made of fine grits or hominy, as follows: Take two or three tablespoonfuls of hominy after being boiled soft, rub well with butter until quite light, mixing in a half pint of boiled milk slowly to pre- vent the hominy becoming lumpy. Strain through a sieve or piece of muslin, then boil it, stirring well. Either sugar and nutmeg or salt can be used according to taste. Serve hot. Rice can be used instead of the grits, and prepared in the same way. Gum Water. This may be made simply by dissolving by maceration half an ounce or an ounce of gum Arabic, previously washed with water, in a quart of water, and adding lemon-peel to impart a flavor; or, by pouring a quart of boiling water on a mixture of quarter of a pound of white gum Arabic, the same quantity of rock candy, and a large thinly sliced lemon, constantly stirring, and kept in a warm place until the gum is dissolved. A pleasant demulcent drink. Ice for the Sick Room (to preserve). Cut a piece of flannel, about eight inches square, and secure it by ligature around the mouth of an ordinary tumbler, so as to leave a cup-shaped depression of flannel within the tumbler to about half its depth. In such flannel cup, ice may be preserved for many hours, and still longer if a piece of flannel three or four inches square be loosely laid over the ice-cup. Cheap, open mesh flannel is preferable, as the water easily drains through it, and thus keeps the ice quite dry. DIETETIC PREPARATIONS FOR THE SICK. 419 Iceland Moss. (See Irish Moss.) Imperial Drink. (See Cream of Tartar Water.) Invalid's Lunch. Put a layer of bread crumbs and a layer of jelly alter- nately in a tumbler until half full, then fill the tumbler with milk. Currant jelly or any slightly acid jelly is preferred. Irish or Carrageen Moss. Wash carefully half an ounce of moss in cold water, then put in a quart of water, boil gently for fifteen minutes, or until the consistence of warm jelly; strain and sweeten, or flavor with lemon or white wine. Milk may be used instead of water, by which a more nourish- ing liquid is obtained. Iceland moss may be similarly prepared. A nourishing demulcent article of diet. Lemonade. Slice a lemon thinly and put into a jug, with two ounces of white sugar, pour over them one pint of boiling water, cover closely and digest until cold, when the liquid may be strained or poured off. Lemonade Jelly. Slice very thinly three fresh lemons and two Seville oranges, pour over them a pint of boiling water, cover closely for half an hour ; while the orange and lemon are steeping have one and a half ounces of isinglass soaking in half a cup of cold water; when quite soft put it in a porcelain-lined saucepan and pour over it the orange, 420 DIETETIC PREPARATIONS FOR THE SICK. lemon, and water; let it simmer for fifteen minutes, stir in two tablespoonfuls of white sugar and half a pin* of good wine; let it simmer two minutes, and strain through jelly-strainer or bag. Lemon-Peel Water. Pare the rind from a lemon, being careful not to use any of the white or inner part of the rind. Put the peel- ings in a jug, and pour over them a pint of boiling water ; cover closely, and when quite cold pour off the liquid, and add a tablespoonful of powdered white sugar. A tablespoonful of good brandy or sherry may be added. A pleasant, cooling, astringent drink, when iced ; given in diarrhoea, etc. Liebig's Food for Infants. (See Dietetic Treatment of Infants, p. 202.) Macaroni and Milk. Soak two or three pieces of macaroni in a pint of warm milk for twenty minutes, or until soft; add a little salt and boil gently for twenty minutes or a half hour. May be flavored with cinnamon or nutmeg. Macaroni Pudding. Simmer two ounces of carefully washed macaroni in a pint of milk and a teacupful of water. Beat up the yolks of three eggs and the white of one egg with an ounce of white sugar, and half a pint of milk, and a few drops of essence of lemon; when the macaroni is quite tender add the mixture and bake in a slow oven. An agreeable article in convalescence. DIETETIC PREPARATIONS FOR THE SICK. 421 Macaroni Soup. Boil a quart of beef-tea until reduced to two-thirds, add two ounces of well-cooked macaroni, and boil downi to a pint. Season to the taste. A pleasant soup for convalescents. Marshmallow Tea. Add two ounces of dried marshmallow root and one ounce of Sultana raisins, to two and a half pints of boil- ing water; boil slowly until reduced one-half. Strain without pressure. An excellent demulcent drink in renal disease, with a tendency to gravel. Milk and Egg. Add a pint of good milk to a well-beaten fresh egg, a pint of cold water, and salt to make it palatable; let it come to a boil quickly (if heated slowly it is apt to curd, and if so it is useless), stirring all the time; as soon as it comes to a boil it is cooked sufficiently. Can be given in all forms of sickness of the stomach, and an admirable drink for infants suffering with chole- raic diarrhoea. Milk Lemonade. Dissolve half a pound of loaf sugar in a pint of boiling water, add a teacupful of good sherry wine and the same quantity of lemon juice freshly pressed from the fruit; mix well, then add a pint of cold milk; stir well to- gether and pass through jelly-strainer or bag without pressure. Milk and Soda Water. Heat a teacupful of milk almost to boiling, dissolve in it a teaspoonful of white sugar ; pour into a large tumbler, and add two-thirds of a bottle of good soda water. 422 DIETETIC PREPARATIONS FOR THE SICK. Useful in acid conditions of the stomach, when milk alone will disagree. Milk Porridge. « Stir two tablespoonfuls of oatmeal into a pint of milk, then stir quickly into a pint of boiling water, and boil until it thickens, stirring constantly. Milk Punch. Mix well together a tablespoonful of white sugar, two tablespoonfuls of water, a wineglassful of good brandy, and half a wineglassful of rum ; pour in a large tumbler, add some small pieces of ice, and fill the tumbler with milk; stir well and grate a little nutmeg over the top. Mint Tea. Put a few mint leaves (fresh or dried) in a pint of boil- ing water, cover and stand near the fire for an hour. To be used in febrile and other complaints. When made of the fresh leaves it relieves vomiting. Mustard Whey. Boil one quart of milk with an ounce of bruised mus- tard seeds, until the milk curdles; strain to separate the whey. Useful in dropsy as a urinary stimulant. Mutton Broth, or Tea. Take three or four ribs out of the loin of a piece of mutton, remove all the fat, break the bones and put into a covered saucepan with a quart of cold water, and a little salt; cook slowly for an hour and a half or two hours, being careful to skim off all the fat which may rise ; pour off the broth from the pieces of mutton, and it is ready DIETETIC PREPARATIONS FOR THE SICK. 423 for use. A tablespoonful of rice may be added half an hour before the broth is removed from the fire. This is an agreeable change after a patient becomes tired of beef-tea. Oatmeal Gruel. (See Gruel.) Oatmeal Porridge. Mix two tablespoonfuls of oatmeal with three table- spoonfuls of cold water; stir into a pint of boiling water ; boil for three-quarters of an hour. To be eaten with a little salt and butter, or sugar and milk. Good to relieve constipation, where there is no dyspep- tic tendency. Orange Jelly. Melt a quarter of a pound of sugar in some hot water, and pour it over five ounces of orange juice previously pressed from fine ripe fruit. ■ In the mean time have three-quarters of an ounce of gelatine melted in a little water, and add to the syrup ; boil for two minutes. Orange Water. Pour a quart of water over the juice of six oranges and two lemons; cover for ten minutes, sweeten, and * serve iced. A pleasant, cooling drink. Oyster Soup. Drain one pint of oysters through a colander for five minutes; remove the liquor, and then pour over them one pint of boiling water, which must be thrown aside. Add to the liquor already drained a pint of boiling water, and put over the fire in a porcelain-lined saucepan, boil until all the scum has risen and been skimmed off; then 424 DIETETIC PREPARATIONS FOR THE SICK. add half a pint of fresh milk, one water cracker rolled to a powder, a piece of butter, and a little salt and pepper. Boil ten minutes, and just before the soup is to be served, turn in the oysters from the colander and let them scald for three minutes. Oysters cooked in this way are not apt to give discom- fort, and are therefore adapted to invalids. Panada, Bread. Put two slices of stale bread in a covered bowl with a little more than enough hot water to cover them, and let them soak for ten or fifteen minutes, then add two spoon- fuls of sweet milk and a little wrhite sugar; boil for ten minutes, stirring constantly. Five minute panada may be made by mixing in a coffee cup of hot water, a glass of wine, a dessertspoonful of white sugar, and a little nutmeg. Set over the fire to boil. Have ready some grated bread crumbs, and the moment the mixture boils, stir the crumbs in rapidly, and continue stirring until it has boiled to a proper thick- ness to drink. Panada, Chicken. (See Chicken Panada.) Panada, Cracker. Break three or four water crackers (Trenton crackers are the best) in a bowl with half a pint of boiling water, cover and let stand until the crackers are quite soft, then serve with a little sugar and grated nutmeg. A dessert- spoonful of wine may be added. Quince Water. Take the cores of six or eight quinces or a few slices of dried quinces and pour over them a pint of boiling DIETETIC PREPARATIONS FOR THE SICK. 425 water, simmer for ten minutes, cover tightly, and when cold, strain. An acceptable mucilaginous drink. Raspberry Vinegar. Mix a quart of raspberries with a quart of best cider vinegar, let them stand for a week, stirring occasionally, then add one pound of loaf-sugar, boil slowly twenty minutes, strain and bottle. Raw Beef. (See Beef, Raw.) Rennet Whey. Steep a piece of rennet in a pint of boiling water or less, according to the size of the rennet; separate the fluid, and stir a dessertspoonful of it into a quart of milk; cover with a cloth, and place near the fire until it curds. Divide the curd with a spoon to separate the whey, which should be quite clear, and of a sweetish taste. An excellent diluent in febrile affections. Restorative Soup. The following modification of Liebig's formula for beef-tea is suggested by Dr. Tanner. Chop finely half a pound of fresh beef or chicken, add four fluidounces of soft or distilled water, two or tliree drops of pure hydro- chloric acid, fifteen or thirty grains of common salt, and stir well together. After two hours the whole is to be thrown on a hair sieve, and the fluid allowed to pass through with slight pressure. On the residue in the sieve pour slowly one ounce of distilled water, and let it run through while pressing the meat. About five fluid- ounces