Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924091024558 CORNELL UNIVERSITY LIBRARY 3 1924 091 024 558 In compliance with current copyright law, Cornell University Library produced this replacement volume on paper that meets the ANSI Standard Z39.48-1992 to replace the irreparably deteriorated original. 2001 BOUGHT WITH THE INCOME FROM THE SAGE ENDOWMENT FUND THE GIFT OF iage 1891 HI l^/^J/.. NAPHEYS' MODERN THERAPEUTICS. VOLUME I. VOLUME II. OF THIS WORK. GENERAL SURGICAL THERAPEUTICS. GYNECOLOGY. BY THE SAME EDITORS. NAPHEYS' MODERN THERAPEUTICS MEDICAL AND SURGICAL INCLUDING THE DISEASES OF WOMEN AND CHILDREN A COMPENDIUM OF RECENT FORMUL.« AND THERAPEUTICAL DIRECTIONS FROM THE PRACTICE OF EMINENT CONTEMPORARY PHYSICIANS, AMERICAN AND FOREIGN. NINTH EDITION, REVISED AND ENLARGED. VOLUME I. GENERAL MEDICINE, AND DISEASES OF CHILDREN BY ALLEN J. SMITH, M.D., ASSISTANT DEMONSTRATOk OF MORBID ANATOMy AND PATHOLOGICAL HISTOLOGY^ LBCTXntER ON URINOLOGY^ UNIVERSITY OP PENNSYLVANIA; PHYSICIAN IN THE DISPENSARY FOR DISElVSES OF CHILDREN, UNIVERSITY HOSPITAL, ETC. AND J. AUBREY DAVIS, M.D., ASSISTANT DEMONSTRATOR OF OBSTETRICS, UNIVERSITY OF PENNSYLVANIA; ASSISTANT PHYSICIAN TO HOME FOR CRIPPLED CHILDREN, PHILADELPHIA. PHILADELPHIA : BLAKISTON, SON & CO., IOI2 Walnut Street. i8g2. COPYRIGH'A 1892, BY D. G. BRINTON, M.D. PREFACE TO THE NINTH EDITION. The present edition of Napheys' Therapeutics represents, it is hoped by the editors, all the best portions of its predecessors, with the addition of considerable new matter culled from the literature which has appeared during the past five or six years. In removing the old and inserting the new, it has been an object to remove only what was positively antiquated, unfit, or a repetition of other matter in the book ; to insert what is new or to replace by a clear set of in- structions what was less well told in the old editions. The parts which have been retained, together with the additions, have been all more or less rearranged, to follow as consecutively as possible the leading indications of each affection. About one-fourth or one-fifth of the matter is new, and the size of the work is considerably in- creased, in spite of efforts to prevent this. It is proposed, however, as a matter of greater convenience, to re- turn to two volumes, even two bulky volumes being deemed more convenient than four smaller ones. The indices have also been con- solidated, therefore, into two series ; and it is hoped by the editors that the present edition will meet the approval of the profession, both upon the ground of the scope and character of the material pre- sented and the manner of its presentation. The Editors. PREFACE TO THE EIGHTH EDITION. In presenting this work to the profession for the eighth time, every part of it has been subjected to a careful revision. All valu- able new material which has appeared since the last edition has been incorporated. The recent additions to the Materia Medica, large in number, and some of great importance, have been introduced, and their merits stated. These additions have unavoidably increased the size of the volume, and this in spite of the omission of the section on " Diseases of Chil- dren," which it is intended to make the nucleus of a special treatise on the same plan. This brings up the actual increment of new mat- ter to considerably more than a hundred pages, while all that is re- tained from former editions has been closely scanned, and much of it recast. A portion of this new matter has never before been published. It has been received in answer to an inquiry sent to a number of emi- nent physicians as to their most successful methods of treating vari- ous diseases^ and also from notes of hospital and clinical lectures. PREFACE TO THE SEVENTH EDITION. The present edition of this work is not a mere reprint of the last one. The whole material has been subjected to a close scrutiny, and the most recent writings on materia medica and therapeutics have been searched in order that no addition of moment should be overlooked. Some paragraphs have been dropped, others have been condensed ; but the additions, in spite of such condensation, have been so extended that in order to keep the volume within its previous limits, it has been found necessary to select a smaller type for the Resume of Remedies. By this change, the editors have been enabled to add several topics not previously treated, and many new names and references, to those heretofore given. Especial attention has been given to the periodical literature of the last few years, as so many valuable suggestions are sure to lie neglected in journals unless transferred to the more accessible form of a volume. It will be noted that this volume is confined to diseases strictly medical. Surgical diseases are treated in a similar manner in the companion volume on Surgical Therapeutics; while diseases of women and obstetrical complications are considered in the third number of the series, the Therapeutics of Gynecology and Obstetrics. PREFACE TO THE SIXTH EDITION. In presenting the sixth edition of this work to the medical public, the editor has endeavored to render it worthy the very favorable re- ception it has had, by subjecting it to a thorough and careful revision. The progress of therapeutics has been very marked within the last few years. Standard treatises on Practice, written by men still living, have, in many instances, become, in great part, obsolete. Watson and Wood, Aitken and TANNER, no longer represent the best ther- apeutics of the day. Their methods and their remedies have been largely superseded ; and the practitioner who would keep abreast of the advances made in his profession, must look to a more modern class of writers for his information. The recognition of this fact has led to many substitutions in the present edition. The monographs and treatises, as well as the numerous medical periodicals of the last year or two, have been carefully examined and collated, so as to render this work in reality what it professes to be — a treatise on modern therapeutics. At the same time, the effort has been made to exercise a judicious conserv- atism in regard to long-known and well-tried remedies ; and to avoid admitting what is new simply because it is new. EXTRACT FROM THE PREFACE TO THE FOURTH EDITION. This work stands alone, of its kind, in medical literature. It pre- sents the Art of Therapeutics in all its aspects, and divested of that barren theorizing which has been its bane. Acquainting the reader with the exact treatment of each disease by living clinical teachers and careful practitioners of several countries, it vastly widens his therapeutic resources, prevents him from becoming a routinist, and inspires him with confidence in the remedies he employs. So far from leading him to become a mere formularum prcB- scriptor, the diversity it exhibits teaches him independence of thought, while the care with which the indications calling for par- ticular remedies or combinations are given, awakens and instructs his powers of clinical observation. But this remark is not intended to belittle the value of definite formulae. The author has most wisely preserved these whenever possible. By skillful combinations, nauseous articles are rendered palatable, which is often no small matter ; ingredients of facile de- composition may be given permanence ; the labors of the pharma- cist are lightened ; and, more than all, the efficiency of pharmaceu- tical products may be very largely increased. The intelligent recognition of the last-mentioned fact may be claimed as one of the later advances of medical science. The poly- pharmacy of our forefathers in the profession has disappeared, not giving way to any nonsensical " law of the single remedy," as Homoeopathy advocates, but to a clear insight into the synergic action of remedies, by virtue of which a judicious combination of several drugs acts in a given direction more forcibly than any one of them singly. It is needless, here, to quote instances of this truth. They may be found in abundance in the pages which follow. TABLE OF CONTENTS. 17 20 21 30 36 ii 43 45 Preface to the Ninth Edition. Preface to the Eighth Edition. Preface to the Seventh Edition, Preeace to the Sixth Edition. Preface to the Fourth Edition. Table of Contents, I. DISEASES OF THE RESPIRATORY SYSTEM. Aphonia •. Notes on Remedies , Asthma Notes on Remedies External Measures 1 , Acute Bronchitis , Notes on Remedies , Chronic Bronchitis , , Notes on Remedies ,.. , 52 External Remedies , 57 Catarrh, Coryza, and Post-Nasal Catarrh 58 The Abortive Treatment of a Cold , . . , 58 General Treatment of Catarrh 61 Post-Nasal Catarrh 65 Notes on Remedies 69 External Remedies 71 Emphysema ., 72 Notes on Remedies 77 External Remedies , 78 H/EMOFTYSIS 79 Notes on Remedies 83 External Measures , 86 Hay Fever, Hay Asthma, Rose Cold, Autumnal Catarrh 87 Notes on Remedies ....,..., ,... 95 Laryngitis 95 Acute Laryngitis 95 Membranous Laryngitis .<.....>....,..«,....,., 97 Oedematous Laryngitis • . • 4 97 (xi) Xll TABLE OF CONTENTS. PAGE Phlegmonous Laryngitis 97 Chronic Laryngitis 99 Tubercular Laryngitis 'O' Notes on Remedies 103 Externa] Measures - 104 Phthisis 105 Acute Phthisis 105 Chronic Phthisis 106 Specific Treatment 107 General Treatment I2I Climate and Travel 129 Treatment of Complications 131 The Anaemia and Debility 131 The Cough 1 33 The Gastric Symptoms 134 The Diarrhoea 135 The Dyspnoea 136 The Fever 136 The Night Sweats 136 Notes on Remedies I gg Inhalations I^ External Remedies I^c Pleurisy 146 Pleurisy with Efifusion 147 Notes on Remedies , 140 Pneumonia 150 Abortive Treatment I co General Treatment 152 Notes on Remedies jco External Remedies 162 II. DISEASES OF THE CIRCULATORY SYSTEM. General Therapeutics of Heart Disease 164 Treatment of Secondary Affections of the Heart 1 69 Aneurism i^c Angina Pectoris '. lyg Notes on Remedies l3j Cardlac Dilatation 182 Notes on Remedies .' j g^ Cardiac Hypertrophy igc Notes on Remedies i gy Carditis, Endocarditis and Pericarditis igg Notes on Remedies I02 Rheumatic Carditis lo^ Fatty Degeneration of the Heart iqr Notes on Remedies loc TABLE OF CONTENTS. xiii PAGE Functional Palpitation and Other Derangements 196 Notes on Remedies iqg External Measures ion lRRiTABt.E Heart 200 Valvular Disease of the Heart 201 Notes on Remedies 206 III. DISEASES OF THE DIGESTIVE SYSTEM. Appetite, Loss of 209 Biliary Calculus 211 Notes on Remedies 214 Cholera Asiatica 216 Notes on Remedies 226 General Measures 230 Colic 230 Notes on Remedies 235 Constipation — Habitual 237 Notes on Remedies 246 Diarrhcea — Acute and Chronic 251 Notes on Remedies 259 Acute Diarrhcea 259 Sub-Acute and Chronic Diarrhoea 261 Dysentery 265 Acute Dysentery 265 Chronic Dysentery 270 Notes on Remedies 273 External Measures 277 Dyspepsia 279 aimacteric Dyspepsia 284 Notes on Remedies 280 Gastritis, Gastro-Enteritis and Enteritis 293 Notes on Remedies 297 External Measures 297 Gastric Cancer 298 Gastric Ulcer 298 Notes on Remedies • 3°S H^matemesis 3°7 Notes on Remedies 3°8 Hepatitis, Hepatic Abscess S°9 Hepatic Cierhosis 3" Notes on Remedies 3^3 Intestinal Worms 3i4 Taenia, Tape Worms 314 Notes on Remedies 3'9 Ascaris Lumbricoides, Lumbrici, Round Worms 3^2 Ascaris Vermicularis, Oxyuris, Thread Worms, Seat Worms 3^4 xiv TABLE OF CONTENTS. PAGE Notes on Remedies 32° Trichinae, Trichinosis 3^9 Jaundice 33° Catarrhal Jaundice 33° Notes on Remedies 334 Torpidity and Functional Derangement of the Liver 33° Notes on Remedies 337 Pyrosis 338 Notes on Remedies 339 Peritonitis 34° Typhlitis 34' Vomiting 342 Notes on Remedies 343 IV. DISEASES OF THE URINARY SYSTEM. Albuminuria 346 Notes on Remedies 350 Bright's Disease 352 Acute Bright's Disease ; 352 Notes on Remedies 357 External Measures 358 Chronic Bright's Disease 359 Notes on Remedies 370 External Measures 372 Diabetes Insipidus, Polyuria, Polydipsia 373 Notes on Remedies 376 Diabetes Mellitus 377 The Milk Diet Treatment 381 Notes on Remedies 383 Dropsy 387 Diuretics and Cathartics 390 Notes on Remedies . 392 External Measures 305 Functional Urinary Disorders 39c Incontinence of Urine 39c Dysuria 39g Notes on Remedies 395 HiEMATURIA 400 Paroxysmal Haemoglobinuria 403 Notes on Remedies 403 Nephralgia (Renal ColicJ 404 Ur/emia 406 Notes on Remedies 408 Uric Acid Diathesis 408 TABLE OF CONTENTS. xv V. DISEASES OF THE NERVOUS SYSTEM. General Therapeutics of the Nervous System 4,1 Apoplexy and Cerebral Hyper«ml^ 41 - Notes on Remedies .,, .................................. ^,23 General Remedies ..^ External Remedies -26 Cerebral Anemia ._., 427 Notes on Remedies -28 Chorea ^28 Notes on Remedies .^6 External Remedies . ,q Epilepsy ^, Inhalations ^q Mechanical and Physical Means 449 Notes on Remedies 450 External Remedies 455 Headaches ^cy Local Measures 457 Bilious or Dyspeptic Headache 458 Congestive or Plethoric Headache 459 Migraine, Hemicrania, Periodical or Sick Headache 461 Malarial Hemicrania 464 Nervous Headache 465 Rheumatic Headache 468 Gouty Headache 469 Anaemic Headache 470 Notes on Remedies 470 > External Remedies 473 Insanity 474 Hypochondriasis 474 Acute Insanity 476 Physical Restraint 480 Chronic Insanity 482 Notes on Remedies 483 Insomnia 484 Notes on Remedies 489 External Remedies 490 Neuralgia 491 Tic Doloureux 498 Sciatica. 500 Various Special Forms 503 Notes on Remedies 504 External Remedies 5'° Neurasthenla 514 Notes on Remedies S'S xvi TABLE OF CONTENTS. PACK Paralysis 5' ciS Electricity in Paralysis -> Notes on Remedies 5 9 External Remedies • 5 Progressive Locomotor Ataxia (Posterior Spinal Sclerosis) S^i Suspension Treatment ^ Notes on Remedies 5^3 External Remedies 5^4 Spasmodic Diseases 5^^ Vertigo S3' Notes on Remedies 533 VI. DISEASES OF THE BLOOD AND INFECTIOUS DISEASES. Anaemia 535 Chlorosis 535 General Symptomatic Anaemia 539 Pernicious Anaemia '• 54' Leukaemia 54^ Notes on Remedies 543 External Measures 544 Cerebro-Spinal Meningitis 544 Notes on Remedies 548 Dengue (Break-Bone Fever) 550 Notes on Remedies 55^ Gout 553 Mineral Waters 558 Notes on Remedies 559 External Applications > 561 Influenza, or La Grippe 563 Notes on Remedies , 567 Intermittent Fever (Ague, Chills) 569 The Personal Prophylaxis of Malaria 569 Hemorrhagic Malarial Fever ^gl The Anti-Quinine Treatment 582 The Treatment of Enlarged Spleen or Ague Cake 583 Notes on Remedies rg6 Purpura Hemorrhagica 594 Notes on Remedies ■ 596 Relapsing Fever cg6 Acute Rheumatism •. cgS Salicin and the Salicylic Acid Treatment -. 598 Lemon or Lime Juice Treatment 601 Alkaline Treatment 601 Notes on Remedies 609 Local Applications 611 TABLE OF CONTENTS. xvii PAGE Chronic Rheumatism 5, Notes on Remedies gj r Scurvy ^i» Typhoid Fever gjg Bath Treatment 610 Turpentine Treatment 623 Specific or Antiseptic Treatment 625 Typho-Malarial Fever 628 Notes on Remedies 629 Typhus Fever 633 Treatment by Cold Baths 636 Notes on Remedies 637 Variola — Small Pox 638 Notes on Remedies 641 To Prevent Pitting 642 External Measures 643 Yellow Fever 644 Notes on Remedies 65 1 VII. TOXIC DISEASES. Alcoholism (Intoxication; Delirium Tremens; Chronic Alcoholism) 654 1. Drunkenness 654 2. Acute Alcoholism or Delirium Tremens 657 3. Chronic Alcoholism 660 Notes on Remedies 665 Arsenicism (Chronic Arsenical Poisoning) 668 Opiism (Opium Eating; the Opium Habit) 669 Cocaine Habit 672 Mercurialism (Chronic Mercurial Poisoning) 672 Plumbism (Lead Poisoning) 676 THERAPEUTICS OF DISEASES OF CHILDREN. GENERAL REMARKS 681 Therapeutic Measures 693 Special Therapeutic Methods ^7 Alimentation ^7 Infant Feeding •. ^9^ Rectal Alimentation 7'5 Natural Mineral Waters 7'^ School Hygiene 7i8 xviii TABLE OF CONTENTS. FEVERS AND MIASMATIC DISEASES. PACE Typhoid Fever ' Treatment of Complications ' ^ , ........ 727 Scarlatina • ' Notes on Remedies ' ''*" External Measures ' 5^ Rubeola '^^ Notes on Remedies '59 Malaria ' Parotitis ' ^ Erysipelas ^ * New Methods of Treatment 7^6 Diphtheria •. 7"° Diphtheritic Paralysis 7°^ Notes on Remedies 79^ Croup 802 Notes on Remedies °" Intubation of the Larynx ^13 Catheterization of the Trachea 815 Tracheotomy in Diphtheria 8x6 Pertussis 8' 7 Notes on Remedies 828 Inhalations • 833 Scrofula 835 Syphilis (Inherited) 837 Notes on Remedies 847 Rachitis 847 Notes on Remedies 852 DISEASES OF THE RESPIRATORY TRACT. Acute Coryza 854 Pharyngitis 859 Tonsillitis 860 Laryngitis (Acute) 861 Laryngismus Stridulus 863 Pneumonla 866 Fleuritis 875 Empyema 880 Bronchitis 883 Bronchitis, Chronic 891 Notes on Remedies 892 Broncho-Pneumonia 893 TABLE OF CONTENTS. xix DISEASES OF THE ALIMENTARY TRACT. r. „ PAGE Stomatitis, Catarrhal g„- Stomatitis, Parasitic gq. Stomatitis, Aphthous g„6 Stomatitis, Follicular goo Stomatitis, Gangrenous gng Notes on Remedies gog Dyspepsia gg^ Diarrhoea, Acute go3 Diarrhoea, Chronic 503 Curative Treatment g,g Notes on Remedies 528 Cholera Infantum 931 Notes on Remedies 944 Dysentery 946 Constipation 950 Parasites of the Intestines 95 1 Intussuscfjtion 955 Prolapsus Ani 958 Notes on Remedies 959 Perityphlitis 960 Peritonitis 961 Pericarditis 963 Endocarditis 964 AHJBMIA 965 Notes on Remedies 966 Pernicious Anaemia 967 Chlorosis 967 h.emophilia 968 Chorea 969 Convulsions 972 Notes on Remedies 976 Hysteria 977 Pavor Nocturnus 979 Infantile Paralysis 983 Meningitis, Acute 985 Meningitis, Tubercular 988 Prophylactic Treatment 99° XX TABLE OF CONTENTS. PAGE Hydrocephalus 993 Notes on Remedies 997 External Remedies 998 Hydrocephalus, Spurious 998 Ophthalmia Neonatorum 1000 Incontinence of Urine 1003 Headache 1004 Eczema 1006 Local Treatment loi i Dentition 1012 PART I. DISEASES OF THE RESPIRATORY SYSTEM/ Aphonia— Asthma— Bronchitis, Acute— Bronchitis, Chronic— Catarrh — Coryza and Post-Nasal Catarrh — Emphysema — Hemoptysis Hay Fever, Hay Asthma, Rose Cold, and Autumnal Catarrh- Laryngitis — Phthisis — Pleurisy, Acute, Subacute arid Chronic — Piteumonia. APHONIA. The forms of aphonia usually encountered are (i) the catarrhal, (2) the hysterical, nervous or spastic, and (3) paralytic aphonia. The indications in each case are dependent upon the nature of the cause, the treatment of the inflammatory condition, and of the ner- vous state, either by nervous sedation in the hysterical state, or by careful nervous stimulation in the paralytic variety. In catarrhal aphonia and excessive hoarseness, DR. J. M. DA COSTA, PHILADELPHIA, states that the local application of the sulphate of zinc is often pro- ductive of permanent good. 1. R. Zinci sulphatis, gr-j-vj Aquje, f.|j. M. Use as an inhalation. Miiriate of ammonia is another efficient agent. 2. K. Ammonii chloridi, § ss Syrupi prun. virgin., i; § iij. M. A teaspoonful thrice daily. This can be advantageously supported by jV of a grain of strychnia thrice daily, to give tone to the relaxed laryngeal muscles. Nitre and Benzoin are efficient drugs in this variety. ♦ The subjects Empyema, Stomatitis, Pharyngitis, Tonsillitis, Tonsillar Hypertrophy, Ozsena and Rhinitis are treated in Napheys' Surgical Therapeutics. Diphtheria, Croup, etc., will be found under Diseases of Children. 2 (17) 1 8 DISEASES OF THE RESPIRATORY SYSTEM. DR. H. NICHELL, OF BUFFALO, has found great advantages from the following combination in catar- rhal aphonia: 3. R. Potassii bromidi, 3ij_ Extract! aconiti, gr.ij Ant. et pot. tartrat., grj Syr. pruni virgin., Aquas destill., aa f. § ij. A dessertspoonful every three hours until relieved. Dr. H. V. SWERINGEN, of Indiana, has used with advantage a combination of muriate of ammonia and cubebs, 5ij of the former and gtt. XXX of the tincture of the latter in a Svj mixture, of which a tablespoonful should be taken every three hours. N. GALLOIS, M. D., PARIS. 4. R. Immerse a piece of thick paper in a solution of nitrate of potassium, and dry it; then cover it over with the compound tincture of benzoin, cut it up into pieces 3i ^1 'i inches, and make into cigarettes. These cigarettes are highly praised in aphonia. PROF. O. REVEIL, M. D., PARIS. 5. E. Pulveris benzoini, § ss. Place a portion on some live coals, and inhale the vapor, by deep inspiration, in cases of aphonia and hoarseness. Common salt is often beneficial. 6. R. Sodii chloridi, g,_ y Aquadestil., f.lj f^_ Use with an atomizer. M. ROZIERE, PARIS. 7. R. Balsami tolutani, fXy ^ther. sulphuric, i^'isi. M. Put in a wide-mouthed bottle and inhale for a few minutes every half hour ih aphonia and excessive hoarseness. ' The German physicians use largely inhalations ol oil of turpentine, one to five drops to the ounce of water. It is also highly spoken of hy TROUSSEAU, Cohen and others. APHONIA. jg DR. G. M. LEFFERTS, NEW YORK, in his monograph upon the Treatment of Diseases of the Larynx Pharyx and Nasal Passages, 1884, commends in cases of aphonia occuring in chronic laryngitis the following vapor for inhalation : 8. R. Aquse ammonias, ^''"^' a f.3iv. M. A teaspoonful in a pint of water at 80° F. for each inhalation. Or it may be given in combination with any of the volatile oils, or camphor, as 9. R. Aquse ammoniae, fSiv ■"•y™"'. gtt. xij Kaolm aut Magnes. carb. lev., gr xij ^'l"*' q.s.adf.§j. M. In the latter prescription the kaolin or light carbonate of mag- nesia is necessary to hold the oil in proper suspension. The following vapor, of juniper, is also commended: 10. R. Olei juniperi anglici, TH xx Magnesii carbonatis, gr. x Aq"«. q.s. adf.ij. M. A teaspoonful in a pint of water at 140° F. for each inhalation. A serviceable inhaler may be readily m.ade from a bit of wide glass tubing (or other material if not. acted on by the drug), by saturating a bit of sponge, loose cloth, or cotton wool, with the in- halant, and placing in several inches in the tube, loosely plugging both ends of the tube for protection with a bit of cotton. Sir MORELL Mackenzie commends in the aphonias of the chronic laryngitis class, and those due to nervo-muscular weakness, a lozenge made of benzoic acid (^ grain in each) held in red currant paste, four or five being allowed to dissolve slowly in the mouth at the back of the tongue during the day. In hysterical or nervous aphonia, the inhalation of an anaesthetic sometimes gives prompt relief. Dr. RusSELL REYNOLDS has found benefit in blistering the larynx. But undoubtedly the most effect- ive treatment is the electrical. Both kinds of electric currents have given satisfactory results ; and when local applications fail, Dr. JOH. SCHNITZLER, of Vienna, has obtained prompt cures from galvaniza- tion of the nerve centres. {Medicinsche Presse, No. 22, 1875.) Locally, one may employ 20 DISEASES OF THE RESPIRATORY SYSTEM. II. R. Ferrichloridi, fi"j ,, Aqux. f-§J- M- For an inhalation. 12. R. Argenti nitratis, f^: ^■'•' Aquoe, 5 J- For an inhalation. M. Air, exercise, diet, and the daily shower-bath, are important aux- iliaries, and will often of themselves restore the voice. Subjecting the patient to complete anaesthesia will sometimes at once break up the neurosis. A number of cases of nervous aphonia are spoken of as depend- ing upon intra-nasal morbid conditions. (Vid. Revista Clinica e r^r^/^«/?Va, Naples, April, i888; London Lancet, Octdb^x 13, 1888; Arch, de Laryngologie , etc., November 15, 1888.) Women seem especially disposed, although it may show itself in either sex and apart from hysteria. The treatment in such cases is of course the removal of the cause for the reflex spasm or paresis, as growths on the turbinated bodies pressing on the septum, etc. Temporarily relief may be obtained by applying a solution (2-10 per c), to the nasal surface, of cocaine. Paralytic aphonia may also be treated by inhalation. Prof. Joseph PancoAST has used, with success, chlorine vapor, evolved by dropping slowly dilute muriatic acid into a solution of chloride of lime. Turpentine and tannin, in inhalation, may also be used. The correct treatment of this form is undoubtedly by electrisa- tion. Drs. Beard and Rockwell remark that there are few local disorders that yield more uniformly to any mode of treatment than aphonia to electrization. The current may be applied externally ; but the proper course is to use the faradic current, and make the application directly to the cords by means of laryngeal electrodes. NOTES ON REMEDIES. Alumen. Benati, formerly physician at I'Op^ra Italien, Paris, ordered the following prescription to restore the natural tones of the voice : I3- R- Aluminis, 'z\ Decocti hordei, f. g jjss. M. .To be used as a gargle, the strength to be gradually increased. The general health should be, at the same time, carefully looked after, and the exercise of the voice regulated. The internal administration of alum (gr. x a day, in divided doses, gradually increased to gr. xlv), has been also found very bene- ficial. Alum lozenges are indicated to complete the cure, and are efficient alone, in milder cases. APHONIA. 2 1 Ammonia. The inhalation of ammoniacal vapor, disengaged from a mix- ture of a solution of chloride of ammonia and carbonate of potas- sium, has given excellent results in aphonia in consequence of ex- posure to cold. The utility of inhalations of chloride of ammonium vapor, in these cases, has been tested by Dr. Beigel in a number of cases. {Practitioner, August, 1868.) Atropine, Dr. Robert Bartholow says, is almost sure to cure hysterical aphonia, if given to produce constitutional symptoms. Acidum Nitricum is very effective in the hoarseness of singers, when the aphonia is reflex from stomach disorder, and in fatigue of vocal cords. It should be given, well diluted, in sweetened water. Benzoinum, in vapor, is recommended by French physicians. (F. 4.) Benzoic Acid is used with benefit by Mackenzie. Chlorinum. Chlorine inhalations are serviceable in aphonia following an ordinary cold, without organic lesion. Jodinium. Iodine inhalations, and the application of the tincture of iodine to the fore part of the neck, are worthy of trial in cases arising from chronic thickening, or from debility and relaxation. Juniperus Anglicus is used in the form of the oil in vapor in the London Hos- pital for Throat and Chest Diseases. Quinines Sulphas. In all cases where the aphonia is intermittent in character, malarial poisoning may be suspected, and the free administration of quinine will be appropriate. Sodii Boras. According to Dr. J. W. Corson, {Medical Record, January, 1873) relief will often be given when the voice has been suddenly lost, by slowly dissolving in the mouth and partially swallowing a piece of borax, grs. iv-v. Znci Sulphas is of use, either locally applied, in solution, to the cords, or inhaled (F. i.) Zingiber. A ginger gargle, or a piece of the root employed as a masticatory, is often usefiil in aphonia from relaxation of the parts. ASTHMA. Many drugs are more or less beneficial in asthma; but what suc- ceeds admirably in one case, may fail completely in the next one, and the physician must resort to something else. Attention must be paid the fact that dyspnoea is not invariably due to true asthma, but occurs from cardiac fault or from uraemic toxication. The 22 DISEASES OF THE RESPIRATORY SYSTEM. diagnosis of true spasmodic asthma being made, certain common causes of reflex spasm must be eliminated, or, if found present, subjected to treatment or removal— such as intra- or post-nasal or pharyngeal morbid conditions. (The consideration of cardiac and uraemic dyspnoeas is reserved for the sections on Cardiac Disease and Uraemia.) Whenever possible, treatment should be directed to the cause ; and in all instances, hygienic rules should be insisted upon, especially diet : DR. JOHN C. THOROWGOOD, OF LONDON. Diet in asthma. This writer calls attention, in the Medical Press and Circular, 1884, to the importance of carefully regulating the diet in cases of asthma and bronchitis. An over distended stomach, by pressing on the diaphragm, may offer a mechanical impediment to free respiration, and may also interfere with the proper action of the heart. He mentions a gentleman who gained a great reputation for his ability to cure bronchitis and bronchial asthma by diet, and says that the great secret of this diet cure was judiciously starving the patient for a time. The stomach may be, to a certain extent, sluggish, so that it will not at the time feel any inconvenience from the excess of food forced upon it, but in an hour or two dyspepsia in some form will indicate the outrage that has been perpetrated. The food used should be nutritious, without being bulky. A lightly-boiled egg, the wing of a chicken, or some fish, with one cup of tea, coffee or cocoa, and toast, will form three alternatives of breakfast fare. Soups should be avoided at dinner, because they tend to distend the stomach. Vegetables should be used sparingly. Malt liquors, pastry, cheese and dessert should be rigidly eschewed, and for drink, claret with water, or lemon juice and water, may be allowed. Effer- vescing drinks of all kinds are not to be commended. By this ar- rangement of diet we keep up nutrition, while we avoid overloading the stomach, and so oppressing the diaphragm. The heart and lungs are enabled to act freely, and the danger of sudden stoppage of the first-named organ is put at a distance. ■ Lanphear (Kansas City Medical Index, December, '88), says that the principal means in the prevention of asthmatic attacks is that gastric digestion, be complete before the patient retires, that there may be no upward pressure from gastric flatulence. The evening meal is hence to be light, and it is advisable to omit as far as pos- sible sugar and starches. ASTHMA. 2? M. HUCHARD, OF FRANCE. uses the following when the symptoms of bronchial catarrh are added to the attacks of asthma : '4- R. Distilled water, Iodide of potassium, ^ ™ Tincture of lobelia. Tincture polygala, 55 ,0 Ex ract thebaic, .^ P„j, ^ A teaspoonful to be taken night and morning. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. In the treatment of the paroxysms of asthma, all nauseants have a certain influence in relaxing the bronchial spasms. Lode/ta inflata is particularly serviceable, because it acts both as a nauseant and expectorant. 'S- R- Tincturse lobelis, Tincturae hyoscyami, Spiritfls aetheris compositi, Syrupi tolutanti, aa f.|j. M. A teaspoonful in water every half hour, during the paroxysm, until some effect U produced on the breathing, and then every hour or two. Or one of the following combinations : 16. R. Spiritfls aetheris compositi, Extracti Valerianae fluidi, aa f. § j. Tincturae lobeliae, f. 5ss Potassii chloratis, 5iss .Syrupi tolutani, f. § j. M. A dessertspoonful in water three times a day. Direct, also, the following stimulating liniment : 17. R. Chloroforrai, f.gss Olei terebinthinaj f. § j Spiritfls rosmarini, f. § iss. M. To be rubbed on the chest several times a day. 18. R. Potassii iodidi, 3'j Morphije sulphatis, gr. | Tincturae scillae, Tincturae lobelise, Syrupi, aa f.§j. M. A teaspoonful thrice daily, in asthma with emphysema and chronic bronchitis. In order to prevent the recurrence of the paroxysms, too great care cannot be taken to inquire into the state of all the functions. In perhaps one-half of the cases, asthma is not a disease of the lungs, but a reflected trouble. In cases of stomach origin : 21. R. Morphinae acetatis, gr-M Atropinse sulphatis, gf- Ths Aquae, q. s. For one hypodermic injection in spasmodic asthma. .24 DISEASES OF THE RESPIRATORY SYSTEM. 19. R. Klulae hydrargyri, g^-^- At night, to be followed by one-half an ounce of Rochelle salts in the morning. Afterwards direct arsenic, combined with gentian or belladonna; as, 20. R. Liquoris potassii arsenitis, fa-- m Tincturse gentianae composita;, '• 3 "J- M. A dessertspoonful thrice daily. Opium and belladonna, or their alkaloids, morphia and atropia, have been extensively used. Dr. J. G. OuvER, of London, com- bines them in subcutaneous injection. M. The conclusions he reaches, are : 1. Morphia and atropia are superior to morphia alone; the good effect is more speedy and complete, and they produce no depressing gastric disturbance. 2. The very frequent use of the injection does not appear to injure the general health. 3. Speedy relief. The effect is generally declared in five minutes, in the form of comfortable sleep and quiet breathing. The most intense attack has given way completely in from fifteen to twenty minutes. (^Tke Practitioner, ]znna.ry, 1876.) DR. LECLERC, FRANCE. 22. R. Extract! belladonnae,- gr. xv Myrrhae pulveris, Ipecacuanhae pulveris, aa 3ss. M. Divide into thirty-six pills. One thrice a day, in nervous asthma. Nitre paper to be burned in the chamber of the patient, and stramonium leaves to be smoked. N. GALLOIS, M. D., PARIS. 23. R. Extracti opii, gr. a_iss Belladonnae foliorum, , 3j. Dissolve the extract in a small quantity of water, and then moisten the belladonna leaves with this solution; dry them, and roll into cigarettes. Trousseau substitutes for the belladonna leaves, stramonium leaves. Such cigarettes are useful in nervous asthmas and dry coughs. DR. POULET (Bull. Med. des Vosges, April, 1889). Dr. PoULET has found oxalic acid a remedy of importance in asthma and bronchial dyspnoea. It ASTHMA. 25 prevents the crisis when it is employed some hours before the in- vasion ; and is useful in the midst of the attack. 24. R. Acidi oxalici, jsj Syrupi aurantii corticis, f. § jj Infusi thete, f^gvj. M. Sig. — Tablespoonful every hour until relieved. In cases of epileptic asthma {i. e., where these conditions are as- sociated) described by this writer, he has had excellent results from the use of bromide of potassium. DR. R. B. FAULKNER, OF NEW YORK. In pure spasmodic asthma this writer (Med. Record, 1883,) advo- cates a treatment by painting a strip of iodine over the course of the pneumogastric nerves in the neck. He gives three cases of pure spasmodic asthma, which were relieved of their attacks by this means, after having resisted every other remedy of which he could think. Dr. Robert Saundby, of England, subsequently tried this method, and reported excellent results from it in the British Med. jFournal. PROF. FELIX VON NIEMEYER, GERMANY. Among medicaments especially in repute for the prevention of new paroxysms, and for the radical cure of asthma, quinine stands first. The shorter and more regular the intervals of the attack, so much the more is to be expected from this drug. It is unsuitable when the pauses between the seizures are very long or irregular in their occurrence. In such cases we must have recourse to other remedies from the list of the so-called nervines. As a rule, the metallic nervines are to be preferred before tincture of valerian, assafoetida, castor or camphor. The following may be used: 25. B- Ferri carbonatis, Syrupi, For twenty pills. One thrice daily. 26. B. Zinci oxidi, Syrupi, For twenty pills. One thrice daily. 27. K- Argenti nitratis, Confectionis rosae, For twenty-four pills. One thrice daily. 3j q.s. M, gr. XXV q.s. M, gr. iij-iv q.s. M, 26 DISEASES OF THE RESPIRATORY SYSTEM. The iodide of potassium was a favorite with PROF. ARMAND TROUSSEAU, PARIS. 28. R. Potassii iodidi, SiJM Spiritus vini gallici, f I -^ f.|j. M. Decocti senegae, Syrupi papaveris, In essential asthma, give a tablespoonful twice a day, an hour before the meals, in s little sweetened water. During the attack, the tincture of lobelia may be administered, in doses of from twenty to thirty drops, from half-hour to half-hour. The respiration of chloroform is also useful ; also stramonium ciga- rettes. PROF. GERMAN s£e. {nUnion Med., March 6, 1883), regards asthma as made up of three elements : Nervous, catarrhal, and emphysematous. When the latter condition is unduly prominent, we have permanent asthma. His method of treatment, for which he claims excellent results, consists in the exhibition of full doses (thirty to forty-five grains per diem) of iodide oi potassium. Under its continued use for some length of time, the asthmatic exacerbations disappear, and the per- manent dyspnoea is greatly lessened, if not entirely controlled. It is sometimes useful to add from three-fourths to one and one-half grain of opium to the daily dose of the potassium salt, to prevent iodism. Dr. Williams also highly favors this remedy (^Am. Jour. Med. yii., August, '88). He believes its good effect to lie in its action in reducing enlarged bronchial glands. The indications in his opinion are the absence o( catarrh, presence of a marked neurotic element, and dullness on right or left edge of the first piece of the sternum or in both interscapular regions, showing enlargement of the bronchial glands. He combines arsenic with the iodide of potassium, with much benefit. During the paroxysm, however, M. See employs the iodide of ethyl, a substance discovered in 1825 by Gay-Lussac, and com- posed of iodine and ether, the new compound possessing the respect- ive properties of both these substances. He administers it by inha- lation, and he has often found that a single dose of five or six drops has been sufficient to cut short a paroxysm. The breathing once relieved, he then trusts to the iodide of potassium to effect a cure. The above treatment has been found useful in all cases of asthma, whatever their origin. ASTHMA. 27 DR. WILLIAM M. WELSH, OF PHILADELPHIA, has found the following compound of great benefit in asthmatic cases : 29. R. Potassii nitratis, 2 J parts Belladonnae fol. pulv., ^ part Stramonii fol. pulv., 5 parts Sacch. alb., ^ part. Dissolve the nitre in just enough water to make a saturated solution, mix with the leaves, dry the mass into a coarse powder, and add the sugar. A small quantity is to be placed on a tin plate and ignited, and the smoke inhaled. J. S. MONELL, M. D., NEW YORK. Our author recommends (^New York Medical Record, August 15, 1Z66,) forced expiration and inspiration, for the relief of spasmodic asthma. He directs that all the air be expired that it is possible for the patient to do, and not to inspire until it is found absolutely neces- sary. Then carry inspiration to its fullest capacity, and retain, with great effort, for many seconds. This act of forced expiration, wait- ing, thorough inspiration, and again waiting, should be continued for some fifteen minutes, when it will be found that the spasm is relieved. It requires great exertion on the part of the patient to perform this act. The first attempt at retaining the inspired air, during the asthmic attack, will cause the patient to think he cannot continue it, but perseverance will soon delight him with relief from the spasm. A general estimate of the value of the various remedies in asthma, is given in his classical treatise by HYDE SALTER, M. D., LONDON. Coffee relieves about two-thirds of the cases in which it is tried. The relief is very unequal, often merely temporary, sometimes very slight, sometimes complete and permanent. The following are val- uable hints on its administration : i. It cannot be given too strong. 2. It is best given without sugar and milk — pure cafe noir. 3. It should be given on an empty stomach. 4- It seems to act better if given hot — very hot. Lobelia is given by Dr. S., in the form of the tincture, in repeated doses, every half hour, increasing the dose "l v each time, till either the physiological effects (faintness, sickness,) are manifested, with or without relief, or that relief is obtained without such symptoms. 28 DISEASES OF THE RESPIRATORY SYSTEM. In either case, the medicine is to be at once discontinued. Gener- ally, no relief takes place until symptoms of lobelia poisoning show themselves. Any amount may be given, short of producing the effects, without any relief at all. The quantity required differs in each case— generally, "ll-lx suffice ; in others, f.5iss fail to produce an effect. When once the necessary dose has been ascertained in this way, the patient should start with it on the next occasion, which generally has the desired effect at once. Iodide of potassium entirely fails in a great many cases. Some- times, however, the most striking results attend its use. It often requires to be continued for some time before it begins to manifest its effects. It should be used in every case in which it has not been tried, because of its occasional great value. Quinine is the best of all tonics in asthma; next to it \s iron. The two may be combined with a mineral acid and given with good results. Stramonium is, in some cases, the remedy; in the majority of cases, as ordinarily used, it does some good : and in some few it is positively injurious. Its value in any case can only be ascertained by personal experience. When the leaves and stems fail, substitut- ing the seeds may prove effectual. They appear to be more power- ful in their action. The inhalation of the smoke, and swallowing the saliva, may be advantageously combined with the ordinary method of smoking. The earlier in a paroxysm it is had recourse to, the more likely will it be to relieve the spasm ; over one that has been long established, it has but little power. As the great thing is to give it in time, an asthmatic should keep his pipe all ready filled, with the means of lighting it by his bedside, so that on waking with dyspnoea, he may immediately use it. A good plan is to adopt the habit of smoking a pipe of it the last thing at night, whether a paroxysm is threatened or not. -The extract (gr. y^, gradually in- creased to gr. j,) sometimes produces excellent effects, or the tinc- ture ("Lx— XX every four hours) may be substituted. Tobacco smoking affords, in some cases, remarkable ease. The habit of smoking has rendered powerless, in a large number of cases, what may, without any qualification, be called its most potent remedy. Chloroform inhalations, short of ancestkesia, are often of benefit, and may be used in all cases. Of the later remedies eitrate of caffeine is prominent, given in ASTHMA. 2Q dose of gr. i-v in warm water. It is said that the relief from the use of the drug is very prompt. Quebracho is a remedy several years since in excellent repute as a new remedy. Its action is, however, irregular; sometimes being of marked service, it not infrequently produces very indifferent re- sults. It is especially indicated in the purer forms of the malady. Cocaine, in pill or tablet form, in doses of gr. yi-y^, will often give prompt relief. Antipyrin is often at first able to cut short an attack, but the drug loses its effect sqon ; and it would seem from the experiences pub- lished that subsequent attacks are not infrequently much heavier in consequence of its use. Pyridin. About a drachm of the drug is placed on a hot plate in a room, the patient visiting it every few minutes, inhaling the vapor. The drug soon loses any efficiency it may have had at first. DR. ILLINGWORTH {Med. Press & Circtdar, July 24, 1889). Dr. ILLINGWORTH looks upon spasmodic asthma as due to central venous congestion. With this view the indications are to stimulate the heart, prevent conges- tion, and contract the central and dilate the peripheral blood vessels. To this end he employs for the first two indications the carbonate or acetate of ammonia and the iodides or nitrates of potassium or sodium, also alcohol, and for the third belladonna. 30. R. Ammonii carhonatis, Potassii iodidi, aa 3ij-i'j Tincturse belladoniiEe, f. 3 j Spiritus vini Portensi, f. § ij Aquse, ad f. 5 iv. M. Sig. — ^Teaspoonful in water before retiring, and in intervals of eating. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. Asthma, when purely spasmodic, is usually quickly checked by inhalations of amyl nitrite. The paroxysms of difficult breathing which accompany emphysema and cardiac disease are not relieved in this way; indeed, the author has known the most serious distress to be produced by the inhalation under these circumstances. Some cases of spasmodic asthma are much relieved by nitro-glycerine. One minim of a one per cent, solution is the dose.* In uraemic * It should not be forgotten that the alcoholic solution will explode if struck with a wet hammer. so DISEASES OF THE RESPIRATORY SYSTEM. asthma and chronic bronchitis, with asthmatic breathing, quebracho has afforded very considerable rehef. It is much less useful, if not injurious, in the dyspncea from valvular disease of the heart, and has had no effect in the dyspnoea of old persons, due to atheroma of the vessels. The preparation most used is the extract, and the adult dose is five grains. In asthma with profuse expectoration [humid asthma] pilocarpine has been very successful. According to Berkhart, when injected subcutaneously, it will arrest the most violent paroxysms of spas- modic asthma, and the relief persists for some time. In humid asthma Dr. B. highly lauds the following: 31. R. Tinct. sanguinarias, 3j Tinct. lobelise, 3j Ammonii iodidi, 3j Syr. tolutani, 3yj. M. S. — A teaspoonful every two, three or four hours. The same formula may be used in spasmodic asthma. DR. WEILL (Z« France Medical, March 8, 1888). Weill has the patient inhale pure carbonic acid gas from five to ten minutes at a time, using from 4 to 10 pints of the gas twice a day. It seems to cut the paroxysms short when given during the attacks, and the palpitations following are diminished. Used between the attacks it prevents their fre- quency and severity. The inhalation is of the gas given off from a glass containing bi- carbonate of sodium and tartaric acid in effervescence. The relief is often for hours and days, and in no wise does the treatment seem any but an innocent one. In order to manufacture the gas, a flask suitable for the purpose, with rubber tube fitted for inhaling, is partly filled with water ; and about four drachms of soda and three of tartaric acid are added. These quantities suffice to give off 4 or 5 quarts of the gas. The rubber tube placed in the mouth, inhalation is easy from the out- ward pressure of the gas. The method of Bergeon [see Phthisis] is also of value in cases of humid asthma. NOTES ON REMEDIES. ^ther by inhalation is sometimes resorted to \vith benefit in asthma. The following formulas have been recommended : ASTHMA. 