of cold red juice will thus be obtained, having a pleasant soup taste, of which a wineglassful can be taken 426 DIETETIC PREPARATIONS FOR THE SICK. at pleasure. It must not be warmed, as the albuminous portion will be deposited. Spice or a little claret may be added, if desirable to modify the taste. If the acid be contraindicated, the soup may be prepared by merely soaking the minced meat in plain distilled water. The minced meat may also be given alone, one part to two parts of sugar, to children. A valuable dietetic preparation in continued fever, dys- entery, and adynamic conditions generally. Rice (Baked). Prepare as in boiled rice, and when nicely done, place in the bottom of a baking dish, mix with it a small piece of butter, salt to the taste, a small teacupful of milk, and one egg well beaten. Put in the oven and let it bake until nicely browned. Rice (Boiled). To a half a teacupful of rice (well washed and picked), allow half a pint of water and a little salt; put it over the fire and let it boil rapidly ten minutes, then drain through a colander. Before removing from the colander pour a little cold water over it, let it drain for a minute, and return to the saucepan with only the water which may adhere to the grains; cover, and set on the oven door or near the fire, where it may swell and dry. Rice Caudle. Pour one quart of boiling water over a teacupful of rice which has been well washed and picked, add a little salt, and cook slowly for an hour. Beat the yolk of an egg with a tablespoonful of white sugar to a cream. Pour off the water and stir slowly the egg and sugar into the rice; cook for five minutes, then pour into a bowl, and DIETETIC PREPARATIONS FOR THE SICK. 427 grate a little nutmeg over it. A glass of sherry wine may be added. Rice Jelly. Wash and pick carefully a quarter of a pound of rice, put it in a porcelain-lined pan, with one quart of water, a small piece of cinnamon, and a half pound of loaf sugar, or not, according to fancy; let it boil one hour, pass through a sieve, and when cold it will be a firm jelly, v Excellent in dyspepsia and irritable conditions of the stomach. Rice Pudding. Thoroughly wash a coffee cup of good rice, pour over it a pint of water and let it simmer until the grains are well softened, then drain; put the rice in a pudding dish and pour over it one quart of new milk, a small piece of butter, a little salt, and grated nutmeg or cinnamon. Bake thirty minutes, or until the rice is well done. Stir frequently while baking. Rice Water. Pick and wash one ounce of rice in cold water, then put in a quart of water and set near the fire, where it may soak and be kept warm without cooking, for two hours, then boil slowly for one hour, until reduced to a pint, and strain; add a little salt. A pint or half a pint of milk added to the rice water, before it is taken from the fire, renders it more nourishing. An excellent drink in diarrhoea, dysentery, and irri- table conditions of the alimentary canal, especially in children. Sago, tapioca, barley, or cracked corn can be prepared in the same manner. 428 DIETETIC PREPARATIONS FOR THE SICK. Sago. Cleanse a half teacupful of sago by washing carefully, soak two or three hours in cold water, then put it over the fire in the same water, and simmer until the grains become quite clear; it may be sweetened slightly, and a little orange or lemon juice added. Sago Jelly. Wash carefully an ounce of sago, put it to soak for four or five hours in a half pint of cold water, then add half a pint of hot water, a little salt, half an ounce of sugar, and a little lemon peel or cinnamon ; boil gently fifteen or twenty minutes, stirring constantly. Just before re- moving from the fire add a tablespoonful of port or sherry wine. Serve hot, or pour into a mould to cool. Sago Posset. Boil two ounces of sago in a quart of water until it is the consistence of mucilage. Then mix a teaspoonful of tincture of ginger, with half an ounce of white sugar, and a half pint of sherry wine; add this to the sago and boil for five minutes. Excellent in debility after acute non-inflammatory diseases, in wineglassful doses repeated. Sippets. Put three or four small square pieces of bread on a very hot plate, and pour over them some beef or mutton gravy from which the fat has been well skimmed; sprinkle a little salt over them. The bread may be toasted, if preferred. Very nutritious when meat is not acceptable to the stomach. DIETETIC PREPARATIONS FOR THE SICK. 429 Slippery Elm Bark Jelly. Stir four tablespoonfuls of ground bark into a quart of cold water; let it stand all night; in the morning strain and add the juice of one lemon; simmer gently twenty minutes, then sweeten, and pour in a mould to cool and» harden. Slippery Elm Tea. Add one pint of boiling water to one ounce of slippery elm bark; cover and stand near the fire for about three hours, and strain. A nutritious demulcent, useful in renal, intestinal, and other affections. Staff of Old Age (Consomme). Make a beef broth by taking two pounds of beef from the leg, round, or chuck; wash well, cut in pieces and put on to boil in three quarts of cold water; while boil- ing skim frequently, and when reduced to one quart take from the pot and strain, after which return to the digester or pot with a few thin slices of onion, half a pound of lean beef, chopped finely, and well mixed with three raw eggs ; beat all thoroughly with the broth, which is to be returned to the fire, and boiled for about half an hour, or until perfectly clear. Nutritious and healthful, especially to old people with feeble masticatory powers. Tamarind Whey. Two tablespoonfuls of tamarinds stirred into a pint of boiling milk; boil ten minutes and strain. Refrigerant and slightly laxative. 430 DIETETIC PREPARATIONS FOR THE SICK. Tansy Water. Take a dozen leaves of fresh tansy, wash them and pour over them a pint of cold water, cover closely and let stand in a cool place for three or four hours, when it is ready for use. Sage may be used if preferred to tansy. Refreshing in febrile affections. Tapioca. Take two tablespoonfuls of the best tapioca ; after wash- ing carefully, soak it in fresh water over-night; add a little salt, a pint of water or milk (the latter being more nutritious); simmer until quite soft, stirring frequently, if milk is used, to keep from scorching. When done pour into a bowl, and stir while cooling; sugar, a little nutmeg, and a spoonful of wine may then be added. Tapioca Pudding. Beat the yolks of two eggs with half an ounce of sugar, and stir into a pint of tapioca mucilage, made with milk, as directed above, and bake in a slow oven. Useful in convalescence. Wine may be added if not contraindicated. Toast, French. Take half a dozen water crackers, pour over them enough boiling water to just cover them. Cover them tightly, and while they are soaking simmer a pint of milk with a little salt and a small piece of butter, and when the crackers arc quite soft pour the hot milk over them. A little grated nutmeg may be added. Toast Jelly. Cut a breakfast roll into thin slices, toast a light brown, and boil gently in a pint and a half of water until it jellies, strain and flavor with a little wine and nutmeg. DIETETIC PREPARATIONS FOR THE SICK. 431 Toast Water. Toast a slice of stale bread quite brown, but do not scorch; while hot put it into a pitcher and pour over it a pint of boiling water; cover tightly, and when cool pour off the liquid. A little orange or lemon put in the pitcher gives a pleasant flavor. A valuable cooling drink in febrile affections. Veal Tea. To be prepared as beef-tea, substituting the veal for beef. It requires, however, much longer cooking. Vegetable Broth. Slice a turnip, two or three pared potatoes, a small carrot, and a stalk of celery in a quart of boiling water • cook until the vegetables are well done, then add a small piece of butter and a little salt. Toast a slice of bread, butter it, put in a bowl and pour the soup over it. Vermicelli Pudding. (See Macaroni Pudding.) Whey. Curdle warm milk with rennet, and strain off the liquid, or put into boiling milk as much lemon-juice or cider as will curdle it and make it clear; then pour off, add a little hot water, and sweeten if desired. A useful diuretic drink in febrile complaints. Wine, Mulled. A pint of wine, half a pint of water, and a teaspoonful of allspice, boil together for three minutes. Beat three eggs with a large tablespoonful of white sugar; pour the boiling wine on the eggs, stirring all the time. If the eggs are poured into the wine, they are apt to curdle. 432 SPECIAL FORMS OF DIET. Wine Whey. Boil a pint of new milk, while boiling pour in a small tumbler of white wine, put it over the fire to boil again, being careful not to stir it, and as soon as it boils remove and set aside until the curd settles, then pour off the clear whey. If too strong add a little water. Useful in low fevers or those requiring a moderate degree of stimulation. SPECIAL FORMS OF DIET. Under this head might be included a consideration of such dietetic hints and precepts as are applicable to the prevention and cure of special diseases. The principles governing the employment of articles of diet appropriate to such conditions are generally, however, sufficiently intelligible to the physician, and it is not difficult for him to decide, in inflammatory and other conditions, what should be interdicted and what allowed. His own medi- cal knowledge, added to the results of the personal ex- perience of the patient, will usually be a sufficient guide to both as to the quality and quantity of the food to be taken. So much benefit, however, has been derived from the practice of strict dietetic regulations in such affec- tions as diabetes, obesity, etc., that the reproduction of rules here will possibly be of service to the practitioner in similar cases. Dietary for the Diabetic.1 As diabetes mellitus is a condition attended with want of assimilative power over the amylaceous and saccharine 1 F. W. Pavy, Treatise on Food and Dietetics, Philadelphia, 1874. DIETARY FOR THE DIABETIC. 433 principles of alimentary substances, such a diet must be prescribed as will, as far as possible, exclude such prin- ciples. The following table, although containing several dietetic articles of purely English employment, is repro- duced in its entiretj'-, being an especially valuable guide in this disease. He may eat—Butcher's meat of all kinds, except liver, ham, bacon, or other smoked, salted, dried, or cured meats, poultry, game, shell-fish and fish of all kinds, fresh, salted, or cured, animal soups, not thickened, beef-tea, and broths; the almond, bran, or gluten substitute for ordi- nary bread;1 eggs dressed in any way; cheese, cream cheese, butter, cream, greens, spinach, turnip tops, tur- nips,2 French beans,2 Brussels sprouts,2 cauliflower,2 broc- coli,2 cabbage,2 asparagus,2 seakale,2 vegetable marrow,2 mushrooms, water-cress, mustard and cress, cucumber, lettuce, endive, radishes, celery, vinegar, oil, pickles, jelly flavored, but not sweetened, savory jelly, blanc mange made with cream and not milk, custard made without sugar, nuts of any description, except chestnuts, olives. He must avoid eating—Sugar in any form, wheaten bread and ordinary biscuits of all kinds, rice, arrowroot, sago, tapioca, macaroni, vermicelli, potatoes, carrots, pars- nips, beet-root, peas, Spanish onions, pastry and puddings of all kinds, fruits of all kinds, fresh and preserved. He may drink—Tea, coffee, cocoa from nibs, dry sherry, claret, dry Sauterne, Burgundy, Chablis, hock, brandy, and spirits that have not been sweetened, soda water, Burton bitter ale, in moderate quantity. 1 See Bran-loaf, p. 277. 2 May only be eaten in moderate quantity, and should be boiled in a large quantity of water. 28 434 DIETARY FOR REDUCING WEIGHT. He must avoid drinking—Milk, except sparingly, sweet ales, mild and old, porter and stout, cider, all sweet wines, sparkling wines, port wine, unless sparingly, liqueurs. Dietetic Rules for reducing Weight ("Bantingism"). Although the general principles on which these rules are founded are not new, they have attained greater prominence, within a few years past, from the publica- tion of the experience of one who had successfully sub- jected himself to their rigid exactions, under the advice of a medical practitioner of London.1 The mainspring of the system is the avoidance of all starchy and saccharine matters, such as bread, butter, milk, sugar, potatoes, beer, etc., all of which have a tendency, from their chemical composition, to create fat. In elucidation of this dietary plan, the following general bill of fare is offered, similar to that under the use of which a weight of 200 pounds was, in the instance cited, reduced in a year to nearly 150. BILL OF FAKE. For Breakfast.—Four or five ounces of beef, mutton, kidneys, broiled fish, bacon, or cold meat of any kind except pork and veal, which are not easily digested; a large cup of tea (without milk, or sugar); a little biscuit, or one ounce of dry toast, brown bread, or ordinary bread crust; an egg, if not hard boiled. For Dinner.—Five or six ounces of any fish except salmon, herring, and eels (owing to their oily nature), any meat except pork and veal; green vegetables, and any vegetable except potatoes, parsnips, turnips, beets, and carrots; one ounce of dry toast; fruit out of a pud- 1 Wm. Banting, Letter on Corpulence. 11th edition. Philadelphia, 1876. DIETARY FOR REDUCING WEIGHT. 435 ding; any kind of poultry or game, and two or three glasses of good claret, sherry, or Madeira; Champagne, port, and beer being forbidden. For Tea.—Two or three ounces of fruit, a rusk or two, and a cup of tea without milk or sugar. A little coffee may be permitted. For Supper.—Three or four ounces of meat or fish, similar to dinner, with a glass or two of claret. For Nightcap, if required, a tumbler of grog (gin, whisky, or brandy, without sugar), or a glass or two of claret or sherry. The latter portion of the bill of fare will doubtless be omitted in the majority of instances. Indeed, the items here indicated should not be blindly followed without the exercise of a watchful care, lest, in individual cases, this systematic reduction should be followed with unfa- vorable results to the general health. The principles which underlie the construction of such an itemized list are, however, correct, and should govern the practitioner when consulted in cases of corpulency. It may be added that in the case alluded to a draught was also ordered to be taken, once or twice daily, on an empty stomach, containing a drachm of the aromatic spirits of ammonia with ten grains of carbonate of magne- sium, to obviate the induction of the uric acid diathesis as a consequence of the restricted diet. 436 TESTS FOR IMPURITIES IN WATER. RULES FOR TESTING AND DISINFECTING IMPURE DRINKING WATER. The purity of the water supply of towns and cities, and its effects on the health of individuals and of communi- ties, are matters of vital import to all classes and all professions, but the medical man is supposed to be espe- cially familiar with the tests for its impurities, and with the agents that are best calculated to disinfect it. Such knowledge on his part will generally place him in the foremost rank of sanitary reformers, and enable him at times to be of inestimable service in the hygienic im- provement of the locality in which he resides. Tests for Impurities in Water. A full examination of the character of a potable water as to its organic constituents is, perhaps, one of the most difficult problems in the ordinary run of analytical chem- istry.1 There is organic matter decomposed, decompos- ing, and ready to be decomposed, to be looked for; a discrimination to be made between organic matter of all grades, from the perfectly inert up to the pestilence-pro- ducing; and, more, these frequently can only be recog- nized by the products of decomposition, usually the same from all classes mentioned. The tests described are all in use by experts in water- analyses; they have been altered, in some cases, in the details, so that they can be applied by any physician with 1 Dr. Chas. Mo In tyre on the Detection of Organic Matter in Drinking Water,—Phila. Med. Times, March 6, 1875, from which excellent paper most of tliese facts are obtained. TESTS FOR IMPURITIES IN WATER. 437 an ordinary amount of apparatus. They aim at qualita- tive, not quantitative determination, and can, therefore, be used on ordinary occasions, while the latter would require the special apparatus of a chemical laboratory with the skill of a professed chemist. We may have organic material— I. As to its derivation: animal, or vegetable. II. As to its condition: not decomposed, or decomposed. a. If not decomposed, either (1) in the same form as it exists in the organism, or (2) changed into some complex organic substance. b. If decomposed, it may exhibit any of the products of decomposition down to the purely inorganic—e. g., carbon dioxide, nitric acid—and these may be present along with organic material, which may escape detection. III. As to its effect: deleterious, or harmless. If the organic material is of animal origin, the nitrogen compounds will ordinarily be more abundant. These are supposed to exert the greatest influence in causing the water to be unwholesome. The presence of ammonia, or even, perhaps, of albuminoid substances (not readily putrescible), does not, however, of necessity render the water unfit for domestic purposes, or even prove the presence of recent organic material. Unfortunately, most of the methods will not enable us to tell of the source of the organic material, and in doubtful cases it may be difficult to decide as to the condition of the water. Tests. 1. For Organic Matter.—If a quantity (f^viij) of water is evaporated carefully to dryness in a clean porce- lain or glass vessel, and then heated gently, the blacken- ing of the residue will indicate the presence of the more stable organic compounds, which will all disappear by a further application of the heat with access of air. If 438 TESTS FOR IMPURITIES IN WATER. during this latter operation there is any deflagration or rapid combustion, it indicates the presence of nitrates in the water. A very rough approximation of the amount of this organic matter can be made by weighing when dry, and again after it has been burned off. There are very few waters so free from organic matter as not to leave a blackened residue, while at the same time it would be possible to have a water rich in organic mate- rial which would leave little or no char. This test, then, is of use when the amount left is greatly in excess of the char from comparatively pure water. Allow another portion of the water to stand in a warm place, exposed to the light, for several days. Should it become putrid or show the presence of animal or vege- table growths, either to the naked eye or by the aid of the microscope, there should be grave doubts as to the fitness of the water for domestic purposes. It is asserted that at times organic matter is contained in water in such a condition as not to respond to the ordinary reagents until after it has undergone some decomposition. Conse- quently, in a suspected water, if no reactions can be obtained in the fresh water, it would be advisable to let a portion stand as above, and then test. The presence of ammonia, nitrous and nitric acids, any or all, indicates the presence of nitrogen in the water. It is possible, however, for this nitrogen to have its origin in inert organic material, or even to have an inorganic origin, and, hence, exercise no deleterious effect upon the water. Their presence is suspicious, and should always be looked for. In many cases the organic material is readily oxidized by means of potassium permanganate. Render the water slightly acid by means of sulphuric acid, and drop in a few drops of a solution of potassium permanganate; the TESTS FOR IMPURITIES IN WATER. 439 solution becomes decolorized, owing to the permanganate giving up its oxygen for the oxidation of the organic material. This test, while not a reliable one when used with so few precautions, may, nevertheless, act as one witness among many to prove the character of the water. A simple plan, for testing for organic impurities has also been suggested1 by making a solution of chemically pure permanganate of potassium, gr. viij to flj of distilled water. Into a half pint of the impure or suspected water in a goblet or tumbler, put one drop of the red solution; if the red tint disappears from the glassful in half an hour, add more of the solution. For every drop that loses its color in the half pint there will be found to be from one and a half to two grains of putrid organic matter in the gallon of water. 2. Test for Ammonia.—Nessler's reagent is perhaps the best test for ammonia. It is prepared by dissolving gr. xxxv of iodide of potassium in giij 3yj of distilled water; to which add a cold concentrated solution of mercuric chloride until the mercuric iodide at first forms, then dis- solves by agitation in the solution, and at length produces a very small permanent precipitate; 100 grains of caustic potassa are next dissolved in Jvj 5ij of distilled water; mix the solutions, and add distilled water to make 3xv 3v. This added to water containing .03 of a grain of ammo- nia to the gallon will give a yellow color; a larger amount of ammonia a brownish-yellow color.2 This reagent may be extemporaneously prepared by adding to a solution of potassium iodide (1 pint of salt to 20 pints of water) a solution (1 to 16) of mercuric chloride (corrosive sublimate) until a permanent precipi- 1 Report of the New York Board of Health for 1873, p. 574. 