3 1 32. R. i^theris sulphurici, 30 parts Acidi benzoici, jr « Balsarai Peruvian!, 8 " M Or the following : 33- R- j^theris sulphurici, 2 parts Spiritus terebinthinoe, 15 >■ Acidi benzoici, I c « Balssimi Peruviani, g « jj. Place the mixture in a vessel having a large opening; the warmth of the hand is sufficient to volatilize the materials, and inhalations maybe used four' or more times a day, as occasion demands. Ammonii Carbonas has proved (in doses of gr. x-xv) more successful than any other remedy, in the hands of Dr. J. Hope, in cases of asthma arising from, or connected with, disease of the heart. In a very ob- stinate case, the following afforded much relief: 34. R. Ammonii carbonatis, gr. vij Antimonii et potassii tartratis, gr. J^ Aquae anjsi, f. § iss. M. A draught to be taken every alternate hour. Ammoniacum is of great service in both spasmodic and hysterical asthma. In the former case it should be combined with tincture of squill and a small portion of hyoscyamus or conium ; in the latter, with equal parts of assafoetida. Plasters of ammoniacum applied to the chest often prove useful. Antipyrin is often of value if given in comparatively large doses (gr. x-xx every three hours) ; in employing it caution is to be had less it depress too severely. Apomorphia given hypodermically in dose of gr. yi-yi produces beneficial effects from the relaxation following its employment. It is usually necessary to bring on vomiting by the drug before its best effects are noted. Aqua Ammonia (four parts to one of water) applied to the velum palati, has proved of service in simple idiopathic asthma. This application, which may prove dangerous, is only to be made, if at all, with great caution, so as not to touch the back part of the pharynx. The inha- lation of the vapor of aqua ammonias is useful. Arsenicum is recommended by Dr. Handfieud Jones and others, but is inad- missible in organic disease of the lungs and heart. Dr. Martelli, of Florence, claims excellent results from hypodermic injection of Fow- ler's solution, one part to two of water. Dr. Thorowgood {Med. Times, 1883,) says : " I know of no drug so generally useful in the treatment of asthma as arsenic, and could give, from fifteen years' ex- perience, a great many cases of spasmodic asthma that have seemed 32 DISEASES OF THE RESPIRATORY SYSTEM. to me to get quite well under the influence of small doses of arsenic. I have never exceeded the dose of three minims of either Fowler's solution or of liquor sodse arsenitis three times in the day, and have never seen any symptoms of a dangerous character." Aspidosperma Quebracho. The good effects of this new drug in spasmodic asthma appear to be well established by the observations of Dr. Pen- ZOLDT and others. Dyspnoea in all forms is often relieved by it. The drug has been difficult to obtain heretofore in this country, but at present several preparations of it are manufactured by Parke, Davis, & Co., Detroit. The dose of the fluid extract is .^ss. Aspidospermine. This is the alkaloid of quebracho bark. Dr. Maragliano {Land. Med. Record, 1884,) uses gr. ^ for hypodermic injection in cases of asthmatic dyspnoea. Relief is felt in about five minutes. Assafcetida, in combination with other antispasmodics and with narcotics, is often very beneficial in spasmodic asthma. 35- R- Tincturse assafoetidae, f. 3s3 Tincturse opii, HI xx Spiritus Eetheris compositi, f. 3 ss Aquae camphorae, f. § iss. M. For one draught. Belladonna is a valuable remedy in spasmodic asthma, administered in the manner directed by Dr. Hyde Salter, viz., in one full dose, sufficiently large to produce the full physiological effects of the drug, every night at bedtime. This plan he regards as infinitely superior to the system of divided doses during the day. As there is a marked difference in the tolerance of belladonna in individuals, the proper dose may be as- certained by commencing with small doses and gradually increasing them until the requisite full dose is ascertained. Bromides relieve in purely spasmodic asthma, but soon lose their effect. Camphora is recommended by Dr. Copland as one of the most generally beneficial in any of the class of narcotics or antispasmodics. In nerv- ous and spasmodic forms of asthma it should be given in large doses, (gr. iij-x,) and combined with musk, castor, assafcetida, etc., or with sedatives. Cannabis Indica is said to occasionally prove very beneficial, but in the hands of Dr. Hyde Salter it has been a complete failure in the few cases in which he employed it. Dr. Emil Koller has, however, found it val- uable in nocturnal asthma, in doses of gtt. v-vj of the tincture every three or four hours. Carbonic Acid Gas inhalations are recommended by Weill and others. Casioreum, combined with ipecacuanha (equal parts of the tincture of castor and the wine of ipecac) is recommended by Dr. Graves. ASTHMA. 33 Caffea is an efficacious remedy. For its administration, see directions above, (p. n) ; its alkaloid is also of value. Chloroformum by inhalation is an excellent and prompt remedy for spasmodic asthma. Chloral is recommended by many writers as efficient in most cases of asthma, but should be used only in those instances not associated with organic cardiac or renal affections. Cocaine, given internally or by injection, occasionally gives excellent results in neurasthenic asthma. Datura Tatula is said to be of great efficacy smoked in cigarettes. Digitalis has been employed, but is inferior in efficacy and safety to other remedies, except in the cardiac form, where it is often the main remedy. Dracontium sometimes succeeds (in doses of gr. xxx-1 of the powdered root during the paroxysm) in obstinate cases of spasmodic asthma. Euphorbia pilulifera. This plant, obtained in Queensland, may be taken in decoction or extract, and is said to relieve severe attacks of chronic bronchial asthma. (Beck, Therapeut., 1884.) Masset and See have found that it acts on the nervous centres, the respiratory and cardiac, first stimulating and then depressing. In cardiac and anaemic asthma it has little value, but in purely nervous asthma its good properties are brought out. Grindelia Robusta. The plants and flowers of this native of the Pacific coast have been much lauded of late in spasmodic asthma. One drachm of the fluid extract may be taken when the paroxysm comes on, or half a drachm three times a day as a prophylactic. Grindelia cigarettes are made as follows : Impregnate well-nitred tobacco with an alcoholic fluid extract of grindelia ; let dry and use in cigarettes. Owing to the nitre, they will continue to glow and to develop smoke. Hyoscyamus is, according to Dr. Harley, the appropriate remedy in cardiac and pulmonary asthma. It is best administered subcutaneously. Its alkaloid in the form of the hydrochlorate may be given hypodermically with benefit in doses of liii-rw grain. lodum. In cases of dry asthma, of constitutional character, without ob- vious exciting cause. Dr. C. K. L. Reed, of St. Louis, recommends, in the Clinical Record, 1879, the following prescription: 36. B- Liquor iodi comp., f-3j. Mellis, f-3'J- M. Teaspoonful every three hours. He finds that the use of this is promptly (after the third dose) fol- lowed by a restoration of the secretion, diminution in the frequency 3 34 DISEASES OF THE RESPIRATORY SYSTEM. and severity of the paroxysms from the start, an improvement in the appetite, and an increase in the tone and vigor of the general system. Ipecacuanha, in full emetic doses (not less than gr. xx), is often effectual in arresting a paroxysm of spasmodic asthma, if given at or near the outset of the attack. Proportionate doses to children may be given with safety and advantage. Small doses of the wine (n^v) repeated every ten to thirty minutes for two or three hours, unless relief comes much sooner, in which case the dose may be diminished and taken less frequently, is a method of treatment recommended by Dr. C. D. PHir.LiPS, {Practi- tioner, November, 1869,) in nocturnal spasmodic asthma, when there is no organic disease of the heart or lungs. Lobelia. Dr. Hyde Salter reports favorably of the tincture, (.p ir.) Dr. Ringer, while regarding it as a remedy of great efficacy, considers that it should be given with caution where heart disease exists, as the pulse may become irregular and very weak. It should also be remembered that some persons exhibit great intolerance of its action, poisonous effects following the smallest doses, and that different specimens differ considerably in strength. Moschus, in doses regulated according to the severity of the attack, is often productive of benefit in purely spasmodic or nervous asthma. It has also been applied endermically (gr. vj-xv) with advantage. Nitrite of Amyl. Cases have been reported in which the inhalation of five drops of this liquid has arrested very distressing attacks of spasmodic asthma. Nitrogen. Dr. Edgar A. Holden recommends nitrogen inhalations. {Amer- ican Jour, of the Med. Sciences, October, 1872.) The following is the method adopted with the protoxide : The gas, fresh and pure, is passed through a jar containing a fluid extract of conium. Calabar bean, or belladonna, according to the necessities of the case ; and from this jar is inhaled by the patient once daily, before retiring, and for four or five consecutive days, the quantity varying according to the condi- tion of the patient, but not exceeding five to eight gallons, never to anaesthesia, the sitting occupying at least ten minutes. Relief almost always follows the first inhalation, and produces an uninterrupted night's rest. Upon the disappearance of the nightly paroxysm and the sub- sidence of all oppression in breathing, the remedy must be discon- tinued, but must be instantly resorted to upon the first evidence of return. Opium is of questionable value in asthma. Dr. Hyde Salter says : " Prefer any other sedative to opium ; and unless there is some special compli- cation that indicates it, never give it at all." Oxygen Inhalations have been tried with reported " wonderful" results in ner- vous asthma. ASTHMA. , c Paraldehyde in doses of half a drachm has been found of value in cutting short an attack, by Dr. Scott. (O-imes and Register, August 15, 1889) . Petroleum. Dr. H. V. Sweringen, of Indiana, reports that in asthma he has derived the most benefit from the administration in half teaspoonful doses, gradually increased, of an emulsion of petroleum. Pilcocarpine is highly recommended by Bartholow in spasmodic asthma. (See above.) Potassii Bromidum, in fijU doses, at night, has been recommended in spas- modic asthma. In the spasmodic asthma of childhood, given in syrup, in doses of gr. vj every two hours, it has proved very successful after the failure of other remedies. Potassii lodidufn is an uncertain remedy, which sometimes, however, proves strikingly successful. Potassii Nitratis. The inhalation of the fumes of paper impregnated with nitre, is often of striking benefit. The following formula is given in the Journal de Pharmacie et de Chemie : Take four ounces of white paper, and allow to macerate in warm water, until reduced to a uni- form paste. Then press out the greater portion of water, and mix the residue in a mortar with the following powder : 37- R- Potassii nitratis, § ij MyrrhiE, Olibani, 5i 3ijss Belladonnse, Stramonii, Digitalis, 5i gr. x. When a uniform mass has been formed, roll into sheets a line or so thick, dry, and cut into strips. This paper is said to bum less quickly than the ordinary nitre paper, and to be more effective. On account of the unpleasant odor of the burn- ing paper. Dr. R. E. Thompson {Practitioner, April, 1879) recommends the following formula as a basis for a medicinal cigarette : 38. R. .Swedish filtering paper, size, 4 in. x 2)^ in- Potassii nitratis, gr. 3^ Tinct. tabaci, TUx Olei anisi, "l^S- The tincture of tobacco is made with § 2)^ of the leaf to a pint of spirit. A solution of any drug which is to be experimented on, can then be prepared, and the paper, having been floated through the solution in a flat dish, when dry, can be cut into a certain size, and the dose thus accurately measured. Quinice Sulphas is highly recommended by Drs. Niemb:yer and Hyde Salter. (See above.) Flint says that gr. xx-xxx at one dose, will often break up a paroxysm. Quebracho is recommended by Dr. Roberts Bartholow. (See above.) Sanguinaria has been prescribed with good effects. Dr. L. B. Anderson, of Virginia, gives it as in croup, until vomiting occurs. It rarely fails to give prompt and grateful relief. As a preventive, he continues it in doses of 20 drops of the tincture three times a day. (Southern Med- ical Record, February, 1876.) 36 DISEASES OF THE RESPIRATORY SYSTEM. Scilla. Benefit is sometimes derived from squill, combined with hemlock or henbane. The following formula is often useful : 39- R. Tincturae scillEC, gtt. xv Extract! hyoscyami, gr- "J Acidi nitrici diluti, Mlxxx Aquse, f.3iss. M. For one dose. Spiritus /Eiheris Compositus. Hoffman's anodyne is of extreme value in the asthma of old people, where emphysema and chronic bronchitis are associated. It is given in doses of half a teaspoonful or more, as re- quired. Stramonium. (See above.) Strychnine is indicated when there is weakness of the respiratory muscles. Sulphur, in doses of about gr. viij daily, to be given while fasting, and perse- vered in for a long period, has been recommended by French physi- cians. Tabacum. The palliative effects of tobacco fumes, in nervous asthma, are well known. Veratrum Viride has been advised in nervous asthma. The following formula is said, by Dr. J. L. Cook, to give admirable results when other rem- edies fail : 40. R. Tinct. veratri viridis, gtt. xxxvj Morphias sulphatis, gr. j Syrupi ipecac, f. 5^. M. A teaspoonful every three hours, if necessary. (^Louisville Medical News, April, 1 876.) Zinci Oxidum is strongly recommended by Dr. Symonds, (British Medical News, June 13th, 1868,) who states that, whether for abating the mor- bid susceptibility of the respiratory nerves which engenders the spas- modic paroxysms, or for diminishing the liability to catarrhs, he knows nothing to surpass long courses of the oxide of zinc, with or without extract of conium for the one indication, and quinine for the other. It is also recommended by Dr. Niemeyer. Zinci Sulphas has been employed, with the result of diminishing the frequency and force of the attacks. Zinci Valerianms is sometimes prescribed. EXTERNAL MEASURES. Acetum applied as a bath over the chest every morning is more or less a measure of prophylaxis against the attacks. Cold Bathing, employed in the intervals of the attacks of spasmodic asthma, is stated to lessen the morbid sensibility to the impression of cold atmospherical changes, and to give tone and vigor to the system. ACUTE BRONXHITIS. 37 Simply sponging the body is preferred by some to immersion ; salt (gj, to water Oj) may be added, and a rough towel or flesh brush em- ployed. The best time is immediately after.getting out of bed in the morning. The shower-bath is preferred by Sir T. Watson. Electricity has been employed in some cases, but Dr. Hyde Salter con- demns, altogether, its use. Galvanization of the pneumogastric has been tried by Bartholow with doubtful results. Professor Munter, of Russia, recommends excursions of three or four hours daily upon salt water, as of the greatest value. Grunert (Die Behandluns; des Lung emphysemas tmd Asthmas mittelst des Athmungsstuhles — Halle a. S. : Kaem merer & Co., 1889) describes a chair so arranged by means of levers and bands as to exert pressure on the thorax, the intra-abdominal pressure being increased by the pressure of a broad band. The effect is to aid forced respiration, by driving out a large amount of the increased residual air in the vesicles, and opening the way for a larger amount than usual of oxygen. It is stated that in a very short while the dyspnoea disappears. ACUTE BRONCHITIS. JOHN SYER BRISTOWE, M. D., LONDON. The treatment is, (i) Hygienic; an equable temperature, about 65°; moist atmosphere; hot foot-baths; regulated diet. (2) Local; mustard plasters, or dry cupping to the upper chest ; inhalations of steam, simple or medicated, (i) Medicinal. The expectorant or' nauseating drugs, combined with the narcotics and sedatives. A combination of ipecac, squills, and small doses of opium, is very serviceable in earlier stages. Later, when the bronchial secretion becomes abundant and muco-purulent, this may be replaced with a more stimulating mixture. That recommended by Dr. STOKES is very efficacious, namely, carbonate of ammonia, senega, and opium. The balsams and gums and resins are also valuable in this stage. In protracted cases and during convalescence, tonics are called for. DR. FENWICK (Hand-book of Prognosis and Treatment.) In adults examine for phthisis, emphysema, heart disease, chronic disease of the kidney, and if any of these be present modify treatment accordmgly. For example, in dilatation of the heart, you will most likely require to 38 DISEASES OF THE RESPIRATORY SYSTEM. . prescribe digitalis ; in diseased kidneys, active purgatives. In chil- dren examine the teeth and the state of the evacuations. If the teeth are projecting, lance the gums ; if the stools seem to be dis- ordered or the bowels confined, prescribe a dose of calomel. If the symptoms are at all threatening or severe, maintain the room at an even temperature (65° to 68° F.), and encourage secretion from the mucous membrane by filling it with steam. Your remedies will require to be varied according to the age of the patients and the part of the bronchial mucous membrane in- flamed. In adults, where the larger tubes alone are affected, you may prescribe small doses of tartar emetic : 4'- R- Vini antimonii, f. 5ij Liquoris aramonii acetatis, f. § j Syrupi tolutani, f. 3vj Aquae, f.fiv. M. Sig. — ^Teaspoonful to a desertspoonful every four hours. Or ipecac, in combination with diaphoretics, until expectoration begins : 42. R. Solutionis ammoDii acetatis, f. 3 ij Vini ipecacuanhse, TT^xx Aquae, adf.gj. M. Sig. — Teaspoonful to dessertspoonful every four hours. When the symptoms are only slight, chloride of ammonium, with or without tartar emetic, is valuable : 43- R- Ammonii muriatis, g,. , Spiritds chloroformi, Tl\.ia. Vini antimonii. m^ Aquae camphors, adf.|j. M. Sig. — ^To be taken every four to six hours. Where much soreness is complained of a linseed or mustard poul- tice may be ordered, or in case of adults an opiate liniment may be rubbed on the chest. In capillary bronchitis, even in adults, tartar emetic is to be avoided because of its tendency to depress. Dry cups to the chest may be of advantage. Mostly stimulants are required, as carbonate of ammonia. 44- R- Carbi-nate of ammonia, ~ jy Decoction of bark, f i : „ Sig. — One dose, every three or four hours. Or infusion of senega, along with small but repeated doses of alcohol : ACUTE BRONCHITIS. 39 45- R. Ammonii carbonatis, „_ jy Spiritfls chloroformi, p^xv Infusi senegEe adf.gj. m. Sig. — One dose every three or four hours. When the larger tubes alone are involved, the treatment is to be changed as soon as the secretion becomes loose and copious. Small doses of squills, paregoric and senega form the most appropriate treatment. 46. R. Tincturae opii camphoratse, tUxv Tincturae scillse, Hjx Infusi senegs, ad f. | j. M. Sig. — One dose every three hours. In bronchitis of the larger tubes in adults a sedative draught of chloral, or some Dover's powder, may be given at bedtime to pro- cure rest. Where there is capillary bronchitis opiates should be used with caution, and avoided in children or where the secretion is excessive. As in all other inflammations, the diet should be light, and as much as possible, liquid. The patient should be confined in an equable temperature, and in severe cases put to bed. PROF. M. CHARTERIS, M. D., GLASGOW. In his Hand-book of the Practice of Medicine, 1878, this writer states that during the early or catarrhal stage, bronchitis may be aborted by a full dose of opium in wine whey. If the fever is too intense for this, give a hot bath, followed by a weak saline mixture. As an expectorant: 47. R. Oxymel. scillae, 5ss Spir. aeth. nitrici dulc, Tinct. camph. comp., aa f. 3j Mist, amygdal., f.3j. M. This amount every six hours. If a gouty dycrasia is present, add colchium to this. For local applications, sinapisms, hot water and turpentine stupes, and jacket poultices of linseed meal, are valuable. The following is useful in children : 48. R. Vini ipecac, f.3iss Syrupi simp., f- 3 ss Tinct. camph. comp., f- 3 iij Liq. ammon. citrat., f- 3 " Aqure, adf.fij. M. A teaspoonful every two hours, in the febrile stage. 40 DISEASES OF THE RESPIRATORY SYSTEM. The wine whey, above referred to, may be made as follows : 49. To half a pint of boiling milk add one or two wineglassfuls of Sherry or Madeira. Separate the curd by straining through a fine sieve or piece of muslin. Sweeten the whey with refined sugar. The following is a useful and agreeable demulcent drink : 50. R. Extracti sarsaparillae fiuidi, Syrupi scillse, aa f. 5 iss. M. A teaspoonful in a teacupful of barley water, to be frequently taken during the day DR. C. J. HARE. Suffocative Bronchitis. In this distressing condition Dr. HARE .{Brit. Med. Jour., 1883.) strongly recommends emetics. As he vividly expresses it: "You are called to a patient who has been ill a few days, with increasing dyspnoea ; she is sitting up in bed, for to lie down is impossible ; she is restless, and tossing about ; the lips, and indeed the whole face, blue ; the eyes watery and staring ; the pulse quick and small; the cough constant; the expectoration semi-transparent and tenacious ; over every square inch of the chest, front and back, from apex to base, you find abundance of rhonchi; moist, sonorous and sibilant ones in the upper part of the lungs, and muco-crepitant or mucous rales toward the bases. Ammonia and stimulants, right and good in their way perhaps, in such a case are too slow in their action ; the patient is, in fact, more or less slowly, more or less rapidly, suffocating. An emetic of twenty-two grains of ipecacuanha in an ounce of water is given ; in ten or fifteen minutes, the patient vomits and brings up a huge quantity of that tenacious mucus, and the whole aspect of the case is altered ; the distressed countenance is relieved ; the breathing is at once quieter; and the patient is able for the first time for the past twenty-four hours to lie moderately low in bed, and to get some sweet refreshing sleep. The patient is, in fact, rescued from the extremest peril, and in this case, and in many similar ones too, from otherwise most certain death." PROF. J. M. DA COSTA, M. D. Combinations like the following may be employed : S'. R. Vini ipecacuanha;, f. 3ij Liquoris potassii citratis, f.Siv Tincturse opii camphoratae, Syrupi acaciae, £5 f.gj. m. A tablespoonful thrice daily, in the first stage of ordinary acute bronchitis. 41 M. M. ACUTE BRONCHITIS. 52. R. Morphiae acetatis, _ : Potassii acetatis, kjj; Liquoris ammonii acetatis, f 5 j;; Syrupi tolutani, f 5 i A dessertspoonful every third hour. A useful diaphoretic alkaline mixture. S3' R- Ammonii carbonatis, g, ^^j Spiritds setheris compositi, f. 3iss Syrupi tolutani, AquK, £i f.|j_ Ateaspoonful every two hours; a stimulating expectorant for a child a year old aftected with bronchitis of two weeks' standing. ' Counter-irritation to be applied to the chest by means of weak mustard plasters (one part of mustard to four of Indian meal). Also, if the child be much debilitated, 15 gtt. of brandy every four hours. When the child is seen frequently, so that the effect may be watched, there is no better treatment than relieving the lung mechanically by emetics. Hoffman's anodyne, in the above recipe, acts as a diaphoretic and quieting agent, which latter influence would not be obtained from sweet spirits of nitre. Where there is obvious bronchial catarrh : 54. R. Tr. verat. viridis, 5j Ammon. mur., 5ij Mist, glycrrh. comp., § iij Syr. pruni. virg., f. 5 vij. M. S. — Teaspoonful four times a day, in water. After taking this for a day or two, the dose ought to be reduced. Use, also, mustard to the chest. PROF. GEORGE JOHNSON, M. D., LONDON. Acute bronchitis is an exaggerated catarrh ; the two diseases are essentially the same, and they require the same principle of treat- ment, only modified according to the character of the symptoms. .(^British Medical Journal, October 23, 1869). In the early stage of acute bronchitis, when the mucous mem- brane is dry and swollen, the hot-air bath or the wet packing may be employed once or oftener with advantage. Another very useful remedy in this stage is tartar emetic in doses of jS^ of a grain, com- bined with liquor ammonii acetatis : 55. R. Ammonii et potassii tartratis, P'- |Ji Liquoris ammonii acetatis, f. § ij Syrupi tolutani. Aquae, aa f.gj. M. A tablespoonful thrice daily. The inhalation of steam, repeated several times in in the course of the day, is often very soothing and beneficial. In the second stage, when free secretion has been established^ 42 DISEASES OF THE RESPIRATORY SYSTEM. antimony and acetate of ammonium are to be discontinued. At this period, a combination of carbonate of ammonium, with spirit of chloroform, is useful as a stimulating expectorant or antispas- modic. 56. R. Ammonii carbonatis, 3 is» Spiritfls chloroformi, ^'^7. Syrupi acacise, f- 3 'J Aquam, ad f. § iv. M. A dessertspoonful thrice daily. Brandy or wine, in moderate quantities, may now also be required to sustain the strength. When, in the advanced stage, there is a profuse secretion, with copious perspiration, the ammonia mixture may be replaced by the following : 57. R- Quiniae sulphatis, gr- xvj Zinci sulphatis, ' 3] Acidi sulphuric! aromatici, f. 3 ▼ Aquse menthse pipericse, f. S iijss. M. A dessertspoonful thrice daily, in water. This combination often checks, very rapidly, the excessive secre- tion from the bronchial mucous mumbrane. The stimulating expec- torants are sometimes useful at this stage of the disease — senega, squill, ammoniac, and the compound tincture of benzoin. If, as sometimes happens, the stimulating expectorants suddenly check secretion, tighten the breath, and increase dyspnoea, their employ- ment must at once be discontinued. When the secretions accumu- late and threaten suffocation, the patient being blue, and cold, and drowsy, and the cough nearly or quite ceasing, an emetic of sul- phate of zinc is often wonderfully efficacious in clearing the air- passages. Dr. Johnson gives an' especial warning with regard to opium. Never order an opiate for a bronchitic patient who has the slightest blueness of the lips. DR. DEMBITZ i^Am. Practitioner and News, December 22, 1888). This physician urges the use of apomorphia instead of ipecacuanha, as it has less action on the digestion than the latter drug, and is equally efficient. His formula for administration is : 58. R. Apomorphiae muriatis, gr. yi-y^ Acidi muriatic!, gtt. v Syrupi, f.gj Aquse destillatae, q. s. ad f. § iv. M. Sig. — Teaspoonful every two hours. ACUTE BRONCHITIS. 43 The above dose is suitable for a child of five or six years of age. He considers musk the respiratory stimulant par excellence. NOTES ON REMEDIES. Aconite. The tincture of aconite in small doses combined, with a correspond- ingly small dose of tincture of belladonna, will often in the earliest stage of a cold suffice to break it up if taken at frequent intervals. A quarter to half drop of aconite, with equal amount of belladonna, should be taken in water every ten or fifteen minutes. Hot mustard pediluvia and rest in bed are useful adjuvants to such treatment. Ammonii Acetatis Liquor makes a useful diaphoretic alkaline vehicle for anti- mony, morphia, &c. Ammonii Carbonas may be given with benefit, combined with ipecacuanha, squills when expectoration is scanty or difficult, or with tincture of lo- belia if much spasm be present. Five grains, given at bed-time, when the first symptoms of a common cold express themselves, often at once subdue the disease. Ammonii Bromidum has been recommended. Ammonii et Potassii Tartras is of service in small doses (gr. t« — i), in the earliest stages of acute bronchitis in young plethoric subjects, and where much febrile action is present. When the phlegm accumulates in the bronchial tubes, an antimonial emetic will readily remove it. The nauseating and depressing effects of antimony should not, how- ever, be long kept up in this disease, as they interfere with proper nutrition, which is of much importance in these cases. Apomorphia. 59. R. Apomorphise hydrcchloratis, gr. \ Infusi senegse, f. 3 v Syrupi, f-3v Aquae destillate, f- 5 iv. M. A teaspoonful every half hour in severe cough in children. Chloral in strong persons is often of value at night by allaying the cough and permitting sleep. Chloroformum by inhalation is said to palliate the cough and excitement, and directly favor the resolution of the extravasated fibrin, and prevent the deposit of more. A drachm of chloroform should be inhaled in the course of fifteen or twenty minutes, and the inhalation repeated from two to twelve times in the twenty- four hours. Cimicifuga is an excellent expectorant. 60. B. Ext. cimicifugae fl., f-|?' Tinct. opii deod., '• 5J „ Syr.ToK ^■5='- '^■ S. — A teaspoonful every four hours. This U very useful in acute bronchitis, after the more active symptoms have sub- sided. 44 DISEASES OF THE RESPIRATORY SYSTEM. Colchicum is recommended in acute stages ol gouty bronchitis by Dr. Green- how, who gives the following with great success : 6l. R. Potassii iodidi, Ammonii carbonatis, Sa gr. iv Vini colchici, "Ix Tincturae scillse, Tincturse hyoscyami, ia Tllxx Aquae camphoroe, q. s. Make a draught, to be taken thrice daily. Ipecacuanha is a valuable expectorant and diaphoretic, and a useful adjunct to other remedies of the same class. In light colds its administration in the form of compound powder of ipecac is excellent as a sedative and diaphoretic. Monarda. The warm infusion of horsemint makes an excellent diaphoretic. Oleum Ricint seems, more than any other medicine of its class, to mitigate the inflammation and promote resolution by expectoration. Opium, or morphia, given in full doses at the very outset of a common cold, often averts the attack. But an opiate should never be given to a bronchitic patient with the slightest blueness of the lips. Oxygen. In the dyspnoea of capillary bronchitis, the inhalation of oxygen affords reUef, and has been the means of preserving life. Phellandrium Aquaticum is considered by French physicians a specific seda- tive to the bronchial mucous membrane. Pilocarpine is often serviceable, if given at the beginning. Sanguinaria. Dr. Bartholow speaks highly of this formula : 62. R. Tinct. sanguinariae, f. 5j Tinct. lobelise, f. 5j Vin. ipecac, f. 5 ij Syrup, tolutan, f.fss. M. S. — A tablespoonful every three hours. Senega in decoction is a valuable remedy in the treatment of acute bronchitis in the aged. Terpene. This drug, the terpene hydrate, is an expectorant quite like turpen- tine, but apparently without its objectionable features. It may be given as follows with much benefit, where elimination of secretion is demanded : 63. R. Terpene bydratis, gr. xxv Glycerini, q. s. ut. ft. sol. Syrupi lactucarii, q. s. adf. 5j. M. Sig. — Teaspoonfu] every two hours. Veratrum Viride is often of service in the early stages. Zinci Sulphas is used in the advanced stages, when there is profuse secretion. CHRONIC BRONCHITIS. 45 Counter-irritants to the chest are often of service. For this purpose, dry- cupping, hot turpentine stupes, or mild sinapisms may be employed. Turpentine embrocations are also serviceable. An elegant preparation suited for prolonged slight counter-irritation is made of alcohol (95 per cent.), in which is dissolved as much turpentine as the alcohol will take up without turbidity after shaking. Stimulants are often useful, and sometimes necessary, as in the bronchitis of the aged, attended with profuse secretion, threatened apncea, and a weak pulse. At the very outset of a common cold, a full supper, with a moderate alcoholic stimulant, will frequently abort the attack. Water. The vapor of hot water is often of signal benefit. Wet packing is also of service in the early stages. CHRONIC BRONCHITIS. PROF. FRASER, EDINBURGH. (London Lancet, 1887.) In a clinical lecture this gentleman maintained the efficacy of the old treatment by the nitrites of the bothersome dyspnoea in cases of chronic bronchitis. He prefers sodium nitrite (gr. j.) and nitroglycerine ("liv. of a one per cent, alcoholic solution), being more stable than those of amyl or ethyl, and easily administered by mouth or hypodermatically. Sweet spir- its of nitre probably should be classed with these, as it evidently is valuable in the expectorant mixtures so favorably known, because of its anti-dyspnoeal effects in bronchitis. DR. GEORGE ST. GEORGE, OF DUBLIN. This author highly recommends the following formula in chronic bronchitis. (Dublin Journal Medical Sciences, 1883.) 64. R. Tr. scilla;, "Itv Sp. sether. nit., f- 3 j Liq. amin. acet., f- 3J Tr. hyoscyam., f- 3 ss Aq. comp., adl.ij. M. S. — ^Taken three times a day. As soon as the urgent symptoms have subsided, substitute the following : 65. R. Acid nitro-hydrochl. dil., '^'^ Tr. hyoscyam., __ Tr. laricis, »» , '-fps Inf. gent, c, >df.Sj. M. S.— Taken three times a day. 46 DISEASES OF THE RESPIRATORY SYSTEM. For bronchitis caused by the inhalation of dust mixed with fine particles of flax, or other irritating substances, the following : 66. R. Ammon. carb., gr. v Tr. scillae, Tr. camph. c, aa TUxv Inf. senegse, adf.§j. M. S. — ^Taken three times a day. After improvement has set in, give the patient two drachms of cod liver oil after each meal, and as a tonic before meals the following : 67. R. Acid nitro-bydroch. dil., Tr. camph. c, aa lUx Vin. ipecac, TIlvj Inf. gent, co., ad. f. 5 j. M. PROF. WILLIAM AITKEN, M. D., EDINBURGH In chronic cases of bronchitis, especially in patients who have made considerable progress in the journey of life, remedies which tend to invigorate the general system are indicated. Besides the selection of a beneficial climate and the use of nutritious, easily-digested food, stimulating embrocations are useful. The following liniment, em- ployed at the Meath Hospital at Dublin, is highly recommended for this purpose: 68. IJ. Spiritds terebinthinae, f-Siij Acidi acetici, f. 5ss Vitelli ovi, j Aquae rosse, f. § ijss Olei limonis, f. 3 j. M. To be rubbed, morning and evening, not only over the chest, before and behind, but also along the sides of the neck. It generally reddens the skin and produces small pimples. Of the foetid gums, ammoniac in particular is a useful remedy. From the following combination (formula of Prof Easton, of Glas- gow,) decided beneficial results are obtained : 69. R. Ammoniaci, 5ij Acidi nitrici diluti, f. 5 ij Aquae, f.|xij. Two tablespoonsfuls in gruel, thrice daily, In the chronic bronchitis of age, as well as that of advanced phthisis, Dr. H. C. Wood commends the following as a valuable formula : CHRONIC BRONCHITIS. 47 70. B . Pine tar, q. s. ad solutionem sat. Lime water, f. 5 W. Macerate the tar for three days in the lime water, filter and percolate through 30 grains of ground wild cherry bark, adding sufficient lime water to make the perco- late measure f. 3 iv. Dose : Two to four teaspoonfuls. In the protracted bronchitic affections of the aged, diuretics are of great service. The following formulae are recommended by our author, and by Drs. MaclachLAN and Stokes, as well suited in a variety of cases of senile chronic catarrh : 71. R. Potassii nitratis, gr. xxxvj Tincturas conii, f. § ss Spirit&s setheris nitrosi, Oxymellis scillae, aa f. 5 vj Decoctum senegse, ad f. § vj. M. A tablespoonful thrice daily. 72. K.. Potassii acetatis, § ss Aceti scillae, Spiritfls setheris nitrosi, aa f. 3vj Tincturse opii camphoratae, f. § ss Liquoris ammonii acetatis, f. % iijss Syrupi aurantii corticis, f. 5 XJ- A tablespoonful thrice daily. M. DR. BENJAMIN F. WESTBROOK. (N. Y. Med. Journal, 1887.) In the local treatment of chronic bronchitis the writer makes use either of one of the spray appara- tuses in general use (preferably that of Sass), Evan's inhaling ap- pliance or the pneumatic cabinet. In using the direct method, carbolic acid or extract of hyoscy- amus may be used to allay the cough : 73. R. Acidi carbolici, ^ff^ Sodii biboratis, 3}.'J Sodii phosphatis, ^3. The nasal passages are first to be cleaned by the spray, and the patient directed to draw out the tongue while the spray is thrown into the pharynx or directly into the larynx. The treatment is re- peated daily or every other day for five or six times, the strength of the carbolic acid being increased to the point of tolerance by the addition to the above of a 50 per cent, solution of the acid m gly- cerine. Astringents may be necessary where there is a copious secretion 48 DISEASES OF THE RESPIRATORY SYSTEM. of mucus, preferably tannic acid, chloride of iron or the fluid ex- tract oi pinus canadensis (Kennedy's). 74. R. Acidi carbolici, J^^T. Glyeeriti tannin, *• | "^^ Aquae menthse piperitae, ■• 3 ^ss. M. Dr. Westbrook does not in most cases add any home treatment, relying upon these local measures for relief: DR. BEIGEL, LONDON. 75. R. Pulveris aluminis, gr. ij Tincturae opii, "Ix Aquae destillatse, f- 3 j- M. For inhalation by means of atomizer, night and morning, in obstinate cases of chronic bronchitis. The following inhalation also affords relief in severe cases : 76. R. Acidi tannici, gr. iij Extracti hyoscyami, gr. ij Aquae destillata, f. § j. M. To be inhaled night and morning. On account of the taste, sulphate of iron (gr. It to f. § j) may be substituted for the tannic acid. E. HEADLAM GREENHOW, M. D., LONDON. 77- R. Vini ipecacuanhae, Acidi nitro-muriatici diluti, aa TUx Tincturae hyoscyami, IRxx Tincturae gentianae compositae, f-5ij M. For one dose. To be taken in water three times a day, in chronic bronchitis. In almost all cases of chronic bronchitis, a time arrives when ex- pectorants cease to be useful. The expectoration has become of the nature of an habitual flow from the bronchial membrane. Treat- ment of a tonic character is then required. In these cases, Dr. Greenhow has long been accustomed to prescribe, with great ad- vantage, the mineral acids, especially the nitro-muriatic, in combina- tion with a vegetable bitter, as above. In chronic cases attended by very copious expectoration, he adds to each dose of the above mix- ture, twenty minims of the tincture of larch, which has the effect not only of lessening the expectoration, and with it the cough and dyspncea, but also, apparently, of restoring the debilitated mem- brane to a more healthy tone, and of rendering patients less liable to catarrhal attacks at every change of the weather or season. CHRONIC BRONCHITIS. JOHN FORSYTH MEIGS, M. D.. PHILADELPHIA. 49 78. R. Acidi carbolici fiuidi, m Aquxc, ^-^ ~ , , . Uss. M hrnnVv?"? T "l °'a'""^ '"^^''"^ bottle, and used three or four times a day 'in bronchial catarrh, oBensive secretion from the bronchial tubes, etc. '' L. PARISEL, PARIS. 79- R. Fulveris cinchonse flavje, Sulpburis loti, ^ 1 35 Syrupi altL-E, ^ ^ ^ This solution should be inhaled by means of an atomizer: useful both in the simple form of chronic bronchitis and in that which usually complicates the advanced stages of phthisis. It diminishes the secretion, and thereby lessens the waste of substance and the exhaustion occasioned by repeated and urgent coughing. PROF. ALFRED STILLE, M. D., PHILADELPHIA. 80. R. Acidi carbolici fluidi, (.tt. xv-xx 'J incturoc ccnii, f 5 j_jj Afiure destillatce, Oij. M. For inhalation. PROF. WILLIAM STOKES, M. D., DUBLIN. 81. R. Potassi iodidi, 5iij TinctursE 0],ii camphoratce, f. § ss Decocti senegJE, f, § iv Syrupi tolutani, f. § iss. M, Two tcaspoonfuls a day, in chronic bronchitis. 82. R. Tincturce opii caniphoratEe, f. Sss ^theris, lincturi tolutani, aa f.Sij- M. A tcasjioonful in a small quantity of warm drint, to quiet the cough, in bronchitis. 83. R. Tinctura; opii camphoratae, Tincturas scillce, aa f. 3iss Ammonii carbonatis, gr.xviij Decocti senegje, f. § iv tiyrupi tolutani, f. §ss. M. Two or three teaspoonfuls a day, in chronic bronchitis, after the infiammatory symp ■ toms have lost a little Of their intensity. 84. R. Acidi benzoic!, Ammoniaci, aa 3 si Eaponis, q. >. Divide into tiventy pills. From four to eight in the twenty-four hours, in chronic pulmonary catarrh. Repeated sinapisms to the chest. 4 50 DISEASES OF THE RESPIRATORY SYSTEM. JAMES TURNBULL, M. D., LIVERPOOL. 85. R. Ipecacuanhoe, iS- Olei olivae, ^3 'J „ This pomade is to be spread upon the skin once or twice a day, when it is desired to produce an eruption or a rubefacient effect in bronchitis. Or: 86. R. Emetinae, ^-^"^ .. Adipis, 3SS. ■ M. The emetine is to be dissolved in a small quantity of alcohol, and the solution thus obtained is thoroughly mixed with the lard. Rubbed on the skin for a few minutes, once or twice a day, this ointment produces a copious crop of small pustules, unattended with pain, which remain out for many days, and leave no scars. In this last point, it has an advantage over tartar emetic ointment, for which Dr. T. proposes it as a substitute. SIR THOMAS WATSON, LONDON. In cases of chronic bronchitis, which are especially remarkable on account of the great abundance of the bronchial secretion, our author has derived great advantage from the administration of the sulphate of iron in two or three-grain doses, in the compound mfusion of. rose thrice daily. When there is any fever present, these remedies are apt to augment it ; but when the pulse is quiet and the skin cool, they are often of the greatest service. Our author has also seen the excessive expectoration diminished, and the patient gain strength, under the use of the balsams, the compound tincture of benzoin, for example, a form of medicine much employed formerly, and too much neglected at present. JOHN WILLIAMS, M. D., LONDON. 87. R. Ammoniaci, Ammonii carbonatis, ui gr. xt Ipecacuanhse, gr. iv Morphiae muriatis, gr. iss . Mucilaginis acaciae, q. s. M. Divide into ten pills, which coat with a solution of balsam of tolu in chloroform. One pill, morning and evening, in chronic bronchitis, especially when the secretion is thick and the expectoration difficult. J. MILNER FOTHERGILL, M. D., LONDON. 88. R. Sp. chloroform!, nixx Acidi hydrobromici, 5 ss Syr. scillae, 5 J Aqux, q. s>. ad §j. For one dose, three times a day. CHRONIC BRONCHITIS. ,51 The dose, of course, is reduced for children. Any other acid in this mixture is very agreeable, but the hydrobromic acid, from the eflfect of bromine upon reflex mechanism, allays the cough often so troublesome. It possesses much the same action as opium, without the ill effects upon the digestive organs or on the bronchial secre- tion. In some recent articles, Dr. FOTHERGILL dwells at some length on the great value of strychnia as an expectorant in bronchitis. By its action on the respiratory centre, it proves useful when increase of respiratory power is needed for the expulsion of mucus gathered in the air-tubes. He gives it either alone or in combination with the ordinary cough mixture. On other expectorants, Dr. F. gives these directions : As long as the skin is dry, and the bronchial lining membrane tumid, and secretion arrested, ipecacuanha with acetate of ammonia is indicated ; or, a little antimony may be added with advantage. When the skin is once thrown into action, and the bronchial secretion also established, then acids with syrup of squills are suitable measures. But it is not a successful plan to administer squill with acids until the skin is moist. When there is a tendency to the free action of the skin, this latter combination, in full doses, is a useful plan of treatment. Neither is the union of carbonate of ammonia and senega, in severe cases, indicated until the secretions alike of the skin and bronchial lining membrane are thoroughly es- tablished. Putrid Bronchitis. — This form, associated usually with bron- chiectasis, is found to depend upon the presence of putrefactive bacteria in the retained secretion. The affection is best treated by meansof local antiseptic inhalants or the administration of stimulant expectorants and tonics. BELLEVUE HOSPITAL, NEW YORK CITY. 89. R. Ammon. carb., gr.xxxij Ext. f 1. senegae, „ Ext. a scillse " '-3). Tr. opii campb., \\^ Aquae. ' ,W^ « Syrup, tolut., q.s.adf.Siv. M. Teaspoonful at a dose. 52 DISEASES OF THE RESPIRATORY SYSTEM. MISTURA PECTORALIS OF BLOCKLEY HOSPITAL. Two teaspoonfuls contain: 5P. f^. Ammonium chloride, gr.vijss Syrup of senega, Tlfv Comp. licorice mixture, q. s. ad f. 3 U- Dose : Two teaspoonfuls. NOTES ON REMEDIES. Acidum CarboUcum, by atomized inhalation, is of service when the bronchial secretions acquire a repulsive fcEtor, and indeed quite generally. Acidum Hydrocyanicum is a valuable anti-spasmodic, used in sedative cough mixtures, as : 9-- K £. Acidi hydrocyanici diluti. mi Spiritus chloroformi, rfiv Acidi hydrobromici (3-4 per cent.). Ulvijss Syrupi senegas. Syru;n scillas. ia nixv Syrupi pruni virginianse. adf.Sij. Two teaspoonfuls. Dose: Acidum Hydrobromicum is also of value as a sedative in cough mixtures. Alumen. Dr. F. L. Andrews, of London, recommends alum in acute as well as in chronic bronchitis, both in children and adults, when the expectoration is ropy. To children of three years, he gives one grain in solution, every five or six hours ; to adults, six to eight grains, at like intervals. Ammonii Carbovas is an excellent stimulant expectorant, of benefit in the ad- vanced stages of bronchitis, when there is no febrile action present, The following formula may be employed : 92. ]J. Ammonii carbonatis, gr.iv SpiritCis chloroformi, TTlxx Aqute caniphoraa, f. 3x. M. To be taken every three or four hours. Infusion of senega may often replace, with advantage, the camphor water in this recipe. It is of especial benefit in the asthenic bron- chitis of old age. Ammonii Chohridum is a most valuable remedy in chronic bronchitis, but must be given in ten-grain doses in order to be effective. The foUow- lowing is a useful formula : ^Z- R- Ammonii chloridi, 5ij Spiritus xtheris compositi, f. 3ij Lxtracti glycyrrhi^je, 5 j Decoctuai senegce, ad f. § yj. Tablespoonful every two or three hours. Ipecacuanha or squill may be added, if in- dicated. CHRONIC BRONCHITIS. 