2 Transactions of the Medical Society of the State of Pennsylvania, vol. x, p. 19. 440 TESTS FOR IMPURITIES IN WATER. tate is produced. Then add about twice the volume of liquor potasses, let stand for a few days, and decant from the sediment. This will be delicate enough to detect an exceedingly small quantity of ammonia ; a brownish pre- cipitate or coloration being formed, depending on the amount of ammonia present. If there is much testing to be done, the reagent had better be prepared according to the formula. 3. Test for Nitrous Acid.—Nitrous acid is readily de- tected by its power to liberate iodine from potassium iodide. Prepare some starch paste, add about one-eighth the volume of the solution of potassium iodide, acidulate the water with hydrochloric, or, preferably, sulphuric acid, to liberate the nitrous acid if combined as a nitrite, and then add the mixture of starch paste and potassium iodide. The immediate formation of blue iodide of starch will indicate the presence of nitrous acid. Pure acids and clean vessels must be used to insure accuracy. 4. Test for Nitric Acid.—To test for this acid, the un- ignited residue had better be employed. Dissolve some morphia, or, better still, brucia, in a drop of sulphuric acid, on a piece of white porcelain; it should develop no color: if now a few pieces of the solid residue be added, the presence of nitric acid will be shown by a rose-red coloration in the former instance, or a deep blood-red if brucia has been used. 5. Test for Sewage-matter.—When the water may be contaminated with sewer-refuse, there is a large increase of the alkaline salts, notably common salt—sodium chlo- ride—the chlorine of which can readily be detected after rendering it strongly acid with pure nitric acid, by a solu- tion of silver nitrate, a white curdy precipitate being formed. Since this salt is normal in small quantities in DISINFECTION OF IMPURE WATER. 441 most waters, the resulting precipitate should be quite decided to indicate any sewage-matter. 6. Test for Albuminoid Matters.—This test, known as Chapman & Wanklyn's test,1 requires more laboratory manipulation. It attempts to give us intelligence of animal matte? while still in an albuminoid condition, and depends on the principle that a solution of caustic potash and potas- sium permanganate is able to cause the nitrogen of albu- minoid substances to enter into combination with hydrogen and form ammonia, which then can be detected by Ness- ler's reagent. To apply the test, it is first necessary to remove all ammonia in the water, as well as urea, which readily changes into ammonia; this is done by distilling a portion of the water until portions of the distillate give no reaction with the Kessler solution ; then add a strong solution of potassium hydrate.and a solution of potas- sium permanganate; collect the distillate, and examine again for ammonia. Its presence indicates albuminoid material in the water. How to Disinfect Impure Drinking Water. To purify such water, if it must be used, drop in a solution of chemically pure permanganate of potassium, gr. viij to f'3j of distilled water, until a slightly perceptible red tint remains in the water. This very weak solution of permanganate is not unwholesome; but for common purposes and among the poor it is better to depend upon the thorough boiling of impure water, if such water must be used. The permanganate quickly tests the presence of organic impurities. It destroys them by instantly oxidizing or burning them. It is contended by some that recently calcined charcoal, well pulverized, is the only substance which can with im- i Jour. Chem. Soc, xx. 445, 591. 442 DISINFECTION OF IMPURE WATER. punity be mingled with water in excess, without commu- nicating taste or hurtful properties. It is usually placed in layers between clean gravel, or broken quartz, through which the water is filtered. The charcoal should be fre- quently renewed, for as its efficiency depends alone on its absorbent power, it becomes inert when saturated. If water be boiled to deprive it of infectious germs and of odor, it should afterwards be exposed for a time to the air, to absorb again a portion of oxygen and carbonic acid.1 It has been found that ^clvv of salicylic acid will keep river or pond water in casks perfectly fresh, and without unpleasant taste, for weeks. A plan has been suggested to prevent the decomposition of water on shipboard, by adding the acid in the proportion of one part to 200,000, by covering the bung-hole of the casks with cotton-wool steeped in salicylic acid, the preservation being effected by the filtration of the air.2 1 S. Oakley Vander Poel, M.D., Transactions of the Med. Soc. of the State of New York for 1875, p. 233. 2 British Medical Journal, February 20, 1875 ; Boston Med. and Surg. Journal, March 11, 1875. HOW TO CONDUCT A POST-MORTEM EXAMINATION. (443) HOW TO CONDUCT A POST-MORTEM EXAMINATION. The practitioner must so conduct these investigations as to leave behind no offensive traces of his work, and must avoid wounding in any way those whose suscepti- bilities at that time are particularly impressible. To insure a satisfactory performance of a post-mortem examination, certain preliminary arrangements are necessary.1 What to Provide.—The undertaker must have the body ready. The carpets must be thoroughly protected from injury from the dripping of fluids, discharges, etc. The family must provide hot and cold water, a waste bucket, and basins, sponges, bran, a small funnel, oil for the hands if necessary, or preferably collodion, which is also useful in gangrene, etc., a small water pitcher, towels, and rags. In order to label specimens for pre- servation, the operator should provide himself with slips of wood on which he can write with a lead pencil, as the lead is not acted on by the fluids. Instruments.^-Uuder ordinary circumstances, the phy- sician will be able to perform a post-mortem examina- 1 Many of the facts detailed in this chapter have been arranged and condensed from the following sources : R. Virchow, A Description and Explanation of the Method of Performing Post-mortem Examinations in the Dead-house of the Berlin Charite Hospital, translated by T. P. Smith, Philadelphia, 1877 (from Med. Times and Gazette, 1876) ; C. Heath, Manual of Minor Surgery, etc., Philadelphia, 1875; and manu- script notes of Lectures on Pathological Anatomy in Jefferson Medical College delivered by Dr. W. W. Keen, and kindly loaned by him. ( 445 ) 446 HOW TO MAKE POST-MORTEM EXAMINATIONS. tion satisfactorily if provided with a case of instruments containing two large knives, two small knives, a saw, rachitome, scissors, a hammer, forceps,' needles and thread, and a pocket measure; or an ordinary dissecting case plus a saw, rachitome, hammer, needles and thread. Important suggestions, however, as to instruments, have been made by Virchow for the more satisfactory performance of these operations. The blade and handle of the ordinary dissection-knife are made by him thicker and broader; the anterior part of the blade rounded off, the very broad surface termi- nating with a considerable curve in the slightly project- ing point, thus lengthening the cutting edge and diminishing the risk of pricking one's self or others. On the back part of the knife the blade is narrow and strong near its insertion, the handle flatter posteriorily, and much curved inwards from both edges, to lie more conveniently in the hand. In its original condition, be- fore being ground down, the knife is twenty-three to twenty-four centimetres long, of which nine and a half belong to the blade. The incisions with this knife should be with a traction movement, rapid rather than forcible, to avoid crushing, as in the brain. Place the handle be- tween the thumb and forefinger only, so that great pressure is impossible. If pressure be required, use a knife with a stronger handle than the ordinary cartilage knife, a thicker and more bulging blade, and a broader back, to which the forefinger or thumb may be conve- niently applied; the handle made of two strong plates of wood or horn, one of them being applied to each side of a flat prolongation of the blade, reaching the entire length of the handle; the back of such a knife being sixteen millimetres broad, the free end of the handle flattened and broad. To sum up—the operator HOW TO MAKE POST-MORTEM EXAMINATIONS. 447 requires a section knife for dissecting large viscera; a strong cartilage-knife for coarser work, such as dividing cartilages, large incisions through skin, muscles, joints, etc., and a dissecting knife for the finer parts, vessels, nerves, etc. The operator should also have a bag for his instru- ments, or to carry away specimens for preservation. In the bag, he should carry oiled silk and tin seidlitz- powder boxes, and a bottle of Lugol's solution, to detect amyloid degeneration. In winter, the overcoat pocket will forrn. a convenient receptacle for various articles. In medico-legal examinations, additional caution is necessary that clean glass jars be used. Sealing wax, a seal, and string should also be provided. What to Observe.—In medico-legal cases special care must be exercised to ascertain three distinct points:— 1. Was the individual viable, and did he live? 2. If he has lived, how long has he been dead ? 3. The cause of death. In medical cases, the latter inquiry alone is necessary, together with 4. The pathology of the disease. Notes of Cases.—In noting, on the instant, the appear. ances revealed, state the exact time of the examination, and how long after death it is made; enter only facts observed and not inferences. Measure everything ; guess at nothing. If nothing abnormal be found in any organ, state the fac . If desirable, take specimens home for microscopic examination. 448 HOW TO MAKE POST-MORTEM EXAMINATIONS. External Examination. Special care is needful even to the smallest particulars.1 1. Position of the Body.—It has a marked bearing as to question of violence and mode of death. 2. Clot/ling.—Important in relation to identity ; if torn, it may prove violence. After and closer examination may detect spots of blood, or semen (rape), fecal matters in infanticide, etc. 3. Condition of the subject as to putrefaction, etc. Im- portant as bearing on date and cause of death, or on identity. Even in case of advanced putrefaction, the ex- amination must be conducted, for the hair, nails, teeth, lesions of the bones, arteries, foreign bodies, poisons, pregnancy, etc., afford data to guide judicial examinations. 4. Age.—In children recognized by extent of ossifica- tion., especially of the lower end of the femur, at the ninth foetal month. 5. Sex.—Not always easily determined, by reason of anomaly or putrefaction or destruction. The presence of the uterus, beard, breasts, parting of the hair, etc., will or may assist us. 6. General Conformation, Constitution, Emaciation, etc.