53 Angelica is useful in the chronic bronchial catarrh of aged and feeble persons, under circutnstanc'es when senega is usually prescribed. Apomorphia. Dr. Wertner, of Vienna, has used this substance internally as an expectorant with the most pleasing success. His prescription is : 94. R. Apomorphias, gr.i-iij Aquse destillatse, f. § xij. M. Tablespoonful every two hours for an adult. It is an exceUent cough sedative, es- pecially useful in bronchial catarrh in the exudation stage. (Dobell's Reports^ 1876.) Arsenicum is recommended by Dr. Thokowgood, {Lancet, November 13, 1869,) in chronic bronchitis where copious expectoration and much emaciation are present. At times, he finds it to act quite like a spe- cific in improving the breathing. He gives n^^ij of Fowler's solution in alkaline infusion of columbo thrice daily. Assafxtida. is of service when the cough is spasmodic, and the expectoration difficult, on account of general debility. It is, therefore, often useful in the chronic bronchitis of old persons. Bahamum Peruvianum. The balsams, both of Peru and of Tolu, are useful stimulant expectorants, and vehicles for squill and other remedies of the same kind, in chronic bronchitis. The vapor, obtained by placing them upon a piece of hot iron or hot coals, is also of benefit. Benzoinum. The compound tincture of benzoin is a useful stimulant expec- torant ; the tincture of benzoin may often be employed with benefit, by means of a steam atomizer. Benzoin must be used only in cases not injuriously influenced by stimulation. Calcis Phosphas, in doses of gr. i-ij several times a day, is recommended by Dr. Ringer as of great value in checking profuse discharges in chronic bronchitis. Cerii Oxalas. Dr. Thomas Clark {Practitioner, K^Ti\, 1878,) considers this drug to be purely sedative, and therefore a great desideratum in treat- ment of lung diseases, inasmuch as it does not disturb the digestive tract — the only unpleasant subjective feature of its use being occa- sional dryness of the mouth. In gr. v doses he has found that it will relieve many harassing coughs, irrespective of the pathological condi- tions which cause them. Dyspnoea is usually relieved at the same time. He claims that relief for a period of twenty-four hours often follows a single dose taken before rising in the morning. Citnicifuga is especially useful in the chronic bronchitis and coughs of old age. Cinchona. The acidulated cold infusion of bark is very useful when there is rapid wasting of the system, under the influence of profuse expectora- tion and night sweats. 54 DISEASES OF THE RESPIRATORY SYSTEM. .m Copaiba often restrains and modifies the bronchial secretion in chrome bron- chitis attended with profuse expectoration, when there is no fever and not much vascular irritability. Creasotum is sometimes given by inhalation and by the stomach, in the bron- chorrhoea of old persons. Cubeba, in small and often-repeated doses, is of service in the chronic bron- chitis of old age, attended with profuse secretion and much debility of constitution. Digitalis. The tincture is exceedingly useful in the bronchitis of elderly per- sons with deficient circulation and dyspnoea. It may be conbined with ammonia. Verba Santa. The leaves of the Eriodictyon Californicum, known by this name, have been long used as a popular expectorant on the Pacific coast. A fluid extract is now manufactured by Parke, Davis & Co., of Detroit. Dose, f. 3 j-, as required. An appropriate combination is : 9S- R- Hd extr.. yerbse Santas, r z •• Syr. pnini virgin., a* r 1 ■ Glycerini, '• 3 ]• A dessertspoonful thrice daily. It is a tonic expectorant, agreeable to the palate, and without nauseating properties. Ferri Mistura Aromatica is highly praised as calculated to improve the gen- eral health and check superabundant secretion, by Dr. Graves. He orders : 96. K. Misturse ferri aromaticse, f. Siss-iij Aquae raenthae piperitie, f. 5 yj- M. Tablespoonful thrice daily. Bartholow prefers the Mistura Ferri Compositae. Gelsemium is an efficient sedative when the cough is of the habitual nervous variety. Iodoform is often valuable in chronic bronchitis, particularly where there is a tendency to putrescence of the secretion. It is best applied by spray from a mucilaginous preparation. It may also be given internally in pill, in doses of gr. j-ij. t. d. Ipecacuanha is a useful expectorant, usually given combined with other reme- dies. Dr. William Murrell, of London, uses ipecacuanha spray in winter cough. The spray has proved most successful in those cases of winter cough in which the dyspnoea is the prominent symptom. The ipecacuanha wine was used either pure or variously diluted, the most usual strength being one part of the wine to one or two of water. Thie use of undiluted wine occasionally produces dryness of the throat and nausea, the latter symptom most frequently occurring in those cases CHRONIC BRONCHITIS. 55 in which the patient is not careful to expectorate the mixture of saliva and condensed spray which accumulates in the mouth. The quantity of wine used at each inhalation varied from a half to two drachms. Koumiss. Bartholow says that koumiss possesses great value in the treat- ment of chronic bronchitis, its efficiency depending upon its nutritive value. Larix Eitropaa is recommended by Dr. Greenhow, to check profuse passive expectoration in chronic bronchitis. Myrrha, when there is no fever or irritability present, is a valuable medicine in long-standing chronic bronchitis, particularly after a course of ex- pectorants. Naphthaline, C,„ H„ reduced to powder and united with a litde gum acacia, in gr. j-ij, or advantageously combined with a small quantity of codeia, not only slightly lessens expectoration, but alleviates cough without in- terfering with the other secretions. It is to be watched, lest it show its irritant effects on the kidneys and produce disturbances of nutri- tion in the eye. CEnoikera Biennis. Dr. F. H. Davis, of Chicago, (Half- Yearly Compen- dium, July, 1879,) considers this an exceedingly valuable drug in cases where much local catarrhal inflammation is present. His medi- cation is : 97. R. Acid carbolic, cryst., gr.vj Glycerini, f. § ss Ext. oenotheree bi. fl., f.§ isi Aquae, f-iij. M. S. — Teaspoonful before each meal. In addition the following : ^8. R. Pil. hydrargyri, Rt.x Pulv. aloes, gr.v Zinc, oxidi, 3j- M. Ft. massa ex qua ft. pil. no. xx. S. — One pill to be taken at bedtime, or after breakfast and at bedtime. Oleum Morrhua. Cod liver oil is one of the most valuable remedies in the treatment of chronic bronchial affections, not only having great nutri- tive worth, but being as well an efficient sedative to the mucous mem- brane of the pharynx and neighboring mucous membranes, thus allay- ing in a great measure the cough. It may be given in the form of emulsion with various aromatics to hide its taste, or alone where the patient does not object. Opium, though often of much service in allaying bronchitic cough, may prove dangerous if there is much accumulation in the bronchi. Petroleum. In the form of "terraline" this oil is used in the treatment of bronchitis of a subacute or chronic type, and is an efficient remedy in 56 DISEASES OF THE RESPIRATORY SYSTEM. many cases. It is administered in doses of a teaspoonful to table spoonful. Filoearpin. In chronic dry catarrh, as well as in acute bronchitis, Dr. O. Kahler, of Prague, has witnessed much benefit from this alkaloid. (CentralblattMed. ^Yi-., April, 1878.) Fix Liquida is of some value in bronchial catarrh. The following formula was recommended by the late Prof. Dunglison : 99. R. Picis liquife, J-SJ Aquae destillaUe, *''J- Digest for eight days, and decant. Dose, from eight to twelve tablespoonfuls, daily, in milk. Dr. Sydney Snyder gives tar in two-grain doses, every three or four hours in winter cough. Flumbi Acetas frequently proves useful when there is profuse mucous secre- tion. Fotassii Ckloras is recommended by Prof. Da Costia in both acute and chronic bronchitis, to thin the secretion and promote expectoration. 100. R. Ammonii chloridi, 30 Potassii chloratis, 3j Tincturse hyoscyami, ''1?? j. Extract! pruni virginianse fluidi, f. 5 U^^- "*• A dessertspoonful thrice daily where there is tenacious secretion. loi. R. Potassii chloratis, O'i Tincturse scilte, f' 3 ss Misturae glycyrrhizae comp., f. §ijss. M. Sig. — Dessertspoonful three or four times daily where there are dry rales. Flint gives g ss of the saturated solution, two or three times a day. FoiasscB Liquor, tT\,x-xv, added to an ordinary expectorant mixture, is often attended with good results when the sputum is scanty, thick and viscid. Fotassii lodidum acts beneficially in the advanced stages of chronic bron- chitis, in restraining inflammatory action and promoting absorption. Flint says of it, that it exerts more curative influence over the disease than any other drug. Frunus Virginiana. The wild cherry bark, either as an infusion or syrup, is commonly prescribed for a sedative, and at the same time relaxing ex- pectorant. It probably owes its properties to the hydrocyanic acid in its composition. SciUa is of service after all active inflammation has subsided in mild cases unattended with purulent expectoration. It is best combined with an alkali and a small quantity of opium. (F. 62.) Senega is a highly serviceable remedy, particularly when combined with car- bonate of ammonium. (F. 67.) CHRONIC BRONCHITIS. 57 5/7 lini- ment is sometimes very useful. Turpentine liniments are highly ser- 58 DISEASES OF THE RESPIRATORY SYSTEM. viceable- Iodine may be often used with signal benefit as. a mild counter-irritant. The following combination, supposed to be an imita- tion of that used by St. John Long, is recommended by Dr. Graves : 104. B. Olei terebinthina, f-5"j Acidi acetici, f- 5 " Ovi vitelli, j- Olei limonis, ^- 5 j Aquae rosmarinse, f. 3 ijss- To be well rubbed in over the chest, the nape of the neck, the epigastrium, and the course of the cervico-spinal and pneumogastric nerves generally. Sinapisms to the chest are sometimes of service. Electricity. A fine primary induction current, of low intensity, passed through the chest from the back and neck, stimulating the sympathetic and spinal nerves, has been found productive of great benefit. Nitro-muriatic Acid lotions sponged over the chest are recommended for checking profuse expectoration, and mitigating the severity of the symptoms. Flasters. A Burgundy fitch plaster often proves of service as a protective against atmospheric changes, and as a rubefacient. An opiate plaster is sometimes of benefit. CATARRH. CORYZA. AND POST-NASAL CATARRH. THE ABORTIVE TREATMENT OF A COLD. A successful method is that used by DR. HORACE DOBELL, LONDON. His plan is as follows : 1. Order: 105. R. Ammonii carbonatis, gj Morphias sulphatis, gr. ^ Misturse amygdalae, f. § iy. M. Two tablespoonfuls every three hours. 2. At night give a tablespoonful of spirit of mindererus in a tumbler of cold water, after the patient has got into bed and been covered up with several extra blankets; cold water to be drunk freely during the night should the patient be thirsty. 3. In the morning, the extra blankets should be removed, so as to allow the skin to cool down before getting up. THE ABORTIVE TREATMENT OF A COLD. 59 4. Let him get up as usual, and take his usual diet, but continue the ammonia and morphia mixture every five hours. 5. At bedtime, the second night, give a compound colocynth pill. No more than twelve doses of the mixture, from the first to the last, need be taken, as a rule; but should the catarrh seem disposed to come back after leaving off the medicine for a day, another six doses may be taken, and another pill. During the treatment the patient should live a little better than usual. As everything depends upon the promptitude of the treatment, persons who are subject to catarrh, especially if it inclines to the in- fluenza character, should be provided with a prescription for the medicine, and full instructions how to manage themselves when a cold sets in. An addition to this plan is needed in persons whose colds seize at once upon the bronchial mucous membrane. Besides the manner of proceeding just described, they should use the following inhala- tion : 106. R. Extract! conii, gr. jc Tincturae benzcini, f. 3 j SpiritCis amraonise aromatici, f. 3ss Aquae (170OF.,) Oj. M. Inhale the steam for fifteen minutes at bedtime each night; put a mustard plaster on the front of the chest one night, and between the shoulders the next; and, unless the weather is warm, wear a respirator out-doors until all signs of the cold have disappeared. Dr. Beverly Robinson (Boston Medical and Surgical Reporter, November 14, 1889) considers the best means of aborting an attack of acute coryza to be the administration of rather large and fre- quently repeated doses of carbonate of ammonium. DR. C. J. B. WILLIAMS, LONDON, has found the "dry plan" eminently successful; and it does not oblige the patient to leave his business. His directions are : 1. Begin with a sharp aperient in the solid form of pills, swallow- ing them with as little water as possible. 2. The food should be rather less in quantity and more digestible than usual, and at first should be dry; later on, the moister forms of food are more easily swallowfed and digested. 3. No fluid should be taken whatever. 4. As much exercise as possible should be taken, in warm cloth- ing, so as to promote the action of the skin and bowels. 60 DISEASES OF THE RESPIRATORY SYSTEM. Twenty-four hours of this treatment will give immense relief; thirty-six to forty-eight hours will effect a cure ; and rarely even a trace of bronchial irritation remains. T. J. MACLAGAN, M. D., LONDON. This writer (Practitioner, November, 1877), prefers, as an abort- ant in commencing cold, a full dose of quinine, (gr. x,) or several doses of salicin (gr. xv— xx, every one or two hours, until -Dii— iij are taken). With this treatment may be well combined such measures as hot mustard pediluvia, the drinking of hot lemonade or hot alcoholic beverages as diaphoretics, and the frequent administration of minute doses of aconite and belladonna as anti-inflammatory agents. As a prophylactic for those cases who are constantly "catching cold," a writer in the Practitioner, February, 1875, recommends fill- ing the ears with cott07t-zvool . Not only does this prevent them, but both sore throats and colds are much benefited during their contin- uance by this simple device. Dr. Ferrier advocates the use of this snuff: 107- R. Morph. sulphatis, gr. j Bismuth, subnitrat., 3iij Pulv. acacice, 3j. M. Use by insufflation at the commencement of a catarrh. DR. J. S. PROUT, NEW YORK, advocates the use of the tincture of the chloride of iron, "Ixx-xxx, taken directly after the cold is caught. The improvement should be decided in half an hour; if not, the dose ought to be repeated two or three times. A convenient vehicle for the iron is glycerine. {Medical Record, ^Anudiry, 1874.) One full dose of opimn or morphia will often succeed in promptly dissipating the symptoms. So also will twenty or thirty drops of tincture of belladonna. The following powder is highly recommended by the editor of the Archives of Neurology, 1877 : 108. R. Camphorje, ^ ^theris sulphuric!, 5* . Dissolve to the consistence of cream, and add : Ammonii carbonatis, 2- Pulveris opii, g?' ^ Keep in a tightly-corked bottle. GENERAL TREATMENT OF CATARRH. 6 1 The dose is regulated by the opium, and ranges from gr. iij-xv. This much may be taken in a little water just before retiring, or at any hour of the day when there is a suspicion of having caught cold ; and the dose may be repeated if necessary. The taste is not disagreeable, and the effect is " singularly and inexplicably effica- cious." It is well and safe to keep it on hand and take about as much as one can lay on the finger-nail, whenever one becomcs'badly chilled. DR. BRAND, VIENNA. 109. g. Acidi carb olici, Liq. ammonii forlis, aa f. 3v AlcohoUs, f 5 ij j^f_ Keep in a stoppered dark-glass bottle. When a catarrh is commencing, a few drops are placed on three or four layers of blotting-paper; the patient holding this in his hands, and closing his eyes, inhales deeply from it as long as any smell is perceptible. The remedy should be applied every two hours. In a note to Phillips' Materia Medica, Dr. H. G. Piffard, of Nevvf York, says that ia,ij-v of the imported tincture of eye-bright, Euphrasia offi.ci7ialis, repeated every two or three hours, will often abort acute nasal catarrh. Dr. G. M. Garland (Boston Med. &■ Surg. Journal, November 7, 18S9), calls attention to the same drug, recommending it at the be- ginning of acute colds, in doses of ten drops of the tincture every second hour. Its use in the acute coryza of children is commend- able, because of its agreeable taste and failure to disturb digestion. Dr. J. SOLIS-COHEN has found that the inhalation of chloroform to the induction of anjEsthesia will often abort acute coryza attended by intense pain and tension in the frontal region, and obstruction to breathing. GENERAL TREATMENT OF CATARRH. PROF. FELIX VON NIE.MEYER, M. D., TUBINGEN. In the treatment of acute nasal catarrh, the production of active diaphoresis is the only procedure worthy of confidence. A Russian bath should be advised where practicable. In most cases, all that is necessary is to direct the patient to confine himself to his room for a few days ; to keep the head and feet warm ; to swallow some hot 62 DISEASES OF THE RESPIRATORY SYSTEM. drinks frequently during the day ; to use linen pocket-handkerchiefs, not silken or cotton, and to change them frequently; and to smear the upper lip with salve, to protect it from the acrid secretion. In the latter stages, a long walk in the open air, or even an occasional pinch of snuff, hastens the cure. In infants at the breast, the nostrils should be cleared by syringing them with warm water, and they should be fed by the spoon or bottle so long as the obstacle to sucking continues. In the treatment of chronic nasal catarrh, the cachexia, whatever it may be, should be attended to. Local remedies are also of the utmost importance. The most effective is penciling the swollen mucous membrane with the following solution : no. R. Argenti nitratis, gr. i-rxr Aquas destillatae, f. 5j. M. Or cauterizing with the lunar caustic in substance. It is often best to precede the use of such remedies as nitrate of silver by paint- ing or spraying the membrane with a weak solution of cocaine. III. R. Cocainae hydrochloratis, 4. Aquae destillaUe, g6. M. This application seems to render the surface anaesthetic, and materially aids in the application by allaying the swelling. The cocaine may be applied with benefit combined with liquid cosmoline (2%) unassociated with other local remedial agents. When the discharge is tenacious and the swelling of the turbinated bodies so marked that breathing through the nostrils is impossible and local applications difficult. Dr. Chas. E. Sajous (Diseases of Nose and Throat), commends the insertion of small rolls of tissue paper. These readily take up the moisture and contact with the erected turbinated bodies causes them to collapse, thus permitting readier use of sprays, etc. The following, to be used as a snuff, is in great repute : 112. R. Hydrargyri chloridi mitis, Hydrargyri oxidi rubri, aa _ „:: ror one powder. When the discharge is offensive, and the above treatment fails, the followmg may be tried : GENERAL TREATMENT OF CATARRH. 63 "3- R- lodi., j_j^ Potassii iodidi, f; V^iij '^'J'"'' f-ivj. M. To be used as an injection into the nostrils. To diminish the irritation of the mucous membrane, a variety of snuffs have been suggested. A simple one, and yet effective, is that recommended by Dr. Brown-SeQUARD. It is pulverized white sugar, used ad libitum. Dr. E. C. Mann, of New York, modifies this to : 114. B- Pulv. sacchari albi, Pulv. camphorse, ££ q. g. j^{_ For a snuff. Dr. Lefferts, of New York, in his small handbook of the rem- edial measures used in nasal and laryngeal treatment, mentions the following powders as excellent in acute coryza, blown into the an- terior and posterior nares : 115. R. Pulveris foliarum belladonnae, gr. xx Pulveris morpliias sulphatis, gr. ij Pulveris acacioe, ad § ss. M. 116. R. Pulveris camphorje, 3ij Acidi tannici, 3ss Pulveris sacchari lactis, ad § ss. M. The powders should be insufflated thoroughly once or twice during the day. A useful "smelling salt" is mentioned by the same writer, made as follows : No. I. 117. R. Acidi carbolici, 3j Carbonis ligni, § ss lodi, 3j. M. Mix the carbolic acid with one-half the charcoal, mix the iodide with the other, then mix together thoroughly. No. 2. It 8. li. Ammonii carbonatis, §j Carbonis ligni, § ss Camphorse, § J. M. Add No. I and No. 2 together lightly, then add olei lavandulx gtt. xx, and sufficient quantity of tinctura benzoini composita to make a thick paste; keep in a wide- mouthed, glass-stoppered bottle, from which inhalations through the nose are made from time to time. Prof. Trousseau recommends, in chronic coryza, a snuff of finely 64 DISEASES OF THE RESPIRATORY SYSTEM. pulverized tannin. Prof. Still6 also recommends a snuff contain- ing tannic acid and white sugar, reduced to a very fine powder and forcibly inspired twice a day or oftener, according to the exigencies of the case ; or, a glycerine of tannin, applied with a brush, after the parts have been cleaned by the usual douche or otherwise. L. WALDENBERG, M. D., BERLIN. 1 19. R. Amnionii chloridi, gr. iv Aqiue destillatae, f. i j. M. For inhalation by atomizer, in that form of coryza known as dry snuffles. When the mouth is closed and the proper inclination given to the head, the nebulized spray can readily be inspired into the nostrils. Solutions of common salt may also be employed in the same manner. DR. CHEATHAM, OF CHICAGO. This physician commends in the acute coryzas of children, and in children who suffer a great deal from colds in the head, a spray of the following: 120. IJ. Sodii biboratis, Sss Infusi cocojE, f. § viij. The fluid may be either used with the atomizer or dropped into the nostrils with an ordinary glass dropper. He believes the solu- tion reduces the tendency to relapses, and regards it as safer than cocaine. Trechinski {Medical Register, OclohQv 13, 1888) suggests that in the treatment of either acute or chronic rhinitis powdered quillaya bark should be snuffed into the nostrils every few minutes. The powder should be placed in a paper bag and shaken, the dust being vigorously snuffed by the patient. At first it inceases the secretions, but later causes them to decrease. DR. LOMBARD, GENEVA. 121. g. Pulveris opii. Palveris benzoini, Sacchari, 55 g,_ ij_ jj_ For one powder. To be used in catarrhal neuralgia complicating coryza, in the fol- o«i,,g manner: Heat in the fire a thin plate of iron (a shovel), and throw upon It this powder, holding the head over it, so as to breathe the fu.ues through both nose and mouth. To be repeated two or three times a day, or oftener. It acts like a charm, frequently giving immediate relief. Others advocate the inhalation of iodine vapor, in this affection, POST-NASAL CATARRH. 65 effected by placing a bottle of the tincture under the nose, the hand supplying warmth enough to vaporize the iodine. The inhalations, each lasting a minute, are to be repeated every three minutes during an hour. POST-NASAL CATARRH. DR. CARL SEILER, OF PHILADELPHIA. Atrophic nasal catarrh. The treatment of this troublesome form of catarrh is given by Dr. Seiler in the Med. Surg. & Reporter, 1884. This treatment is to be divided into two portions, viz., the removal of the accumulation of secretion and the disinfecting of the nasal cavities to remove the odor, and the stimulation of the mucous membrane, with a view to the regeneration of the serous glands. This may be accomplished in the following manner : The nasal cavities are first cleansed with a copious stream of alkaline solution from the nasal douche ; this is the class of cases in which this much- abused instrument is not only applicable, but extremely useful with- out being harmful. If after this any plugs remain in the nasal cavi- ties, they must be removed with a pair of forceps, and the washing repeated until all secretion has been removed. The next step is to disinfect the nasal cavities. Various substances have been used for this purpose, such as permanganate of potash, chlorine water, tar water, carbolic acid solution, iodoform, and many others ; but they all have either great disadvantages, or else are but partially effec- tual. Lately he has used Listerine, which answers the purpose admirably, without having any of the disadvantages of other disin- fectants. It is a combination of the essential oils of thyme, eucalyp- tus, gaultheria, and other plants, together with a small quantity of benzo-boracic acid, and should be diluted one-half with water when used by the atomizer. The immediate effect is to at once destroy the stench from the nose, and to substitute for it the odor of the oil of thyme, which is rather pleasant than otherwise. The patient is directed to cleanse his nose with a solution of two drachms of bicar- bonate of soda to one quart of tepid water morning and evening, and to throw a spray of the Listerine solution into the nostrils after the cleansing. The oil of thyme and of eucalyptus, besides being disinfectants, have also a stimulating effect upon the mucous mem- brane, and thus aid in the second portion of the treatment. The stimulation of the serous glands to a normal action may be 5 66 DISEASES OF THE RESPIRATORY SYSTEM. brought about by a variety of remedies, such as astringents in var- ious strengths ; but the insufflation into the anterior nasal cavities of finely-powdered nitrate of silver, diluted with starch powder, has given the best results. Where there is complete absence of the lower turbinated bones, the introduction of a wad of absorbent cotton, which is to remain until washed out, and then be re-intro- duced by the patient himself, often aids in the stimulation by con- tinually irritating the mucous surface with which it is in contact. Next in effectiveness to the silver powders, is a weak solution of ferric alum in the form of a spray thrown into the nasal cavities, and the natural iron water of Cresson springs is peculiarly adapted for these cases. A treatment such as this, carried out for several months, has given most satisfactory results. The internal administration of small doses of bromide and iodide of potassium in combination, on account of their influence upon the nasal mucous membrane, will greatly aid the local treatment. At the same time we must look to the general health of the patient, and administer tonics when their use is indicated. DR. S. BARUCH. This author (Proceedings South Carolina Medical Association^ 1883), very wisely urges that every diseased part must be seen by the eye of the attendant before medication, and again examined to ascertain if the remedies have been applied to the entire surface.. The anterior nares and a small portion of the posterior surfaces can be best reached by the atomizer ; the posterior nares and vault of the pharynx by the post-nasal syringe. He uses the following formula: R. Acidi carbolici, Sodii bicarbonat., Sodii biborat., gr.J gr.ij Glycennae, f_5s5 ^1"*' f.Sj. M. This is used to thoroughly cleanse the parts before applying the curative medication. Not until every diseased and healthy part pre- sents itself clearly, should medication be thought of. He then re- commends finely-powdered arrow-root as a vehicle, and nitrate of silver, zinc sulphate, tannin, alum and bismuth as the medicinal agents. By dusting the parts well, the powder mixes with the POST-NASAL CATARRH. 67 mucus and forms a firmly adhering plasma, which slowly dissolves in the secretion, thus permitting a thorough action on the subjacent tissue. By attention to the thorough cleansing of the parts, many obstinate cases of catarrh can be made to yield to medication. Many cases of catarrh are maintained by the habit of nose-cleaning, now so much in vogue. The delicate lining of the nasal cavities will not brook the frequent scouring. DR. LEFFERTS, OF NEW YORK. This physician, in cases of simple chronic rhinitis and in the earlier stages of hypertrophic rhinitis, makes the following applica- tions, given in the order of preference : 123. Zinc iodide, gr. V to an ounce of water Zinc sulphocarbolate, if « ti tt 14 tt Zinc sulphate. (t tt tt «< tt tt Ferric and amnionic sulphate. « It tt tt tt tt Ferric chloride, •• (1 (( tt tt tt Tannic acid. jr. v-xx B- Acid, gallici, 3j Ergotine (aq. ex.,) __ Digitalis, aa »J. «• Ft. Pil. No. XX. S. — One every four hoon. 84 DISEASES OF THE RESPIRATORY SYSTEM. Alumen is serviceable in purely atonic haemoptysis. It may be given in solu- tion, by inhalation, or be allowed to dissolve slowly in the mouth, In substance or in lozenge. In moderate but persistent tubercular haemop- tysis. Dr. Symonds recommends {British Medical Journal, ]nne 13, 1868,) the following: 155- R- Aluminis, 9>j.. . Acidi sulphuric! diluti, '• 3 ijss-iv Magnesii sulphatis, 9iv Aquae, f-Siv. M. A tablespoonful in water, every three hours, or oftener, as required. Ammonii Chloridum is recommended by Dr. Copland, in combination with muriatic acid, in passive cases of haemoptysis, when the vital powers are depressed; The following is his formula : 156. R. Ammonii chloridi, 3i3S Acidi muriatici, f. 3 ss Decocti hordei compositi, Oj. M. A small wineglassful every two or three hours. Antipyrin. See New Remedies. Argenti Oxidum, in doses of gr. ss-j, thrice daily, has been recommended, in atonic haemoptysis. Atropia. See New Remedies. Chloroform. Several cases are reported by Dr. A. M. Weir, of Edinburgh, (Lancet, January, 1877,) in which the haemoptysis was promptly checked, after other remedies had failed, by applying a flannel pad soaked in chloroform, over the lung from which the blood flows. Cupri Sulphas is highly recommended by Prof. Da Costa, in cases of persist- ent slight haemorrhage. Digitalis is advised by Dr. Walshe, when there is irritable heart and mod- erate haemoptysis. By some it is regarded as the best remedy for haemorrhage from cavities in the advanced stages of phthisis. It is given by Dr. Brinton in the form of the infusion — 157. R. Infusi digitalis, f.Jig. Sig : Dose — a tablespoonful every hour until the pulse is reduced. Ergota is strongly recommended by Dr. Dobell, who, however, usually asso^ ciates it with other medicines. Dr. J. M. Williamson {Lancet, No- vember, 1875,) gives it in niyX doses of the fluid extract every half hour. Prof. J. Hirschfeld, of Vienna, believes the very best remedy in haemoptysis is hypodermic injections of ergotin in concentrated solution (one part m ten of glycerine.) (DobeWs Reports, 1877.) Hy^f.MOPTYSIS. 3r Bartholow uses the following : 158. R. Ext. ergotae fl., f.5iij Ext. ipecac fl., Tinct. opii deodor., aa f. 3ss. M S. — A teaspoonful every half hour or hour. When the sputa are heavily charged with blood, but there is no defined hemorrhage, he uses : 159. R. Ergotinse (aq. ex.), 9j Pulv. ipecac, gr. ^ Acid, gallic, 9j. m . Ft. Pil. No. XX. S. — One every hour or two. Ferrum is particularly of service in haemoptysis connected with amenorrhoea. The preparations most employed are the tincture of the chloride, the solution of the nitrate (in large doses, n\^xxx-lx,) the sulphate, and the am monio-sulphate. Gallicum Acidum is highly recommended by Profs. Da Costa, Walshe, and others as one of the best remedies in haemoptysis, but it must be given in large doses gr. x— xxx, repeated as necessary. Geranium Maculatum is largely commended by Dr. Shoemaker in doses of one drachm of the fluid extract. Hamamelis. Dr. Hugo Engel (Med. and Sur. Rep., May, 1879,) states that this drug is far superior to any other in haemoptysis. In violent cases, he gives two teaspoonfuls of the fluid extract of hamamelis right away, and repeats the dose every half hour till the severe bleeding stops, and continues it later, in the dose of one or half a teaspoonful three times daily, until all signs of the spitting of blood have disappeared. Hydrastis Canadensis, in doses of 20 to 30 drops of the fluid extract, is fa- vorably mentioned by Dr. Kceniger. Hydrocyanicum Acidum seems to possess some power in controlling haemo- ptysis when the system is irritable and spasmodic symptoms are present. Ipecacuanha is recommended by Prof. Graves and other practitioners, as a remedy of considerable value. From one to two grains are given every fifteen or thirty minutes, until nausea is felt, when the benefit is generally evident, and the medicine is discontinued. Many cases are reported, attesting the efl[5cacy of this treatment in arresting the hem- orrhage and restoring heat and life to patients who were in a state of collapse from excessive loss of blood. Although it is better to avoid vomiting, no ill effects, it is said, are produced by it. The haemoptysis of the early stages of phthisis may often be readily arrested by this remedy. It is given by Dr. Holmes in doses of gr. xx by suppository. Maiico is sometimes employed. In slight cases, the infusion alone is often sufficient. It is advantageously combined with ergot. 86 DISEASES OF THE RESPIRATORY SYSTEM. Oleum Terebinthina: is often efficient. Phosphoricum Acidum Dilutum, in doses of gtt. x-xxx in mucilage, thrice daily, is reported upon favorably by M. Hoffman, {The Practitioner, August, 1868,) who considers it superior to other mineral acids in haemoptysis. Pyrogallicum Acidum. Dr. A. Vesey has found this of the greatest service, in doses of gr. j every half hour. It may advantageously be combined with ergot {Dublin Jour, of Med. Science, December, 1875). It has the advantage of not disturbing the stomach. Plumbi Acetas, in combination with morphia and acetic acid, or with opium, is a remedy much used. Dr. Pereira considers that the action of sugar of lead and opium in haemoptysis is rendered more certain and speedy by being given with a draught containing nitric acid, nitrate of lead being thus formed in the stomach. Potassii Nitras is useful where there is much excitement and fever, but is not to be relied upon alone. It may be given in doses of gr. viij-x, sev- eral times daily, largely diluted, or combined with tartar emetic or digitalis. Sodii Chloridum is recommended by Prof. Walshe, in drachm doses, either in powder or dissolved in water. It is sometimes promptly successful, even when it produces emesis. It has been successfully administered by Rosenbusch hypodemically in pulmonary and gastric hemorrhages, in doses of several drachms. Sulphuricum Acidum Dilutum \s a. -a^sivA remedy, though less certain in its action than gallic acid, and is a valuable adjunct to other treatment. Tannicum Acidum, in combination with opium and ipecacuanha, has been highly recommended. Veratrum Viride in full medical doses, will sometimes control active hemor- rhage, occurring in the plethoric. EXTERNAL MEASURES. Cold. Ice to the chest, to the spine, or over the heart, will sometimes in- stantaneously arrest the hemorrhage. Swallowing small pieces of ice is recommended by many physicians in severe cases. The inhalation of dry cold air is shown to be of value as a pulmonary haemostatic by TuLLio. Dry Cups. In the Allg. Wien. Med. Zeii., May, 1878, Dr. H. Schneider ex- presses the opinion that the best means for the relief of congestion, or a hyperaemic condition about the lungs, is an old remedy which has fallen into disuse of late years — the application of cups. The number of cups to be applied must depend on the amount of congestion, and the effect which it is desired should be produced. A considerable AUTUMNAL CATARRH. 87 amount of blood can be withdrawn from the general circulation, and will be kept in the outer wall of the chest. In comparatively 'mild cases, dry cups are applied to the thorax on the side corresponding with the congested lung, while if the bleeding is severe, wet cups should be applied placed on the affected side. Ligation of the limbs by a tourniquet, or the Esmarch bandage, so as to pre vent the venous flow, is of service in severe cases. " Jounod's boots " have been used for the same purpose. HAY FEVER-HAY ASTHMA-ROSE COLD- AUTUMNAL CATARRH. PROFESSOR HARRISON ALLEN, OF PHILADELPHIA. The conclusions to be drawn from the study of a number of cases Tcported by Dr. Allen, (in the American Journal of the Medical Sciences, January, 1884,) may be summarized briefly as follows: 1 . That the treatment of all conditions of obstruction in the nasal •chambers, no matter from what cause arising, can be successfully ■carried out by destroying the causes of obstruction. If the cause be an overgrowth of bone-tissue, it must be filed, sawed or drilled away. If it be caused by a deviated cartilaginous portion of the septum, such portion must be re-set in a new place. If, as is often the case, it is due to periodic turgescence of the mucous membrane, or the resulting secondary hypertrophies, such growths must be de- stroyed, either by the galvano-cautery, by the snare, or by caustic acids. 2. That the treatment of hay-fever and allied periodically-recur- ring nasal affections in no way differs from the treatment of other nasal diseases accompanied by obstruction, and that the treatment may be conducted during an attack as well as in the. intervals be- tween any two attacks. Many authorities, prominently among them Dr. Carl Seiler, of Philadelphia, claim that an hypertrophy of the post-nasal mucous membrane predisposes to hay fever, and that the tendency cannot be eradicated until this hypertrophied tissue is removed. This can be accomplished with the galvano-ecraseur. Dr. Charles E. Sajous, of Philadelphia, has cured some severe cases by the topical application of glacial acetic acid, but owing to 88 DISEASES OF THE RESPIRATORY SYSTEM. the pain produced by this agent, he prefers the galvanic cautery. (Med. and Surg. Reporter, December, 1883.) DR. JOHN O. ROE, OF NEW YORK, contributes an article on this subject to the N. Y. Med. Jour., May 19, 1883, in which he reaches the following conclusions: 1. That the treatment during the attack can only be palliative,, such as to soothe the inflamed parts and to quiet the systematic dis- turbance which may be occasioned. 2. That in most cases the only effective relief during the attack consists in going to a seaport or mountainous region, or to any locality where the air is free from the substance which produces the irritation. 3. That curative measures can only be adopted when the individ- ual is free from the attack. 4. That the removal of the diseased tissue in the nasal passages removes the susceptibility of the individual to future attacks of hay fever. For the removal of this tissue, Jarvis' snare is the most efficient means of removing that at the posterior end of the turbinated bone^ while that covering the middle and anterior portion is most reliably removed by the galvano-cautery. In later articles. Dr. RoE (N. Y. Med. Jour., 1887), continues tO' advocate the same views. It is a notable fact, however, that while for a time such treatment seems curative, and in some cases really is, not all patients are immuned from their annual attacks, recur- rences being recorded within three or four years. DR. GEORGE M. BEARD, NEW YORK. According to this writer, there is no specific for hay fever in gen- eral, but individuals may be able to find a specific for their own cases. Many measures afford great relief in all cases. A sea voy- age rarely fails, as well as a residence in elevated regions, and in certain localities. The medical treatment he divides into general and local. Of in- ternal remedies he considers quinine the most efficient. When given to prevent the disease, gr. j-iij, two or three times a day, for several weeks before the time of the attack, is the proper dose. Arsenic, especially when combined with belladonna, is efficient. AUTUMNAL CATARRH. gg 160. R. Liq. potassii arsenitis, f.5j Tinct. belladonnse, f. 5 ij. M From five to ten drops after meaK Phosphide of zinc, gr. Vs-i acts well in many cases. Opium in any form will palliate the symptoms. One of the best preparations for the purpose, is the " cold powder," as follows : 161. g. Camphorse, gv Ether, sulphuric, q. s. Dissolve to the consistency of cream, and add : Ammoniae carbonatis, g iv Pulveris opii, 2J- M. Keep tightly corked. DR. BIGG, OF DOVER. (British Med. Jour., July 28, 1888.) Dr. Bigg advocates spray- ing the palate and throat, both prior and subsequent to entering any grassy or grain-growing district, with the following : 162. 1: . Solutionis cocainse hydrochloratis (5 per cent). Solutionis acidi carbolici (l in 120), aa M. Two small sponges soaked in the above are placed in either nostril and the eyes are bathed in '63. R. Solutionis hydrargyri bichloridi (i : 1000), Solutionis zinci sulphatis (gr. ij to ounce of water), aa M. The following as a tonic is given internally: 164. R. Solutionis potassii arsenitis, 6*'-.y Potassii iodidi, gr- ij Spiritus ammonise aromatici, gtt. xx Aquae, q. s. adf..^j. M. Sig: — One dose, to be given three times a day. DR. KINNEAR, OF BOSTON. (Med. Record, July 14, 1888.) Believing that hay-fever is due to reflex disturbances following hyperaemia of the nervous centres, and that this hyperemia is aggravated through further reflexes from the irritation of summer heat, pollen, etc., this writer makes use, with considerable success, of Chapman's spinal ice bag applied to the cervico-dorsal portion of the column. The eff"ect is to dilate the ar- terioles of the general circulation, and thus draw the blood from the swollen nasal mucous surfaces. In violent attacks the ice bag is applied to the dorso-lumbar region, inducing dilatation of the ves- sels of the lower extremities and drawing the excessive blood away 93 DISEASES OF THE RESPIRATORY SYSTEM. from the head. These applications usually should last from half an hour to an hour and a half, and should be made once, twice or three times during the day. Applied at night the distressing symptoms are relieved and the common loss of sleep may be avoided, the cerebral anaemia directly inducing somnolence. The dose is to be regulated by the quantity of opium borne. Locally, many substances can be applied by means of the atom- izer. Solutions of quinine are perhaps the most effectual of all. The following is commended by Dr. R. P. LINCOLN, of New York : '65. R. Quiniae sulpbatis, gr. vj Aquae camphorae, f. ,5 vj Sodii chloridi, 3 ss Aqu3e, f-S'^- M. Use in an atomizer or snuff from the band. The pinus canadensis has been used in the same way. 166. R. Fid. ext. pinus canadensis, f. 3j Aquae, Oj. M. The following is well spoken of: 167. R. Potassii chloratis, gj Morphiae sulphatis, gr. xij Aquae, f.jvj. M. Use with the atomizer. Inhalations of aquae ammoniae relieve some cases. Smoking stramonium leaves, nitre paper, etc., benefits some. Dr. Morrill Wyman recommends : 168. R. Belladonnae fol., gr. ix Hyoscyami fol., Stramonii fol., ^ ot^ jygg Phillandrii aquatici fol., gr. jss OP"' gr." ^. M. Make two cigarettes by rolling in paper. Only two to be used during an attack. DR. E. C. SEGUIN, NEW YORK, 169. R. Ammonii bromidi, >Tj_ij Aquae, f_jj_ Use as a gargle frequently. 170. R. Ammonii bromidi, gr x-xxx Aquae, f,^j_ Use by an atomizer, or inhale into the nostrils. AUTUMNAL CATARRH. 91 This has given marked relief to patients. (New York Medical Record, l^ovemher, 1876.) DR. J. S. HOLDEN, ENGLAND. 171- R- Quinioe sulphatis, gr. xij Acidi hydrochlorici diluti, tt\_xxx Aquse, f-.^vj. M. Add Sodii bicarbonatis, q. s. To make a neutral solution, add one ounce of hot water to two ounces of this lotion, and douche the nasal passages three times a day for a few days at the beginning of the attack. (Lancet, May, 1876.) The grindelia robusta is said to give prompt relief. 172. R. Fid. extracti grindelise,, f-3'^ Fid. extracti rhei, Fid. extract! sennae, aa f. ,^j. M. A dessertspoonful every half hour during the spasm, and afterwards at intervals of three hours. DR. HORACE DOBELL, LONDON. 1 73- R- Chloral hydratis, Camphotse pulv., aa gr. xvj Acidi carbolici, 9j Morphiae, gr- xij Acidi oleici, ' gr- vij Oleiricini, f-3""J- ™- Rub well together to make a lotion. Apply by means of a little ivory or hard-wood club to the interior of the nostril. This author states that the tincture of eucalyptus globulus is val- uable in hay fever where there is much prostration. SIR ANDREViT CLARK. (Brit. Med. Jour., 1887.) 174. R. Hydrargyri bichloridi, P; '^ Quinise hydrochloratis, .^J Acidi carbolici, j rz-'™ Glycerinae, ad f.^j. Heat the mature to cause the solution of the quinine. Applications are to be made to the nasal mucous surfaces by means of a camel-hair pencil. ad f.3J. M. DR. EDWARD R. MAYER, PENNSYLVANIA. 175. R. Quiniffi sulphatis, g^-'^ Tinct. gelsemii concent., »"• )• 92 DISEASES OF THE RESPIRATORY SYSTEM. This amount in water every four waking hours. Regarded by Dr. Edward R. Mayer as the best remedy for and preventive of this disease. Cures in forty-eight hours. (Hints on Specific Medication, p. 21.) DR. ROBERTS BARTHOLOW, PHILADELPHIA. 176. R. Potassii iodidi, 3J Liq. potassii arsenitis, ••3j Aqu4 f-.l'V. M. A teaspoonful every four or six hours. In addition to this internal medication, apply locally the following with a post-nasal syringe : 177. R. Tinct. lodi, f-3J Acidi carbolici, gtt. x. AquK destillatse, f- .? iv- M. Arsenical cigarettes, as recommeftded by TROUSSEAU, inay be used with advantage : 178. R. Potassii arsenitis, gr. xv Aqus, f.gj- M. Moisten unsized white paper with this solution, cut and roll into cigarettes. Two or three may be smoked daily. NEW REMEDIES. Antipyrine is recommended highly by Dr. CHEATHAM, of Ken- tucky (Amer. Pract. and News, 1887), in daily doses of gr. x-xxx. Antifebrine was also used by Dr. CHEATHAM with equally good results, being administered in doses of gr. iv— vj, daily. It is be- lieved that these two drugs have special action on the nerve centres, to the diminution of the sensitiveness of the mucous surfaces. Peroxide of Hydrogen is mentioned as having a favorable action by Dr. INGRAHAM (Chicago Med. Times, 1887), applied by means of a post-nasal syringe. The preparation of Ch. Marchand' New York, is reliable, and may be used, mixing with equal quantities of glycerine. For preservation it should be kept in a cool atmosphere. Cocaine. For a time this drug was much lauded as a temporary means of relief, but, except as a very brief aid, it has lost much of its reputation. A solution of 2 to 5 per cent, strength applied by spray will often afford great amelioration for half an hour to several hours ; but it is believed that its constant use leads to a worse con- dition, the vessels often becoming paralyzed and the membranes much congested as a final result. Within the limits outlined, how- AUTUMNAL CATARRH. q. ever, it is of utmost value, except where idiosyncrasy prevents its employment. H. C. Wood, of Philadelphia, recommends that the drug be ap- plied in bougies made of cocoa-butter, each containing one grain of cocaine hydrochlorate and rh grain of atropia. The patient lying down, these should be forcibly inserted between the septum and the swollen turbinated bodies. (Therapeutic Gaz., January, 1889.) Menthol. This drug applied in solution of olive oil is commended by Hill, of London (London Lancet, June 22, 1889). It should be applied by means of a brush or as a coarse spray. 179. R. Menthol, f. 5j. Olei amygdali, f. 3 .jx. M. NOTES ON REMEDIES. Acid Carbolic. Bartholow says that inhalations of carbolic spray are highly useful. A solution in water, to the proportion of one per cent., can be used. Acidum Sulpkurosum. According to Dr. James Dewar, of Ireland, the symp- toms of hay fever are often checked at once by inhaling sulphurous acid in the form of the fumes of burning sulphur. (Dublin Medical Press, September, 1866.) Aconitum has been recommended by Dr. Ringer. Ammonia Murias, taken internally, is suggested by Dr. Beard. Anthemis Nobilis. Chamomile flowers smoked, or their fumes inhaled, often act very well. Antipyrine has been extolled by Dr. Cheatham in daily doses of gr. x-xxx. Antifibrin is also commended as of merit in doses of gr. iv-vi. daily. Arsenicum is an important auxiliary. Atropia is useful when the secretion is profuse. Belladonna, either the leaves smoked or in doses of the tincture, is occasion- ally efficient. Mr. W. F. Phillips (Brit. Med. Jour.) 1884, uses : 180. R. Succi belladonnae, "V*^.'y Aquam, ad f. 3'U- M. — A teaspoonful to be taken every hour till relief is obtained. " The medicine was taken without the production of any undesirable effect, and with very marked advantage indeed — an advantage that became still more evident and unmistakable, both to the patient and myself, when the dose was increased from one minim to one and a quarter (half a drachm in three ounces) ." Caffea. Strong hot coffee is a useful palliative. 94 DISEASES OF THE RESPIRATORY SYSTEM. Camphora is a useful local application. It may be placed dry on the pillow at night. Chloroform, by inhalation, will quickly relieve the spasm. Cocaine as a palliative is of excellent merit. Its value is, however, limited because of the brief duration of its effect. Euphrasia Officinalis {vulgb eyebright), gtt. ij-v of the tincture, as often as required, is reported upon very favorably by Dr. H. G. Piffard, of New York. Guarana is useful in relieving the headache. Grindelia Robusta. In the asthmatic attacks consecutive on hay asthma, great relief has been experienced from the fluid extract of wild sun- flower. It may be administered as follows : i8i. E- Grindeliae rob. ex. fld., (Parke, Davis & Co.,') ^^'^.■■ Syrupi simplicis, f. 5 "J- A teaspoonful at a dose. Hydrogen Peroxide is one of the new local applications meriting further use. It is applied in a solution in equal quantity with glycerine, by spray or brush. Iodides. The iodides carried to iodism afford great relief; they may be com- bined with arsenic. lodutn, in inhalation, benefits some cases. Dr. J. G. Westmoreland re- commends placing one grain in a wide-mouthed vial, heating till it fumes, and inhaling. Repeat every day. (Atlanta Medical and Sur- gical Journal, October, 1870.) Menthol is used with benefit by Dr. Hill, of London, in a ten to twenty per cent, solution in almond oil, applied in a coarse spray or by a brush (F. 179). Muscarine will probably prove useful in the asthmatic stage if the membrane is dry. Oleum Mentha Piperilce. Dr. James E. Bell, of Georgia, himself a sufferer, states (Medical and Surgical Reporter, December, 1877,) that the remedy which he has found superior to all others to allay the irritation and to quiet the cough, is the oil of peppermint, applied locally, in vapor or in substance. Opium is a valued palliative. The hypodermic injection of morphia gives great relief. But there is danger of inducing the opium habit by a re- sort to these palliatives. Quinia Sulphas is the mpst generally useful remedy yet found. (See above.) Salicin, gr. xx-xxx, twice daily, is extolled by Dr. T. J. Macxagan. Stramonium Leaves, smoked, are efficient to allay the paroxysm. LARYNGITIS. gj Tabacum. The smoking of tobacco, to those who have not been much accustomed to it, has proven beneficial. Tannin, in solution, may be used with the atomizer. Zinci Sulphas. Dr. Fuller reports ten cases effectually cured by means of sulphate of zinc, administered internally, in gradually increasing doses, whilst zinc lotion was applied to the eyes, and a lotion composed of eight grains of sulphate of zinc and an ounce of glycerine to the Hning membrane of the nostrils. Mechanical Measures. Wearing a thick veil, or a respirator, or keeping two fine sponges in the nostrils, moistened with a glycerine solution, and learning to breathe constantly through the open mouth, are procedures which have relieved some cases. Cauterization and the removal of the morbid mucous membrane by snare, etc., the correction of faults of growth of the membrane, cartilage and bones, must all be considered where more than palliation is sought. Localities. Certain localities are apparently, from their altitude or some un- known factor of their climate, free from the causes which induce the peculiar attacks. Bethlehem, N. H., is the most noted of these re- sorts ; Asheville, N. C, is also commended. Generally high mountains and the air of the ocean may be found to afford relief — but not in- variably. Chronic Laryngitis. < LARYNGITIS. For clinical purposes, the varieties of the disease may be classed as follows: Acute Laryngitis. Follicular or glandular laryngitis. Aphonia clericorum, clergyman's sore throat. Tubercular laryngitis. Syphilitic laryngitis. The tubercular and syphilitic forms are characterized by ulcers, which are not present in the other varieties. ACUTE LARYNGITIS. In an acute laryngitis the following general indications are those to which attention is to be paid in the course of the treatment. As a matter of hygiene, the patient is to be kept in a moderate equable temperature, the atmosphere being preferably kept moist by steam. Depending upon the severity of the case, relaxants and depletives 96 DISEASES OF THE RESPIRATORY SYSTEM. are to be employed, and measures tending to the withdrawal of the blood from the inflamed membrane. In the membranous form, efforts to dislodge or remove in some way the membranous forma- tion, or in case of danger of suffocation from this cause or from oedema of the parts to cause free emesis are to be made, and pos- sibly the operation of intubation or tracheotomy performed. The danger gone, if weakness of the cords and aphonia persist, the treatment recommended under that head is to be attempted. The rules of treatment of the common form, which so often at- tends an ordinary catarrh, are thus laid down by JOHN SYER BRISTOWE, M. D., LONDON. The patient should be kept in a warm atmosphere, free from ex- posure to draughts ; apply hot fomentations (a sponge wrung out in hot water) or mustard plasters to the throat, and use a gargle of warm milk, or some slightly astringent substance. The faucial dis- comfort may be relieved by the inhalation of steam (in which the patient should be taught not to take deep, but ordinary inspirations.) Diaphoresis should be encouraged by warm foot-baths, etc. Opium, in small doses (Dover's powder), greatly relieves the discomfort. In cases severe from the beginning, leeching externally and scarifi- cation within are of essential importance for the cedematous condi- tion, which may even demand tracheotomy, an operation which it is better to perform early, before the patient is moribund. No patient should be permitted to die of this disease without having this chance placed in his favor. DR. KRISHABER, GERMANY. When the laryngitis is of the dangerous cedematous variety, this writer recommends the following treatment : If it is markedly in- flammatory, antiphlogistic treatment should be practiced; one or two general bleedings, and wet cupping on the neck, will give con- siderable relief, diminishing the inflammation, and lessening the en- gorgement of the tissues. By means of a spray apparatus, water impregnated with tannin or alum may be applied to the back of the throat. In the absence of a spray- producer, a simple irrigator filled with astringent fluid may be used. Recourse may also be had to cauterization with nitrate of silver, insufflations of tannin or alum, and scarifications and divisions of the ary-epiglottic folds. These last two methods are somewhat difficult to practice, but often, under the LARYNGITIS. 97 influence of spray irrigation and local bleedings, the inflammation •diminishes and disappears. When the oedema of the glottis is due to tuberculosis or cancer, art is powerless against the diathesis and the laryngitis. INTUBATION IN MEMBRANOUS OR CEDEMATOUS LARYNGITIS. This procedure was suggested by Dr. O'DWYER, and consists in the insertion into the larynx, which is in danger of occlusion from pseudo-membranous formation or from oedema, of a small silver tube made with shoulders at the upper end to prevent its passage into the trachea,- and generally conforming to the laryngeal cavity. The insertion is accomplished by means of a suitable readily detach- able handle, and after practice the procedure is usually performed with but little difficulty. It is intended to take the place of the op- eration of laryngotomy in cases of severe character. The laryngeal tube is further kept within control by the attachments of silken threads. Modifications of the original apparatus with a view of pro- viding a covering so as to permit swallowing more easily have not been as successful as is to be desired, although by no means entirely a failure. The apparatus is recognized as a valuable addition to the re- sources of the physician in these cases, and is entirely commendable in many cases. (See O'DWYER — Maryland Med. Monthly, June 23, 1888; Waxham — Peoria Med. Monthly, April, 1888; StorCK— Centralbl. fur Chir., April 21, 1888; Bleyer— i\^. Y. Med. Jour., February 2, 1889; Annandale — Brit. Med. Jour., March 2, 1889; etc.) In feeding with the tube inserted the best method is that sug- gested by CasSELBERRY (Chicago Med. Jour, and Examiner, Octo- ber, 1888). It consists in placing the patient's head as low as or lower than the body wherever the deglutition of fluids is to be ac- complished, the liquid easily escaping being drawn into the tube. For removal of membranous formation by means of digestants, see section of Paediatrics. PHLEGMONOUS LARYNGITIS. SokaloWSKY (Jour, of Laryngology, April, 1889,) states that in the beginning of this affection it must be differentiated from laryn- geal phthisis. He recommends in the treatment distinct purgation, the application of blisters, the use of hot and cold applications to the 98 DISEASES OF THE RESPIRATORY SYSTEM. neck in the laryngeal regions, and if oedenia threatens, scarificatioh. The application of leeches to the neck anteriorly is also of value. Inhalations of carbon dioxide, the painting of the membrane with carbonated solutions, or with solutions of iodoform, are commended by various writers in conjunction with measures as above. As an effective combination in acute febrile attacks of laryngitis, DR. T. WHIPMAN, ENGLAND, has derived great benefit from the following (Med. Times and Gazette^ 1877): 182. R. Vin. antjmon., f-.^ss Vin. ipecac, ^U^ Potass, acet., 9j Spts. seth. nit., f-SJ Potass, nitrat., 9ss, M. S. — To be given every four hours. It may find especial value in those cases of sudden loss of voice in acute laryngitis often met in children. DR. LENNOX BROWNE, LONDON. Inhalation is a valuable means in acute laryngitis. 183. R. Tinct. benzoini comp., f. § iij Chloroformi, TlV;icxv. M. A teaspoonful in a pint of water, at 140° F., for each inhalation. A valuable seda^ tive in acute inflammations of the pharynx and larynx. 184. R. Ammonii chloridi, 9j . Tincturse opii, n\_v Decocti cinchonas, ad f. ^j. M. For one dose, to be taken at n and 4, belvfeen meals. Used in catarrhal conditions and in commencing head-colds. Other inhalations are : THOMAS HAWKES TANNER, M. D., LONDON. '85. R. Acidi hydrocyanici diluti, Tt\pcv Spiritfls chloroformi, f. 5 iij Aquje bullientis, f.^viij. M- For inhalation. LONDON HOSPITAL, 186. R. Tincturae. benzoini compositse, f. Kj Aquae bullientis, f-Mx. M^ Let the vapor be inhaled frequently. 187. R. Tincturae iodinii, H^ Aquae bullientis, f. Jx. M, To be inhaled frequently. LARYNGITIS. CHRONIC LARNYCxITIS. In chronic larnygitis, one of the first requisites is to remove the cause, as the inhalations of dust and other irritative matters, the abuse of the voice, etc. In all cases, as nearly as possible, absolute rest IS demanded. The use of local measures is that which is gen- erally necessary, usually of an astringent or stimulating nature. Occasionally the external use of counter-irritation is indicated. The intimate relations between some cases of chronic larnygitis and rheumatism make it probable that this relation is that of effect and cause, and the administration of anti-rheumatics is advisable and often of benefit. DR. ISAMBERT, PARIS. In clergyman's sore throat, oratory^ tobacco, and all alcoholic drinks, must be interdicted. Gargles are of little avail. Pulverizers and inhalers are not much more useful. Direct local treatment to the walls of the larynx by means of a sponge, is the true plan. For this purpose, nothing equals solutions of zinc chlorides : 1 88. R. Zinci chloridi, parts J-i Aquae, parts loo. M. DR. C. E. SAJOUS. At the Congress of American Physicians, held at Philadelphia, September, 1888, this practitioner, in speaking of the hypertrophy of the vocal cords in chronic laryngitis, recommended their treat- ment by means of chromic acid. The surfaces are first well anaes- thetized by means of a 25 per cent, solution of cocaine hydro- chlorate, and then the acid, introduced on a probe protected by glass, is touched to the cords. The patient is directed to make a sound, so that the cords are approximated and their edges thus protected from cauterization. The spot touched in healing leaves a white patch in the midst of the red of the inflamed cord. By alternate treatment to one and other cord, the surface is in this manner cica- trized, the inflammation being gradually subdued. In the application a silver probe should be used. It is heated, and while hot plunged into a small glass tube heated to melting. It is found on withdrawal to be covered with a thin film of glass, which protects the metal from the acid. lOO DISEASES OF THE RESPIRATORY SYSTEM. DR. J. H. GARNER, CANADA. In all varieties of laryngitis, acute and chronic, in pharyngitis, commencing tonsillitis, etc., this practitioner uses guaiacum. (Can- ada Lancet, July, 1861.) In clergyman's sore throat, for instance, he would prescribe : 189. R. Tinct. guaiaci ammon., Liq. potassse, aa '•.'5||J Tinct. opii, '•j'j... -, Aquam cinnamomi, ad f. 3 viij. M. Make a gargle. Use every hour. The liquor potassae keeps the gum dissolved. It is probable that this prescription owes its efficacy to the fre- quent dependence of laryngitis upon rheumatism. In the hoarseness and sore throat in young ladies, so commonly connected with menstrual troubles, this gargle does excellent ser- vice ; or the pharynx and upper larynx may be swabbed with the pure ammoniated tincture. This produces a momentary asphyxia, but as soon as the patient gives a cough it is gone. PROF. M. CHARTERIS, M. D., GLASGOW. For chronic larnygitis, chloride of zinc has been specially recom- mended : 190. R. Zinci chloridi, gr. xxx Aquae destil., f. g j. M. Apply locally, every day, for a week, and afterwards on alternate days. If the secretion is excessive, turpentine or creasote makes the best inhalation ; and when the laryngeal irritation is the principal feature, inhalations of hops are soothing. 191. R. Creasoti, jiij Magnes. carbon., 3 iss Aquam, ad f. § iij. M. Or: 192. R. Acidi carbolici, f-5j' Aquae, f-3vij. M. A teaspoonful in a pint of water, at 1 50° F., for each inhalation. For touching or painting the inflamed surface, use 193- R- Acidi tannici, 5ss Glycerinsc, giv. Or, when ulceration is present : 194. R. Sodii biborat., gj Glycerinae, 3 ij. M. LARYNGITIS. Iq, DR. LEFFERTS, OF NEW YORK. In his lectures Dr. Lefferts has recommended the use of the fol- lowing formulae for inhalation in cases of chronic laryngitis : As a mild stimulant, '95- R- Fir-leaf oil, ^ptl Carbonate of magnesiuni, gr. xx Water, adf.gj. M. A teaspoonful in a pint of water at 140° F., for each inhalation. As a powerful stimulant, useful in many cases where other stim- ulating inhalations have lost their effect. 196. R. Olei calami, IT^_v Magnesii carbonatis, gr. ijss Aquae, q. s. adf.gj. M. A teaspoonful in a pint of water at 140° F., for each inhalation. MR. LENNOX BROWNE, LONDON. 197- K- Fotassii chloratis, gr. ij Eucalypti extracti, gr. j Pulveris cubebae, gr. J- Confectionis fructus (fruit paste), q. s. M. For one lozenge ; has a joint astringent, sialogogue and expectorant action; valuable as a voice lozenge. 198. R. Morphiae muriatis, gr. ^ Ipecacuanhae pulveris, gr. ^ Confectionis, q. s. M. For one lozenge ; useful in allaying irritable cough, and assisting expectoration in laryngeal and bronchial catarrh. TUBERCULAR LARYNGITIS. Dr. Hunt (Ann. des Mai. de I' Oreille, December, 1889,) states that in the early stages, which are always accompanied by anaemia, he prescribes inhalations of oil of tar or creasote and local applica- tions of chloride of zinc or iron, believing that nitrate of silver is useless at this time. When the catarrhal process is active he uses sedatives or stimulants, as may be indicated, inhalations of mineral astringents, perchloride of iron, or an atomized spray of i to 2000 of bichloride of mercury. The oil of eucalyptus is probably the best remedy for quieting the cough ; and as an insufflation he pre- fers iodol to all other substances, as lactic acid or iodoform. When stenosis and oedema of the larynx appear, he scarifies the mucous membrane; and where it is diseased, uses the curette. When stenosis threatens life, he may require to perform tracheotomy. I02 DISEASES OF THE RESPIRATORY SYSTEM. DR. KRAUSE. (Therap. Monatsk, May 1889.) Dr. Krause speaks in favorable terms of the operation of curetting ; but is more and more favorably inclined to the topical application of lactic acid in these cases. The membrane should in these cases be brushed clean, and in order to diminish the pain of the application, a solution of cocaine ■ may be applied. The lactic acid is then to be rubbed in thoroughly. If the ulcers do not heal under this treatment, they should be thoroughly scraped and the lactic acid again applied. dr. ROSENBERG, OF BERLIN. (La Semaine Med., 1887.) This physician uses a solution of menthol applied directly to the ulcerations, and reports much bene- fit from the measure. 199. R. Menthol, SJ Olei olivse, q. s. ad i.'i,\. M. The application seems to be followed by a subsidence of the pains and difficulty in swallowing, and the ulcers heal in from two to eight or ten weeks. The action of the remedy is that of a sedative and antiseptic. In syphilitic laryngitis the specific treatment for syphilis, especi- ally the mercurial treatment, is essential to success. Locally, the ulcers may be touched with dilute solutions of nitrate of silver. In all cases of syphilitic and tuberculous laryngitis, the local appli- cation of a saturated solution oi nitrate of silver in glycerine once in ten days has been recommended. The object is to substitute an acute for a chronic inflammation, and the inflammation caused by nitrate of silver recovers much quicker than that caused by most of the other caustics. Then use a spray or gargle of common salt- water three or four times a day. Occasionally an antiseptic should be added, and the best are said to be oil of cinnamon, winter-green, pepper, etc. NEW REMEDIES. Chromic acid is used by Dr. Sajous for the purpose of cicatriz- ing the hypertrophied membrane in the chronically inflamed larynx. It is applied at intervals upon a glass-covered probe. Lactic acid, proposed by Dr. Krause, is useful in inducing an acute process of inflammation and healing in tuberculous as well as syphilitic ulcerated throats. LARYNGITIS. jq. Menthol is proposed by ROSENBERG for much the same purposes as lactic acid. The latter is said to be best used in strong, apathetic individuals, and menthol in the more nervous. Carbolic acid is used in ordinary solutions i to 40 or 60, in the •cases of laryngitis associated with infectious processes, and as a sed- ative and stimulant in the chronic sore throats of those who lose the voice. lodol and iodoform are both of value in the ulcerated and phlegmonous sore throats, as topical applications, usually applied by insufflation. NOTES ON REMEDIES. Acidum Carbolicum. The inhalation of pulverized solutions of carbolic acid (gtt. i-v to f. gj. aq., with a few drops of glycerine added), is frequently of service. Acidum Chromicum is used by Dr. Sajous in the hypertrophies of chronic laryngitis, as a topical application. Acidum Lacticum was introduced by Krause in the treatment of tubercular laryngitis, for the purpose of stimulating the tissues into an active in- flammation so as to induce healing. Alumen is valuable as a gargle Oj-iij to aquae f |j) on the decline of the inflammatory symptoms in the acute, and generally in the chronic form, ^mmonii Chloridum. The following is used by Dr. Da Costa : 200. g- Ammonii chloridi, gr. x-xx AquK destillatse, f. §j. M. Use with any form of steam atomizer, throwing a fine spray, in laryngeal calarr/i, acute as well as chronic. The dose best borne is not above ten grains to the ounce, although as much as two drachms to the ounce have been employed. Argenii Nitras may be used in inhalation (gr. v-x to f.^j) as an abortant in the early stages. In the ulcerated forms of tubercular or syphiUtic origin, a strong solution, sj to water f .?j, is the most efficient of all ap- plications. Malsamum Peruvianum. The recommendation originally made by Hoffman, in chronic inflammation of the larynx, of diffusing the vapors of the balsam of Peru, or of benzoin or tolu, throughout the air of the patient's room, by throwing the drug upon hot coals, is an excellent one. Or, the vapor may be inhaled through the inhaler. Benzoinum is of service in strumous laryngitis. The following formula may be ordered : 301. B- Tincturse benzoini compositae, Mucilaginis acacise, Syrupi papaveris, aa f-O^ ' „ Aquae cinnamomi, '• o 'J* For one dose. 104 DISEASES OF THE RESPIRATORY SYSTEM Or: 202. R . Tinct. benz. comp., f. 5 ij Glycerinae, f. % ss Aquam, ad f. J iv. M , For a gargle. Bismuthi Subnitras has been found highly efficacious, applied by means of insufflation. Calamus. The oil of this drug is a powerful stimulant to the relaxed and- congested membrane in chronic laryngitis. Catechu is an excellent ingredient for lozenges. As the pure gum is not un- pleasant, a small piece dissolved in the mouth will be found efficacious- in relaxed conditions of the membrane. Collinsonia Canadensis, the stone root, is esteemed by eclectic practitioners a. specific in clergyman's sore throat. (J. H. Scudder.) Creasotum may be found beneficial in many cases of chronic laryngitis whert inhaled or applied locally. Ferri Perchloridum is an extremely useful addition to inhalations and gargles in the folHcular form. Guaiacum may be regarded as the best of remedies in many inflammatory- cases, notably those associated with rheumatic tendency. Menthol is often used in much the same class of cases as is lactic acid, the ulcerated sore throats of tuberculosis. Potassii Chloras. Saturated solutions of chlorate of potash are valuable gar- gles in all forms of laryngitis and pharyngitis. Some also recommend full doses internally in severe cases. Quinine is recommended by Dr. E. Briand, of France, in a form of laryngitis, which he has observed to be due to malarial poison. Sodii Chloridum. Solutions of common salt, either as a gargle or inhalation^ are of considerable service. Sulphur. Inhalation of sulphurous gas from burning sulphur is often of ut- most value in aiding in the loosening and expulsion of membrane in the membranous forms of laryngitis. Veratt^um Viride. Dr. Handfield Jones has used this drug very successfully in severe acute laryngitis. He gives ni,iv of the tincture every hour until the symptoms abate or vomiting is produced. In the latter case, it may be renewed after a few hours. (Medical Times and Gazette,. January, 1875.) Zinci Chloridum. (See p. 100.) EXTERNAL MEASURES. Cold is useful in cases of acute laryngitis of severe type. It should be ap- plied directly about the neck in the laryngeal region. PHTHISIS. Counter-irritants are of benefit in chronic laryngitis. The following may be employed : Tartar-emetic ointment (not much used) ; Subclavicular Setons (three or four silk threads) ; pustulations of the skin of the throat by Croton oil. Dilatation in laryngeal stenosis has been successfully employed by Prof ScHRoriER, of Vienna. He has devised dilators for the purpose (DobelPs Reports, 1876.) ' Inhalations are largely employed. The following are the principal prepara- tions used : Ammonii Chloridum ; Balsams of Peru and Tolu (vapor generated by placing them upon hot iron) ; Benzoinum (vapor gener- ated by throwing the drug upon hot coals, and thus impregnating the patient's apartment, or from a common inhaler) ; Hydrocyanicum Acidum Dilutum; lodinium ; Olibanum (vapor generated by placing the gum resin on burning coals) ; Sodii Chloridum; Sulphurosum Acidum (spray or fumigation) ; Vapor of hot Vinegar; Steam of boil- ing Water (as much as possible by the nostrils). Insufflations of tannin or alum are serviceable in the cedematous forms. Intubation of the larynx is proposed by Dr. O'Dwyer as a substitute for tracheotomy. Tracheotomy should be performed without hesitation in threatening oedema of the larynx or glottis. PHTHISIS. This formidable disease usually presents itself in one of two forms: (i) acute miliary tuberculosis, or galloping consumption; (2) the insidious and much slower varieties known as chronic phthisis. The treatment of the two kinds is broadly distinct. Acute phthisis, if cured at all, must be by immediate and active medica- tion ; while the management of chronic phthisis is largely hygienic and dietetic, and the exhibition of drugs plays but a subordinate part. ACUTE PHTHISIS. In acute phthisis every effort at overcoming the active agent of the disease is to be made, locally and generally, and the favoring in- fluences of climate are particularly to be taken into account, as well as the nutrition. In the later stages the cough and the debilitating I06 DISEASES OF THE RESPIRATORY SYSTEM. night-sweats are to be specially met, and vomiting and the weaken- ing tendency to diarrhoea counteracted. Throughout the entire course of the case, the skill of the physi- cian is to be especially exercised in maintaining general nutrition as far as possible. DR. MCCALL ANDERSON, GLASGOW. This practitioner claims to have treated, with success, several cases of this most terrible form of the disease. (Lectures on Clin- ical Medicine, 1877.) He feeds the patient every hour or half hour with milk, soup, or other light nourishment, and gives four to six ounces of brandy daily. The night sweats he checks by the hypo- dermic injection of tJ, grain of atropia nightly. As a stimulating expectorant : 203. g. Ammonii chloridi, S-J Syr. scillx, t-Siij Infus. senegae, f-S^- ^- A tablespoonful three times a day. Should the febrile symptoms continue unabated, the following, which is "Niemeyer's antipyretic powder," may be ordered: 204. g. Quinise sulphatis, Pulv. digitalis, aa gr. xij Pulv, opii, gr. vj. M. Make twelve powders. One every four or six hours. The temperature can also be pi-omptly lowered by the application of iced cloths to the abdomen for half an hour, from time to time. To do this properly, the abdomen should be well exposed, and a double blanket placed under the patient. Two pieces of flannel are folded each into four layers, large enough to cover the whole front and sides of the abdomen. One of these is wrung out of ice water, and covered with a piece of dry flannel, whilst the other is left to soak in the ice water. The pieces are changed every one or two minutes. Two nurses are employed to do this. Of course, if there is any tendency to coldness or collapse, the procedure must be stopped. PHTHISIS. Without, so far as therapeutic measures are concerned, drawing any sharp line of distinction between the cases of acute pulmonary tuberculosis or "galloping consumption" and the usual form of PHTHISIS. lO-r phthisis, the particular point to be remembered is the difference of time, depending upon circumstances of the manner of attack on the part of the disease-cause upon the pulmonary tissues, and of various extraneous conditions. This difference of time constitutes a valuable feature in the eyes of the practitioner in the question of treatment, although the process in each case is essentially the same and should theoretically yield to the same measures. The main feature in the treatment is the care of the general state, in order that so far as pos- sible the natural modes of exclusion of the virulent activity of the disease may be operative. Coupled with this, but, until a specific be discovered, necessarily of secondary importance, are efforts to the destruction of the tubercular bacilli, the cause of the affection. In the former of these two classes of indications figure prominently such factors as diet, climate and ventilation, the use of alterative and tonic medication, and rest. In the latter belong various means which have been so numerously applied in these cases, inhalation of antiseptic materials, their administration by the alimentary system, their ab- sorption, their inoculation. Besides these must be added a third class of indications, including the management of the various symptoms whose excessive manifes- tations may constitute prominent and dangerous features. MEASURES DIRECTED AGAINST THE TUBERCULAR INFECTION. (a) By Inhalation : The list of agents which can thus be admin- istered possesses the advantage of medicating the air-passages directly, without disordering the stomach in passing through the general circulation, and whose virtues are not to be measured by their merely antiseptic qualities. Of these we have lime and belladonna (gr. j. — 5iv.), or if the se- cretions be fetid, carbolic acid may be added, after the combination used by Dr. COGHILL, of London, which is composed of 205. IJ. Creasoti, Acid, carbolici, ** 5^ .. Tr. iodin. CO., j,- 3 fJ Alcohol, ^-i '^■ This diminishes the quantity of expectoration, allays cough, and lessens, or entirely destroys, fetor of breath. It may be administered by an extemporized respirateur, made of a cylindrical box, with a perforated cap, in which is placed the ab- sorbent cotton on which the solution is dropped. To be mhaled once or twice daily, 10 to 15 minutes. I08 DISEASES OF THE RESPIRATORY SYSTEM. In the later stages, when the cough is long-continued and interferes with sleep, acetate of morphia may be given with tr. sanguinariae. The pains in the chest may be dissipated by counter-irritation in the form of tr. iodine and croton oil, or mustard or belladonna plaster. Sometimes a flannel bandage worn around the waist affords a relief not to be obtained from drugs. The fever requires special treatment. This symptom will not en- tirely disappear until the substances which cause it are entirely ex- pelled from the body, and for the purpose of abating it, quinia and digitalis are the main treatment ; but neither should be given con- tinuously, on account of their injurious influence on the stomach. Sponging the surface with whiskey and alum is often beneficial. Tablespoonful of whiskey at bedtime and another at period of awakening may be given with advantage. If medicines are to be employed, we have a favorite combination in ext. bellad., gr. J^, in pill-form, with oxide of zinc, gr. ij. Give one at bedtime. Within the past few years the subject of the inhalation treatment of phthisis has been largely developed, in the hope of meeting with some substance which will influence the local tubercular process in the lungs. While up to the present time no absolutely positive re- sults have been obtained, there have been added to the physician's armamentarium several really valuable means of combatting symp- toms. Probably first among these are to be noted the various oxygen in- halants, substances which to a certain extent act favorably upon the suppurative process in the lungs, often changing the character of the expectoration to a marvellous degree. Not only is the use of oxygen marked by the greater or less decrease of the purulent ex- pectoration, but in many cases the improved oxygenation of the blood aids in the nutritional changes generally, and undoubted con- stitutional improvement frequently follows for a time. Of these inhalants, perhaps the most convenient and one of the best for all purposes is afforded by the peroxide of hydrogen. Par- ticularly to be recommended is the preparation of Marchand, of New York, which may be diluted with an equal volume of glycerine and inhaled from any nebulizer which is made of non-oxidizable material, as vulcanized rubber or glass. Dr. Albrecht, of Berlin, also submitted his patients to method- ical inhalations of pure oxygen, without changing their usual diet, and he claims to have checked the progress of the disease ; the PHTHISIS. jQQ patients stop losing weight, and perhaps even gain ; and Koch's bacilli become less numerous in the sputum. Guinea-pigs inocu- lated with tubercle were submitted to inhalations of oxygen as soon as the disease appeared developed. Those having oxygen lived six months ; those not having it, four months. Of germicides for this purpose, thymol has been advocated by some. It may be employed in the form of warren's inhalation. 206. R. Thymol, ^ g Sodii boratis, „ -iqq Glycerine, fl.'oz. ly Aquae camphoise, fl. oz. 2% Kofix picis, fl. oz. 7. To be used as an inhalation, by means of the atomizer. Prof. Petresco, of Bucharest (La Med. Mod., '90), employs the following for inhalation in pulmonary phthisis : 207. K. Eucalyptol, Oil of turpentine, Creasote, a£ f. 5iij Iodoform, gr. vij Ether, HI. Ixxv. M. To be used in an inhaler. Dr. BURNEY Yeo, speaking of the antiseptic inhalations, con- tributes the following: Lemaire's observations on the inhala- tion of carbolic acid may be briefly summarized as follows. It must be remembered that he gave it also internally in aqueous solution. He found, he says, very remarkable effects follow its use. There was diminution of cough after twenty-four hours, in some cases almost a complete disappearance after a few days. The ex- pectoration was diminished or almost suppressed, and, if the sputa were offensive, their foetor disappeared. In many the physical con- dition of the respiratory organs was ameliorated. Two were cured; in others, there was a subsidence or disappearance of rales, and parts became pervious to air which had previously been impervious. In cases in the second stage, he had noticed increase of strength, return of appetite and sleep, increased freedom of breathing, and general exhilaration. The amendment, however, did not persist in all cases. The inhalation of balsamic vapors — frankincense, turpentine, storax, etc. — in phthisis, is of very ancient date, and its value was no DISEASES OF THE RESPIRATORY SYSTEM. from time to time strongly insisted upon by tiie older physicians. Again and again has the dilute vapor of tar been advocated as of much use in pulmonary consumption. There is a peculiar nauseating odor in the breath of many phthisi- cal patients, even before the development of marked physical signs. Of course, if antiseptic inhalations are to be of use, they must be frequently employed, and means must be adopted which will insure the antiseptic vapor reaching the whole of the diseased portion of the pulmonary tissues. The vapor must be evenly diffused through the atmosphere the patient breathes. The following formulae are recommended for the inhalation of creasote for the same purposes (La Bull. Med., 1 890) : 208. R. Creasote, Chloroform, Alcohol, ia M. Sig. — From five to twenty drops in an atomizer or nebulizer; repeat inhalations every three hours. 209. R. Iodoform, gr. xxj Creasote, gtt. iv Oil of eucalyptus, gtt. yj Chloroform, gtt. xlviii Alcohol, Ether. £i q.s. ad f. § ss. M. Sig: — Five to twenty drops in atomizer or nebulizer; to be used every three hours. SHURLEY AND GIBBES. Recently these physicians (Med. News, 1890) have urged the in- halation of chlorine gas as a valuable addition to the means of com- batting phthisis. Their plan in order to permit the necessary amount of gas to be inhaled is to saturate the atmosphere of the apartment in which the treatment is given with a solution of ordinary salt, after which a considerable quantity of gas may be introduced from gas- holder or from generator, without producing the unpleasant effects upon the patient's condition, which are usually observed when the gas is inhaled unguardedly, as cough, etc. Their plan of treatment, from which they claim signal results, is as follows : Beginning the treatment, the patient has administered hypo- dermatically A of a grain of iodine once daily, gradually increasing to >^ or i^ grain for about a week, unless symptoms of iodism supervene. The hypodermatic solution is made of iodine, iodide of potassium, glycerine and distilled water, all chemically pure in order to avoid the production of dermal abscesses. Where iodism results PHTHISIS. J , J from this method, injections of a gold and sodium chloride solution should, be employed instead, beginning with ,V grain of chloride of gold daily in one hypodermatic injection, gradually increasing to ,V grain. The injection of this solution causes little pain. It is most efficient when used alternately with the above iodine solution or mixed with it in proportion of r\ grain of iodine and s\ to jV grain of chloride of gold and sodium. As the best position for the injection, the authors regard the buttocks. In mixing the solutions the iodine solution should be added very gradually to the gold solution to pre- vent the formation of the insoluble iodide of gold, which may induce abscess formation. Cases with much cough, but little expectoration, should be treated almost entirely, if not exclusively, with the gold solution. After some days' preparatory treatment, the authors commend the employment of the chlorine inhalations as above outlined, and after a few weeks the injections may be gradually diminished. The in- halations should be used as soon after the periodic attacks of cough- ing and expectoration as possible, in order that the gas reach as much as possible the exposed diseased tissues. Drs. Shurley and GiBBES report favorable results from this method of combatting phthisis, particularly, of course, in connection with cases in early stages of the disease. They note the fact that for the first two weeks of treatment, as a rule, the temperature keeps up — indeed may go higher than with other plans of treatment. When patients are par- ticularly sensitive it may be necessary at first to precede the gold and iodine injections with injections of morphia or cocaine; but these are not to be mixed with the former. Considerable perspiration usually attends this manner of treatment; the nutrition of the patient must be carefully looked after, it is unnecessary to say. The chlorine gas may be generated from a saucer of chlorinated lime moistened with diluted hydrochloric acid (one in three of water), and when held under the spray of salt solution the gas is carried out into the atmosphere rapidly. BERGEON'S METHOD. (b) By the Alimentary Canal : First in this list is to be mentioned the method of BergEON, which a few years since created such a furore in the profession, but which has since settled into a position which, although by no means as prominent as its advocates de- manded at first for it, is nevertheless not unimportant. References 112 DISEASES OF THE RESPIRATORY SYSTEM. may be found in almost all the journals during the years 1887 and 1888, both pro and con. Briefly, the method consists in the rectal injection of sulphuretted hydrogen gas held in small amount in car- bon dioxide gas as a menstruum. It is practised as follows : A gas generatoi' is partially filled with water, in which is placed calcium or sodium carbonate ; to this is added one of the stronger mineral acids cautiously, with the formation of carbon dioxide gas. This gas (CO,) is passed through a wash bottle, in which is contained a sulphuretted water (natural sulphur water), and thence into a rectal tube and into the bowel. The CO^ gas carries with it a small amount of sulphuretted hydrogen gas, which being absorbed by the bowel is expelled from the organism by means of the lungs. In its passage through the pulmonary tissue it is supposed to exert a direct antiseptic action upon the diseased structures. The injection apparatus may still be procured from some of the larger pharma- ceutical establishments ; and where natural sulphur waters cannot be obtained, a substitute may be made according to the following for- mula : Water, one litre ; sodium chloride, one gram ; sodium car- bonate, one gram ; sodium sulphide, two grains ; flowers of sulphur, one gram. The treatment begun, the injections should be applied gradually at first to bring the bowel into a state of tolerance ; and when the lower bowel is distended, gentle rubbing movements over the ileo- caecal region will aid in the passage of the gas into the ileum. The patient usually in a few (ten or fifteen) minutes feels a slight burn- ing sensation in the chest, and a metallic taste is spoken of. The method, combined with general care in management of the nutrition and hygiene of the case, is said to produce in the ^ arly stages ex- ceedingly favorable results in many cases ; but the unpleasantness of administration, and its failure in a large proportion of cases to which it was forced in the excitement of its announcement, have combined to place Bergeon's method of treating phthisis decidedly below the position it was expected to occupy. DR. DOCHMANN. (Prager Med. Wochenschr., January 22, 1890.) This physician employs calomel in the treatment of pulmonary tuberculosis, es- pecially in the early stages, apparently with good results. He pre- scribes the following pill : PHTHISIS. 113 210. R. Calomel, gr_ vijj Pepsin, g," 1 Tincture of opium, gtt_ ^xx Ext. of phellandrium, q_ ^_ j^ Make into 60 pills. On the first day of treatment 12 pills (2 pills every two hours) are to be administered ; on the second day 10 pills ; on the third 8 pills. After this the patient may take six pills daily, unless badly "borne, with occasional intermissions. If haemoptysis occurs, ergotin should be added to the pills. If the cough is violent, extract of Tiyoscyamus may be combined. DR. WM. H. FLINT. (N. Y. Med. Jour., July 26, 189Q.) Dr. Flint has devoted con- siderable study to the action of creasote, administered in the various ways proposed in order that the drug may have ready means of ac- cess to the disease process. In suitable cases he has advised the employment of this drug administered by inhalation, by interstitial injection and by the mouth. Given internally he at first used Jaccoud's Mixture : 211. R. Creasote, III- ''j Glycerine, f. § j Whiskey, f. % ij. M. He has, however, discarded this combination, since in giving a large quantity of creasote in this mixture it is necessary to some- times give an amount of whiskey entirely undesirable, and in some cases not well borne. For these reasons he recommends the follow- ing formula : 212. R. Cod liver oil, f-3* Mucilage of acacia, f- Z "'"^ Creasote, Hlxlviij. M. Sig : To be given after food. In suitable cases this remedy may be administered in drachm doses every two or three hours a day as long as tolerated. By ad- ministering the above emulsion in milk he was able to have his patient take considerably larger quantities of the creasote without effects. Among the methods employed for administration of creasote may be mentioned the following formula recommended by Gilbert : 8 114 DISEASES OF THE RESPIRATORY SYSTEM. 213. R. Creosote, m. xxx-xlv Arseniate of sodium, gr. ss „ . . . ^. f Huxham's tincture, Quinine wine, Oj | j^^j^^^ ^j^^^ ^ f.