— These have a bearing on previous state of health, identity, strength necessary for the crime, etc. 7. Warmth of various parts and Rigor mortis to be noted; cause of the latter may be coagulation of the muscular substance. If death is sudden it is delayed. 8. Color of Skin, white or negro. Hypostasis is not to be mistaken for congestion or violence. All livid spots 1 Casper relates a case wlrere the body was exhumed three times, the second time to determine about some cicatrices which had not been fully reported, and the third time to examine the teeth—these bearing on the identity. HOW TO MAKE POST-MORTEM EXAMINATIONS. 449 should be cut into to see whether the blood be still in the vessels or effused into the tissues. Blood may even coagulate in a post-mortem cut. The skin may be dis- colored by Addison's disease, yellow fever, etc.1 9. Anomalies of all kinds, as cicatrices (from buboes, chancres, wounds), tattooed spots, herniae, etc.; deficiency of members; ulcers, dirt or fecal matter on the body, abrasions, wounds, etc., even down to the slightest mark of a cord around the neck or other part, or even the trace of a ring having been worn.2 10. Abrasions, Wounds, etc.—If blood from them be on the person, it should be so stated. The size, exact posi- tion (measured), and nature of the wounds, etc., should be noted, whether incised, lacerated, contused, etc. Their direction and depth must be stated and compared with any instruments found anywhere that might be supposed to be the means of violence. Their internal lesions and connections must be investigated at a later stage of the examination. 11. Take up each region separately, and examine the hair, teeth, mouth, as to its contents of foreign body, fasces, etc.; tongue, as to the presence of acids, alkalies, etc.; nose, its condition, presence of foreign bodies, etc.; eyes, as to anomalies, color of iris, etc.; vagina, rectum, etc., for foreign bodies; generative organs, groins, etc., for evidence of anomalies and disease. In very young children and foetuses, other points must be examined, as the fontanelles, diameters of the head, which vary at different months; the eyes for the mem- brana capsulo-pupillaris, which disappears at the seventh 1 Under the subject of Internal Examination (p. 318) will be found further remarks on coloration, etc. 2 Casper gives a case in which a body was disinterred in order to see whether a ring had been worn, so that identity might be established. 29 450 HOW TO MAKE POST-MORTEM EXAMINATIONS. month; the nails; ossification of various bones; the scrotum, for the presence or absence of the testicles,1 etc. Internal Examination. Usually we examine only the thorax, abdomen, and pelvis; the head and spine, if necessary. In medico- legal cases the examination should begin where we sus- pect the cause of death, and thence extend to other parts. If the subject be an infant and viable, the abdomen is first to be opened, to ascertain the position of the diaphragm. The operator should not omit a single part, or his testimony may be impugned, either as a medical witness, if he reports the case, or as a legal one, and this omitted part might be assumed as the seat of the cause of death. Protect the hands, before making the internal exami- nation, with oil and soap. This diminishes the proba- bility of absorption of matter, but has the disadvantage of rendering the holding of instruments more difficult.2 1 During the fifth or sixth month the testicle descends to the iliac fossa; seventh month enters the inguinal canal; at end of eighth month passes into the scrotum. 2 At the outset of the internal examination, it may be well, for the sake of reference, that the practitioner should be reminded of the Average Weight of the Various Organs.* Male. Female. Brain .... 49^- oz. avoir. 44 oz. avoir. Cerebrum 43 oz. 15 dr. 38 oz. 12 dr Cerebellum 5 oz. 4 dr. 4 oz. 12£ dr Pons and medulla oblongata 153 dr. 1 oz. ^ dr Spinal cord 1 oz. 4 dr. 1 oz. 4 dr Heart .... 11 oz. 9 oz. Lungs .... | right eft, 24 oz. right 21 oz. left, 17 oz. 15 oz. * Tabulated from Quain and Sharpey's Anatomy, iu Heath's Manual of Minor Surgery, etc. ; Phila. 1875, p. 288. HOW TO MAKE POST-MORTEM EXAMINATIONS. 451 Incisions.—Short quick cuts are not to be made in autopsies, as in ordinary dissections, as they are tedious and cause too much division of the larger organs; while free incisions, possibly involving the whole of the organ, save time and give increased insight and clearness. The knife-handle should be grasped in the palm, the blade appearing as a direct prolongation of the arm wdien stretched, the cutting movements being made with the whole arm. The right arm must be free, and the elbow raised quite away from the trunk, so that the flexed forearm may be moved freely, and in any direction backwards or forwards, making it easy to divide the integuments of the trunk by a single long incision from the chin to the symphysis pubis, or to display the lung from apex to base in two halves. Incisions should not completely separate the portions of an organ, so that we may restore the connection of parts, in case re-examination be necessary. Order of Examination.—The abdomen must be opened —but not dissected—before the thorax, to ascertain the position of the diaphragm and various organs, abnormal abdominal contents or adhesions, penetrating wounds, foreign bodies, color of exposed parts, etc. Note also how much fat is present in the subcutaneous areolar Male Female Thyroid .... 1 oz. 2 oz. Liver .... 53 oz. 45 oz. Pancreas .... 3 oz. 3 oz. Spleen .... 6 oz. 5 oz. Kidney . H oz. 5 oz. Suprarenal capsule 1- 2 dr. 1-2 dr Prostate .... 6 dr. Testis .... 1 oz. Uterus (virgin) . 7-12 dr. Ovary .... 1-1* dr. 452 HOW TO MAKE POST-MORTEM EXAMINATIONS. tissue. The position of the diaphragm is important for establishment of the respiration-test in the new-born. The thorax must be dissected first, lest by removal of the liver, stomach, etc., and division of the abdominal ves- sels, a collapsed and emptied condition of the right side of the heart may result. The stomach may, however, be at once removed in cases of suspected poisoning. If the thorax be opened first, and the anterior attachments of the diaphragm divided, the general and relative position of the abdominal viscera, thus displaced, and their rela- tion to injuries of the abdominal walls, cannot be readily determined. Peritonitis might exist; it would be a nice point to determine whether it is due to traumatic causes or a pathological process in one of the abdominal viscera. Coloration and Condition of Vessels.—It is a fallacy that arterial blood and arterial vessels are distinguishable by their deep-red or bright-red color, and that in a dead body arterial injection can be recognized by the color test. In the veins or plexuses formed by venous radicles, venous blood may absorb oxygen, and venous hypersemia thus assume the appearance of arterial injection. The color- ation, which has really occurred from exposure during the dissection, after opening the abdomen, for example, might be mistaken for inflammation or irritation. The color must be determined at the moment of opening the abdominal cavity, before the oxygen of the atmosphere has had time to affect it. True capillary injection cannot be recognized by the naked eye; it is red tissue, not red capillaries, that is seen, and what is generally called hyperaemia is usually only veins. The venous or arterial character of a vessel can- not be determined by the quality of the blood contained in it, but by its structure, connections, and position; in puzzling cases the course of the vessel must be followed HOW TO MAKE POST-MORTEM EXAMINATIONS. 453 to a point at which its size becomes a sufficient guide. Note the quantity of blood in a vessel, the kind of ves- sel, the degree of fulness (as profuse, slight, bloodless, etc.). Manipulation, as of the intestines, etc., diminishes the quantity of contained blood, and of gaseous, fluid, and solid matters. EXAMINATION OF THE THOKAX. The reasons for opening—not dissecting—the abdomen before examining the thorax, are stated elsewhere (p. 317). To open the thorax and abdomen, a free incision should be made from the chin to the pubes, along the middle of the sternum and down to that bone, through the skin to the umbilicus, passing around the latter. Then by deep- ening the incision from the lower portion of the sternum, open the peritoneal cavity for an inch or two, introduce the first and second fingers of the left hand, with which to hold up the abdominal wall, passing the knife between them, with its back to the intestines, and cutting through the whole thickness of the muscles at once down to the pubes. Then dissect off the skin and pectoral muscles from the sternum and costal cartilages. The knife must be carried through the eterno-clavicular articulation on each side, by introducing it downwards and outwards at a point close to the inner end of the clavicle; then divide all the costal cartilages as close to their ribs as practicable, bearing in mind that the cartilage of the first rib is further from the median line. In older persons, the cartilages may be somewhat calcified. Lift up the inferior end of the sternum and divide the attach- ment of the diaphragm and the cellular tissue, and remove the sternum, with the pleura partially detached, exposing the lungs to view. In this operation, and while making the incision through the first rib and the articulation, 454 HOW TO MAKE POST-MORTEM EXAMINATIONS. take care not to wound the large veins, and thus fill the pleural sacs with fluid or coagulated blood, rendering it impossible to determine their other contents. We have not one thoracic cavity but two separate pleu- ral sacs and pleural cavities, a pericardium and pericardial cavity. In opening the pleural sacs, note the position, color, etc., of their contents, amount and character of the fluid, presence of a foreign body, of adhesions, wounds, etc. Ascertain the existence of heematothorax, hj'drotho- rax, and pleuritis, and leave the lungs and pericardium for subsequent observation. The lungs should not be removed from the thorax before the heart has been examined, for the pulmonary artery and veins will be separated from them, and the left auricle, trunk of the pulmonary artery, and the right ventricle will be partially emptied. The Heart.—Open the pericardium by a vertical in- cision, examine its condition, amount of fluid, the appear- ance, position, size (atrophied or hypertrophied), shape, consistence (fatty, etc.) of the hea,rt, amount of blood in the superficial vessels, and of fat in the sub-pericardial areolar tissue. Then open the heart in situ, to determine at first the quantity of blood in the cavities and the capacity of the auriculo-ventricular orifices, especially of the left side. Deaths from asphyxia and paralysis of the heart probably occur from overfilling, in the first case, of the right ven- tricle, in the second of the left. To determine the suffi- ciency or capacity of valves, all the parts belonging to the auriculo-ventricular valves, the chordae tendineae and musculi papillares, must be retained in their integrity. As the base of the heart must be preserved, on account of the attachment on the two sides respectively of slips of the tricuspid and mitral valves, and as each auricle and ventricle must be examined separately, four distinct in- HOW TO MAKE POST-MORTEM EXAMINATIONS. 455 cisions are necessary. Tn case it should not be expedient to remove the heart, a tolerably complete examination may be made according to the following brief directions:— 1. To examine the right ventricle, carry the incision from close to the base of the right border of the heart, deeply and forcibly into the interior of the ventricle, bringing the knife out towards the apex, without going dowrn so far as to wound the septum. This incision is a guide for the three others, the place for each incision being found in a plane taking the direction of the first. 2. To examine the right amide, commence the incision half way between the places of entrance of the venae cavae, and let it end close to the base. 3. To examine the left auricle, the incision should com- mence at the left superior pulmonary vein, and end close to the base, as indicated by the prominent coronary vein. The coronary vessels should not be injured. 4. To examine the left ventricle, begin the incision close below the base, carry it deeply and forcibly through the wall of the heart, and let it end just short of the apex. The heart is brought into proper position for examina- tion of the right side, by pushing the firmly extended left forefinger under the organ, and keeping it against the base, so that the ventricular portion hangs down over the forefinger. Then turn the heart on its axis towards the left until the right border presents anteriorly, press the left thumb just behind this border at the base, and make, one after the other, both the incisions for the right side, as above described. To examine the left side, draw the apex upwards and to the left, and place the heart encircled in the fingers of the left hand. By gentle pressure, make the posterior wall to bulge out a little, and withdraw itself from the septum. 456 HOW TO MAKE POST-MORTEM EXAMINATIONS. Then make the incisions for the left side as above de- scribed. After making the incisions in the right side, remove and examine the quality and quantity of blood from the right auricle ; then insert the left index and middle fingers from the auricle through the tricuspid opening into the ventricle, and endeavor to open this latter cavity. Remove the blood from the right ventricle, determine it as before, and do the same on the left side. Do not ex- amine the valves at this stage, as adhesions, coagula, etc., may be disturbed. The contracted condition of the left side of the heart must be borne in mind, but this con- traction, with the rigor mortis, may be overcome by gentle pressure. To remove the. heart, introduce the left index finger into the left ventricle, and the thumb into the right, through the already existing incisions; raise up the apex, and with it the whole of the heart, and with three or four long, free, horizontal incisions, made not too close to the heart, divide the venae cavae, the pulmonary veins and artery, and the aorta, all together. After removal, ex- amine the cut openings of the aorta and pulmonary artery, the size of these vessels, the thickness of their walls, and remove any and all coagula. Examine the capacity for closure of the arterial orifices by pouring water into the aorta and pulmonary artery, holding the heart freely sus- pended in the air, so that the orifices will not be closed or the walls compressed by pressure of the hand. The points of the fingers should be applied to the vessels to be examined, or externally near the base of the valves, so that the plane of the orifice shall be exactly horizon- tal, and not drawn to any side. To prevent dragging, stretching, or valvular closure, both hands must be used, HOW TO MAKE POST-MORTEM EXAMINATIONS. 457 to support the heart properly, and the water must be poured in by a second person. In examining the aortic orifice, apply the tips of the fingers closely around it on the right and left auricles and pulmonary artery ; for if applied simply to the edges of' the aortic opening, the parts may be stretched unequally, and besides we have to divide the aorta again at a dis- tance of four or five centimetres above the orifice by an incision parallel to the plane of the aperture. If the coronary arteries were divided when the left side of the heart was first incised, the water poured in may escape through them. In the case of the pulmonary artery it is different, and to test the pulmonary orifice the heart can be suspended by fixing between the fingers the edges of the opening into the vessel. For thorough examination of the heart, after removal, place it exactly in the position it occupied in life, on a board or table. The parts to be examined are the au- riculo-ventricular valves, with their chordae tendineasand musculi papillares, the cavities themselves, their endocar- dium, the arterial valves, auriculo-ventricular septum, and muscular substance. For the right ventricle, the incision is made in a straight line prolonged from the pulmonary artery, and near the base of the heart, with a long pair of scissors; one blade being inserted into the previous incision in the right border (p. 321), and carried towards the pulmonary artery, care being taken, by introducing the blade in front of the papillary muscle, and carrying the incision close to the base, not to cut through the muscle of the tricuspid valve with its chordas tendineae, which would interfere with the demonstration of the tricuspid valves. For the left ventricle, the incision, with similar scissors, is in a straight line prolonged from the ascending aorta, 458 HOW TO MAKE POST-MORTEM EXAMINATIONS. and close to the septum ventriculorum ; commencing at the apex and dividing the anterior wall of the ventricle and of the aorta. Care must be taken not to divide the base of the mitral valve. Avoid cutting through the valves of the pulmonary artery by drawing that vessel to the right when making the incision, and by continuing this to the left, close to and behind the artery ; not too far to the left, as the right border of the base of the mitral valve is inserted quite close to this spot, and this valve is con- nected immediately with the left border of the aortic orifice. If the incision goes only a few millimetres too much to the left, that portion of the mitral valve will be cut off which forms this junction, and the result will be an aperture in that valve when the divided portions of the heart are put in apposition. Externall}' this spot corresponds exactly with the right border of the base of the left auricle, and should be the guide, the incision being carried through midway between the pulmonary orifice and the left auricle. This completes the examination of the heart—all of which can be done in ten minutes—unless it be desirable, in exceptional cases, to open the auricles by cutting through their wall with the scissors, between the open- ings of the venae cavae on the right, and of the pulmonary veins on the left side; or to make further incisions in the muscular substance or the coronary arteries. The Lungs.—In examining the lungs we must take • care not to injure the root, where the vessels, nerves, and excretory ducts occupy important relations, as it may be necessary to probe, dissect, inject, or use the blowpipe in the vessels or canals. As already stated, the lungs should not be removed until after the examina- tion of the heart. Should it be desirable to remove the lungs and heart together, tie the trachea and vessels to HOW TO MAKE POST-MORTEM EXAMINATIONS, 459 prevent the exit of blood and air. Then cut through the trachea, dissect it from the oesophagus, divide the great cervical vessels, and separate the heart from its remain- ing attachments to the diaphragm. We must examine whether the lungs float in water, whether they have breathed, and in adults, to see if there be consolidation, and also crepitation. If we cut the lungs in pieces, ex- amine whether the pieces float. In opening the lung divide each lobe, by a perpendicular incision from above downwards, and from its thick border towards its inner (anterior, medial, sharp) border. Lay open the bronchial tubes, if necessary, by scissors introduced along the posterior wall of the trachea. Note any evidences of pneumonia, and examine the bronchial tubes, the parenchyma, bronchial glands, etc. The larynx, tongue, etc., are sometimes removed with the lungs, and their condition examined, but not usually in private practice. The Larynx.—Make an incision from the chin to the sternum, carefully dissecting back the skin, and then separate the floor of the mouth from the jaw, pulling the tongue down through the opening. Divide the pillars of the fauces, and the pharynx; and the tongue, pharynx and larynx may be brought down together, and, if neces- sary, separated from the lungs. EXAMINATION OF THE ABDOMEN. The usual order of sequence in the examination of the abdominal organs, except in special cases, should be as follows: The omentum; spleen; left kidney, suprarenal capsule, and ureter; the right ditto; the bladder, prostate gland, vesiculae seminales, and urethra; the testicles, spermatic cord, and penis; or the vagina, uterus, Fallopian tubes ovaries, etc.; the rectum ; duodenum and intestinal 4G0 HOW TO MAKE POST-MORTEM EXAMINATIONS. portion of the ductus communis; stomach; small omentum, gall-ducts, vena portae, gall-bladder, and liver; pancreas and semilunar ganglia; mesentery, with its glands, vessels, etc.; small and large intestine; retro- peritoneal lymphatic glands, receptaculum chyli, aorta, and vena cava inferior. In regard to some of these organs no special directions are necessary, as they are removed without trouble or simultaneously with others of greater importance. The mode of opening the abdomen has been already described (p. 319). The Spleen.—This organ may be divided by a single long cut from above downward, over the middle of its outer or convex surface. The same precautions as to wounding the hilus are necessary as in the examination of the lungs (p. 324). Note the size, color, and appear- ance of the capsule and parenchyma. The urinary organs should be examined in the fol- lowing order : The kidneys, ureters, bladder, and urethra. The suprarenal capsules and generative organs will be examined in connection with them. Kidneys.