|^;ij. K- Sig. — Two small wineglassfuls should be taken directly after each meal. And the following (La Bull. Med., 1890) : 214. R. Creasote, gtt. xxiv Glycerine, f- S j Syrup of orange flower, ^ f-Sj M, Sig. — One teaspoonful every three hours. Or, 215. R. Creasote, Tincture of capsicum, ai lO parts Mucilage of acacia, IS " Distilled water, 120 " M, Sig. — One teaspoonful, well diluted, at meal time. Or (L' Union Medical, 1890 — Gilbert), 216. R. Creasote, gtt. xxx Rum, f. S iss Syrup of tolu, f. § j Distilled water, f. § ij. M. Sig. — A dessertspoonful twice or thrice daily, in a wineglassful of water, to persons having a tubercular tendency. Terebene is similar in its influences to creasote, for which it is a good substitute, when the latter drug is not well borne. It may ad- vantageously be administered in vapor, or by the stomach. In cap- sules containing several drops it is well borne : 217. R. Terebene, gtt xxiv. Divide and place in twelve capsules. Sig : One every three or four hours. DR. HUGO WEBER. (Berlin Klin. Woch., 1890.) Noting the apparent fact that lime burners enjoy a certain immunity from phthisis, that phthisis is sometimes seen to be temporarily arrested in pregnancy, that phthi- sis is rarely found to supervene upon chronic heart disease and pul- monary emphysema — in all of which cases the blood is probably overcharged with carbonic acid — Dr. Weber proposes to administer carbonic acid by the stomach in the form of effervescing powders. For this purpose any of the lighter effervescing preparations may be used. The writer reports decided improvement in the cases in which, the treatment was tried. The author claims the good results in Bergeon'S treatment are really due to the diluent, carbonic acid gas, and not to the sulphuretted or fluoretted hydrogen employed. PHTHISIS. I J r DR. LAWRENCE F. FLICK. (Med. News, 1890.) Dr. Flick, recognizing the influence of the tubercle bacillus as the causative agency of phthisis as well as of other forms of tuberculosis, states that all the treatments which are likely to prove valuable must have underlying them some effort to the destruction of this micro-organism. He mentions among the remedies offered with a view to such destruction, iodoform, creasote, terebene, sulphuretted hydrogen, carbonic acid, boric acid, arsenic, mercury, tar, ethereal oils, chloride of calcium, salts of gold and silver, iodine, hydrocyanic acid, and the aniline preparations. He is especially favorably inclined to the use of iodoform, which he be- lieves really has curative powers over tuberculosis. It acts best in the early stages, before there is any breaking down of the pulmonary tissues and before the circulation of the diseased area is entirely cut off. He uses the drug preferably in capsules with pepsin, pancre- atin and some bitter extract ; some such formula as the following probably representing the usual method of administration : 218. R. Iodoform, gr. ij Pepsin, Pancreatin, aa gr. xij Extract of gentian, gr. xij. M. Divide into twelve capsules : Sig : One after meals. Where the stomach is intolerant, the remedy may be given by the bowel ; or mixed with cod-liver oil, in which it is soluble, in the pro- portion of I to 15, it may be rubbed into the skin for half an hour or more twice daily. He states that he has never been able to give creasote with any satisfaction, except by inhalation, the drug being volatilized by hot air. He believes it is thus readily absorbed into the blood, and does good as a general medicament rather than by local effect upon the diseased lungs. He looks upon the other drugs mentioned with considerable favor, although he states his experience has not been sufficient with them to permit him to speak positively, save of terebene, to say that it is very like creasote in its action, and may be used as a substitute, and of boric acid, that, except for some benefit in checking the fever and night sweats, it is not very valuable, and is apt to create gastric dis- turbance. However, inasmuch as the nutrition of the body is so dependent upon the condition of the digestive function, the stomach is the first Il6 DISEASES OF THE RESPIRATORY SYSTEM. thing to be looked after in the treatment of tuberculosis. Proper taking of food, mastication, etc., should be insisted upon ; and a good, nutritious and suitable dietary provided. Congested, irritated stomachs, as indicated by large, heavily coated tongues, should be met by light diet, and such remedies as bismuth, magnesia or bicar- bonate of sodium. Where the stomach and liver are sluggish, shown by a rather small, fissured, slightly coated, pale tongue, pep- sin and muriatic acid and some bitter stomachics should be given. When intestinal digestion is bad pancreatin should be given. Easily digested food should be prescribed, and milk should enter largely into the dietary; vegetables and fruit may be freely eaten. Meat once in a day, and then largely ; and cod-liver oil should be taken, but care is to be had lest it disarrange the digestion. Dr. FLICK commends the use of oxygen after meals, inhaled slowly for half an hour, as an aid to digestion. Quinia, strychnia, and other tonics and stomachics may be given to stimulate the appetite. Occasionally an interval may be given for rest for the stomach in this forced feed- ing, when it may be well to give a dose of calomel followed by mag- nesia. Next in importance is to see that the patient gets plenty of fresh air and proper amount of fresh air. In the acute stage the proper place for the patient is in bed; and during this period digitalis has a very soothing effect, and was at one time looked upon as almost a specific. It may be given in the form of NiEMEYER's pill: 219. R. Pulveris opii, gr. iij Pulveris digitalis, gr. yj Quinise sulphatis, gr. xij Confectioriis rosse, q. 3. Misce et fiant pilulae, no. xij. Sig. — One pill four times a day. For the reflex irritation and resulting symptoms of cough and sometimes vomiting, the best remedies are opium, bromides and chloral. The first should be used only where indispensable, but when necessary it is to be given in as large doses as practicable in order to entirely remove the harassing symptoms. Where there is bronchial secretion, opium should be entirely eschewed, and bro- mides used instead. Where the temperature persists in remaining high, in spite of rest in bed and digitalis, quinia, antifebrin or anti- pyrine may be used. Counter-irritation over the seat of the deposit, when it can be positively made out, is indicated. PHTHISIS. 117 When the disease has advanced to the stage where symptoms arise from absorption of the products, the treatment becomes neces sarily symptomatic. M. GARCIN, OF PARIS. (New York Med. Jour., 1887.) This gentleman claims to have obtamed positive results by placing phthisical patients an hour daily in a small cabinet containing six cubic meters of air saturated with hydrofluoric acid. This saturation was obtained by pumping a cur- rent of air through a rubber bottle containing one part of the acid to three parts of distilled water, and the air pumped into the cab- inet is renewed every fifteen minutes. He states that the general condition of the patients rapidly improved, appetite increased, night sweats ceased, and some patients treated a year before the report remained well to date. (c) By Absorption and Hypodermatic and Parenchymatous Injec- tion : In the first of these connections, the inunction of iodoform just referred to is to be recalled. Gavoy (Gaz. Med. de Paris) recommends that morning and night a hypodermic injection of 30 minims of this solution : 220. R. Iodoform, I Olei amygda. dulc, loo. M. In the employment of this method the writer claims the most promising results, the character of the sputum and cough changing almost at once. The appetite is renewed and the night sweats cease. The voice becomes clear and inspiration becomes more deep. DR. ANDRESEN. (Internat. Klin. Rundschau, 1890.) Dr. Andresen has recently used creasote in the treatment of phthisis by parenchymatous injec- tion. The operation is done with a hypodermic syringe with long needle, the apparatus being in perfectly clean and sterile condition. It causes little pain, especially if practiced on the back ; anteriorly in the second intercostal space it causes slight pain, lasting several hours ; an immediate cough, burning sensations in the throat and a strong odor of creasote on the breath constitute resultant symptoms which are often rather distressing to the patient. The amount of creasote injected into the pulmonary parenchyma is not stated defi- nitely by the author. The results of this method have been to afford at least a temporary improvement in almost all cases. Il8 DISEASES OF THE RESPIRATORY SYSTEM. In the same class must be mentioned the use of iodine, which has for many years been periodically brought forth, as of value when injected through the thoracic walls into phthisical cavities. This is done with a twofold purpose, first with a view of its direct action on the tubercular process, and, second, in the hope of its exciting suf- ficient inflammatory reaction in the tissues immediately surrounding the tubercular focus to cause its isolation. The value of the remedy is clearly limited to the low-grade forms of phthisis known as fibroid, inasmuch as in the more rapid varieties the process is too general to be affected by such localized efforts. The same may be said of the more recent surgical attempts at excision of tubercular foci in the lungs. The latter practice is performed by first opening the chest wall, inducing, by the air pressure thus brought on the outside of the lung, a collapse and general contraction of the organ. In this state the tubercular area is more readily and safely excised, being more definitely bounded, and the hemorrhagic tendency being greatly diminished. When it is performed, the lung is best brought to the chest wall, and afterwards left there, adhesions being induced ; and the wound is covered by cutaneous flaps. In a case mentioned by TiLLMANS (London Lancet, 1 890,) the patient had remained in good health for two years after the removal of tubercular nodes from one lung and pleura ; and was regarded by this physician as definitely cured. {d) By Lnoculation. — ^Within a very recent period one of the greatest excitements in the medical world was induced by the an- nouncement of Dr. Paul Koch, of Berlin, that he had been able to cure in the rabbit and guinea pig the tuberculosis which he had ex- perimentally induced in these animals. After considerable time, the delay having been occasioned by interference with the discoverer from the German government, it was published that the cure was due to the inoculation or injection into the body of the tubercular animal of a lymph-like substance of unknown composition, derived from cultures of tubercle bacilli in the ordinary culture media. The lymph is made by taking the tubercle bacilli cultures, and treating the entire mass with glycerine ; this is drained off and filtered, and a small amount of cyanide of gold and carbolic acid added in order to preserve the fluid, which is of unstable character. This substance is injected into the subcutaneous tissue of the tubercular subject, preferably beneath the skin of the back, in doses beginning with somewhat less than one milligram of the fluid suspended in sterile PHTHISIS. „g <3istilled water. In this condition the lymph, which is a brownish <:lear fluid, tends to undergo change; and to prevent any change if -the diluted lymph be kept for any time, it should be sterilized care- fully by heat, and preserved under a cotton-wool stopper; or it may be prepared with a one-half per cent, solution of carbolic acid. In using the lymph, however, the best effects are said to be ob- tained by not allowing the diluted material to stand for any great length of time before injecting it. Introduced into the stomach, the •effect is totally negative. Beginning with the first injection of about ■one milligram of the solution properly diluted, as the patient bears the remedy, it is increased rapidly until forty or fifty times as much may be given without danger. The effect of the injection is to bring about within a few hours afterwards a febrile reaction varying with the individual, the temperature rising frequently to 104° or 105° during the intensity of the reaction; there are general aching pains felt, inclination to cough and fatigue. It is said that this re- action arises only in the tubercular individual, others being unin- fluenced by the lymph even in large doses ; and claims have been made for a crucial diagnostic power in the substance in cases of sus- pected tuberculosis. Under treatment with this remedy, the more localized and superficial forms of the disease have been those in which benefit has been especially noticed, tubercular bone and joint -disease, lupus and tubercular lymphadenitis. Pulmonary tubercu- losis, except in its mildest and earliest stages, has not been improved ; and in fact many cases are positively injured by the violent reactions which follow. That the remedy tends to cause a generalization of the disease is probably untrue, the reports to that effect having been probably aroused through envy ; but that it is everything which in the first hopes of the discovery was predicated of it, is also unfortu- nately false. There seems a great probability that the remedy will be found useful in the distinctly localized forms of tuberculosis, and that the circle of its employment will constantly increase as the power of the profession to recognize the earliest manifestations of the disease broadens. As matters now stand, the reports of its value are too conflicting to permit of any really positive judgment ; but there seems no real reason for not accepting it as a valuable therapeutic agent against the tubercular process, although its hoped-for value promises to be unattained. The remedy, because. of injudicious newspaper publication, rapidly reached the widest recognition, and in every city and hamlet, in hospital, laboratory, I20 DISEASES OF THE RESPIRATORY SYSTEM. dispensary, private home and apothecary, the fabulous powers of the remedy were tried. Of course the result of the entirety was a fail- ure ; nothing more could be expected from the wholesale and utterly inexperienced manner of use. Cases that naturally had but a few more suns to see went to their grave, and counted against a remedy brought to overcome a disease which was already the con- queror. Cases which with proper care would have done well for some time even without specific medication, were placed upon the lymph, and all other care suspended that the fluid's action might be undisputed ; and as a result, nutritive and assimilative changes being" neglected, the commonest attention to the symptomatic treatment denied, these cases rapidly approached a fatal termination. The remedy is bound in the end to be regarded with some favor_ The quiet, unpublished laboratory and ward work in which this- remedy must find its only recognition, will bring the pendulum, of popularity, now in the reaction of disfavor, to again swing into- repute. The renledy may be relied upon by careful workers in the very earliest cases of pulmonary tuberculosis if the collateral treat- ment directed to nutrition, assimilation, and general hygiene be properly introduced with it; but under other circumstances there is little more to hope from it than has been derived from a host of other methods that have been proposed only to be forgotten. It is believed that the active substance in KoCH'S lymph directs its power not particularly against the tubercle bacilli, although this theory is also advanced and asserted by some believers in the rem- edy, but that its action is against the tissues in which the tubercle bacilli exist. How this activity is induced is not understood, but the tubercular tissues, as seen at least in cases of superficial tuberculosis^ undergo a rapid necrotic change, and a very marked reactive inflam- matory process starts up about each necrotic area. If there be ready means for the removal of the dead masses with their con- tained tuberculous matter, as in cases of superficial tuberculosis, by a surgical aid, there is left behind a healthy granulating wound, which presently heals and replaces the vicious focus by a scar. In pulmonary tuberculosis where there is but a small area of disease in the apex in the beginning of the aff"ection, there is no little probabil- ity of the success of nature in removal of the tissue necrosed through the influence of the remedy in question, and the final cicatrization of the diseased spot; but where the entire lung is riddled with tubercles and tubercular conglomerations, even should all be coughed PHTHISIS. J2, up and scar-tissue take the place of the removed tissue, these could not benefit the case, as there would be no more lung space added Rather would the dense scar-tissue render the little remaining lung structure still more useless by its constrictions; and at the very best the result in such cases would be a retardation of the active advance of the disease, nothing more. What the lymph is, is another question which may well be asked here. It has not as yet been reduced to a definite formula from chemical examination ; but it is known to belong in the class of or- ganic substances known as tox-albumins. It is a product of the life activities of the bacilli, but whether it represents the waste from these organisms or whether it is a secretive product intended to aid in tissue destruction, is not known. The former of these views is held by those who look on the substance as directly acting upon the bacilli ; it being a well-known fact that organic life is impossible in the presence of an excessive amount of the excretions from that life. The failure to produce a uniform and decided diminution in the tubercle bacilli in the sputum militates gravely against such a view. The modes of reckoning the relative amounts of bacilli in sputum are so very incomplete, and the reports issued from different observers at this date so conflicting, that anything like a just deci- sion on the point is practically out of question. Professor KocH evidently looks on the substance rather as something which in the usual course of events is of advantage to the life to the bacilli, and probably secreted for a definite purpose by these organisms, but which in undue proportion is entirely subversive of bacillary exist- ence. Just as if one compared the matter to water, which when used in proper degree for drink and bathing is decidedly advantag- eous to human existence, but when present in floods removes the very traces of human occupation. THE GENERAL TREATMENT OF PHTHISIS. PROFESSOR JACCOUD, PARIS. The following review of the drugs most lauded in phthisis is given by this distinguished authority: Arsenic. — In chronic phthisis, as soon as the phenomena attrib- uted to anaemia have been remedied by iron, or in the absence of amelioration after a delay of a couple of months, the author aban- dons ferruginous preparations, and has recourse to arsenical medi- 122 DISEASES OF THE RESPIRATORY SYSTEM. cation. He employs exclusively granules of arsenious acid, of gr, sV each, and administers them at the commencement of each of the two principal meals. He commences with two a day, and every week increases two a day, until eight or ten a day are given. When this maximum dose is attained, he maintains it indefinitely, unless phenomena of intolerance make their appearance, such as cramps, inflammation of the eyes, cutaneous eruptions, vomitings, diarrhoea. Then, however, he does not stop the medicine, but diminishes tem- porarily the dose, and returns, as soon as possible, to the maximum of toleration. Arsenic acts powerfully upon the nutritive processes in chronic pulmonary phthisis. It quiets the nervous excitement, and possesses an anti-febrile action sufficiently marked to effectually combat the evening intermittent fever. So long as the disease remains chronic, and does not develop acute attacks of pseudo-continuous fever, the arsenical medication ought to be maintained at the maximum of toleration, conjointly with the special regimen, cod-liver oil, cinchona and alcoholized raw meat. Cod-liver Oil. — When the cod-liver oil is badly supported alone, in chronic pulmonary phthisis, the author adds to it brandy, rum, kirsch or whisky, in the proportion of two parts of the oil to one of the spirit, and reccomends the patient to close the nostrils at the moment of swallowing it. He commences by small doses of the oil and spirit mixture, then two tablespoonfuls a day, and advances to five or six fluid ounces a day. Iron. — ^The author reserves the employment of ferruginous prepa- rations for those cases where the patients present the certain signs of globular anaemia. He gives, in preference, the syrup of the iodide of iron to young children, and the pills of the iodide of iron in other cases. From four to eight of these pills are to be taken a day, at the commencement of the meals. He advises not to administer the iron where there has been recent haemoptysis. Raw Meat. — In the treatment of patients with whom the physician is obliged to dissimulate, he may order the pulp of raw fillet of beef, well deprived of all fibrous matter, in some unleavened bread, under the pretext of administering medicinal boluses. When he can act openly, the author prefers to mix the pulp of the raw meat, properly prepared with brandy, rum or whisky, in such a manner as to ob- tain a dough-like mass, which the patient takes with sugar or salt. PHTHISIS. J 2, according to taste, in tablespoonful doses during the day. This mixture is very palatable, and does not produce that rapid intoler- ance which is often observed with other meat preparations. Counter-irritation.— lYv^ author, in acute phthisis, attacks the pul- monary disorder by means of large flying blisters, renewed without interruption. Instead of the ordinary dressing, he covers the vesi- cated surface, and envelops it in every direction, a finger's breadth, by diachylon plaster. On removing the protecting plaster at the end of four days, the cicatrization is found complete. In commencing chronic phthisis, the author applies, under the clavicle of one or both sides, cauteries of Vienna paste, of the size of a sixpence at the maximum, and repeats these punctiform cauter- izations as long as any favorable influence is noticed. In addition to what has been said above, we quote from various specialists their directions for the exhibition of cod-liver oil, a most valuable medicament. DR. C. J. B. WILLIAMS, LONDON, gives the following minute rules for administering the oil: i. The best time for administering it is immediately after, or to those who prefer it, at or before, a solid meal. 2. In cases of peculiar weak- ness of stomach, with tendency to retching or vomiting, strychnia (gr. V^—iV) proves a valuable adjunct. So does salicine. Neither of these, though a powerful tonic, has any of the heating properties of quinine or iron. If their bitter taste is objected to, they may be given in the form of pill, after or before the oil. 3. It may be ad- vantageously combi^ted mith a mineral acid. Nitric acid is best in inflammatory cases, and in those attended with much lithic deposit in the urine, but its tendency to injure the teeth is an objection to its long-continued use. Sulphuric acid is more eligible where there is liability to haemoptysis, profuse sweats, or diarrhcea. But in most cases, for long continuance, diluted phosphoric acid is preferable to either. 4. The bulk of the whole dose of the oil and vehicle should be so small that it may be swallowed at a single draught ; therefore, the vehicle should not exceed a tablespoonful, with at first a tea- spoonful of the oil, to be gradually increased to a tablespoonful. 5. The dose of the oil should rarely exceed a tablespoonful, twice or thrice daily. Larger quantities either derange the stomach or liver, or some of it passes unabsorbed by the bowels. 6. The diet requires attention. With some persons the oil agrees so well, and so much 124 DISEASES OF THE RESPIRATORY SYSTEM. improves their digestive powers, that they require few or no restric- tions in diet ; but this is not the case with the majority. The rich- ness of the oil proves more or less a trial, sooner or later, to some persons ; therefore it becomes proper to omit or reduce all other rich and greasy articles of food. All pastry, fat meat, rich stuffing, etc., should be avoided, and a great moderation observed in the use of butter, cream, and very sweet things. Even new milk in any quantity is not generally well borne during a course of oil, and we may find malt liquor too heavy, increasing the tendency to bilious attacks. A plain nutritious diet of bread, fresh meat, poultry, game, with a fair proportion of vegetables, and a little fruit, and only a moderate quantity of liquid at the earlier meals, commonly agrees best. 7. Should a bilious attack come on, indicated by nausea, headache, furred tongue, offensive eructations, high-colored urine, etc., it is necessary to suspend the oil, lighten the diet, and give an aperient. In regard to taking the oil, DR. J. M. DA COSTA, PHILADELPHIA, suggests the following plan of administration : 221. R. Olei morrhuae, f. 5ss. For one dose ; to be taken three times a day in carbonic acid water. Place in a tumbler a small amount of any preferred syrup, (orgeat or sarsaparilla is the best adapted to disguise the taste of the oil,) and fill up with carbonic acid water, from a bottle furnished with a siphon for table use ; then, while it is still foaming, put in a table- spoonful of the oil. It is astonishing how perfectly the taste is concealed in this manner. Other modes of taking the oil are, float- ing on ice water, in lemon juice, and in the froth of porter. Less than a tablespoonful is not worth taking. The best time for its ad- ministration is between meals, after the process of digestion is pretty well finished. Persons are exceptionally met with who take it in preference just before meals, and thus avoid the disagreeable eructa- tions. Nobody likes to take it the instant after meals. DR. THOMAS H. TANNER suggests that in cases of phthisis where the stomach will not tolerate any form of cod-liver oil, resort may be had to cod-liver oil embro- cations : PHTHISIS. 125 222. R. Old morrhuae, f.5iiiss Spiritds ammoniae aromatici, f! 5 i Tincturae opii, f 5 ^^ Olei lavandulae, ^^xx. M. One-half to be rubbed over the chest and abdomen, night and morning. Or, 223. R. Olei morrhusE, fgj Olei cajuputi, fISj. ^ To be rubbed over the chest at bedtime, and applied by means of lint well saturated with it. The cajuput oil well disguises the smell of the embrocation. PROF. HOBART A. HARE, M. D., PHILADELPHIA, suggests in cases where cod liver oil (Boston Med. and Surg. Jour., 1887) is to be used by inunctions for any length of time, or where excessively large amounts are required to be rubbed into the patient, that the use of the biliary salts will cause the oil more easily and fully to be absorbed by emulsifying it. As much of the salts of bile (which may be obtained from the Fairchilds) as may readily be contained upon a dime should be placed on the skin and the oil poured over, the mass being rijbbed into the skin by the hand of the attendant. The unpleasant odor of the oil is very much les- sened by this procedure. In the event of having no biliary salts on hand, ordinary inspissated ox-gall is temporarily of service. It seems to be well settled that the assimilation of the oil is materially hastened by combining it with ether. The following is the prescription of PROF. BALTHAZAR W. FOSTER, M. D., LONDON. 224. R. ^theris, f-|ijss Olei morrhuae. f- 5 >v- M. Dessertspoonful thrice daily, before meals. He gives many cases where this combination acted much more efficiently than the oil alone. (Lectures on Clinical Medicine, Lon- don, 1874.) J. F. CHURCHILL, M. D., PARIS. His own formulae, as published, are : SOLUTION OF HYPOPHOSPHITE OF SODA. 225. R. Sodii hypophosphitis, ',.0 parts!'' Aquae destillatae, ^ "^ . . . Dissolve and filter. Dose, . teaspoonful three or four times a day, m sweetened water. 126 DISEASES OF THE RESPIRATORY SYSTEM. SYRUP OF HYPOPHOSPHITE OF SODA. 226. R. Sodii hypophosphitis, 5 P*''* Sodii carbon, crystal., ' P^'' Syrupi simplicis, 5°° parts. Dissolve, keep in a dark place. Dose, one to four tablespoonfuls four times a day. SYRUP OF HYPOPHOSPHITE OF LIME. 227. R. Cal.ii hypophosphitis, i P^' Aquae destillat., 3° P^rts Sacchari albi, 64 parts Aquae calcis, 6 parts. Dissolve with gentle heat; filter; keep in a dark place. Dose, teaspoonful three to twelve times a day. Dr. Churchill's usual method of treatment is to give a table- spoonful of the syrup of hypophosphite of soda and lime (of the strength of six grains of the salt to the fluid ounce) once or twice a day, in the absence of any inflammatory symptoms — sometimes a teaspoonful of syrup of hypophosphite of lime in the morning, and the same dose of syrup of hypophosphite of soda at night. For females, particularly persons of nervous temperament or delicate constitution, leading a sedentary life, and unused to physical exer- tion, the dose should be decreased one-half. For children from seven to fifteen, the dose is the same as for females. From two to seven years of age, one or two teaspoonfuls daily, of the syrups, are sufficient. For infants of a more tender age, the dose should seldom exceed a quarter or half a teaspoonful in twenty-four hours. The syrups may be taken alone or in a wineglass of water, and should, in general, be exhibited at meal time, either before or after. They have no medicinal taste whatever. Contra-indications. i. The use of the hypophosphites ought not to be commenced during an acute inflammatory state. 2. Their employment should be temporarily suspended, if, during the course of the treatment, the patient be attacked by any inflammatory com- plication, but resumed as soon as acute complication shall have dis- appeared. 3, They should not be given during an active haemopty- sis of a passive form. 4. Their effects should be carefully watched, in the case of patients aff"ected with disease of the heart. 5. The dose should not be too high, nor the administration too prolonged. Great mischief may result from incautiously pressing the remedy. Among the signs which indicate that the hypophosphites have been given in excessive doses, are lassitude, wandering pains, headache, buzzing in the ears, vertigo, sudden loss of appetite and strength, PHTHISIS. and, above all, bleeding at the nose, however slight the loss of blood may be. DR. MCCALL ANDERSON, (Brit Med. Jour., 1890; -Medical News, 1890) has found that under the following plan he has been enabled to cure a number of cases of pneumonic phthisis: 1. Two thoroughly trained nurses are required, one for day and the other for night. The patient must be fed upon fluid food day and night, soup being advised if diarrhoea is present. From two to ten ounces of whiskey daily are required in the beginning of the at tack, but should be given in frequent small doses with the food. 2. At bedtime a subcutaneous injection of sulphate of atropine (from tJj to ?V grain) is given. This checks perspiration, acts as a sedative, indirectly helps to reduce the fever, and diminishes the secretion from the lungs. 3. Remedies to lower the temperature are given, and are of the utmost importance. Some benefit is obtained by permitting the patient to suck ice freely, from giving the food and drinks iced, from sponging the body with iced vinegar and water, and from using iced enemata ; but the main reliance must be upon the following : NiEMEYER'S antipyretic pill : 228. R. Quiniae sulphatis, gr. xij Pulveris digitalis, gr. vj-viij Pulveris opii, gr. iij-vj Ext. gentian, q. s. M. Ft. massa ex qua ft. pilulae, no. xij. One of such pills is given every four hours, the opium in the pill being increased in case of diarrhoea. The effects of the digitalis must be watched, and if the pulse becomes very slow or the urine scanty, the remedy must be omitted for a time. The daily adminis- tration, shortly before the time that the temperature tends to be highest, of from ten to thirty grains of quinine, either in a single dose or in divided doses within an hour. The application of iced cloths to the abdomen for half an hour, every two hours, so long as the temperature exceeds 100°. In ap- plying the cold cloths, the night dress should be drawn up to the chest, a folded blanket placed under the patient, and the bed clothes arranged so that they cover the chest only, the remainder of the body being protected with an extra blanket. Two pieces of flannel are employed, each being sufficiently large, when folded into four 128 DISEASES OF THE RESPIRATORY SYSTEM. layers, to cover the front and sides of the abdomen. One cloth is applied and covered with a long piece of flannel, while the other is placed in a vessel of iced water by the side of the bed. The flannels should be changed at intervals of a minute. DR. BREHMER, OF GCERBERSDORF SANITARIUM. (Occidental Medical Times, 1890.) This physician, whose suc- cess in phthisis was well known, was an advocate of its treatment in sanataria, which in his belief were best situated in the mountains, the elevation stimulating the cardiac action and improving nutrition by exciting the appetite. The locality for such an institution should be one immuned from phthisis and sheltered from winds. The patients should have plenty of out-door exercise, but the least fatigue should be considered as requiring immediate rest. Dr. Brehmer in his institution provided five meals a day, vegetables occupying a high place in the dietary. Every patient was urged to drink three pints of milk daily, increasing to four pints if anorexia is pronounced. Wine is useful because it increases the power of the heart and econ- omizes nutrition. The dry irritative cough as much as possible must be controlled by effort and by drinking cold water, or hot milk with seltzer ; and morphia is only indicated where the cough is violent, fruitful and interferes with sleep. Streaking the spittle with blood, a moderate haemoptysis is to be controlled with hypodermics of morphia and an ice-bag to the cardiac region, possibly the use of ergotin if it be necessary. Where weakness and dyspnoea are prominent symptoms champagne is a useful stimulant. Fever may be diminished by cold to the pericardium, or antipyrin or antifebrin may be useful. A glass of milk with one or two teaspoonfuls of cognac will often pre- vent night-sweats. DR. S. SOLIS-COHEN, OF PHILADELPHIA. (Dietetic Gazette, 1 889. ) After commenting unfavorably upon any microbicidal treatment. Dr. SOLIS-COHEN bases his treatment of consumption upon hygienic and medicinal measures directed towards maintaining and improving nutrition — the hygienic of prime import- ance, the medicinal secondary. He states that a nitrogenous diet is the best, and offers the following dietary : Meat, principally beef, with milk, fish, eggs, leguminous vegetables and greens, should form the bulk; with the addition of fats, in large quantities, in the form of PHTHISIS. j^g cream, butter, oil dressing for salads, or, if necessary, cod-liver oil or oleaginous inunctions. Alcohol is a food in phthisis; it should ■be combined with malt, milk, glycerine or cod-liver oil. Not more than three or four hours, at most, except during sleep, should be allowed to elapse without taking food. Milk punch on going to bed and a glass of wine or spirits with liquid peptonoids in case of wak- ing during the night, are strongly urged. Hot water before meals, lavage, if necessary, to prepare the alimentary tract for the digestion and absorption of increased food, and the free drinking of water to wash out waste products, are essential to success. Pre-digested foods may be employed with great benefit, especially peptonized milk and beef peptonoids. In case gavage is employed, they should be re- sorted to almost entirely ; gavage should be preceded by lavage with an alkaline solution and chloroform water. Over-feeding in this manner securing proper aliment, the bowels being kept in order, the respiratory demands are also to be attended to. The stronger forms of exercise, especially in the open air, may be permitted while the patient is still strong enough ; but in the most cases artificial aid must be employed. The inhalation of compressed air is, in the writer's opinion, the best method of pul- monary gymnastics ; the apparatus of Waldenberg or that of Dr. Cohen himself, being modelled upon the simplest and most effect- ive plan. The effects of these measures are to increase the volume of respired air, to open up unused air-cells, facilitate the expulsion of waste products, increasing the space for and quantity of blood in the pulmonary circulation and inducing a more certain aeration of the blood. In this manner local and general nutrition are much in- creased, the products of digestion are properly used, and the imma- ture substances destroyed or completed. CLIMATE AND TRAVEL. The benefit of change of climate is most perceptible in cases in over-worked persons of sedentary life, who leave their in-door habits at home when they travel, and in hemorrhagic cases. In ordinary chronic phthisis a dry climate is best ; in phthisis with considerable bronchial irritation, a moist air is preferable. (Dr. C. T. Williams.) The most important of all considerations is that the air shall be pure, i. e., containing plenty of oxygen and free from organic im- purities. 9 130 DISEASES OF THE RESPIRATORY SYSTEM. As a general rule, according to Dr. MADDEN (Health Resorts of Europe and Africa, 1876), in the first and early second stage of or- dinary cases of phthisis a dry and stimulating climate is preferable. When the disease is of a chronic, bronchial type, with irritative symptoms, a moist, equable, unstimulating climate will be most beneficial. All patients in the third stage should stay at home. It is the advice of Dr. A. L. LOOMIS, (Diseases of the Respiratory- Organs, 1875,) to be governed in the choice of a climate by inquir- ing of the patient whether his health has usually been better in warm or cold weather, in a dry or moist atmosphere ; and to direct his travels accordingly, without much reference to the particular form of his disease. Two general rules should be observed: (i) In whatever locality a phthisical patient finds himself improving, he should remain there, (2) Whenever he finds his health deteriorating in a locality, he should leave it. Special praise has of late years been given to altitude as a curative agent in phthisis. Dr. Lombard, of Geneva, even claims that the disease cannot arise in localities over 5,000 feet above the sea level. Certain it is that not only are residents of lofty plateaux singularly exempt, but patients seeking these elevated regions are often sin- gularly improved. This has led to the establishment of mountaia sanitaria in Europe and America, the benefit of a residence in which has been amply demonstrated. In regard to sea voyages, Dr. RODERICK Maclaren ( Practitioner^ 1878,) states that when the infiltration of the lung is localized and chronic, when it is confined to the one side, and there is absence of evidence of disease elsewhere, it may be looked on as a favorable case ; and the further the departure from this condition, the less are the patient's chances of benefit. It is stated that cases in which haemoptysis is the first, or at least a very early symptom, do espec- ially well. Cases are unsuitable for a voyage in which there are signs of extensive progressive excavation, and all in which there is great muscular weakness. When we have evidence of the disease being general, as shown by glandular, bowel, or laryngeal disease, our recommendation should certainly be withheld. The bowels in particular should be in good trim, for the sedentary life and peculiar diet of a ship are apt, in healthy people, to produce intestinal dis- turbance (constipation and subsequent diarrhoea, or either of these alone). In a case which persistently grows worse under favorable PHTHISIS. 131 Circumstances of habitation, etc., on shore, the prospect of benefit would be small. A phlegmatic habit of body should also be looked upon to a considerable extent, as a counter-indication for this remedy. The following list embraces the most important health resorts in phthisis : Mountain Sanitaria. Europe: Davos, Moritz, Lamaden, in Switzerland; Hohwald Wangenburg, Soultzmatt, in the Vosges; Chaumont, Chateau, Ranz' in the. Jura; Gerbersdorf, in Silesia. America: The Andes of Bolivia; Denver and the higher levels in Colorado; the Appalachian plateau about Asheville, N. C; the various sanitaria of the Kaatskill Mountains in New York, iii the Blue Ridge Mountains of Maryland, West Virginia and Georgia. Lower Dry Climate. Europe, Asia and Africa : Montpellier, Cannes (warm, moder- ately exciting) ; Nice (variable, exciting) ; Mentone and the Riviera (cold and changeable) ; Upper Egypt (the best tonic, dry, warm climate) ; the Kirghis Steppes. America : The Costa Rican and Mexican plateau ; Minnesota, (dry and exciting); Colorado about Denver; the Adirondack region, (cool, moderately dry, very good at all seasons) ; Aiken, S. C, and northern Georgia; Santa Barbara, Cal. (dry, warm), about the re- gion of Tucson, Arizona. Lower Damp Climates. Europe, etc. : Madeira (very moist, equable) ; Arcahon ; South- ern Italy (now condemned) ; Algiers (warm, moist, equable.) America: The Bermudas (doubtful); the Bahamas (moist and equable) ; Florida (moist, but changeable) ; Isle of Pines, Santa Cruz, etc. (very equable and moist), and the Atlantic coast along the New Jersey shore. TREATMENT OF COMPLICATIONS. THE ANi^MIA AND DEBILITY. According to Dr. Symes Thompson (Practitioner, September, 1868,) the tincture of the chloride of iron is far superior to other chalybeates. The improvement of appetite, diminution of flat- 132 DISEASES OF THE RESPIRATORY SYSTEM. ulence, etc., which occur under its administration, are often remark- able, cod-liver oil and other fats, refused previously, being digested without discomfort. It both checks diarrhoea and relieves constipa- tion, by giving tone to the feeble muscular fibres of the bowels ; it lessens night-sweats, though these often call for oxide of zinc in ad- dition, and is a valuable remedy in haemoptysis. Many believe the iodide of iron one of the best chalybeate tonics which can be em- ployed in the anaemia of phthisis, if it does not prove too stimulating. The syrup (ftLxx— f .^j, thrice daily) is the best form. The iodide of calcium has been extolled as an excellent tonic by Dr. A. Malet, of Rio de Janeiro. (Bull. Gen. de Thcr., Aug., 1868.) He administers gr. viij in solution, in divided doses, daily, and says it awakens the appetite, regulates the digestion, renders the respiration freer and deeper, diminishes the cough and modifies the expectoration, increases the strength and lessens the perspiration. If constipation ensue in consequence of its long use, it will often dis- appear, of itself; otherwise the dose may be diminished, or the rem- edy temporarily stopped. Prof FURTER, of Montpellier, employs, with good results, raw mutton or beef, given in conjunction with strong or diluted alcohol, in small doses. 229. R. Take some finely-minced raw mutton or beef, and roll it up in sugar or in a saccharine electuary. Give in teaspoonful doses to the amount of 3—10 ounces per day. 230. K. Alcoholis, , f.5j Syrupi, f. I iij. M. A teaspoonful dose every hour. The dose and frequency of administration are to be modified by the patient's individuality. Dr. J. Waring Curran. praises the oxide of zinc. 231. R. Zinci oxidi, gr. jj Extract! conii, gr.j. i^_ Por one pill; to be taken three ►imes a day. The quantity of the oxide of zinc is gradually to be increased. In the latter stages of phthisis, where profuse sweating and colli- quative diarrhoea harass the patient and rapidly lower the vital ca- pacity, this combination is very effective. It is of great value, also, in the earlier stages of the disease. It seems to steady the nervous system, and act as a sedative to the wandering pains. PHTHISIS. , , , THE COUGH. Anodynes are urgently demanded when the cough is troublesome. The following is recommended by Dr. Sunderlind : 232. R. Amraonii chloridi, gr. xxx Opii pulveris, gr. jx Digitalis pulveris, Scillse pulveris, aa gr. xv. M. Divide into thirty pills. One every six hours, to quiet the cough and facilitate the expectoration in the early stage of phthisis. 233- R. Morphise sulphatis, gr. j Syrupi fern iodidi, f. 5 ss Glycerins, f.gijss. M. A teaspoonful two or three times a day, to quiet the cough and retard the emaciation in phthisis. The following is in use in most chronic pulmonary affections, in the Charity Hospital, New York : 234. R. Potassii bromidi, Potassii chloratis, Ammonii muriatis, aa 3 iss Syrupi tolutani, f. § iv. M. A teaspoonful every few hours. A writer in the Canada Lancet, March, 1879, says the following formula is almost a specific in phthisical cases with troublesome coughing : 235. R- AtropiiE sulph., gf- J . Morphiee sulph., P- y."J Acid, sulph. aromat., f- 3 y Aquam menth. pip., ad f.3j. M. ' Dose, five drops thrice daily and at bedtime. The Consumption Hospital, London, employs, as a house pre- scription : 236. R. Morphiae muriatis, P'- ^* Acidi hydrocyanici diluti, "l^^^ Acidi muriatici diluti, JH''^* Oxymellis scilte, \^J^ „ Aquam, =>■'■ Dose, one to two drachms. Combinations like the following are employed by Dr. J. M. Da Costa : 237. R. Morphioe acetatis, |^' ■' Potassii cyanidi, l\\ Acidi acetici, ■''■' Extracti pruni virginianae fluidi, „ ^ _ jj A teaspoonfultuTorsix rimes a day. as a sedative mixture>r th; cough of phthisis. 134 DISEASES OF THE RESPIRATORY SYSTEM. 238. R. Liquoris morphiae sulphatis, f-|j. Extracti pruni virginianse fluidi, '• 3 U Acidi sulphuric! diluti, f-3ij- M. A teaspoonful three or four times a day, when night-sweats and cough are trouble- some. 239. R. Extracti opii, f- ?s Aquje, f-3J- M. For one inhalation twice a day, by means of any form of steam atomizer throwing a fine spray. In the irritative cough of phthisis, causing gastric irritability. Dr. J. Hutchinson, of Philadelphia, recommends : 240. JJ. Acidi sulphurici dil., Tinct. opii deodoratae, aa gtt. iij Syr. pruni virginianse, Elixir, cinchonae, aa f. 5ss. M. Signa. — ^Take at a dose. Locally, various methods to allay the irritation may be employed. The inhalation of warm water, impregnated with emollient herbs, such as althcBa officinalis, or with narotic extracts, palliates cough, dryness of throat, and laryngeal irritation. Inhalations of tar, crea- sole, and carbolic acid, simple, or in association with sedative extracts, have occasionally produced remarkable improvement in both the local and constitutional state. Also, hyoscyamus, gr. v of the extract to Oj of boiling water. Dr. Ringer strongly recommends the application of the glycerite of tannin, with a small quantity of morphia added, to the throat. When the cough is troublesome, a good night's rest may often be obtained by applying it at bedtime. For the distressing night cough, Dr. Yeo finds croton chloral an efficient agent. It may be given in doses as high as sixty grains. Dry cupping on the chest, under the clavicles, often gives great relief in distressing dyspnoea and cough. Dr. Sandby, of London, (Rrit. Med. Jour., April 12th, 1879,) has found nothing so good as codeia. It allays the cough without dis- turbing the digestive system. He prescribes gr. j, dissolved in syrup of tolu. THE GASTRIC SYMPTOMS. The vomiting of phthisis is exceedingly exhaustive, and the greatest care should be taken in medication and in dietary to pre- serve the tone of the stomach in as high degree as possible. To this end frequent washing of the stomach by drinking hot water before meals or by actual lavage is a considerable service. Sedatives are PHTHISIS. 135 of great value in soothing the gastric nerves and preventing the harassing cough which is apt to induce the act of vomiting. Prof. John H. MusSER, of Philadelphia, is in the habit of prescribing for this condition the following pill : 241. R. Acidi carbolici, gtt. vj Pulveris carbonis ligni, gr. xxiv Bismuthi subnitratis, gr. xlviij Extracti colcoynthi comp., gr. xij Extract! hyoscyami, gr. iij. M. Ft. massa ex qua ft. pilulse no. xxiv. Sig : — One after meals. For the nausea a small bit of ice is often sufficient, or a sip of Avine, especially the wine of cocoa. THE DIARRHOEA. The complication of diarrhoea is not very frequent, but is exceed- ingly exhaustive. When caused by the presence of irritating ingesta, Dr. Barlow uses : 242. R. Olei ricini, Tinclurae rhei, aa f. 3'j Tincturae opii, Tlliv Aquae cinnamomi, f. 5iv. M. To be taken at a draught. This may be followed by : 243. B- Acidi nitrici diluti, ITlxij Tinctur^E opii, TUv— x Syrupi, f. 3 j Aquae cinnamomi, f. 5 x. M. Make a draught to be taken every fourth or sixth hour. The logwood is a pleasant astringent. Dr. F. W. PARRY com- tines it thus : 244. R. Extracti hsematoxyli, 3 ij Misturae cretse, f. 3xij Vini ipecacuanhae, f. 3 ij Vini opii, f. 3j. M. A tablespoonful twice, thrice, or oflener daily. Dr. Graves has recommended as one of the best remedies nitrate of silver, gr. j, in pill, three or four times daily. He speaks ■well of: 245. R. Acidi sulphurici diluti, nixv-xx Tinct. opii, TTlx-xv Tinct. cinchon. comp., ad f. 3 j- M. For one dose. 136 DISEASES OF THE RESPIRATORY SYSTEM, The following injection is recommended for cases of tubercular diarrhoea (Jour, de Med. de Paris) : 246. R. Olei olivae, i. 5vj Guaiacol, gtt. x Aquas, f. § vfq, M, Add to the above, and beat in, the yelk of one egg. THE DYSPNOEA. The external use of dry cups or croton oil liniment to the surface of the chest and under the clavicles will sometimes reh'eve the dis- tressing dyspnoea. When it is greatly aggravated by coughing^ spells, the inhalation of chloroform will often check these. Inhala- tions of hyoscyamus vapor, gr. v of the extract to O] of warm water, is also recommended. Terebene in capsules containing one or two drops, is often to be highly recommended in these cases, its use be- ing attended with decided relief. THE FEVER. The following pill is said to be used by LlEBERMElSTER in the hectic fever of phthisis : 247- R- Quininae sulphatis, gr.xxx Pulveris digitalis, gr. v^ss Extract; gentianse, q. s. M. Ft. massa ex qua ft. pilulse, no. xl. Sig : Six to ten pills daily. Antipyrin and its congeners are also temporarily of great service, but for continued use are worse than useless, as they appear to con- siderably diminish the vitality of the patient by the depression fol- lowing administration. THE NIGHT SWEATS. Nothing so effectually controls these as belladonna or atropia, as suggested by RiNGER, Fothergill and Bartholow. The average dose of atropia is gr. sV, which may be given in pill, or in solution ; or gr. rb hypodermically. It can very advantageously be combined with morphia. The aqueous solutions soon spoil, so the pill form is better. Dr. A. H. Hassall, of the Ventnor, England, Hospital for Consumption, gives : 24S. R. Atropiae sulphatis, ~. 1 _ 1 Extracti gentians, |r.' j^f ''* m. For one pill. PHTHISIS. 137 Dr. J. T. Nairne (British Medical Journal. February, 1 878,) uses the ordinary tincture of belladonna externally in these cases : 249. R. Tinct. belladonnse, Spiritfls frumenti, aa f. 3 ij M. This is usually sufficient to cover the body and produce the de- sired effect. Dr. Leu (Therapeutic Gazette, 1890) has commended the employ- ment of camphoric acid given in doses of thirty-five to fifty grains in the evening, and about twenty-five or thirty grains in the middle of the day. The drug is best given in capsules. Dr. Thomas H. Tanner uses one of the following for night sweats : Or: 250. R. Acidi gallici, Extracti cannabis indicx, Confectionis rosse, 9ij gr. V gr. A. For ten pills. One to be taken every night at bedtime. 251. R. Zinci oxidi, Extracti conii vel Extracti hycscyami, For six pills. One to be taken every night at bedtime. gr. xij gr. xviij, M. M, An excellent combination is : 252. R. Extracti belladonnse, Zinci sulphatis, Extracti gentianse, aa gr. j. For one pill at night. Or: 253* R- Zinci sulphatis, gr. j Extracti hyoscyami, gr. iij. M. For one pill at night. Dr. Fraentzel recommends (Wiener Med. Blatter,) hydriodate of hyoscin in the treatment of the night-sweating of phthisis, in subcutaneous doses of half a milligramme (^^\^ gr-)' °'' '" P'^'' ^^' ginning with the same dose. He does not find it so universally beneficial as atropine, and it sooner exhibits a narcotic action ; but he has seen good results from it in cases where atropine has proved useless, or has failed to act after being in use for some time. Speaking of the unsatisfactory results of all the remedies recom- mended for this condition. Dr. J. R. Forrest writes to the Lancet, 138 DISEASES OF THE RESPIRATORY SYSTEM. October 27, 1883, that he has found the following a most efficacious lotion : 254. R. Sulphate of zinc, gf; iv Tincture of belladonna, 3j Water, Sj- The body to be sponged with the lotion at bedtime. Dr. Hayden believes that Dover's powder, if judiciously given, is more efficient than belladonna. If the sweating occurs towards morning, as is usually the case, gr. v of Dover's powder, once or twice during the night, will check it. Tepid sponging with vinegar and water is a useful auxiliary. (Dublin Journal of Med. Science, April, 1877.) Quinine is another useful remedy. It proves of most avail when there is a considerable rise of temperature at some period of the day. It is frequently given in two-grain doses, but five grains are much more likely to succeed. A large dose (8 or 10 grains) ad- ministered at once or in portions repeated hourly, is a good form. Nitrite of amy I is a good remedy for night-sweats, but for prompt- ness of action is decidedly inferior to atropia and other remedies. Agaric, gr. v— vj, at night, is occasionally effectual. Externally, sponging the surface with hot water (130° Fah.) is recommended by Dr. Druitt ; or with a strong solution of common salt. Aromatic vinegar and water is also useful, but has its disad- vantages. Dr. EllioTSON speaks well of a mixture of sulphuric acid and water — a drachm to the pint — as a wash. The application of belladonna is useful for local sweating, but when the sweating is general, the internal administration of atropia is to be preferred. Duboisia was reported upon favorably by the late Prof. GUBLER. In the Philadelphia Yio=,-^\tiS.y jaborandi has been found very effec- tive : 255. R. Extract! jaborandi fluid., f. |ss Tinct. cardamomi, Syrup, pruni Virginian., aa f.3ij- M. One teaspoonful in half a wineglassful of water the first night, then half a teaspoon- ful every following night until cessation of sweats. It will rarely be necessary to give the medicine oftener than four consecutive nights. If, after some weeks, the sweats should return, which is frequently the case, one or two of the smaller doses will be sufficient to stop them again. Picrotoxin, gr. xU-%^, in solution, has been used with success in many cases. (Practitioner, October, 1878.) PHTHISIS. 139 Pilocarpine, the alkaloid of jaborandi, has been given in the form of pill made up with sugar of milk, and in one-twentieth grain doses three or four times a day ; equivalent to about eight drops of the fluid extract of jaborandi. NOTES ON REMEDIES. Acidum CarboHcutn. The inhalation of pulverized solutions of carbolic acid is of frequent benefit in the advanced stages of phthisis, by diminish- ing the secretion and lessening the cough and exhaustion, and by cor- recting fcetor of the expectorations. A solution of drops xv-xx, in two pints of water, with the addition of one or two ounces of tincture of conium, or of alcohol, may be used. Lately, Dr. J. Schnitzler, of Vienna, has claimed " remarkable success " in the treatment of phthisis by hypodermic injections of carbolic acid, using a one or two per cent, solution twice daily. (^DobeWs Reports, i8tj.) Acidum Tannicum. Prof. Stille says that this medicine appears sometimes to remove the crepitating rhonchi so generally observed around crude tubercles at the apex of the lung during the first stage of phthisis, while it diminishes the dyspnoea, cough and expectoration. At a late period, it sometimes so manifestly palliates all the symptoms as to in- spire a belief that a cure has been accomplished, converting moist rhonchi, or gurgling, into signs of solidification merely, or of a dry cavity. The more nearly the disease resembles the acute form of phthisis, the less appropriate will the medicine become. ^iher has been recommended to promote the assimilation of cod-liver oil, by Dr. Foster. The objections to his preparation are its disagreeable taste, and the eructations it occasions. Alcohol. Dr. Anstie says that there is a variety of pulmonary phthisis, es- pecially common in persons with delicate skin and slight frame, with a marked tendency to colliquative sweating, and a notable inability to assimilate either ordinary food or fatty matter of any kind, in which the tolerance for large and long-continued doses of alcohol is very re- markable, and the benefit produced by such treatment very great. Prof. Flint also recommends strongly the alcoholic treatment in cases in which stimulants are well borne. Ammonii lodidvm is recommended in incipient phthisis by Dr. Richardson. It is also advised by Dr. Tanner, in cases in which cod-liver oil is not tolerated. Antipyrtne, according to Zarerzhevski (London Lancet, 1887,) is almost a specific in phthisis, although this opinion has not been home out by the experience of others. The above writer prefers to give it hypo- dermically rather than by the stomach, as the action is more prompt. I40 DISEASES OF THE RESPIRATORY SYSTEM. Aniline has been tried by various members of the profession, and according to most reports is worse than useless. Arsenicum is often a remedy of great value, but it is frequently badly borne by the stomach. Prof Da Costa recommends it as often beneficial in slow consumption. It is highly advocated by a number of French physicians. Arseniosum Acidum. Dr. A. Jacobi, of New York {Med. News, 1884), says that in phthisis arsenic is the best alterative and nutritive which we can employ. He does not use it while hectic fever is high, but when the temperature falls arsenic in small doses is a very valuable agent, in doses of from one-fifteenth to one-sixth of a grain, with a little opium. Digitalis is also valuable. Aurum. As cyanide, gold is used in the treatment of phthisis, given hypo- dermatically, and is also supposed to enter into use in " Koch's Lymph," as an adjuvant. Calcii Chloridum is valuable in strumous phthisis. Dr. A. H. Mellf.rsh says many cases improve upon it. {Medical and Surgical Reporter, Feb- ruary, 1878.) Calcii Phosphas is said by Rebovy {Brit. Med. Jour., 1887,) to be of benefit in the night sweats of phthisis. Caoutchouc, dissolved in turpentine and made into a confection, has been given in many cases by Dr. Varick, of Jersey City, and has been found very useful where cod-liver oil cannot be tolerated. {Med. Record, Nov., 1873.) Cinchona. The acidulated cold infusion of bark is an excellent remedv for the profuse perspiration, night-sweat and hectic fever. Creasotum has lately been recommended by Dr. Hugues, of Paris, in a thesis. He tried it with good effect in twenty-seven cases, in the following formula : 256. R. Creasote, «: Alcohol, ■'^ Water, i£ {^^■„ jj_ Of this, a dessertspoonful twice daily. The creasote must be pure and of wood-tar, not the impure stuff usually found in the shops. It may be given also as an in- halant, hndmg considerable value as thus administered. Digitalis enjoyed formerly a higher reputation than it now possesses, although it is still highly spoken of. Dr. Niemever considers it, in combina- tion with quinine, as an admirable agent for arresting the abnormal calorification. It is often very useful in haemoptysis, especially in the advanced stages of the disease. Ferrum. Almost any of the preparations of iron are usefiil in the eariy stages, the choice of which should depend on the patient's idiosyncrasies. PHTHISIS. 141 Glycerina. In the non-febrile stage of phthisis Dr. Tisne, of Paris, uses the following as a stimulant to the digestive organs : 257. R. Glycerinse, f. §iv. Spiritfls vini, f. § ss Essentise menthi., gtt. j. M. In three doses each day. It is well to begin with half this quantity daily, though the above amount can soon be tolerated. It should be suspended if excitability of the heart is present. The Hypophosphites enjoy a high reputation in the treatment of phthisis, pre- ferably those of calcium, sodium and quinine, in doses of two to four or five grains. Hydrogenii Peroxidum is said to greatly improve digestion in the first stage of phthisis, and aid the action of iron ; in the last stage, it unquestionably affords relief to the breathlessness and oppression, acting like an opiate without producing narcotism. Given in a nebulized form as an inhal- ant, it is of great value in reducing the purulent character of the sputum and in diminishing the pyaemic symptoms. lodinium is a valuable counter-irritant. Dr. Fuller recommends : 258. R. Hydrargyri chloridi mitis, gr. viij lodinii, 3 ss Alcoholis, f. 3 iss Unguenti, §j. M. Rub in a portion over the affected lung, morning and evening, until a pustular erup- tion comes out. Jodoformum. Prof. Chiarmelli, of Milan, states that even at an advanced period of the disease, with the presence of cavities, iodoform gives ex- cellent results. " Iodoform," he says, " diminishes the fever and af- fects the expectoration, which it not only diminishes in quantity, but alters in character, preventing the putrefaction of its albuminoid ele- ments. I am also convinced that the contents of the cavities in the lung exercise a powerful influence upon the production of hectic fever." He claims that it arrests the march of this malady and prolongs the life of the sufferer. He also holds that in cases where caseous pneu- monia is commencing, iodoform administered for a time proves effica- cious in arresting the progress of the disease. With many individuals affected with chronic bronchitis and emphysema, it renders great ser- vice. The formula which is employed is as follows : 259. R- Iodoform, gr. iss Powdered lycopodium, gr.j Ext. of gentian, q. s. Make into ten pilules. Take three to five in the day. If the dose is increased gastric disorders supervene, and it is better to continue the above dose for a considerable time. 142 DISEASES OF THE RESPIRATORY SYSTEM. Juglans. Infusion of the leaves oi the Juglanda regia, or an extract, is much used in Germany when cod-liver oil cannot be tolerated, or in the hot season when the oil is apt to disagree. Koumiss, the fermented milk of mares or cows, is a popular remedy, and is now prepared by druggists in our leading cities. A " cure " requires 12 to 15 lbs. of koumiss daily, taken every half hour, conjoined with plenty of open-air exercise. The Russian method of preparing koumiss is as follows : Take two teacupfuls of wheat-flour dough, two spoonfuls of millet flour, one spoonful of honey, one of beer yeast ; mix with milk to a thin paste, and put in a warm place to ferment. When fer- mented, put in a linen bag and liang it in a jar with 16 lbs. of fresh milk ; cover, and let stand until the milk is acidulous ; skim, decant and agitate for an hour, then bottle and place in a cold place. The following is an American formula for koumiss : 260. J^. Fresh milk, 5 gallons Spring water, 13 pints Baker's yeast, 2 " Simple syrup. I^ « Mix, and skim oflF the top. Then put the liquid into bottles, which are to be laid on their side, from one to four weeks, in a cool place, the temperature of which must be below 70°. The different stages of the preparation are as follows : After one week the koumiss is fresh ; after two weeks, medium ; after three or four weeks, old. A champagne tap is very convenient for drawing the liquid. A preparation called ferruginous koumiss is prepared by daily add- ing ordinary doses of lactate of iron to two or three bottles of common koumiss. The iron salt easily dissolves, without changing the taste of the koumiss. This preparation is very well borne, even by patients who cannot take iron administered in pills, powders, etc. Morrhua Oleum is deserving of the highest confidence. The eariier it is employed in the disease the better. In regard to its mode of action and method of administration, see opinions quoted above. Muriaticum Acidum, alone or in combination with other mineral or vegetable tonics, is an important auxiliary to treatment. Nitrogen Gas. Inhalations of this gas have been recommended by Prof. Si-EINBRUCK, of Vienna. In the first and second stages, especially in young persons, they give great relief and sometimes cure ; but in the third stage they are injurious. Their immediate effect is to allay ner- vous irritability and lower the circulation. (DobeWs Reports, 1876.) Oleum Tiglii, as a counter-irritant to the chest in the earlier stages, is un- doubtedly beneficial. opium, by the mouth or enema, is often a valuable palliative in advanced stages of phthisis, to reheve the cough,, lessen the expectoration, check diarrhoea, and afford comfort to the patient. PHTHISIS. 143 Pancreatic Emulsion, introduced by Dr. Horace Dobell, is an excellent remedy, either with or without cod-liver oil, and is well borne by per- sons unable to retain the oil. He says it is best to give the Pancreatic Emulsion from one to two hours after a full meal, such as breakfast or dinner, particularly avoiding a longer interval, and also avoiding warm drinks for two or three hours afterwards. When cod-liver oil agrees, give a tablespoonful of oil directly after breakfast, to supply olein to the blood through the portal system, and a tablespoonful of emulsion, in a cup of milk or water, two hours after dinner, to supply the blood with pancreatized solid fats through the lacteal system. If cod-liver oil cannot be taken, give the emulsion two hours after breakfast, and two hours after dinner. Peptonized Meats, in the shape of either solid or liquid peptonoids, are of ex- treme value in the preservation of the nutrition. Pilocarpine, at one time much lauded, is probably of no more value than the host of other substances used in phthisis. It does, however, given in hyjwdermatic manner, tend to relieve the dyspnoea. Plumbi Acetas is very useful in diminishing expectoration, checking hemor- rhage and diarrhoea, and, to a less extent, the profiise perspirations of phthisis ; but its administration is objectionable, because of the ano- rexia which often speedily results. Potassii Chloras is recommended in the painful deglutition of advanced phthisis. Potassii lodidum is of value, given with iron and cod-liver oil, when there is a syphilitic taint. Prunus Virginiana improves the appetite and palliates the cough. Quinice Sulphas is a valuable tonic in phthisis, given in conjunction with iron and cod-liver oil. Saccharum. Dr. Symonds recommends {British Medical Journal, June r3th, 1868,) sugar as an article of diet in phthisis, taken to the extent of a quarter of a pound or more daily. He gives it with eggs as a suc- cedaneum for cod- liver oil, when the latter disagrees. Sanguis. The fresh blood of animals, drunk while warm, is a nutritive drink, and has proved of value in many phthisical cases. Sanguis Bovinus Exsiccatus. This nutritive preparation has been found of great use in combating the exhaustion of phthisis. Dr. F. W. Putnam states that it is the most satisfactory of any such substance he has used. {Therap. Gazette, 1883.) Sevum PrcBparatum, Suet, is a popular and useful remedy, boiled in milk, and taken in the morning. Silphium Cyrenaicum. In Italy, Dr. Antonio Lombardo assigns the following effects to the treatment of phthisis with Silphium Cyrenaicum : " The 144 DISEASES OF THE RESPIRATORY SYSTEM. expectoration is much facilitated ; the dyspnoea is diminished, and the circulation becomes more regular ; while no digestive disturbance re- sults from its administration." {DobeWs Reports, 1877.) Sodii Sulpho- Carbolas has been recommended by Dr. Sansom. {Practitioner, July, 1869.) Sulphur is useful in the costiveness of phthisis, and may also be employed against profuse perspirations. Verbascum Thapsus, the common mullein, has been praised for its effect in phthisis by Dr. F. J. B. Quinlan. In the Brit. Med. Jour., December 8, 1883, this gentleman reports a case of pre-tubercular phthisis, in which the patient gained twelve pounds in weight in one month under the use of mullein. He considers that it possesses all the advantages and none of the drawbacks of cod-liver oil. Vitis Vinifera. The grape cure is of benefit in chronic catarrhal cases, but is of doubtful propriety in tuberculosis cases. Zinci Oxidum is strongly recommended by Dr. Waring Curran, as a tonic. INHALATIONS. Arsenicum. Trousseau and others have recommended arsenious fumigation by means of cigarettes — a mode of treatment which should be con- ducted with caution. Benzine and Naphtha have both been used as inhalation substances, and have been favorably reported upon by Scherbakoff. The patient is re- quired to inhale the substance for five minutes of every hour of the day. Carbolicum Acidum. Dr. Marcet recommends {Practitioner, November, 1868,) the atomization of the following solution : 261. R. Acidi carbolici, gr. ss-iss Aquae, f.|j. M. This inhaled in the form of spray acts beneficially in the first stages of the disease, by improving the circulation in the lungs, but in the advanced stages it should be withheld. Chloroformum. A few whiffs (ttlvj-x) are often useful in the cough and dys- pnoea of phthisis, but the effect is only temporary. Eucalyptol seems to have some effect, in the bronchial secretions, diminishing the expectoration and somewhat improving its character. lodinium. In cases of troublesome cough and abundant expectoration, bene- fit sometimes results from employing, night and morning, vapor of iodine : 262. R. Tincturae iodinii, f. 5j Aquae, f. § j. M. Apply gentle heat, and let the vapor that arises be inhaled. Or, the dilute compound tincture of iodine may be atomized. PHTHISIS. 145 Jodoformum. The inhalation of the dilute vapor obtained by mixing iodoform with starch, spreading it on paper and allowing it to volatilize, has been recommended. Opium, by inhalation, is an excellent means of soothing irritative cough. Oxygen inhalations can only be looked upon as palliative, and seem, in some cases, after affording immediate relief, to invite fresh and more intense exacerbations. Fix Liquida. Tar vapor is now little used, having lost the reputation it once enjoyed in phthisis. EXTERNAL REMEDIES. Aceticum Acidum Dilutum. The application of diluted vinegar to the chest and upper part of the body, to allay the profuse perspirations of phthi- sis, is recommended by Dr. Wai-she, Sir C. Scudamore, and others, as a measure greatly conducing to the comfort and well-being of the patient. The mixture of one part of vinegar, one of eau de cologne, and two of water, is employed by Sir C. Scudamore. Ammonii lodidum, in ointment, is recommended by Dr. Tanner. Baths. The Turkish Bath is sometimes of service in incipient phthisis. The Compressed Air Bath may often be employed with great advantage. Counter Irritation. The counter-irritants most frequently resorted to in phthisis, are the following : Aqua Ammonice; Tartar Emetic Oint- ment ; Calomel a?id Iodine Ointment; Croton Oil Liniment ; Tinc- ture of Iodine (painted over the chest every night) also does good, by the iodine which is inhaled, from the air around the patient being slightly impregnated by the evaporation of the tincture ; Burgundy Pitch Plaster; Thapsia Plaster; the following plaster is recom- mended by Dr. Barlow, in the first stage of phthisis : 263. R. Emplastri picis com., 3iss Antimonii et potassii tartratis, gc. x. M. Make a plaster. Electricity. As far back as 1863, Dr. Bastings, of Brussels, announced the cure of twenty-five cases of phthisis out of thirty-seven patients, by means of electricity. ( Traite de la Phthisic, 1863.) The Archives Med. Beiges, 1879, Contains the details of a case of well-marked phthi- sis, added to his success. Dr. B. electrizes the muscles of the chest and arms by means of an electro-galvanic machine of Gaiffe, employ- ing such a strength that the resulting contractions correspond to those natural to respiration. One or two sittings of five minutes daily, are sufficient. Setons. In the early stages, a sub-clavicular seton of three or four silk threads sometimes retards the progress of the disease. 10 146 DISEASES OF THE RESPIRATORY SYSTEM. PLEURISY. JOHN SYER BRISTOWE, M. D., LONDON. In mild cases of so-called dry pleurisy, the chest should be irri- tated by a mustard plaster, and then swathed in a broad flannel roller, so as to restrain motion, while small doses of opiates should be commenced. When there is manifest fever and commencing effusion, it is often beneficial to apply half a dozen to a dozen leeches to the surface of the chest, followed up by poultices, or flannels wrung out in hot water. Opiates are here, also, of extreme value, and some febrifuge medicine may be employed. If the effusion still increases, diuretics and purgatives, mercury, digitalis, and iodide of potassium, have been employed. All these Dr. B. rejects as useless. He would prefer tonics, especially iron and quinine ; counter-irritants, especially repeated small blisters ; and, finally, paracentesis thoracis or aspiration. DR. RICHARD OTTO, OF DUPONT. This physician states that a bandage 2 j/^ to 4 inches broad, tightly bound around the thorax, will greatly relieve the pain in beginning pleurisy by limiting the respiratory movements of the chest. Not only in the very earliest stage is it of value, but as long as the pleu- ral layers are not separated by effusion or are not adherent. ALFRED L. LOOMIS, M. D., NEW YORK. In mild as well as severe cases of pleurisy, all the treatment re- quired for the successful management of the disease is to put the patient quietly to bed (very important), apply an anodyne poultice to the affected side, and administer hypodermic injections of mor- phia in quantities sufficient to relieve all pain. Ordinarily, the pa- tient can sit up in four or five days, and in two weeks resume his business. But if the exudation is abundant, he should keep his room and avoid exertion. If the patient is ansemic, the syrup of the iodide of iron should be given, gtt.x-xv, three or four times a day. Stimulants should never be given until the second or third week of the disease; and all so-called antiphlogistics and counter-irritants should be avoided. Iron is the remedial agent which has the greatest power to pro- PLEURISY. 147 mote absorption. When |the case is sub-acute, the most nutritious food and free stimulation are in place. The nutritive processes should be raised to the highest point. In any case, when the fluid accumulation remains stationary for one week, or is increasing after the cavity is half filled with fluid, aspiration should be resorted to. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. 264. R. Potassii acetatis, gr. xv Spirjtus aetheris nitrosi, f. 3 ss Vini ipecacuanhse, gtt. iij Syrupi tolutani, f. 3ss. M. For one dose, four times a day. Useful in sub-acute pleurisy. 265. g. Tincturae veratri viridis, IUxxiv Potassii acetatis, § ss Morphise acetatis, gr. ss Liquoris potassii citratis, f. § ijss Syrupi tolutani, f. | ss. M. A dessertspoonful every three hours, in dry pleurisy. Locally, apply, two or three times a day, turpentine stupes. 266. R. Potassii acetatis, §j Tincturse digitalis, f-3ij Extracti cinchona fluidi, f. §j Aquae, f. § ij. M. A teaspoonful thrice daily, in pleuritic e6fusions. 267. R. Potassii iodidi, 3ii Tincturoe scillae, f. 3vj Tincturse opii camphoratas, f. § iss Misturse acacise, f. 3vj. M. A teaspoonful four times a day, in chronic pleurisy with consolidation of the lung. Also, a good, nourishing diet; either whisky or gin, half an ounce three times a day; and counter-irritation by means of tincture of iodine. PLEURISY WITH EFFUSION. In the treatment of this condition where the effusion is not exces- sive, the method known as that of Hay is to be warmly recommended. It has been found of great service by many practitioners. The plan consists in the administration of a full dose of sulphate of mag- nesia dissolved in the least possible quantity of warm water early in the morning, after a period of some hours during which no water was drunk. No liquids should be permitted until the remedy has begun to act. The salts, by provoking the usual serous diarrhoea, consider- ably diminish the watery elements of the circulation and the effusion is quickly drawn upon to make good this deficiency. Acetate of potash and other salines are also indicated in the same condition. 148 DISEASES OF THE RESPIRATORY SYSTEM. Where, however, the effusion becomes chronic or excessive, aspira- tion must be resorted to. The arguments against tapping are almost entirely caused by the faulty performances of the operation and the results of such improper procedures. According to Dr. GiBB (Glasgow Med. Jour., 1887), the rules for tapping are when the fluid rises above the middle of the scapula ; when it fills more than half the cavity and remains stationary for over a week, even if the fever continues ; when the chest is full, the heart displaced and the dia- ghragm depressed, even if there are no urgent symptoms ; and when the patient is losing flesh, with malaise, feeble circulation, dyspnoea, irregular pulse, and dyspepsia. The best point for the puncture is in the seventh or eighth interspace before the posterior axillary fold. TREATMENT BY COMPRESSION OF THE THORAX. Professor CONCATO, of Bologna, has introduced a new treatment of unilateral pleurisy with effusion, which has been received with much approbation in Italy. It is by manual compression performed with both hands applied to the healthy side twice a day, during five to fifteen minutes each time. The patients experience rapid benefit from this treatment, the dyspncea disappearing and rapid absorption taking place. According to Dr. Sante Albertozzi, of Florence, it takes the place of thoracentesis, and is, of course, safer. No reme- dies are required, and the treatment is assisted only by nourishing diet. To succeed well, fever should be absent and the effusion re- cent. (Dobell's Reports, 1876, 1877.) On the other hand, Dr. J. C. Gleason, of Boston, recommends strapping the affected side with adhesive strips, so as to limit motion and secure the greatest possible rest in all cases of acute pleurisy, pleuro-pneumonia, etc., in which severe pain, resulting from the re- spiratory movements, comes in as a leading symptom. (Boston Med- ical and Surgical Journal, December, 1877. PROF. AUFRECHT. AUFRECHT some years ago recommended salicylate of sodium in in cases of pleural effusion, and his statements have recently received the fullest corroboration from Fetz (Therap. Monatshefte, 1890,) who states that the action of the drug is as marked in this affection as in rheumatism, and that from his experience this treatment is consider- ably shorter than in other methods. Fetz gives the drug in fifteen- PLEURISY. 149 grain doses four or five times daily at first, later three or four times daily for a week. NOTES ON REMEDIES. Aconite. Bartholow considers aconite and opium as very effective in acute pleurisy before the stage of effusion, and highly recommends the fol- lowing : \ 268. R. Tinct. aconiti rad., f. 5ij Tinct. opii deod., f. 3 vj. M. S. — Eight drops in water, every hour or two. If the pain is severe, a large dose of opium should be given, when the effect can be maintained by the quantity directed in the above pre- scription. Antimonii et Potassii Tartras, in doses gr. ts— K sometimes proves usefiil in the earliest stages of acute pleurisy in young, plethoric subjects. It is, according to Lennec, and the older writers in general, well supported in pleurisy, and contributes powerfully to subdue the inflammatory tendency j but, nevertheless, when the pain in the side and fever have ceased, it loses further power over the disease ; at least, it does not appear to promote the removal of the fluid effused, so that its use must generally be abandoned as soon as the acute symptoms have passed away. Digitalis is an antiphlogistic, adapted to the pre-exudative stage. Pilocarpine aids in the absorption of the exudation. Jodinium. In effusion, after the febrile action, the compound tincture of iodine, in doses oi twenty minims freely diluted, is a valuable medicine. Jaborandi has proved very serviceable in several cases of pleuritic effusion, and in a late number of La France Medical, Dr. MiCHOU reports two cases, the happy termination of which certainly appears to be due to the action of this drug. In both cases the patients were rather bad sub- jects, the symptoms severe, and other remedies unsuccessful. Five grammes (75 gr.) of jaborandi leaves were given in infusion, and in both cases this dose was soon followed by copious expectoration, sali- vation, and diaphoresis, together with marked absorption of the effu- sion, and speedy relief to all the symptoms. Magnesii Sulphas, used in Hay's method as a hydragogue cathartic, often pro- motes absorption of the exudation in moist pleurisy. Morphia. Nothing can be more satisfactory than the treatment of pleurisy in its early stage by the hypodermic injection of morphia. It relieves at oiice the pain, and arrests or diminishes the morbid process. 269. R. Morphise sulphatis, gr. xvj Aquae destillatse, f. § j. M. Dissolve and filter. Dose, for a hypodermic injection, five to ten minims. I50 DISEASES OF THE RESPIRATORY SYSTEM. Potassii Acetas and similar remedies for increasing the urinary flow are of value in the stage of pleuritic effusion. Potassii lodidum, variously combined according to indications, is considered by many of the highest value in restraining inflammatory action and promoting absorption. (F. 267.) Quinice Sulphas, in the advanced stages, when the case assumes a typhoid character, especially when the patient is old or debilitated, is of great service. Scilla is sometimes given, combined with digitalis and mercury. Sodii Salicylas is regarded as almost specific by Fetz, given in 15 -grain doses four or five times daily, for the effusions in pleurisy. Tannicum Acidum. Dr. Duboue (in the Gazette Hebdomadaire, December, 1872,) relates the remarkably good effects which he has obtained from the use of tannic acid. The exclusive use of tannic acid in eleven grave cases of purulent pleurisy, attended with spontaneous evacuation of pus, was entirely successful in a very short time in eight cases ; the ninth case was under treatment for a long time, with only partial suc- cess ; two cases ended in death. He usually administered the tannin in pills : 270. R. Acidi tannici, gr. ij Confectionis rosae, q. o. For one pill. Four to eight daily, one-half in the morning, the remainder in tho evening. Dr. Duboue was guided, of course, by the condition of the stomach, which bore the drug remarkably well as long as there was a source of suppuration ; as also by the effects obtained, and not only the return of appetite, diminution of expectoration, sweats, etc. PNEUMONIA. THE ABORTIVE TREATMENT OF PNEUMONIA. The fact that acute pneumonia sometimes aborts spontaneously leads to the hope that this termination may be brought about by art. With this aim, various means have been used. Blood-letting, free and early, in young and vigorous subjects, es- pecially in healthy country localities, is an old and approved means. As, however, death in pneumonia often comes from exhaustion, in- stead of venesection we may apply a number of cups to the chest, and follow with hot fomentations and poultices. PNEUMONIA. I 5 I Internally, ergot has been used with marked reported success, f.oss of the fluid extract every two hours, by Dr. J. B. ScEARCE (Med. and Surg. Reporter, March, 1878,) and Dr. J. B. Yeaman (St. Louis Clin. Rec., Feb., 1878). Dr. Sidney Ringer and others speak very strongly in favor of acojiite, gtt. i-ij of the tincture of the root every half hour, for two hours, and then less frequently. It must be begun early, or its effects are inconsiderable. It has no power over the consolidated portions. That quinine aborts the disease in a certain number of cases. Dr. A. Flint says there is no doubt. He gives to an adult gr. xx-xl, either in a single dose or in two or three doses during the first day. He thinks it should always be given, as it favorably modifies when it fails to arrest the disease. (Clin. Med., 1879.) Belladonna in the first stage is spoken well of by PHILLIPS. (Mat. Med. and Therap., 1878.) Doses of r^^xv every hour or two may be given until the physiological effects on the eye and throat are pro- duced. Persistent inhalation of the steam from hot water, plain, or medi- cated with some of the above agents, is stated by Cohen to have had long repute as an abortant of pulmonary congestion in its earl- iest stages. Prof. A. B. Palmer remarks in the Trans, of the Am. Med. Asso- ciation, 1876, that for twenty years he had taught and verified in practice the fact that if a patient with the ordinary acute form of pneumonia be seen within a few hours after the attack, and a free dose of an opiate be given, and once or twice repeated, so that its full anodyne effect is produced and for some hours maintained, in a large majority of cases the progress of the disease will be arrested. After the effect of the narcotic has subsided, a mild cathartic and eliminative will complete the cure. Within a few years he had modified this treatment by combining the opiate with quinine as fol- lows : When called to a patient within twenty-four hours of the chill, he immediately gives, 271. R. Morphiae sulphatis, gr. ^-| QuiniEe sulphatis, gr. yj-x. M. For one dose. In about an hour this induces free perspiration. The quinine alone is then repeated, gr. v-x, every two or three hours, until 3ss-j 152 DISEASES OF THE RESPIRATORY SYSTEM. has been taken. No attention should be paid to the ringing in the ears, etc., as these symptoms are transitory and of no moment. The effect to be produced is the checking of the fever, and this nearly invariably occurs. If the treatment is commenced later, after con- solidation is present, the morphine must be omitted, but the quinine administered as above. The use of salicylic acid as an abortant of the disease has been recommended by Dr. L. L. SiLVERTHORN. (Chicago Med. Jour, and Exam., Feb., 1878.) He administers gr. xx. every two hours until four or five doses are taken, when free diaphoresis should fol- low, with resolution. GENERAL TREATMENT. PROFESSOR BAMSLER, OF THE UNIVERSITY OF FREIBURG, directs his efforts chiefly towards sustaining the patient's strength until the disease leaves him. The pyrexia being a chief cause of exhaustion, the endeavor is to keep down the body-heat, which he does by cold baths, wet packing and quinia in 15 to 20 gr. doses, in the evening, or grains 60 to 80 of salicylate of soda within an hour in the middle of the night. The patient's diet must receive careful attention. See to it that lie is sufficiently nourished, as by broths, beef tea, milk, and a half to a pint of light wine, in twenty-four hours. When there are pleuritic pains, an ice-bag is applied to the chest. Restlessness, great pain or diarrhcea, is to be met by morphia or Dover's powder. If bronchial catarrh is a prominent symptom, ipecacuanha in in- fusion is administered. He never employs sweet spirits of nitre in. pneumonia. M. RIEBE, OF PARIS, has tested clinically the iodide of potassium in pneumonia. He used it exclusively in thirty-seven cases, in twelve of which there was double pneumonia, while three cases were complicated with pleurisy. He administered every second hour a tablespoonful of the following solution : 272. U. Potass, iod., 5;ss Mu^e. f.Sviij. M. A bladder containing ice was placed over the region of the PNEUMONIA. 155 thorax corresponding to the affected portion of the lung. Of the- thirty-seven cases but one died, and this was a case of double pneumonia. DR. EUGENE ' GRATZER. (Therapeut. Monatshefte, 1890.) Dr. Gratzer prescribes calomel in a few large doses, each of four grains to adults, at intervals of three or four hours in the early stages; and believes that the course of the disease is ameliorated by such a procedure, and that the tem- perature is reduced. In cases further advanced he prefers to give four-grain doses of antipyrine three times daily. He also prescribes- as an expectorant the following : 273- R- Decoction of senega, f. Siiss Extract of opium, gr. iss-iv Syrup of althsea, f. 3 v. M. Dose, a teaspoonful. In young children opium and morphia are avoided and laurel water substituted. During convalescence digestion is stimulated by the following: mixture : 274. R. Dilute hydrocyanic acid, TUxv Water, f. § iv Spirit of nitrous ether, f. 3 j Syrup, sufficient to mjike f. 5 vj. M. One tablespoonful every two hours. PROF. NATHAN S. DAVIS, M. D., CHICAGO. In the treatment of active sthenic pneumonia in its first stage,, when the patient has been strong and healthy, a free bleeding from the arm (oz. 16—20) during the first day or two, followed by arterial sedatives, just enough to control circulation, united with just enough anodynes to lessen irritability and pain, constitutes the most efficient treatment. When the disease is associated with a typhoid condition of the system, as is usually the cases in cities, bleeding is not well borne.. In this class. Dr. Davis has succeeded best by giving, during the first two or three days, the two following prescriptions : 275. R. Ammonise muriatis, 3iij Antim. et. pot. tartratis, gr. ij Morphiae sulphatis, gr. iij Syrupi glycyrrhizae, i. § iv. M. A teaspoonful every four hours. 154 DISEASES OF THE RESPIRATORY SYSTEM. 276. R. Hydrarg. chloridi mitis. Ipecac, pulveris, ** S'- .^ Opii pulveris, £''• "J Sacchari albi, gr- ""'• **• For six powders. One powder every four hours alternately with the preceding pre- scription. At the same time cover the chest with emollient poultices. At the end of twenty-four hours the powders should be omitted, and if the bowels have not been moved, a mild laxative should be given ; but the muriate of ammonia mixture may be continued every three or four hours for several days. If the symptoms are not favorably modified by the third or fourth day, a blister from three to six inches square should be drawn on the side of the chest most affected. If the pulse becomes soft and frequent, the breathing ab- dominal, and the lips of a leaden hue, the following may be given with advantage between the doses of the other medicine : ^b^ 277. R. Quiniae sulphatis, gr- jj Ammoniae carbonatis, gr. iv. M. For one dose. If delirium or morbid vigilance becomes troublesome, add chloro- form, "ix-xij, to each dose of the ammonia mixture. This will generally produce sleep, or greatly improve the condition of the patient. Where a diurnal remission of the fever indicates the pres- ence of malarious influence, fair anti-periodic doses of quinine should be given during the remission. Dr. Davis reports recently (Journal of the American Medical As- sociation, 1884) two cases of pneumonia, in which certain alarming features of the disease were promptly relieved by the exhibition of ergot. He remarks, that there is no fixed or routine treatment which is adapted to all cases of pneumonia, simply because the morbid processes which constitute the different stages of pneumonic inflammation, are liable to be much modified by the previous con- dition of the patient, and the coincident meteorological and sanitary influences that surround him. The benefit to be derived from ergot is when there is a demand for more steadiness and tone to the ac- tion of the heart. Given in connection with digitalis under those circumstances, it is, perhaps, the most reliable agent we possess for resisting the over-engorgement of the pulmonary vessels, during the first stage of the disease, in which the condition of the heart referred to is found to exist. PNEUMONIA. DR. ST. PHILIP. 155 (Rev. Gen. de Clin, et de Therap., 1890.) In children St. Philip practices the following method of treatment: In the congestive stage he administers quinine. If failure of respiration exist, he sug- gests that it be given in black coffee ; where the fever is marked and the circulation excited, from one to two drops of tincture of aconite may be given every three hours ; and where the bronchitis is marked, ipecac should be employed. When the quinine is to be given hypodermatically he prescribes as follows : 278. R. QuiniK muriatis, gr. xxx Glycerinse, Aquse destillatae, aa f. 3iiss. M. Twenty minims of this solution, preferably warm, may be used as one hypodermatic dose. Where the catarrhal products induce suffocative symptoms, coun- ter-irritation in the form of mustard plasters, large blisters or wet cups, may be of service. The latter are not to be used if the patient be very young. To control nervous symptoms no opium should be used, but tepid baths administered, and cautious use of antipyrine. Inhalations of steam may be sometimes of value when the cough is troublesome. Where the case becomes serious and collapse threat- ens, quinine and caffeine hypodermatically should be relied on, sup- plemented by digitalis and alcohol. Oxygen inhalations may be of value when dyspnoea is marked, and injections of ether may be of value if sudden cardiac failure seems imminent. ALFRED L. LOOMIS, M. D., NEW YORK. This writer discards blood-letting, antimony and calomel, as well as veratrum viride and aconite, as equally useless or dangerous in nearly all cases of acute lobar pneumonia. Rest in bed, in a well- ventilated atmosphere of about 70° Fah., and abundance of liquid nutritious food, are the first steps to be taken. The pain, if severe, should be allayed by morphia subcutaneously ; the cough by small doses of opium or chloral. In severe types, with high temperature, the German system of cold compresses or baths is of temporary avail, and sometimes dan- gerous. The best antipyretic is sulphate of quinine, in doses of gr. xx-xxx per day. This lowers the temperature, shortens the febrile stage, and hastens resolution. 