—Remove the organ with the suprarenal cap- sule, and take away the fat. Note the size, consistence, external appearances, etc. In opening the kidney, make a single cut from the external to the internal border; and examine the cortical and medullary substances, the pelvis of the kidney (for renal calculi), and if fatty degeneration be suspected make a microscopic examination. In removing the organ, divide the lumbar peritoneum, and draw the kidney forward, dividing the vessels and ureter, Label the organs, right and left, to distinguish them. If deemed necessary, examine also the Suprarenal cap- sule and Ureters. The Bladder.—This organ is not usually removed. HOW TO MAKE POST-MORTEM EXAMINATIONS. 461 Note whether it is distended, the thickness of the walls, appearance of the mucous membrane, etc. In medico- legal cases, draw off the water, and put it in a clean jar. The bladder may be removed alone, or with the rectum, uterus, and ovaries; in the latter case, by dividing all the structures on the floor of the pelvis close to the levator ani muscle. If the urethra is to be removed with the bladder, a por- tion of the pubes may be divided, and by proper incisions, and division of the penis, the latter, the urethra and bladder can be removed together. The prostate gland and vesiculse seminales may also be examined. The Testicle.—To open this organ, make a single incision in a perpendicular direction from its free to its attached border, the parts being then forcibly separated. The spermatic cord and penis may also be examined at this time. The Uterus.—In private practice, this organ is not usually removed—unless absolutely necessary—on ac- count of the vagina offering an outlet for the escape of fluids. If it should be removed, the vagina must after- wards be closed up. Note the size, position, consistence, etc., of the organ, and the appearance of the mucous membrane. The vagina, fallopian tubes, ovaries, rectum, etc., may also be examined in this connection. The Duodenum, Liver, Gall-bladder, etc—The order of sequence at this stage should be as follows : first open the duodenum in situ, determine its contents above and below the papilla biliaris, which should be gently squeezed . and by pressure on the gall-bladder determine the presence of obstacles to the flow of bile and the presence of gall-stones. Slit up the ductus com- 462 HOW TO MAKE POST-MORTEM EXAMINATIONS. munis choledochus, examine the vena cava, and remove the liver, taking care not to wound the right supra-renal capsule. Examine the external surface of the liver, make sections of it, and note the appearance of the acini, veins, and ducts. The hepatic may be distinguished from the portal vein by the pad of cellular tissue around the latter, in Avhich run the artery and duct. The ligaments should be divided and the liver should be removed as the last stage but one of the abdominal examination. To remove it at an earlier period would be to wound the large veins and the diaphragm, the small omentum, the vena portae, gall-duct, etc., besides interfering with the detection of obliterations of the vena portae, defects in the perviousness of the ductus communis choledochus and of the cystic and hepatic ducts. If the thorax has already been opened, a portion of the diaphragm may be removed with the liver. The vena cava must be divided above and below, but the blood from it may interfere with any further abdominal dissection. Next open the gall-bladder and examine its contents, The Stomach.—This organ may be opened in situ at the same time as the duodenum, by continuing the incision, except in cases of suspected poisoning. The spleen may be readily separated from it. In a medico legal case requiring removal of the stomach and its contents, tie the oesophagus and divide it above the ligature, before removing the lungs, etc. Then tie the duodenum and remove the stomach. Cut one of the ligatures and pour the contents carefully into a clean glass jar. Take all possible care by labelling and lock- ing them up to see that no mistake is made as to the right jar and that they cannot be tampered with. They should never be allowed to go out of the physician's possession except personally into the hands of a chemist. Open the HOW TO MAKE POST-MORTEM EXAMINATIONS. 463 stomach by carrying a pair of scissors along the lesser cur- vature. Note the thickness of the walls, their condition, and the appearance of the mucous membrane, taking care not to misinterpret the rugae. The Pancreas and Semilunar Ganglia should next be examined. Any change in size, consistence, etc., should be noted; after which the mesentery, with its glands, vessels, etc., should receive the operators atten- tion. The Intestines.—These should be examined last, as, even with the greatest care, the operator, the instruments and receptacles, the subject, and the table are liable to be soiled. If there be valid reason for haste, they can be removed without injury to the other parts, except in the case of the duodenum, its removal being impossible with- out cutting through the excretory ducts of the liver and pancreas which open into it, and even wounding a por- tion of the pancreas. If the intestines must be removed, place two ligatures at the commencement of the jejunum and the rectum and divide the bowel between them. Separate the large intes- tine throughout from its attachments, turn it over to the right side; do the same with the small intestines, and, taking the mesentery in the left hand, isolate them from their connections. Open them on the side that is attached to the mesentery. In examining the intestines, note the state of the walls, the condition of the mucous membrane, particularly as regards inflammation, ulceration (how deep), perforation, the appearance of Peyer's patches, the mesenteric glands, etc. The examination of the retro-peritoneal lymphatic glands, receplaculum chyli, aorta, and vena cava inferior, will com- plete the abdominal investigation. 464 HOW TO MAKE POST-MORTEM EXAMINATIONS. EXAMINATION OF THE CRANIUM. This examination is usually postponed until after that of the thorax and abdomen, but if it be especially im- portant to examine the head, it is better to do so at once, as the division of the large vessels of the heart might change the appearance of the brain. The head being properly raised, and the hair parted across the vertex from ear to ear, an incision should be made down to the bone in the same direction—never across the forehead; the scalp being drawn forward over the brow and backward over the occiput. The knife is then passed all around the skull, through the temporal muscle, the line passing about an inch above the orbit, and half an inch above the occipital protuberance, and as high in the temporal fossae as the shape of the head will admit. The operator should then saw the skull, standing to the left of the body, with the heel of the saw on the os frontis, and with a few firm and light movements cutting through the outer table, and continuing the cut backwards. The sawing must be thoroughly done at three points; the occiput and the anterior extremities of the temporal ridges on the frontal bone. The dura mater and brain must not be wounded. The above is the usual method; but a better one, since it retains the calvaria perfectly in place without wires or other means, is to make the above horizontal cut from the forehead backward stopping at about an inch behind the ears; from this point on each side saw straight to the middle line to a point an inch higher than the level of the horizontal cut. If these cuts are bevelled at the expense of the inner table, additional security from dis- placement will be given. The scalp alone will retain the calvaria in place, and the forehead will not show the least evidence of mutilation. HOW TO MAKE POST-MORTEM EXAMINATIONS. 465 The chisel and mallet may be used in hospital exami- nation to penerate the inner table. In medico-legal ex- aminations, do not use a hammer in such cases make no violent efforts to remove the skullcap, lest any frac- ture may be.attributed to the violence. Examine the calvaria, and in medico-legal cases take off the perios- teum in order to detect any fissured fractures. These may be made clear by ink, which will be absorbed into the fissure and cannot be wiped off. As a rule, the exposed parts—dura mater, great longi- tudinal sinus, pia mater, surface of the cerebral hemi- spheres—must be first examined and described in succes- sion; unless the dura mater should be adherent to the skullcap, requiring division before forcibly detaching the latter, and the removal of the skullcap with the dura mater adherent to it. Otherwise the parts may become crushed and injured, and accurate examination be rendered impossible. In new-born and young children these parts are usually adherent. Having examined the membranes externally, they may be opened as follows: The dura mater, by passing the knife around the cut edge of the skull, the falx being exposed when the membrane is raised; the falx can then be detached from its connection with the ethmoid bone, and the tentorium, and removed, thus exposing the brain. Before disturbing the falx, however, open and examine the longitudinal sinus. Note the amount of cerebro- spinal fluid. The Brain.—In the brain the incisions should be even and smooth, to avoid crushing, and always through the hemispheres, from within to without, so that the brain can be readily put together again, notwithstanding the num- ber of cuts made in the internal parts. Make each suc- cessive incision across the middle of the existing cut sur- 30 466 HOW TO MAKE POST-MORTEM EXAMINATIONS. face, and divide again and again each new half. This is not practicable with the large cerebral ganglia. The velum interpositum comes iu contact with only a small streak, the stria or lamina cornea, and must be stripped off before commencing the dissection of these ganglia; the latter should be divided by fan-shaped radial incisions, whose common starting-point is the peduncle of the cere- brum, so that the relation of parts may be preserved. After examining the membranes, a lateral ventricle should be at once opened partially as follows : Bearing in mind that between the middle portions (cellae mediae) of the lateral ventricles, there is only the very thin septum lucidum to form a partition-wall, and that it is exactly under the raphe of the corpus callosum, we make a lateral incision, at a distance of a millimetre from this raphe perpendicularly into the corpus callosum, coming directly into a cella media at a depth of two or three millimetres, the incision forming a right angle with the plane of the cen- trum semi-ovale. To open the anterior and posterior cornua of this ventricle, incisions must be made anteriorly or posteriorly, not vertically but horizontally—the ante- rior one higher, the posterior one deeper—in the anterior and posterior lobes of the brain. To remove anything from the ventricles, use only a small stream of water. Having determined the contents of the lateral ventri- cles, the state of their walls and venous plexus, and the condition of the septum, the latter is taken hold of with the left hand close behind the foramen of Monro, the knife pushed in front of the fingers through this aperture, and the corpus callosum cut through obliquely, upwards and forwards, and then all these parts (corpus callosum, septum lucidum, and fornix) are carefully detached from the velum interpositum and its choroid plexus, and the vessels and tissue of the latter examined. Then passing HOW TO MAKE POST-MORTEM EXAMINATIONS. 467 the handle of the scalpel from the front under the velum so as to detach it from the pineal body and corpora quadrigemina, we learn the condition of the latter, and expose the third ventricle. With a long perpendicular incision divide the corpora quadrigemina and the cere- bellum as far as the aqueduct of Sylvius and the fourth ventricle. It may be necessary to make, both in the brain and spinal cord, a large number of cuts, even microscopic sections, to be sure that nothing has been overlooked. The fewer the abnormal changes, the greater the number of sections needed. To Remove the Brain.—Lift up the anterior cerebral lobes and the first pair of nerves, divide the second pair, and internal carotid arteries, the third pair, the tentorium cerebelli,—the knife for this latter purpose being carried along the superior border of the petrous portion of the temporal bone,—dividing the fourth pair, and the others in regular order. The medulla oblongata and vertebral arteries are separated by passing the knife through the foramen magnum. The arachnoid and pia mater of the base and sides of the brain, the lateral sinuses, and the fifth nerve with the ganglion of Gasser should next be examined. The Orbit.—This cavity may be examined after re- moval of the brain, by carrying the saw through the os frontis, at the internal and external angles of the orbit, using the chisel to continue the cuts through the roof, and then tilting forward the portion of bone embraced in the section. The Optic Nerve.—The posterior half of the eyeball can be readily removed, by a pair of scissors, without any disfigurement of the face, in order to examine the 468 HOW TO MAKE POST-MORTEM EXAMINATIONS. condition of the optic nerve. It should be placed at once in Muller's fluid.1 EXAMINATION OF THE SPINAL CORD. Make a longitudinal incision in the median line, and a dissection of the muscles laterally; then saw through the laminae of the vertebrae. A double saw saves time. A chisel or a rachitome and hammer may also be used. Ex- amine the spinal cord in situ. Note the amount of the cerebro-spinal fluid. If expedient to remove the spinal cord, note especially at what vertebra it is cut off, and remove the roots of the nerves along with it. Carry the knife outside of the dura mater, to cut through the nerves at the side, and the cauda equina below. Open the sheath and examine the cord itself on the surface, by sections, and by the microscope, Transverse incisions must be made on the spinal cord, leaving the pia mater attached on the anterior and pos- terior surface, according as the incision has been made from the one or the other aspect. Muller's fluid may be used for the preservation of parts for examination, and tliese should be labelled. To Conclude the Post-mortem Examination.—Remove all fluids from the cavities; replace the viscera; place some rags in the head to absorb the fluids; stuff the vagina or rectum, if either has been opened; fill in with bran wherever necessary, being especially careful to fill the pelvis, if this has been made necessary by the removal of its contents ; replace the sternum, stitching it if it has been altogether removed ; sew up the incisions ; arrange 1 Bichromate of potassium, gr. xxxv ; sulphate of sodium, gr. xvj; distilled water, f§iij. HOW TO MAKE POST-MORTEM EXAMINATIONS. 469 the hair naturally; wash the body, and put everything in as good order as practicable, restoring the body as nearly as possible to its condition previous to the ex- amination. The calvaria may be fastened by brass pins inserted into the diploeat each temple and at the occiput, to keep it in position, or by pieces of copper wire passed and twisted through holes drilled in each temporal fossa, and corresponding holes in the calvaria. ln closing up the abdomen and thorax, sew from below, entering on the under surface of the skin, and at regular intervals. The operator should be particular to cleanse his hands thoroughly with cold water, using a nail-brush, after which he must immerse them in some disinfecting solu- tion, finishing his ablution with a little Cologne water. In case of wounds being received during post-mortem ex- amination, he should wash the hands at once, suck the wound, and apply plaster until after the operation is over, then use water dressings. There is more danger from unseen cuts, of which the operator is hardly con- scious, than from free incisions. 470 ADDITIONAL NEW REMEDIES. ADDITIONAL NEW REMEDIES. Several articles of recent introduction, wrhose thera- peutic properties, in some instances, are not thoroughly established, may be briefly enumerated, with the doses of each in grains and grammes. A few of them were acci- dentally omitted from the table of remedies previously given. (See p. 101.) Bismuth, citrate of Caffein, citrate of " valerianate of Calcium, bromide of Cerium, nitrate of Ciuchonia, citrate of Grindelia robusta Lithium, benzoate of " bromide of Malt, extract of Morphia, valerianate of Pancreatin . Phosphorated oil Potassium, benzoate of Quinia, carbolate of " citrate of . " phosphate of " salicylate of " snlphocarbolate of Strychnia, phosphate of Sumbul, extract of Zinc, phosphide of Grains. Grammes. ij-iv .13- .26 i-ij .06- .13 i-ij .06- .13 x-xl .65- 2.6 i-ij .06- .13 ij-iv .13- .26 xx-xxx 1.3 - 2.0 iij-v .2 - .3 v-xx .3 - 1.3 *3 U-iv 10.0 -20.0 i_i .01- .02 iij-v .2 - .3 gtt. v-x .4 - .8 ij-iv .13- .26 i-ij .06- .13 i->j .06- .13 i-'j .06- .13 i-ij .06- .13 i-iij .06- .2 1 32 .002 i-ij .06- .13 i .01- INDEX. ABBREVIATIONS in common use, 59 Abdomen, post-mortem examina- tion of, 459 Aceta, 137 Albumen in urine, detection of, 274 Alcohol, solubility of medicines in, 40 Alimentary substances, digestibil- ity of, 399 Almond emulsion, 404 Alum whey, 404 Ammonia in water, tests for, 439 Ammoniaco-magnesian phosphates, 2S1 Animal substances, digestibility of, 402 Animal tissues, stained sections of, 377 Antidotes to poisons, 283 ready-reference table of, 292 Apple barley water, 405 Apple water, 405 Approximate measurements, 39 Aquae, 137 Arrowroot, 405 pudding, 405 water, 405 Arsenic, hypodermic injection of, 116 Arsenical bath, 133 Atomized fluids, doses of for inhala- tion, 120 Atropia, hypodermic injection of, 116, 119 BANTINGISM, 434 Bark enema, 132 Barley gruel, 406 water, 406 wine, aromatic, 407 Baths, medicated, 1^2 Battery, galvanic, how to use, 331 Beef broth, 407 raw, 407 tea, 132, 248, 408, 410 enema of, 132 Beef-tea, Liebig's, 409 preparations of, 408, 410 Bile in urine, tests for, 277 Biscuit jelly, 410 Bladder, post-mortem examination of, 460 Blanc mange, 410 Blood in urine, 281 Blood spots, how to remove, 378 Borax bath, 133 Bottcher's test for sugar, 276 Bougies, soluble, 128 Bowel affections of children, thera- peutics of, 238 Brain, post-mortem examination of, 465 Brandy and egg mixture, 411 Bran-flour jelly, 411 Bran loaf, 411 Bread jelly, 412 and milk, 412 panada, 412 Bronchitis, diagnostic syllabus of, 258 CAFFEIN, hypodermic injection of, 117 Calves'-feet jelly, 413 Canals, length o'', 67 Carrageen moss, 413, 419 Catarrh, post-nasal, diagnosis of, 263 Caudle, 413 Caution marks, 112 Cells, size of, 66 Cements, how to prepare, 394 Centigramme. (See Weights.) ^ Centimetres,conversion of, 33. (See Weights.) (471) 472 INDEX. Cerata, 137 Chapman's test, 441 Chartse, 138 Chicken broth, 413 jelly, 413 panada, 413 tea, 414 Children, rules for emergencies in, 237. (See Infants.) Children, therapeutics of bowel af- fections of, 238 Cholera infantum, treatment oe, 245 Chyle in urine, 279 Clinical thermometer, 367 Cod-liver oil enema, 132 Collodia, 138 Collyria, doses for, 122 Confections, 138 Conia, hypodermic injections of, 117 Conium bath, 133 Consomme, 429 Corrosive sublimate, hypodermic injection of, 118 Cracker panada, 414 Crackers, soaked, 414 Cranium, post-mortem examination of, 464 Crayons, caustic, 128 Cream enema, 132 Cream of tartar water, 414 whey, 414 Creasote hath, 133 Cystin in urine, 280 DEAD, unburied, rules in regard to, 326 Decocta, 138 Dentition, periods of, 232 Deposits, urinary, 279 Diabetic, dietary for, 432 Diameters of foetal skull, 270 of pelvis, 269 Diarrhoea of children, treatment of, 240 Diet, special forms of, 432 Dietary for the diabetic, 432 for reducing weight, 434 Dietetic preparations for the sick, 403 rules and precepts, 397 Digestibility of alimentary sub- stances, 399 Digestibility of animal substances, •402 of vegetable substances, 403 Diseases, modern treatment of, 163 Disinfect, places to, 316 things to, 319 Disinfectants, how to use, 311 in common use, 310 practical application of, 307 volatile, 311 Disinfection, 307 of impure water, 436 principles of, 307 Doses of medicines, 92 of atomized fluids for inhala- tion, 120 based on weight, 99 calculation of. by age, 92 for children, 92 for collyria, 122 for enemata. 129 for gargles, 121 for hypodermic injection, 116 maximum, 112 of remedies in general, 100 for suppositories, 124 for urethral injection, 123 for vaginal injection, 123 for youns children, 96 Drains, disinfection of, 316 Drinking water, disinfection of, 436, 441 Drops, number of, in fluidrachm, 36 and minims, relative value of, 38 Drowned, directions for restoration of, 299 Ducts, length of, 67 Duodenum, post-mortem examina- tion of, 461 EGG brandy, 415 broth, 415 flip, 415 no£g, 415 Emplastra, 138 Enemata, 129 doses for, 129 nutritive, 132 officinal, 131 Ergotin, hypodermic injection of, 117 INDEX. 473 Eruptive fevers, tabular view of, 252 Erysipelas, diagnostic syllabus of, 253 Ether, solubility of medicines in, 40 Etiquette, rules ov, 74 Extracta, 139 fluida, 139 Eye washes, doses for, 122 FACE presentations, 271 Fat in urine, detection of, 278 Fehling's test for sugar, 276 Fevers, diagnostic table of, 252 eruptive, tabular view of, 252 Fibres, size of, 6NAL LIBRARY OF MEDICINE Q3W JO AaV»8n IVNOIIVN NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NiDia3w jo Aavaan ivnoiivn W *'%/\ Ss § \.m JNAL LIBRARY OF MEDICINE 1 fOfV^ NATIONAL LIBRARY OF MEDICINE 3Noia3w jo Aovaan ivnoiivn V ° NATIONAL LIBRARY OF MEDICINE \ a3w jo Aavaan ivnoiivn 3NIDI0.3W JO AMV»9n IVNOIIVN 3NiDia3w jo Aavaan ivnoiivn NAL LIBRARY OF MEDICINE 1. 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