156 DISEASES OF THE RESPIRATORY SYSTEM. Nearly all the deaths from pneumonia result horn failure of heart power. The most serviceable remedy against this is alcohol. But it must not be used indiscriminately ; as a rule, a feeble pulse, running- 120 or 130 per minute, demands stimulants. If they act favorably, a change for the better will be noted in a few hours. The quantity must be graded to the needs ; f.5 vi-viij of brandy in twenty-four hours is about an average. Narcotics must be used cautiously and in small doses. Counter- irritants are useless and distressing. Carbonate of ammonia, so much used by some, is inferior to champagne as a diffusible stimu- lant. When oedema is detected in the unaffected portion of the lung, dry cups give marked relief. DR. HORATIO C. WOOD. (Med. News, 1 890.) In an ordinary case of pneumonia, when in the flush of the disease, after the chill has gone by, the patient in high fever, with high, bounding pulse and consolidation being marked, veratrum is indicated. It depresses and quiets the heart, and reduces the arterial pressure, sending the blood where least resistance shows. It must be recalled that the relaxed vessels of the abdomen are of such size that they are capable of holding all the blood in the body. All the blood of a man after death can be put into the ab^ dominal vessels, and they will not be over-full. When under the in- fluence of veratrum, the heart has been lowered in power, and the whole abdominal cavity has been opened wide, there is a great sucking of blood from the congested lung, and the man practically is bled — but into his own veing. The patient is depressed, but the blood is not lost, and therefore the man is not exhausted. Early in the attack the veratrum viride is indicated ; but later there comes a time in the course of the case when the lung is actually consolidated, and a large area of circulation closed off. All this is reflected back upon the right heart, and that organ becomes over-worked, dilated, im- potent. At the beginning of symptoms of- such a failure, then is the time to administer digitalis, causing the fagged organ to beat slowly, fully, with long pauses between the beats for rest — long pauses, permitting the blood to pass through the relatively choked lungs and gain the left heart. Thus' the balance is kept and the case probably saved. PNEUMONIA. 157 DR. A. T. H. WATERS, LIVERPOOL. The treatment employed by Dr. W., with a loss of only one case in forty-four, consisted mainly (apart from the occasional use of antimony, as above) oi carbotiate of ammonia, combined with chloro- form (279), chloric ether, opium, a generous, nutritious diet, beef tea, milk, etc., with a judicious use of alcoholic stimulants from an early period. Turpentine stupes, sinapisms and linseed meal poultices, were ■employed in the early stages of the disease, and blisters in the more advanced. 279. R. Ammonii carbonatis, gr. iv Spiritfls chloroformi, TTlxx Aquae camphorae, f. 3 x. M. To be given every three or four hours; may be given either with or without alco- holic stimulants. Dr. W. considers that too high a value has been placed upon mercury as a remedy in the stage of hepatization, for which it has been considered peculiarly applicable. He finds that in these cases it possesses no special properties for promoting absorption of the effused matters. As a purgative, it is very useful, as it tends to re- lieve the portal system, often overloaded in pneumonic inflamma- tion ; but if given in frequent doses, or with a view of producing salivation, its effects, save in a few exceptional cases, will be more •or less prejudicial. It was only administered in one of the above- mentioned forty-four cases, and then it in no wise hastened, in the opinion of Dr. W., the recovery. Opitim is very desirable in many cases, often relieving pain, allay- ing the distressing cough, and procuring sleep. The pain in the side which so frequently'accompanies pneumonia, and for which de- pletion was -formerly prescribed, may generally be relieved by a dose of opium. It is believed of great value in arresting the delirium so apt to supervene in this disease. On the first appearance of the in- dications of approaching delirium, e. g., want of sleep, restlessness, slight staring of the eyes, and slight tremor of the hands, a few doses of opium, and the exhibition of stimulants and nourishments, may at once arrest the attack. At the same time, all depletory measures should be avoided ; the aim should be to improve the nutrition of the brain and give vigor to the circulation, for when these results are accomplished the delirium will disappear. Few cases are now met with which are benefitted by general bleed- ing, and the abstraction of blood by cupping or leeching is not often 158 DISEASES OF THE RESPIRATORY SYSTEM, necessary, except where the right heart is engorged, as evidenced by cyanosis of the patient. The pulse afifords an excellent indication as to the need for stimu- lants. As a rule, it may be said that when the pulse is below 100 the case is not a grave one, and will yield to treatment of a simple character; but when it rises to no, 120, and upward, the case is more serious. The more frequent the pulse, the greater is the need for stimulants, and it is very remarkable to see the effect they produce on the pulse when it is abnormally frequent, in some cases of pneumonia. Intermission of the pulse is an invariable indication for the free use of stimulants. In the pneumonia of aged people, stimu- lants may be given without hesitation. DR. SHESHEMNITZOFF (St. Louis Med. and Surg. Jour., 1890) states that the combina- tion of antifebrin and camphor has given excellent results in the treatment of pneumonia, the latter correcting the depressing effects of the former. The temperature, he states, falls without rigors or collapse. DR. J. M. G. CARTER. (Med. News, 1890.) This physician outlines the following indi- cations : ( I ) To equalize the circulation and diminish determination of blood to the lungs. (2) To reduce the temperature of the body. (3) To sustain the patient's strength. (4) To assist the mucous membranes and organs of secretion and excretion in the perform- ance of their functions. (5) To allay pain. The first two indications he meets with aconite, gelsemium or digitalis, depending on the grade of fever and the condition of the lungs, heart and stomach. In high fever with strong, bounding pulse, he uses aconite, with gelsemium, if there is irritable stomach, with or without headache. He finds digitalis valuable, particularly in the asthenic type ; and sometimes substitutes convallS.ria where the former is not well borne. The writer is not favorably impressed with antipyrine or antifebrin in pneumonia, and prefers not to use them. Where there is a malarial element quinine is essential, not only as a febrifuge but as a germicide and anti-periodic. Early blis- tering with cantharides tends to relieve pain as well as assists in controlling congestion, and where there is pulmonary oedema the author relies upon blisters and digitalis. Baths or cold to the head and affected part of the chest are recognized as of value. PNEUMONIA. 159 For the difficult breathing with small rapid pulse, as often seen about the fifth day of the disease, nothing is better than camphor, benzoic acid or valerian ; alcohol in large doses is now well received. The maintenance of strength depends upon the nourishment of the case. Dr. Carter insists on early and total rest in bed, and liquid diet, full and generous from the beginning. For thirst aromatic sul- phuric acid in water is acceptable and well borne. To aid the secretory and excretory functions, ipecac is stimulant to the mucous membranes and to the liver ; aromatic sulphuric acid stimulates the pancreas, and is especially valuable when the case as- sumes the typhoid type. Digitalis and potassium nitrate are excel- lent nerve stimulants. Mercury, preferably mercury and chalk mix- ture, given for a few days and then followed by ammonium muriate, is invaluable as a hepatic stimulant. Pain must be controlled, and for this nothing can take the place of opium. Dr. Carter is in the habit of ordering: 280. R. Quinise sulphatis, gr. xxx Pulveris Dcveri, gr. xl Hydrargyri cum creta, gr. xx. M. Fiat pulvis et dividetur in capsulas No. x. One of these he gives to an adult every 4 hours. NOTES ON REMEDIES. Aconitum is a potent remedy in the early stages. Ammonii Carbonas. See above. Ammonium Iodide is highly recommended to prevent caseation of the inflam- matory products of catarrhal and fibrinous- pneumonia. To lessen the effect of this remedy on the tissue changes, arsenic should be combined with it, and every means used to support the body nutrition. Antipyrine is used widely by many as an antipyretic in pneumonia, but should be guarded on account of its depressing effects. Atropia is invaluable as a respiratory stimulant in the course of pneumonia. Camphora is recommeded by Dr. Copland, as one of the most valuable reme- dies in asthenic pneumonia, in doses of gr. ij-viij, every four, five, or six hours, combined with calomel and opium, or with antimony and henbane, according to the character of the attack ; the latter being preferred when the inflammation approaches the sthenic form, in which case the doses of the camphor may be lessened. Chloroformum, by inhalation (eight or ten drops at a time, three or four times a day,; is said to relieve the stitch in the side and palliate the cough and oppression. l6o DISEASES OF THE RESPIRATORY SYSTEM. Cinchona. See Quinise Sulphas. Cuprum. Kissel regards the salts of copper as curative in pneumonia, and the preparation which he prefers is the tincture of the acetate {Fhar. Ger.). The mortality under this treatment was only 4.3 per cent. Digiialis has been much employed of late years. M. Rony-Saucerotte re- gards it {Practitioner, March, 1869,) as one of the best means of re- lieving the febrile and other grave symptoms ; less active as an anti- pyretic than veratrum, but more easily managed and less offensive ; act- ing more slowly than leeches, but producing more durable results. JSrgot. Ergot in powder has been used successfully in croupous pneumonia by Dr. Wycesk (New Remedies, No. 2). He would not advise it, however, in large infiltrations, in emphysema, in cases of rupture of cerebral vessels, or in exhausted and decrepit individuals, as it might in such cases prove hazardous. £ther by subcutaneous injection is remarkably effective when there is an ady- namic condition. Fifteen to twenty minims should be injected three or four times a day, according to the degree of the adynamia. Mucaly-btus. When pneumonia passes \vAo pulmonary gangrene , Dr. BuCQUOY, of I'Hopital Cochin, Paris, states that no drugs have given him better results than eucalyptus globulus. He uses it in the form of an alcohol- ate — two grammes (half a drachm) daily in a mixture of water, gum, orange-flower water, and syrup. Muscarine. Bartholow considers that muscarine ought to be very useful in incipient congestion of the lungs, because it produces strong contrac- tion of the pulmonary capillaries. It ought to be especially effective when combined with digitalis, for while digitalis will aid the curative action on the pulmonary vessels, it will at the same time antagonize the cardiac depression caused by muscarine. The dose is from yi to 34 of a grain. Opium is frequently a valuable remedy in arresting delirium, relieving pain and cough, and inducing sleep. Plumbi Acetas is highly recommended in asthenic pneumonia, occurring in debihtated subjects. It may be combined with quinine (gr. j of each every two hours,) or, if the cough be very violent, opium may replace the quinine. Dr. Strohl {Journal de Medecine, February, 1882,) con- siders it to be the best of the internal remedies for pneumonia. It is preferable, he remarks, to tartar emetic, to digitalis, and to veratria, because its action is more certain, more prompt, and more free from inconveniences. Its action is incontestably superior in the pneumonia of old people. About five grains may be taken per diem in solution, in divided doses. He has never observed the slightest indication of saturnine poison in the course of this treatment. Far from produc- PNEUMONIA. l6l ing constipation, it rather occasions diarrhoea. It can be administered at all ages. It does not interfere with any of the phenomena conco- mitant to the critical resolution, as expectoration, diaphoresis, etc. Under its action the pulse rapidly diminishes in frequency ; the febrile symptoms and the temperature fall in the course of six days. The use of the lead may be intermitted as soon as the fever has abated and resolution has fairly set in. JPotassce Liquor, in doses of n|_x-xv, added to an ordinary expectorant mix- ture, is often beneficial in the advanced stages of pneumonia when the sputa are scanty, thick and viscid. ■Quinice Sulphas is of the highest value in asthenic pneumonia, and in the advanced stages of pneumonic inflammation of the old and debilitated. Under the administration of gr. v every third hour, the pulse becomes slow and steady, and the respiration free. Bartholow considers quinine an important remedy under two conditions : in large doses during congestion and in small tonic doses as a stimulant when de- pression comes on. Sanguinaria is recommended in typhoid pneumonia, when respiration is very difficult, the extremities livid, and the pulse full, soft and compressible. The dose should be large in proportion to the violence of the disease, and repeated until it excites vomiting or relieves symptoms. Senega, in decoction, is recommended by Dr. C. J. B. Williams, when the in- flammatory symptoms have subsided, and any amount of debiUty, with weak pulse, cool skin, cough, and dyspnoea, remains. Cases which have resisted other remedies, often almost immediately improve by its use, the pulse becoming slower, the breathing freer, the tongue cleaner, and the strength greater. Serpentaria is frequently prescribed as a stimulant expectorant, combined with carbonate of ammonia, in pneumonia of low grade. Strychnia is one of the most valuable respiratory and cardiac stimulants in the treatment of the asthenic type of pneumonia. It should in these cases be given hypodermically. Turpentine. This is an important remedy in acute pneumonia. Dr. R. E. Power writes in the British Medical Journal, 1876, that for many years he has adopted the following treatment with great success : First, a hot terebinthinate stupe is applied until the skin is well reddened ; then a little plain oil of turpentine sprinkled over the affected part ; finally, a blanket wrung out of boiling water, covered with a dry blanket. He has had patients delirious and gasping for breath, with sordes on the lips, fall asleep as the last blanket was applied, and awake out of dan- ger. The internal remedies subsequently used were quinine and tinc- ture of perchloride of iron. Diet : milk and water, beef-tea, lemonade ad libitum, occasionally wine. The application of the turpentine to II l62 DISEASES OF THE RESPIRATORY SYSTEM. little children must, of course, be modified to suit the age. In all cases, keep the swathe three or four days or more uninterruptedly. As a rule, the active treatment need not be pursued very long, the patient being generally out of danger in twenty-four or forty-eight hours. The sequelae of pneumonia are much modified, frequently altogether escaped. Valeriana. The ammoniated tincture, combined with camphcr, is some- times employed in the advanced stages of pneumonia, but is inferior to musk. Verairia has been employed with great advantage. It may be given in pills or in solution (if the stomach be irritable, with an effervescing draught). Prof VoGT, of Berne, commences with gr. 55, every two or three hours, until it produces vomiting or diminution of the pulse. Veratrum Viride is much employed in pneumonia. The plan recommended by Dr. Norwood, is to begin with gtt. viij of the tincture every third hour, and add one drop to each successive dose, until the pulse is suf- ficiently reduced or nausea supervenes ; the subsequent doses are then to be regulated so as to sustain the depressed state of the circulation, with as little disturbance of the stomach as possible, any excess of nausea being controlled by a little morphia. With the reduction of the pulse the inflammatory symptoms decline, and convalescence ensues. Many physicsans have reported very favorably upon this remedy ; but for all that, its propriety is doubtful. EXTERNAL REMEDIES. Baths. On the theory that the danger in pneumonia arises from enfeeble- ment of the heart. Dr. T. Juroensen, of Kiel, has advocated the with- drawal of heat from the body by cold baths, as often as the tempera- ture reaches 104°. The duration of the bath ought to be from seven to twenty- five minutes, and with the old and weak, tepid water may be used. Before the use of the bath, a stimulant ought always to be ad- ministered, on account of the increased effort which the bath entails on the heart for the time being. In addition to the lowering of the temperature by the bath, Jurgensen recommends the administration of quinia in doses amounting to thirty grains, dissolved in water by the aid of acid. This quantity to be administered every second evening, between six and eight o'clock. There is no danger, he says, in even doubling this dose. He gives a nutritious diet, with a moderate amount of wine. The wet pack is also highly recommended. As a rule, a hot wet pack gives more relief than a cold one, but the feelings of the patient are a proper guide. When the organs within the chest are in- flamed, it is good practice to wrap the whole chest tightly in a pack to limit the motion of the chest walls. The method of proceeding is as follows : Wring out in cold or hot water a large towel, fold it and place PNEUMONIA. 163 over the affected side or part ; have in readiness a bandage or large towel sufficient to encircle the chest, and confine the wet pack by pin- ning as tightly as possible around the chest the bandage or towel. Spongio-pihne is an excellent material for making these hot or cold ap- plications. Blisters are not beneficial in the early, but may be useful in the advanced stages of pneumonia. Lukewarm Baths. Dr. Bozzolo has tried warm instead of cold baths {Lond. Med. Record, 1884). He believes that they exert a decidedly bene- ficial effect. They are of one to three hours' duration. Counter-irritants may be employed in the early stages of the disease. The principal applications employed are tartar-emetic ointment ; croton- oil ; tincture of iodine ; turpentine stupes. Poultices are especially useful in the- early stages of the inflammation. Flax- seed poultices, made so as to envelop the whole chest, give great re- lief, and exercise a salutary influence on the inflammatory action. Venesection. In regard to bleeding, in pneumonia, we may quote the opinions of three good authorities. Dr. Samuel Wiiks, F. R. S., says: "In great engorgement of the lungs or of the right side of the heart, bleed- ing will afford relief," and should be practised. {Guy's Hospital Re- ports, 1874.) Dr. A. L. LooMiS also says : "There is one condition in which a patient with pneumonia may be bled to advantage, and that is when there is evidence that the heart is engorged with blood, accom- panied by the evidences of sudden pulmonary congestion and oedema." In his Clinical Lectures (p. 280), Dr. N. S. Davis, of Chicago, says : " Bleeding and direct sedatives must be limited to the first three days of the disease. That a prompt and free bleeding in the first or conges- tive stage of active pneumonia, followed judiciously by sedatives and ancdynes, is capable of greatly lessening the tendency to exudation, and favorably modifying the whole subsequent tendency of the disease, even to the extent of materially shortening its duration, I have no doubt. I have seen it demonstrated so frequently, that to doubt is to distrust the evidence of my senses." These remarks of Dr. Davis are not intended by him to apply to pneumonia as seen in cities or malar- ious districts, where it neaily always partakes of an asthenic character. PART II DISEASES OF THE CIRCULATORY SYSTEM. General Therapeutics of Heart Disease — Aneurism — Angina Pectoris — Cardiac Dilatation — Cardiac Hypertrophy — Carditis — Fatty De- ge7ieration of the Heart — Functio7ial Palpitation and other Derange- ments — Irritable Heart — Valvular Disease of the Heart. GENERAL THERAPEUTICS OF HEART DISEASE. PROF. GAUTHIER. {Wiener Med. Blatter, 1890. — Therap. Gazette, 1890.) As med- ical knowledge has advanced in the treatment of cardiac disease, new remedies have been added to the already recognized list of cardiac tonics, and advances in the manner of administration of older med- icaments have been prosecuted. As is well-known, digitalis in form of pill or powder is apt to pro- duce vomiting or diarrhoea ; and it has been found that the best form of administering the remedy is by infusion made by macerating the leaves of the digitalis plant. This preparation is the one producing the most prolonged and intense action of the heart, and is the one most productive of diuresis. It should be given in gradually de- scending doses. The author does not regard digitalin as a constant preparation ; but where a very rapid action is demanded, it may be employed. Ordinarily, however, its action is too intense, and its subcutaneous administration is apt to be painful and to produce ab- scesses. Convallaria is also best given in form of an infusion, 8 to 10 parts being macerated in i,ooo parts of water; it should be given freshly prepared to obtain the best results. Strophanthus is best given in the form of tincture in doses of five .drops thrice daily, although ten to twenty drops may be given once or twice in twenty-four hours in a single dose. Adonis may be given in form of infusion or decoction, but both these preparations are apt to be inconstant in activity : they are both (i64> GENERAL THERAPEUTICS OF HEART DIStASE. 165 very bitter and must be masked with some syrup. Adonidine, the active principle of the drug, may be given in from ^ grain to j^ grain in twenty-four hours ; its toxic power is ten times greater than that of digitalis. Caffeine is a reliable remedy when given in sufficient dose, 15 to 30 grains being usually required ; but this dose should not be ex- ceeded without great care, as in large doses the remedy is apt to manifest toxic action. Sparteine may be used either in the form of infusion or decoction ; or its active principle in the form of sulphate of sparteine may be employed in doses of ^ to four grains. The latter is especially val- uable for its tonic action upon the heart ; the decoction has in ad- dition valuable diuretic properties. PROF. GERMAIN SEE, OF PARIS. In the last edition of his Clinical Lectures, (Paris, 1883,) this dis- tinguished teacher sums up the principles he adopts in treating car- diac disease as follows : In cardiac dyspnoea he prescribes belladonna, datura, jusquiamine, which paralyze the nerves of the heart; anaesthetics and oxygen in inhalations, which cause congestion of the lungs ; venesection, which weakens the heart. The application of sinapisms, cups, and blisters, is useful when not harmful. He advises iodide of potash. With the iodide he also sometimes gives digitalis, convallaria, or chloral hydrate. For the paroxysms, he gives inhalations of the iodide of ethyl, injections of morphine, and extract of convallaria daily, dry cups, sometimes inhalations of chlo- roform. In uraemic dyspnoea, the preceding treatment cannot be counted on. In the dyspnoea of haemoptysis, he advises 5j of the aqueous ex- tract of ergot in twenty-four hours, with gr. j of the extract of opium ; simultaneously, turpentine in capsules, and perhaps digitalis, which by strengthening the heart prevents stasis of the blood. In cardiac dropsies he gives diuretics (milk 3-4 quarts, or con- vallaria) and non-emetic purgatives. Opium and belladonna are prescribed, as they check intestinal and renal secretion. Diaphoretics as (jaborandi) can be given with milk and the dras- tics. 1 66 DISEASES OF THE CIRCULATORY SYSTEM. When the cardio-nephritic dropsy accompanies the uraemic dysp- noea, he thinks the subcutaneous use of morphine dangerous. In such cases, iodide of potash should be added to milk diet and digi- talis ; and, if the dropsy persists, recourse should be had to scarifi- cations. Cardiac irregularity he treats by digitalis, convallaria, bromides and chloral. In intermission he prohibits tea, coffee, alcohol, to- bacco ; and prefers convallaria to digitalis. In palpitation from hypertrophy, he prefers iodide of potash; in anaemic palpitations from spermatorrhoea, he rejects iron, douches, bromides and anti-spasmodics, and prescribes iodide of potash twice a day, with meals ; a pill of aqueous extract of ergot gr. j, alcoholic extract of digitalis gr. ^, three times a day; a farinaceous diet, with fat meat and fish ; astringent red wines ; no mineral waters, beer, milk, coffee nor tea ; tepid baths every morning ; intellectual work and moderate physical exercise; absolute continence in sexual matters. In chlorosis, iron is generally successful, if aided by hydrotherapy and a hearty diet. Hysterical palpitations he treats with digitalis, bromides, vera- trine and hydrotherapy. General contra-indications to the treatment of diseases of the heart are hydrotherapy, mineral waters, ordinary and mineral baths, venesection, cauterization and blistering, iron and tonics (quinine). General hygienic prescriptions are: A climate of medium and uniform temperature, rather moist, and with little wind. Mountain air suits some, sea air others, but more choose the temperate cli- mate of valleys and plains, protected against winds. No severe or prolonged exercise (hunting, gymnastics, fencing), no climbing, no excessive study. The diet should be " anti-obesique " and nitro- • genous — soup, fresh vegetables, lean meat, cheese, fruit, milk, eau rougie, beer ; coffee, if no palpitations are present ; no heavy wines, liquor, white wine, tea, aerated and mineral waters. DR. J. M. PATTON, OF CHICAGO. (Medical News, 1890.) This physician, writing on the subject of cardiac arythmia, as it is occasioned by disease of the kidneys and vessels, states the importance of determining how much of the ataxia is due to a hyposystolic condition of the organ, and how much to an increased demand for work. If actual muscular failure GENERAL THERAPEUTICS OF HEART DISEASE. 167 of the heart is not concerned in the irregularity, heart tonics are apt to do harm if administered. For arythmia due to disease of the kidneys and vessels, the necessity is not to force the heart to work harder, but to give it less work to do. This end is gained by in- creasing the function of the kidneys, and by lessening the tension of the arteries by dilating them. This dilatation of the vessels attains two objects : by furnishing a larger channel it diminishes the work of the heart, and thus allows the vis a tergo of the heart to reach the kidney circulation and diuresis is increased, with consequent elim- ination of materials which if retained might cause irritation of the vascular walls directly, or reach them through nervous influences, to the production of a contraction and increased tension. Of the medicines used to produce vascular dilatation, opium has been most serviceable to Dr. Patton ; nitrite of amyl, trinitro- glycerine, chloral hydrate, etc., being too transient in their effects. This latter class of drugs finds its value in urgent cases, but is not of much value for prolonged use. The writer finds Husband's magnesia particularly useful in antagonizing the constipating, ten- dency of opium when the latter is used. As a diuretic he values especially a combination of nitrate of potassium and buchu. DR. S. O. HABERSHON, LONDON. This physician lays down seven rules of treatment applicable in all cases of heart disease. (Guy's Hospital Reports, 1887.) The first is to lessen the work of the heart ; this may be done by mechanical rest, by the recumbent position, and by avoiding stim- ulants and sudden changes of temperature. The second is to insure regularity of action, by avoiding mental ex- citement, by guarding against indigestion, and by never allowing constipation to continue. The third is to lessen distension, especially of the right side of the heart, by purgatives, diuretics, and by mechanically diminishing the quantity of fluid in circulation. The fotirth is the prevention of syncope. With this view, sudden muscular movements must be avoided ; stimulants may be required, as ammonia, brandy, etc. ; and sedatives must be withheld or cau- tiously administered. The fifth is to strengthen the muscular fibres of the heart by suit- able nourishment; a bracing air, if other conditions allow ; chaly- beate medicines ; and if the patient be exhausted by want of sleep, this symptom must, if possible, be relieved. l6S DISEASES OF THE CIRCULATORY SYSTEM. The sixth is to prevent fibrination of the blood. For this purpose, carbonate of ammonia will often be useful ; other alkalies, as potash, soda, and other salts, may be beneficial ; but, if long continued, in considerable doses, they depress the action of the heart. The acetate and iodide of potash may be advantageously combined with the carbonate of ammonia, or perhaps the hydrochlorate of am- monia. The seventh is to prevent secondary complications, and to relieve them when produced. These complications are ; i. Broncho-pneu- monia and pleuritic effusion. 2. Pulmonary apoplexy and other hemorrhages. 3. Visceral engorgement, as hepatic and renal con- gestions, with ascites and anasarca. By freely acting on the bowels, the portal congestion is greatly diminished, and the liver is enabled to act in a normal manner. Thus a free mercurial purge is of great value. The kidneys may be excited to a more vigorous action by a combination of mercurial medicine, and with squill and digitalis, when the latter can be borne. Salivation should be avoided. Diuretics are useful. An effectual way of diminishing the anascara is by puncturing the skin on the thighs. The pulmonary engorgement is sometimes greatly reduced by applying cupping-glasses between the shoulders, or by the application of a blister to the chest. J. MILNER FOTHERGILL, LONDON. Treatment of Primary Heart Disease. It is of the utmost import- ance, in primary disease of the heart, to reduce to a minimum the calls upon its action. Rest in bed is desirable, and light labor alone must be attempted. The tendency usually is for the veins to be- come too full of blood, while the arteries remain insufficiently filled. Much relief is afforded by unloading this venous congestion. Brisk catharsis, say pulv. jalapae comp. 3ij, at frequent intervals, does much good. Diaphoresis is also valuable. The form of diaphoretic best adapted to heart cases, is the application of heat externally. The bath, however., should not include the head, hence Turkish baths are objectionable. In the attacks of dyspncea, so common in diseases of the heart, large, hot poultices of linseed meal, faced with mustard, and applied over the front of the chest and between the shoulders, are most serviceable. Of all drugs in cardiac adynamy, digitalis takes the lead. Its cumulative action has been greatly ex- aggerated, if it exists at all. The continuous use of small doses is the best plan of treating chronic cases. In cardiac dropsy, full GENERAL THERAPEUTICS OF HEART DISEASE. 169 doses must be given. Its effects are most gratifying when it pro- duces a full flow of urine. In simple cardiac debility the following is a pleasant combination : 281. R. Tinct. digitalis, TUx Spiritds Eetheris nitrosi, f. 5 ss Infusi buchu, f-Sj- M. This amount thrice daily. At Other times potash in any of its forms, but especially the citrate, may be added to the mixture. Where atonic gout is combined with the disease, the following is constantly used by Dr. F. : 282. R. Potassii bicarb., gr. x Fer. et pot. tart., gr. v Tinct. digitalis, Tl\x Infusi buchu, f. § j. M. This amount thrice daily, to be followed by a good draught of water, and taken half an hour before meals. Where there is palpitation, acute anaemia and debility, the follow- ing may be given : 283. R. Tinct. digitalis, TUx Ferri ammonio-citratis, gr. v Ammonias carbonatis, gr. v. M. This amount three or four times daily. In the complex condition of cardiac debility, gastric catarrh, co- pious eructations of wind, and inactivity of the bowels, so commonly found together in chronic heart disease, digitalis may best be given in pill, as in this combination : 284. R. Pulv. digitalis, gr. xxx Ferri sulph. exsic, gr. xv Pulv. capsici, gr. xl Pulv. aloes et myrrhse, S ij. M. Make sixty pills. One twice daily. In advanced dropsy, poulticing the abdomen and thighs with digitalis leaves has been found to produce excellent results. TREATMENT OF SECONDARY AFFECTIONS OF THE HEART. High arterial tension is usually the result of continued hyper- trophy, lithiasis (suppressed gout), and spasm of the arterioles. In lithiasis the various natural waters which contain potash are very valuable. When drugs are prescribed, it is a matter of first import- ance that each dose be accompanied by large draughts of water ; lyo DISEASES OF THE CIRCULATORY SYSTEM. this makes them much more effective. A good form of mixture is furnished by the following combination: 285. R. Potassii iodidi, S"'- ^ Potassii bicarbonatis, ^"l^^ n, Infusi buchu, f- OJ- M. This amount, three or four times a day on an empty stomach, washed down with a tumblerful of water. If the pulse be strong and hard, and the first sound of the heart good, then vini colchici, gtt. x, may be added to the above with ad- vantage. If the opposite condition of the heart exist, with a com- pressible pulse and dilatation, then instead of the colchicum, tinct. digitalis, rr^x, may be added. This will maintain the vigor of the heart under the depressing action of the alkalies. DR. THOMAS KING CHAMBERS, LONDON. Dietetics in Heart-Disease. Dr. CHAMBERS points out (A Manual cf Diet in Health and Disease) the fact that in disease of the heart the most remarkable change in respect to digestion is the slowness with which liquids are absorbed by the stomach, owing to the weak- ening of the circulation. The fluid in excess remains in the viscus and impedes digestion. The observation of a dry diet contributes greatly to the comfort of the patient, and more particularly so where dilatation of the heart's walls exists, and where, therefore, distension of the stomach would interfere with the laborious action of the heart ; also, in cases of cardiac disease complicated with obesity. The dietary should be at least as nitrogenous as in health. There is danger of atrophic degeneration of the cardiac muscle, which must be guarded against by generous diet. Alcohol should be used either not at all, or only in sufficient quantity to facilitate the assimilation of food ; as soon as it diminishes assimilation, it is injurious. Indeed, we may say that alcohol is rather indicated during the times of acute failure than as a permanent part of the dietary of heart affections. The use of tea and tobacco, both of which are narcotic poisons when taken in quantities, must be rigidly restricted. Climate in Heart Disease. Dr. CHAMBERS points out that in England degenerative heart disease is the rule and acute the excep- tion ; while in Italy, degenerative disease is the exception and acute disease the rule. Aneurism is almost unknown in Italy. The severe winters of the north of Europe and the northern United States are particularly trying on patients with heart disease. A low tempera- GENERAL THERAPEUTICS OF HEART DISEASE. 171 ture, by contracting the capillaries, raises the blood pressure, and makes additional demands on the weakened heart. The diminished pressure of the atmosphere in elevated regions, as of our western plains, leads to excitability and hypertrophy of the heart. As a rule, cardiac diseases are less common and less fatal near the sea, where the extremes of temperature are less marked, and the atmos- pheric pressure the greatest. These considerations offer suggestions for the proper climatic treatment of cardiac affections. DR. T. CLIFFORD ALLBUT, M. A., F. L. S., ETC., LONDON. To subdue the distress in nervousness, the dyspnoea, the pain and night terrors of advanced heart disease, this writer urges (in the Practitioner, December, 1 869,) the value of the Prunus Virginiana, and especially the hypodermic use 0/ morphia. He justly says there is scarcely any disease more distressing than the latter stages of these maladies, when the patient, with a clear head, but with gasping breath, a striving heart, and swollen limbs, hardly finds a moment's rest from torment. Opium cannot be given, on account of its effect on the kidneys. His experience convinces him of the utility of the wild cherry in many of the milder cases of cardiac distress, and in such, he urges its claim warmly; but it is impotent in the more severe forrns. Here he employs morphia, hypodermatically, espec- ially in angina with diseased coronary arteries, in neuralgic distress from intra-thoracic tumors, in mitral regurgitation, and in aortic dis- ease, where the heart is big and pumping. He uses the hydrochlorate of morphia in doses varying from one- tenth to one-third of a grain ; seldom half a grain, except in such a case as intense pain from angina or intra-thoracic tumor. He always begins, with one-eighth or one-sixth ; and in ordinary cases, he finds a quarter of a grain the proper dose — in a case, say, of mitral regurgitation with pulmonary congestion in an otherwise healthy adult. The dose is best given in the evening, and should always be followed by perfect quiet in the room. The last is an important element in all cases of injection of morphia. The urine should be examined and the drug withheld, or given with caution, if albumen be found. There need be no great fear of it during albuminuria only secondary to the heart disease, unless there be reason to sup- pose that excessive renal congestion be present, and head symptoms at hand. He scarcely ever remembers that morphia caused dis- turbance of the stomach or other inconvenience. As in cases of 172 DISEASES OF THE CIRCULATORY SYSTEM. severe pain, so it seems that in cardiac disturbance, the intolerable distress " carries off" the troublesome qualities of the drug. Its effects, again, are not merely comforting, but are curative so far as such cases are to be cured. An injection of morphia three or four times a week, by tranquilizing the heart and allowing the circulation to recover its freedom, sets free, also, the organs which are op- pressed, and the system can once more find something like its balance. Thus relieved, the patient may, with incessant care, enjoy some respite from his malady, and the occasional use of morphia may put off the day of its return. DR. LAYCOCK, DUBLIN. 286. R. Potassii iodidi, gr. ▼ Potassii bromidi, gr. xv. M. For one dose; to be taken at night. In the distressing dyspncea of heart disease, Dr. L. has found the above combination superior to any other, believing it to be both palliative and curative. Of opiates, he prefers the hypodermic use of morphia, or else ten to fifteen minims of the solution of the bimeconate of morphia by the mouth ; although he is satisfied that in any form opium tends to increase the albuminuria and dropsy which accompany cardiac lesions. Should the gastric vagus be im- plicated, hydrocyanic acid is the most efficacious remedy. (Dublin Medical Journal, December, 1873.) PROF. HUCHARD. (St. Louis Med. and Surg. Jour., 1888.) In cardiac failure, from muscular weakness due to degeneration and dilatation, where a heart tonic is demanded, this writer warmly commends caffeine, re- garding it as superior to digitalis. He employs the following pre- scriptions : 287. R. Sodii benzoatis, Cattemse, ^ g^^ ^tvi Aqiise destillatae, f. Siv. M. Sig : Tablespoonful from two to six times daily. Or: 288. R. Sodii benzoatis, Caffeiiiae, aji „ j^ • Syrupi et aqua gg adf.giv. M. Sig: Dose as above. GENERAL THERAPEUTICS OF HEART DISEASE. 173 Or, for hypodermic use : 289. R. Sodii salicylatis, gr. xIt Caffeince, gr. Ix Aquae destillatce callientis, t3ij. M. Sig : Five or ten minims several times daily. The author also recommends the following wine of caffeine : 290. R. Sodium benzoate. Caffeine, aa 5 parts. Malaga wine, 500 parts. Dose : A wineglassful occasionally. The writer regards caffeine particularly useful in these combina- tions in cases of weak heart, in old age for example, where there occurs an adynamic disease, as the pneumonia of old age. DR. C. M. DURRANT, LONDON. Hygienic Rules in Incurable Heart Disease. The first rule to im- press upon patients, says this writer, (British Medical Journal, Feb., 1875), is the careful avoidance of sudden, htirried or violent mo- tion. Rapid walking, lifting weights, prolonged traveling, must be shunned. The second rule, and one not to be neglected without great risk, is the avoidance of partaking at any one time of a large, distending meal. The sudden death of heart disease is very apt to come shortly after or during a hearty meal. The food, therefore, should be easily assimilable, and taken in small quantities at frequent in- tervals. The third rule is to avoid taking much liquid, especially cold liquids. By exciting nerve irritation, they produce cardiac syncope and sudden death. Lastly, a patient, laboring under serious heart disease, should, as a rule, be absolutely forbidden to indulge in sexual intercourse. DR. BEVERLY ROBINSON. Blisters in Chronic Heart Disease. Dr. BEVERLY ROBINSON re- cently told the Practitioners' Society of New York, (Med. Record, December 22, 1883,) that he had been using blisters over the heart in certain cases of chronic cardiac disease, with enfeebled action and accompanying dyspnoea. They were cases where the ordinary methods failed to give relief. The blistering seemed to strengthen the heart's action. 174 I/ISEASES OF THE CIRCULATORY SYSTEM. The Use of Thermal Baths. There is in Germany a summer resort by the name of Bad-Nauheim, to which for now almost a century thousands of patients, suffering from organic diseases of the heart, have been sent by their physicians. For many years this was done, simply because the experience of many had proven that all such cases vastly improved. Of late, especially by the laborious re- searches of Benedict, of Vienna, the causes inducing such beneficial changes in diseases which, especially in their last stages, are usually very little amenable to treatment, have been scientifically investi- gated. It has been demonstrated that it is the carbonic acid in these waters and the temperature of the latter (70-80°) which exerts such a wholesome influence. With the spirometer, as well as with Waerenburg's pneumatic apparatus, it has been found that the capacity of the lungs to inhale and exhale air greatly increases by the use of these baths, and that they also have a similar tonic effect upon the main organ of circulation, as we know of digitalis that it possesses. Venous stasis in any form, if induced by organic affection of the heart, and, therefore, also dropsies, usually disappear without any other treatment within two weeks after beginning of the cure. That this is not brought about by increased diaphoretic or diuretic func- tions, but in reality by giving the heart greater tone, has been proven by experiments and observations carefully made, beyond a doubt. THE NEW REMEDIES. Adonis Vernalis has been proposed as a. substitute for digitalis as a cardiac stimulant. It is, however, quite uncertain in its action, according to the bulk of evidence. It may be given in the form of adonidine (gr. ?ii) or as an infusion, one to two tablespoonfuls. It is to be used where a slight but prolonged diuresis is of value — diuresis not appearing for several days after the beginning of treat- ment. Adonidine is not so diuretic as the infusion. Strophanthus has been earnestly advocated as a substitute for dig- italis, particularly as it is asserted to have no cumulative effect. This latter statement is, however, not accepted by many. It is at least an excellent substitute where a substitute is necessary for the latter drug. It may be given in doses of gr. % of the extract; or ten or fifteen drops of the tincture ; or in gr. 5^ of the powdered geeds. It is said to be much superior to adonis, spartein and the other recent cardiac tonics. GENERAL THERAPEUTICS OF HEART DISEASE. 175 Caffein in doses of gr. iv to gr. xx has been found of much bene- fit in the cardiac dropsies, having particularly a marked diuretic ac- tion. It is said also to be of value in case of fatty heart where digi- talis does not act or is contraindicated. Convallaria Majalis may be given in doses of fifteen or twenty drops every three or four hours as a substitute for digitalis. It is not as strong as digitalis or strophanthus, and is said to be uncer- tain in its activities. Coronilla Scorpioides is a remedy introduced recently as a cardiac tonic, by Cardot. It is said to act particularly in the heart muscle ; but its dosage is very uncertain, poisonous effects having been ob- served from gr. ^, while three to five grains have been administered without evil results. Spartein sulphate, in the experience of ElCHHORST, has only a weak and unimportant action on the heart and no effect on the renal functions. Nitroglycerine is reported by FUSSKLL (Med. and Surg. Reporter, 1888) to be of great value in cardiac failure with pulmonary cedema, given hypodermatically, one drop of a one per cent, solution. It is given by the mouth in doses of one or two or more drops of a simi- lar solution, as a cardiac tonic. ANEURISM. In the medicinal treatment of aneurism there have been no great advances for a number of years, and the subject of its therapeutics is under considerable discussion. The desideratum is the formation of dense clots in the interior of the aneurismal sac, and the subse- quent organization of these clots — either this, or the strengthening of the wall by actual tissue formation. This latter would seem the ideal method, the contraction of the newly-formed connective tissue theoretically leading to a diminution in the calibre of the sac. The most important treatment of aneurism is surgical, and varies consid- erably with the position of the tumor. If it be located in one of the peripheral arteries, as in the popliteal region, its excision may be considered ; or its reduction by the application of a constant, pro- longed, intelligent pressure, by means of an attendant's hand, or thumb, may be possible. Otherwise, the surgical as well as the medical efforts have the same aim, the coagulation of the blood on the sac walls, and the organization of the coagula. The treatment is rarely really fully accomplished, so far as the desired results are concerned. 176 DISEASES OF THE CIRCULATORY SYSTEM. PROF. BALFOUR. {Brit. Med. Jour., 1887.) With quite a large number of other practitioners, this writer practically bases all his medical endeavors upon the use of the iodides. He places the patient in bed for three or four days, in order to have the heart settle down to its regular rate, and takes this as a standard. He then gives ten grains of iodide of potassium or sodium daily, gradually increasing the dose, but at once diminishing it if the heart rate becomes more rapid. When he has found the full dose which the patient is able to take without in- ducing tachycardia at all, that dose is prescribed for from three to six months. He does not consider that it is necessary to starve the patient meanwhile, as has been suggested by some writers, but be- lieves that the action of the iodide is sufficient. Jaccoud has com- bined with the iodide, bromide. When good effects are being pro- duced, the pains gradually become less, the vertiginous attacks dis- appear, the tumor grows firmer and smaller, and the pulsations cease. Other methods, as galvano-puncture, introduction of wire into the sac, have been proposed with the idea of inducing thrombosis ; but the results thus far have been decidedly unpromising. ANGINA PECTORIS. DR. M. HUCHARD, OF PARIS. The treatment of this writer (Revue de Medicine, 1883) is preven- tive and immediate, and constitutional. To prevent attacks, he advises strict hygienic treatment : to lead a quiet life in a dry at- mosphere ; avoid climbing, and any fatiguing physical exercise ; dispense with exciting foods ; have many meals a day to avoid over- filUng the stomach; an occasional period of milk-diet; abstinence from strong and spirituous liquors, moderation with tea and coffee ; no tobacco, no sexual excesses, no fatigue of any sort, and no ex- tensive movements of the left arm, which provoke attacks in some patients. He relies, for the immediate treatment of the attack, on inhala- tions of amy I nitrite; and, second, hypodermic injections of mor- phine. He says treatment by chloral, electricity or metallo-therapy is unwarrantable, because of their slowness and unreliability. ANGINA PECTORIS. 1 77 When syncope seems imminent, he advises the use of diffusible stimulants — Hoffman's anodyne, ether, ammonia, caffeine, punctate cauterization, hot applications, and perhaps the faradic brush. He thinks amyl nitrite acts by stimulating the intra-myocardic circulation, by producing relaxation-of the spasm which obliterates the coronary arteries. It dilates the peripheral arteries, and in- creases the strength and working-power of the heart. For the constitutional treatment of the disease, he places the great- est reliance on the continued administration of the iodide of sodium. While not pretending to know the modus operandi of the drug in these cases, he is inclined to think with Brown-SeQUARD that it re- lieves by improving the nutrition of the nervous centres, as good nutrition lessens their reflex excitability. He uses sodium iodide in preference to the potassium salt, because the potassium seems to him to exercise a distinct toxic effect on the system in a low grade, which he escapes by using the sodium salt of iodine. He believes that the condition is absolutely curable by means of the iodide alternating with nitro-glycerine. He gives three grains of the iodide ■daily for fifteen days, following it by from two to twelve drops of a I per cent, solution of nitro-glycerine for the same period, continuing these alternations for one, two or three years. He prohibits the use of digitalis, ergot, and whatever tends like these to increase arterial tension, as well as antipyrine and cocaine, which are liable to pro- duce a collapse. PROF. BOCQUILLON. (Medical News, 1891.) Nitro-glycerine has been largely used, especially in France, in the treatment of angina pectoris. HUCHARD, POTAIN and^HERARD regard the drug as a vaso-dilator, resembling in its actions amyl nitrite very much. BOCQUILLON uses it as follows: 291. R. Alcoholic solution of nitro-glycerine (i per cent.), gtt. xxx Distilled water, f. § x. M. Two teaspoonfuls morning, noon and night. For subcutaneous injection he uses the following solution : 292. B. Alcoholic solution of nitro-glycerine (l per cent.), gtt. xxx Cherry-laurel water, i- § iij- **. Twenty minims, given hypodermically. DR. ALFRED L. LOOMIS, NEW YORK. This author states that the only remedies he has found of service 12 178 DISEASES OF THE CIRCULATORY SYSTEM, in delaying and rendering less severe the paroxysms of this disease are iron, strychnine and arsenic, administered daily in small doses. During the paroxysm, rest and free administration of digitalis are of the greatest service. He adds that opiates, chloroform and nitrite of amyl should not be used. DR. T. H. TANNER, LONDON. This author has found the following mixture exceedingly valuable in angina: 293. R. Spiritfls setheris compositi, f. 3 j Liquoris opii sedativi (Battey) gtt. x Misturse campborse, f. Sss. M. This amount as required. (Battey's sedative solution of opium is a secret preparation much used in England ; said to be made as follows : 294. R- Extracti opii (hard), § iij Aquae dest. bul., f. § iij. Dissolve and filter. When cold, add Spirit, vini rect., f- S ^ Aqux q. s. to make Oij. The above are English imperial measures. The dose is half that. of laudanum.) The patient should keep the above medicine by him, in order that it may be taken on the least threatening of an attack. A belladonna plaster worn constantly over the praecordial region may do good. The return of the seizure is to be guarded against by improving the general health, by great attention to diet, and by the avoidance of stimulants, strong exercise, and all mental excitement. DR. F. W. MOINET, SCOTLAND. During the paroxysm of angina, the treatment most efficacious in relieving the symptoms is that by diffusible stimulants and opium, hot brandy and water, sinapisms to the feet, and placing the hands in hot water. Galvanism, carefully and at first gently applied, is of service even in organic angina, by giving tone and stimulus to the heart's muscular fibre. When the circulation is languid and stag- nant, bleeding is called for. Nitrite of amyl is occasionally useful. (^Edinburgh Medical Journal, Feb., 1871.) DR. HENRY HARTSHORNE, PHILADELPHIA. Mustard plasters should be applied between the shoulders and ANGINA PECTORIS. 1 79 over the chest, and the patient's feet placed in a warm foot-bath. Stimulants and anodynes are indicated, as 295. B. Sodii bicarbonatis, 9iv Spts. ammon. aromat.. f.5i Spts. setheris compos., f-ij Tinct. cardamom, comp., f.Siij Aquse camphorje. Mucilag. acaciae. aa f.3x. A dessert or tablespoonful at a dose. 296. Bi. Tinct. rhei et sennse, f.Sissl Syrupi zingiberis. f.Siij Tinct. opii, f.3j. A teaspoonful in hot water. 297. R. Chloroformi, Spts. ammon. aromat.. aa f.3ij Spts. setheris compos.. Tinct. opii camphor., Mucilag. acacise. ia f.iss. A teaspoonful at a dose. DR. G. W. BALFOUR. M. M. In the treatment of angina pectoris. Dr. BALFOUR relies chiefly on the inhalation oi chloroform ; it not only relieves pain, but regulates the circulation. He has also a very high opinion of arsenic, stating that in all forms of cardiac angina it acts almost as a specific, and is a special tonic to the cardiac muscle. It has this effect even in very small doses. The preparation he uses is the liquor arscnicalis. (On Diseases of the Heart and Aorta, London, 1876.) PROFESSOR G. SEE, PARIS. M. See has no faith in nitrite of amyl, chloroform or belladonna, in this disease. Electricity is dangerous. During the paroxysm he repeats twice or three times hypodermic injections of morphia in full strength, following it immediately by an enema of chloral hydrate, gr. XXX— xlv, aquae, f..^v. Sometimes acetate of ammonia, which is an energetic cardiac stimulant, will be found greatly to facilitate res- piration. After the attack the morphia should be used daily for a few days to prevent a recurrence ; and as a prophylactic treatment, the only one of much value is the frequent use of bromide of potassium and digitalis, so as to regulate the circulation. (Gazette des Hdpi- taux, June, 1876.) He recommends antipyrin (Jour, de Med. et de Chir., 1887) for the pain of angina, and for the relief of the pain in aortic insufficiency as well. l8o DISEASES OF THE CIRCULATORY SYSTEM. DR. T. L. BRUNTON, LONDON. On the other hand, Dr. BRUNTON (British Medical Journal, July 13, 1872), highly extols the amyl nitrite, and in the same journal (November 28, 1874) and elsewhere, instances of its great value are given. About two or three drops, used by inhalation, are generally sufficient to afford relief. Fatty degeneration contraindicates it. DR. A. MUHLBERGER, OF HERRENALT, believes that in concussion we have an excellent means of keeping in check the violence and duration of the sterno-cardiac attacks. He further notes that kneading and rubbing have long been tried and approved as remedies against muscular cramp, and that as an- gina pectoris is nothing more or less than cramp of the cardiac muscle, it seemed to him likely a similar result would be obtained in parallel cases by the like means. He finally sounds a note of not unheeded warning in the Deutsch. Med. Zeitimg, against the too bold use of remedies in this affection, and we may add in others also, and recalls the case of an elderly medical man who was relieved of his angina only to die of the mor- phia that procured the relief. DR. LOWENFELD relates a case of angina pectoris, in which galvanization proved bene- ficial. The patient, a man aged forty-seven, was subject to attacks of the disease occurring every month or two. These were character- ized by exciteid respiration, oppression, small, frequent pulse, sternal pain radiating to the left arm, and convulsive tremors of the limbs, and lasted about one hour. The heart was normal. The constant current was applied for one minute to each side of the neck, along the course of the pneumogastric. The sense of oppression was im- mediately relieved. Ten such applications in the course of three weeks were followed by complete freedom from the attacks for more than two years. DR. J. MILNER FOTHERGILL. 293. R. Spirit of chloroform, f. 3vj Tincture of digitalis, f. 3ij Fluid extract of buchu, Compound spirit of juniper, ia f. §iss. Sig: — Dessertspoonful thrice daily. ANGINA PECTORIS. l8i DR. N. GALLOIS, PARIS. 299- R. Tincturae digitalis, Tincture belladonnse, Tincturae Valerianae, Spiritus sctheris compositi, aa f. 3j. M. Dose, ten to twenty drops during the access of pain; stimulating frictions over the sternum; and if the attack prolongs itself, hypodermic injections of atropia. 300. R. Quinize sulphatis, gr. xxx Acidi arseniosi, gr. ss Extract! Valerianae, q. s. M. Divide into thirty pills. From two to four a day for persons subject to attacks, in order to lessen their frequency. NOTES ON REMEDIES. Acidum Aceticum Dilututn. Bathing the chest every morning with vinegar and water is said to lessen the liability to attacks. Ammonii Bromidum. This substance, in doses of gr. xv-xx, three or four times a day, has been very successfully used to check paroxysms of angina by Dr. R. K. Hinton. (Medical and Surgical Reporter, March, 1875.) Amyl Nitrite (see above). Antipyrin. The profession is divided as to the propriety of this drug. It does relieve the pain of angina, but there must be great care exercised lest its depressing effects lead to a collapse. Argenti Nitras, gr. j daily, in the form of a pill, is favorably spoken of by Dr. Copland. Arsenic. Dr. Anstie says he has seen the most remarkable relief afforded by this remedy. It may be given in the form of Fowler's solution ; in pill of arsenious acid ; or (gr. y',) of arseniate of soda, with extract of hop ; by subcutaneous injection ; or, by inhalation of the smoke of arsenical cigarettes. Dr. Anstie states that it will lessen the sever- ity of the attacks, reducing them in time to mere " tightness of the chest." Assafmtida, combined with opium and ether, is sometimes of service. Camphor, in combination with opium or hydrocyanic acid, sometimes acts favorably. Chloroform, taken in doses of twenty or thirty drops, or inhaled in small amounts, is highly commended by certain writers. Ether is praised as a palliative by Dr. Anstie, who considers it, however, as inferior to arsenic or strychnia. Ethyl Bromide. 301. R. Ethyli bromidi, « part Aqua destill., 200 P"ts. Take two to four tablespoonfols. This is recommended by Dr. William Squire, of London, in anginal attacks ( Comptnd. Med. Sci., 1884). 1 82 DISEASES OF THE CIRCULATORY SYSTEM. Morphia, by hypodermic injection, is praised by Profs. Bartholow and See. Niiro- Glycerine acts similarly to arayl nitrite, but more slowly, and is more manageable. The dose is one or more minims of a one per cent, alcoholic solution. Potassium Iodide is very highly commended in the treatment of angina in the intervals. It is said by those adhering to this remedy that angina pectoris is entirely curable by this medicine, if the treatment be pur- sued for several months or more. Strychnia, by hypodermic injection (gr. tiit- 'b) twice daily for several weeks, is highly lauded by Dr. Anstie, who has seen remarkable benefit at- tending its use in presence of a threatening paroxysm. Quinice Sulphas has been advised in intermittent angina pectoris. Sodium Nitrite, in doses of gr. iij-v, has been used by Dr. Hay and M. W. Collier, {Copipend. of Med., 1884), and its effects in relieving the spasms were prompt and satisfactory. As it is a much cheaper drug than the nitrite of amyl capsules, it is a proper substitute in hospital practice. Zinci Sulphas sometimes proves of great benefit, when persevered in during the intermissions. Stimulants. The relief of pain is better accomplished by the use of ether, or of morphia or atropia hypodermically, than by large doses of spirits. Turpentine stupes, applied to the chest, often mitigate the severity of the paroxysm, particularly in the old and debilitated. Issues. An issue at the nape of the neck sometimes acts favorably in miti- gating the symptoms. CARDIA.C DILATATION. DR. ALFRED L. LOOMIS, NEW YORK. The indications are : i. To maintain nutrition. 2. To avoid violent cardiacyaction. For the first, our author commends an exclusively milk diet, the fluid taken in small quantities at short intervals. " As a rule, it is always safe to daily administer iron to a patient with dilated heart." Slightly stimulating baths, flannel next to the skin, the avoidance of emotion, and the arrest of all exhausting discharges, are important. A dry, bracing atmosphere is most suitable. The most important remedy is digitalis, in sufficiently large doses to CARDIAC DILATATION. " 183 regulate the heart's action. As it loses its controlling power by con- tinued use, it should not be exhibited indiscriminately. J. M. DA COSTA, M. D., PHILADELPHIA. 302. R. Pulveris digitalis, gr. t. Extracti belladonnae, gr. j. Ferri redacti, yij. M. For twenty pills. One thrice daily. 303- R- Emplastri belladonnje, 4x4. To be worn over the cardiac region. Belladonna is one of the best agents that can be employed to •overcome irregularity of the action of the heart, and to relieve pain. Digitalis is . also useful for the same purpose, especially where the action of the heart is feeble ; it is the only sedative which will reduce the frequency and not the force of the heart. It may be combined as follows : 304. R. Ferri lactatis, 3s» Pulveris digitalis, gr. t. M. For twenty pills. One thrice daily. 305. R. Tincturae digitalis, f. 5 ss. Ten drops thrice daily, in cases of dropsy caused by cardiac dilatation. Also 306. R. Pulveris jalapse compositi, gr. ». For one dose at night. In such cases, a tablespoonful of lemon juice, three times a day, acts as a diuretic and stomachic. Baths, also, are advantageous. Dry cups applied to the chest relieve the pulmonary congestion. It is more important to start the secretions and relieve internal conges- tions, than to give tonics and iron, which find their appropriate place in after-treatment. DR. ROBERTS BARTHOLOW. 307. R. Ferri redacti, Quiniae sulphatis, _ Pulv. digitalis, «a Bj Pulv. scilte. er. X. M. Make twenty pills. One three or four times a day. Recommended as extremely serviceable in dilatation of the heart and mitral regurgitation, accompanied by cough, difficult breathing and general dropsy. 1 84 DISEASES OF THE CIRCULATORY SYSTEM Another valuable remedy in dilatation, without valvular lesion, is- ergot. It may be given with digitalis. 308. R. Extract! ergotae fluidi, f.Siijss Tinctures digitalis, f- 3 ss. M. A teaspoonful three times a day. Ergot slows the action of the heart and produces a contraction of the smaller vessels. DR. WALSHE. When dropsy appears in cases of dilatation of the heart, the diu- retics which yield most relief are the acetate, nitrate, iodide, and bitartrate of potassium, nitrous ether, compound tincture of iodine^ the infusion and spirits of juniper and gin. Hydragogue cathartics,, elaterium, gamboge, citrate of potassa, and the compound jalap powder, also aid in subduing the dropsical effusion. The following formula is a useful one for the administration of elaterium : 309. R. Extract! elaterii, gr. l-j Extracti creasoti, gr. ij Extract! hyoscyami, gr. ij. M. For one pill. NOTES ON REMEDIES. Adonis Vernalis. This is a popular remedy in Russia for heart disease and dropsy. It stimulates the motor and inhibitory ganglia of the heart, and is not cumulative in its action. Belladonna is prescribed by Prof. Da Costa to overcome the irregularity of the heart's action, and to relieve pain. Casca Bark in doses of five minims of the tincture (one to ten) thrice daily has proved serviceable in the hands of Dr. McCall Anderson, of Scotland. Cenvallaria Majalis is highly recommended in similar cases as digitalis has- usually been prescribed for. Digitalis is recommended in dilatation, by Prof. Da Costa and Prof. Nie- MEYER, Drs. Gull, Wilks, Fuller, Handfield Jones, Trousseau, and others. The conclusions of Dr. Murray are as follows ; i. That digi- talis will stimulate and strengthen a weak heart, and that the weaker are the muscular tissues of the heart, the safer will be the administra- tion of the medicine. 2. That in hypertrophied heart, it will fail to reduce the pulse either in frequency or strength, and in such cases will prove dangerous. 3. That in a weak organ, acting, on account of its weakness, with great rapidity, it will reduce the number of its con- tractions, and, as it were, strengthen or tone them down. To strengthea CARDIAC HYPERTROPHY. 1 85 and quicken the action of a weak, slowly-acting heart, and to reduce the number of the rapid strokes of a full heart, is, according to Anstie, to do the work of a true stimulant ; bringing action up to the normal standard on the one hand, and reducing it to a level on the other. {Brit. For. Med. Chir. Rev., July 1865.) Ergot is a useful remedy in case of enlarged heart, (dilated cavities) without valvular lesion. It may be given with digitalis. 310. R. Ext. ergotfe fluidi, f.gjijss Tinct. digitalis, f. | ss. M. S. — ^A teaspoonful three times a day. Nitrite of Amyl, in dilated heart, has been found of value. Dr. E. Holden has reported a striking case in the New York Medical Record, April 27th, 1878. Nitroglycerine is -wsLrmly commended by Fussell {Med. &f Surg. Rep., 1888,) in cases of cardiac ad)'namia, given hypodermatically, one drop of a one per cent, solution. Opium, in small doses, (five minims of the tincture) in combination with ergot or digitalis, is considered by Bartholow as a valuable tonic to a weak and dilated heart. Strychnia Sulphate in doses of two or three milligrammes three times daily, gives great relief. Strophanthus. Dr. Logan, of Liverpool, {Med. Compend., 1884,) has ex- pressed the opinion that this agent is superior to digitalis as a cardiac tonic. More recent writers agree in this opinion, in that strophanthus may be employed for a continued treatment, having no cumulative ef- fects. Dry Cups to the chest are useful to relieve the pulmonary congestion. CARDIAC HYPERTROPHY. DR. HENRY HARTSHORNE, PHILADELPHIA. When there is dilatation with hypertrophy, the main principle is to avoid exciting causes, especially violent exercise, alcohol, and venery. Moderate venesection at long intervals, is appropriate for robust patients ; occasional leeching or cupping over the heart may be done. As an astringent and cardiac sedative, acetate of lead is worthy of trial. 311. K- Plumbi acetatis, 3ss Pulveris opii, S''- ^ Confect. rosjE, 1- *• Make twenty pills. One thrice daily. M. 1 86 DISEASES OF THE CIRCULATORY SYSTEM. Where abnormal rapidity of the heart is present, digitalis may be used unhesitatingly, but moderately. In violent acceleration of the pulse, we may, however, expect more from veratrum viride as a sedative and palliative (gtt. ij-v of Norwood's tincture every three or four hours, diminishing the dose if nausea follows). Benefit is obtained, also, in such cases, from the use of wild-cherry bark. ALFRED L. LOOMIS, M. D., NEW YORK. This author condemns the practice of blood-letting, to which the full pulse and symptoms of cerebral hyperaemia have prompted some practitioners in this disease. Of all remedial agents to diminish the force of the heart's action, he has found aconite the best. His pre- scription is : 312. jg. Tincturee aconiti rad. (Fleming's), q. u Two to three drops every three or four hours. "No drug so fully and promptly relieves the vertigo and other painful sensations that attend cardiac hypertrophy." It is contra- indicated if the dilatation overbalances the hypertrophy of the cardiac walls. Digitalis is contra-indicated unless there is degeneration of the hypertrophied walls, J. M. DA COSTA, M. D., PHILADELPHIA. In the treatment of hypertrophy of the heart, as much rest as possible should be insisted upon. The patient must be directed to lie down for several hours each day. The sinking of the pulse, which naturally occurs in the recumbent position, makes this posture as potent a cardiac sedative as we possess) All stimulants to the action of the heart should be removed. This includes the removal of any dyspeptic symptoms which may be present, and of any other disordered function which can react upon the heart. There are only two drugs in which our author has any confidence ; one is aconite, or its active principle, aconitia, and the other veratria. These are the only medicines which directly and positively control the element of muscular power of the heart. Digitalis does not compare as a pure sedative with either aconite or veratrum viride. Gelsemium is useless ; it has a false reputation. It is time lost to employ it. Hydrocyanic acid is often a useful and pleasant adjunct where there is gastric disturbance ; alone it is of no value. These principles apply both in the treatment of simple hyper- CARDIAC HYPERTROPHY. 1 87 trophy, and in that complicated with valvular disease. A certain amount of hypertrophy with valvular disease is beneficial, and judg- ment must be exercised in order to determine when to interfere, and when not. 3^3- R- Tinct. veratri viridis, f. 3iss " aconiti radicis. f. 5 ss " 7.ingiberis, f.Svss. M. Fifteen drops thrice daily, two hours after meals, in water. The addition of the tincture of ginger causes the veratrum viride to be better borne by the stomach. Our author also frequently orders : 314. R. Tinct. aconiti radicis, gtt. j Thrice da,i\y /or many months, its effects being watched. In a large number of cases this remedy thus employed prevents the further growth of the heart, and in some it lessens the already existing bulk of the organ. NOTES ON REMEDIES. Aconite is one of the two drugs (the other being veratrum) in which most authorities have any confidence in hypertrophy of the heart. Asparagin. This derivative from asparagus is said by Dr. Mary J. Matlack (Med. and Surg. Rep., July, 1879) to be particularly serviceable in hypertrophy of the heart. The following formula is of value : 315. R. Asparagin, pre. x Potass, bromidi, Sij Sacch. alb., 3"j- M. Make ten powders, one thrice daily. Camphor has been recommended, in doses of from grs. iij-xij, daily, as ren- dering regular the most tumultuous palpitations, and removing the dyspnoea attendant on hypertrophy of the heart with dilatation. Digitalis. The best effects of digitalis in hypertrophy are obtained from small doses, large doses being regarded by many as hurtful, if not dan- gerous, in this affection. Drs. Gull, Wilks, Fuller, W. Murray and Handfield Jones regard digitalis as useless, and even dangerous, in simple hypertrophy, and would restrict its use to cases of dilatation and enfeeblement of the heart. Fel Bovinum Purificatum has been recommended in certain forms of hyper- trophy. Plumbi Acetas has been recommended in the incipient stages of hypertrophy. 1 88 DISEASES OF THE CIRCULATORY SYSTEM. but it is of doubtful value other than in relieving, in some cases, vio- lent palpitations connected with hypertrophy. Potassii Bromidum has been employed, but its utility is not established. Potassii lodidum, in small doses, long continued, seems to exercise, in some cases, a beneficial influence. Here, as elsewhere in cardiac cases, the sodium salt may be employed beneficially instead of potassium, inas- much as the latter seems to exercise some low-grade tonic influence in long administration. Veratrum Viride is one of the only two drugs (the other being aconite) in which Prof. Da Costa has any confidence. (F. 313.) Diuretics are strongly recommended by Dr. J. Hope in hypertrophy, not only when there is dropsy, but also when there is none, as powerful derivatives. CARDITIS. ENDOCARDITIS AND PERICARDITIS. DR. CONSTANTIN PAUL. In his last work (Mai. du Ceur., 1884), this writer disapproves of cupping and mercurials. He relies largely on blisters, but they must be made large, so as to cover the whole cardiac space. Their prompt action can be observed by the stethoscope. The ice-bag is also valuable where there are local pains, tumultuous action of the heart, and anxiety. It may be applied from one to three hours at a time. The pulse and temperature should be watched, and the bag removed as soon as they return to the normal. Digitalis, usually in small doses, is indicated by the rapid action of the heart. The pain may be relieved by opium internally or by subcutaneous injections of morphine. Insomnia may be combated by chloral in doses of grs. xx-.5j. The depression of the vital energies must be met' by wine, brandy punch, and quinine. The chilly sensations sometimes felt may be counteracted by subcutaneous injections of ether or camphor. When effusion has taken place, blistering may be tried, but it usually disappoints. The same may be said of diuretics, and hydra- gogue cathartics, such as squills, nitrate and acetate of potash, jalap,, colocynth, etc. Paracentesis is a last resort. Few of the patients recover, but when suffocation is threatened, it should be performed. The place of election is the fifth intercostal space to the left of the sternum. CARDITIS, ENDOCARDITIS AND PERICARDITIS. 189 care being taken to avoid the internal mammary artery. A prelimi- nary exploration should be made with the hypodermic needle. The trocar can then be inserted safely. After the fluid has been with- drawn, the following may be injected : 316. R. Tinct. iodinii, f. §ss Potassii ioJidi, gr. xv Aquae destill., f. § ij. m. As a rule the patient experiences immediate relief, but it is rarely permanent, as the fluid is reproduced. DR. BERNHARD KRAUS, VIENNA. The principles of treatment of pericarditis embrace absolute rest in the recumbent position, cold applications, as ice bladders or cloths wrung out in ice-water and laid over the praecordial region, and a mineral acid. (Diagnose und Therapie der Krankheiten des Menschen, Wien, 1877.) Digitalis should be given promptly, but after two or three days be suspended, as it is not only alleged to have a cumulative action, but, according to Skoda, a debility of the contractile power of the heart appears, which must be met by qui- nine, opiates, and alkalies. Collapse must be combated by wine, coffee, musk, carbonate of ammonia, and other stimulants. As a diuretic : 317. R. Extract! digitalis, gr. xv Aqu3e petroseUnx, f. S vj Oxymel. scillcc, 3 vj. M. A dessertspoonful every tvi'o hours. Or ten drops of the liquor ammoniae acetatis in a cup of warm infusion every two hours. Should there be much discharge into the pericardium (hydropericardium), the diet should be nourishing, tonics be exhibited, and reliance be placed upon diuretics, as : 318. R. Infusi bacarum junip , Liquoris potassae acetatis, aa f. §iv Liquoris ammonia; succinic!, f- 3 ^^' "^" A dessertspoonful every two hours. The external application of " Hahn's diuretic liniment," has been found of use. It is : 319. R. Olei terebinth., f-5j.. Vitelli ovi. No. ij Aq. menth. piper., f- 3 "*• For external use. To be rubbed over the kidneys two or three times daily. Flannel around the loins. igo DISEASES OF THE CIRCULATORY SYSTEM, If the dyspnoea increases, paracentesis of the pericardium is indi- cated. It is performed in the fourth intercostal space on the inner side of the line of the mamma. Frequently it results in permanent improvement. DR. HAYDEN, DUBLIN. Our author treats acute pericarditis in young and vigorous sub- jects with a saline aperient followed by leeches — ten, twenty or thirty, as the case may demand — following them with a warm poul- tice. If the impulse continues strong and abrupt, the rhythm reg- ular, the sounds normal and sharp, and the praecordial pain and op- pression persistent, he would not hesitate to repeat the leeching. This should be followed by 320. R. Hydrarg. chlor. mitis, gr. ss Pulv. antimonialis, gr. j. M. One such powder every hour until slight salivation is produced. When the improvement has well commenced, frequently-repeated moderate doses of wine are given to remove the cardiac debility and relaxation of the coronary arteries. To ensure sleep at night a mod- erate dose of some opiate is exhibited. The diet should be bland and nutritious. When the acute inflammatory stage is subdued, generally sustaining measures should be adopted, with iodide of potassium and the application of a blister. If the heart becomes tumultuous and irregular, digitalis is useful. When extreme effusion defies remedial agents, parcentesis must be resorted to. The point of election is that of maximum dullness, minimum impulse, and most distant cardiac sounds ; usually a point one or two inches to the left of the sternum in the fourth or fifth interspace. Nearer to the sternum than one inch endangers the internal mammary artery. For acute endocarditis he relies on the same treatment. DR. AUSTIN FLINT, NEW YORK. On the subject of pericarditis, the author says blood-letting should be employed with great circumspection. Depletion by means of saline purgatives, with restricted diet, is indicated in the early stage. For some years the author has treated all cases of pericarditis with- out mercury, and he has found no reason to be dissatisfied with its omission. Opium should be administeted. Locally, mild, revulsive and soothing applications. In the second stage, if the amount of CARDITIS, ENDOCARDITIS AND PERICARDITIS. 191 effusion be sufficient to enfeeble the heart, it is highly important to remove the liquid as speedily as possible. For this end, the praecordia may be painted daily with the tincture of iodine, and small blisters may be applied, removing them as soon as vesication begins. Hydragogue cathartics and diuretics as in pleurisy, taking care not to depress the vital powers. The strength in this stage should be supported by alcoholic stimulants, tonics and nourishment. ALFRED L. LOOMIS, M. D., NEW YORK. Whatever the conditions which develop endocarditis, the patient should be kept in bed. Opium, in small doses, is proper. The temperature of the room should always be kept above 70° Fah. The chest should be covered with flannel, and not exposed. If the heart becomes feeble, digitalis is indicated. " Rest, opium, iron, and the most nutritious diet, with occasional use of stimulants, con- stitute the most serviceable agents to be employed in the treatment of this affection." In the acute ulcerative form of endocarditis, large doses of quinine and stimulants are our only dependence. In pericarditis, the same cautions about rest, etc., are to be ob- served. Blisters, blood-letting, diuretics, and cathartics, our author considers useless ; digitalis of doubtful value. " Opium, iron, mod- erate stimulation, rest in the recumbent posture, anodyne poultices, and concentrated nutrition, are about the only measures which he has found of service in the treatment of acute pericarditis." Aspi- ration he commends only when it can be positively determined that pus is irr the pericardium. DR. SANSOM. (London Practitioner, 1889.) Recently good results have been reported by Dr. S. in connection with acute ulcerative endocarditis by following out an antiseptic method of procedure. He has used, with apparently good effect, sulphocarbolate of sodium, given in doses of thirty grains, several times daily, associated with inunc- tions of carbolized oil. In this connection it may be added that inhalations of carbolate of iodine have seemed to bring about rapid improvement in a case reported by McCIure (London Lancet, 1887). 192 DISEASES OF THE CIRCULATORY SYSTEM. DR. N. O. PARKS, OF RHODE ISLAND. This physician stated to the Rhode Island State Medical Society, 1884, that he had employed topical cardiac blistering in acute rheu- matic pericarditis in seven cases, and in one of them no other meas- ures whatever were used ; the result being in this, as in the other cases, a prompt and complete cure. In the remaining cases, salicin, or one of its allied compounds, and ammonium carbonate, were given internally. Oletim gaultherice was used in some instances — in- ternally in doses of fifteen drops once in two hours, and applied locally to the inflamed joints, combined with an equal amount of lin. camphorse comp. The series described included cases of acute articular rheumatism, and rheumatic gout, so-called. In some of the cases an endocardial murmur was present. Usually, one blister- ing sufficed, but in case of relapse it was repeated. The writer ex- pressed his belief that we have, in the method under consideration, the most valuable adjunct to our means of successfully treating rheumatic carditis. NOTES ON REMEDIES. Aconite is recommended by Dr. Ringer in pericarditis when the heart throbs violently, and thus produces extreme pain. Antimonii Ses-iodidum is sometimes employed. Carbolate of Iodine inhalations are commended in the treatment of acute ulcerative endocarditis. Digitalis, combined with hyoscyamus tincture (aa ttlxv—xx), is recommended by Dr. J. Hope in pericarditis, after the acute symptoms have been subdued. Dr. Beverly Robinson, of New York, considers it the rem- edy indicated for the treatment of the pulmonary complications of acute heart disease. (Medical Record, November, 1877.) Hydrargyrum is considered by Dr. A. T. H. Waters as rarely, if ever, desir- able in pericarditis, except as a purgative. He prefers to the mercu- rial treatment and venesection recommended by Drs. Latham, Hope, and others, the milder but more effectual remedies of opium, bicar- bonate of potash, the moderate and cautious use of stimulants, large linseed poultices to the chest, and blisters in the advanced stage, with good nourishment throughout the disease. Opium, in grain doses, every three, four, six or eight hours, is recommended by Dr. A. T. H. Waters in pericarditis. The great relief to pain which often follows the local abstraction of blood in this disease, may- be equally obtained by the administration of opium. CARDITIS, ENDOCARDITIS AND PERICARDRIS. 193 Polassii lodidum, in doses of gr. iij-v ter die, is sometimes given with advant- age in chronic pericarditis, appearing to favor the absorption of effused fluid. Salicin. Dr. Maclagan, of London, endorses the views of those who hold that salicin possesses the power of preventing cardiac complication in rheumatism. He considers small doses ineffectual, and recommends twenty to forty grains every hour for six hours, or until relief from pain is experienced ; by its early use he thinks we may /rifpirw/ valvular in- flammation. Salicylate of Sodium is also used in the same connection. Sulphocarbolate of Sodium is given in doses of 30 grains in acute ulcerative endocarditis, together with inunctions of carbolized oil. Veratrum Viride is recommended by Dr. Waring-Curran (The Practitioner, August, 1868,) in pericarditis. He gives it in the form of an extract made by inspissating the juice of the root, and combines with it gr. j of calomel, every two hours, carefully watching the effect. A combi- nation of opium and veratrum has been highly extolled in pericarditis and valvular disease by Dr. J. L. Lynch, of Baltimore. It avoids all the unpleasant gastric effects usually attendant on veratrum, and is palatable. It is : 321. K. Tinct. verat. vir., Tinct. opii, aa f. 3j Sodii bicarb., 5ii Sacc. alb., 3iv Aquam, ad 5 vj. M. S. — ^Tablespoonful every two or three hours. For children, the quantity of opium soould be reduced one-half, and the dose gradu- ated for their ages. Blisters are hurtful in the eariy stages of cardiac inflammation, but useful in the advanced stages. Poultices. Large linseed-meal poultices are of signal service in the earlier stages of inflammatory action. Turpentine stupes, which can be employed at a far eariier period than blis- ters, are often of manifest advantage in relieving pain and distress, and arresting inflammatory action. Issues in the precordial region frequently give relief in chronic inflammation of the heart or its membranes. RHEUMATIC CARDITIS. Colchicum, with alkalies, etc., is, according to Dr. Fuller, necessary in rheu- matic carditis, to counteract and get rid of the materies mori>i, with- out the removal of which it is difficult to conceive that a cure can be efltcted. 13 194 DISEASES OF THE CIRCULATORY SYSTEM. Hydrargyrum, combined with opium, and carried to the extent of slight sali- vation, is strongly recommended by Dr. Fuller in rheumatic inflam- mation of the heart, occurring in young, robust subjects, but he does not advocate its use in weakly, irritable and unhealthy constitutions. Opium, in large and repeated doses, is strongly recommended in rheumatic pericarditis by Drs. Walshe, Farre (St. Bartholomew's Hospital Re- port, 1867) and others. If the surface has been blistered, morphia may be used endermically ; and often when opium internally is inad- missible, benefit is obtained from morphia hypodermically. Dr. Ful- ler says that in rheumatic carditis, opium mfull doses is indispensable in every case. In the weak and irritable, where mercury is of little service, it proves particularly valuable. It is, of all remedies, that which comes most powerfully in aid of blood-letting and mercury. If, after all active symptoms have subsided, much irritability of the heart remains, occasional doses of opium and digitalis should be given, and an opium or belladonna plaster applied to the chest, while the general health is being attended to. Quinics Sulphas, in doses of gr. ijss, combined with gr. xx ol carbonate of potash, given in mucilage every four hours, was found by Dr. Winn (Lancet, November 14th, 1868), highly beneficial in a case of rheu- matic pericarditis attended with delirium. Salicin, in scruple doses, every four hours, has been found by Dr. G. P. May of great use. (British Medical Journal, January, 1877.) Salicylate of Sodium is used in rheumatic cardiac complications, in doses from gr. x to gr. xx. Stimulants. Alcoholic stimulants are often very beneficial in rheumatic peri- carditis, especially when the attack is characterized by great pain, sleeplessness and jactitating movements of the limbs. In this form ot the disease. Dr. Anstie regards alcohol as superior to opium as an anodyne and specific. It should be given in repeated small doses, the production of even the minor signs of intoxication being carefiilly avoided. Blood-letting. Dr. Garrod states that so much relief follows the application of leeches to the cardiac region in rheumatic pericarditis, and in en- docarditis, that he has no hesitation in recommending the measure, the bleeding never being allowed to produce any appreciable weaken- ing of the patient. Generally, from three to twelve leeches are suffi- cient. The slow loss of blood by leeching is preferable to the more expeditious abstraction by cupping. Blisters are recommended by Dr. Fuller in the advanced stages of rheumatic carditis, when effusion has taken place; as of all local remedies the most serviceable, their virtue being most unequivocally displayed when the amount of fluid is greatest. FATTY HEART. igj FATTY HEART. OERTEL'S TREATMENT. In cardiac weakness, due to early fatty change, and to the altera- tions brought about by over-digestion, over-stimulation and lack of exercise, even where there is shght valvular lesion, Oertel's treat- ment has seemed to produce excellent effects. Its three cardinal principles are (i) decrease of water consumed, (2) increase of water excreted, and (3) mountain climbing to reduce fat and in- crease the heart power. The best results come only in the early stages of fatty heart — later it is often accompanied by untoward symptoms. Hausmann (Deutsch Med. Wochensch, 1888,) states that the withdrawal of fluids and mountain climbing must be regu- lated with the utmost circumspection in regard to quantity and modified according to circumstances. Mountain climbing is not to be practised in case of an over-worked heart, of a heart with valvular disease, together with muscular weakness, or in uncompensated con- ditions after endocarditis, etc. In the matter of liquids, milk is best administered, regulating its quantity by the amount of fluid ex- creted, keeping the former within the limits of the latter. The nearer normal the heart muscle is, the more good may be ex- pected from a regulated and gradually increased amount of moun- tain climbing more good being derived in cases of fatty infiltration than in cases of active muscular degeneration. DR. A. T. H. WATERS, LIVERPOOL. Ferri tinctura chloridi is highly recommended by Dr. A. T. H. Waters, who believes that if it be given in small doses for a long time, it will often restore to an enfeebled and fatty heart a good deal of its vigor, and possibly of its structure. But its administration must be continued for months, and even years, being omitted from time to time as the digestive organs may demand. A chalybeate mineral water may be substituted for the tincture of chloride of iron, if the latter cannot be taken. NOTES ON REMEDIES. Arseniosum Acidum is, according to Dr. Ixjckie, of great value in fatty de- generation, and this in spite of the fact that experiments tend to show that fatty degeneration of the heart is one of the results of feeding animals with arsenical preparations. 196 DISEASES OF THE CIRCULATORY SYSTEM. Cimicifuga is, according to Bartholow, more efficient and safer, in fatty heart, to relieve the symptoms, than digitalis. Digitalis, according to Dr. A. L. Loomis, will sometimes afford relief when there is yielding of the cardiac walls. By some, fatty degeneration is held to contra-indicate digitalis ; but such an authority as Balfour states that it may be given without danger and with advantage. Ergot is recommended by Dr. Waring Curran, as of material use in severe cases. Ferrum in any of the officinal forms will frequently prove of use. Fotassium Iodide is commended for its action on the muscle in the early stages of degeneration. Strophanthus , in form of the tincture, in doses ten to twenty drops three or four times daily, has been highly commended in the heart failures from degeneration. Strychnia. Phillips says this will sometimes do good in cases of fatty heart, when all other remedies have failed ; but it must be pushed cautiously, and stopped if signs of nervous worry appear. (Mat. Med., 1879.) FUNCTIONAL PALPITATION AND OTHER DERANGEMENTS. DR. H. BERNHEIM, PARIS. With regard to the treatment of functional deficiency of the heart, when there is a presumption that the cardiac tissue is healthy, and when at the same time the obstacle which produces asystole is not insuperable, digitalis is indicated. When either of these conditions is absent, digitalis is contra-indicated. Thus in those cases of pal- pitation in which strong, full pulse, arterial plethora, and abundant urinary secretion point to exaggerated cardiac activity, those drugs which, like tnuscarin and aconitia, abate cardiac velocity and arterial tension, should be prescribed, to the exclusion of digitalis. So also in the functional disturbances accompanying cyanosis, dropsy, oedema, etc., with high arterial tension, the use of digitalis is attended with danger. (Lemons de Clinique Medicale, 1877.) J. MILNER FOTHERGILL, M. D., LONDON. This writer commends (Medical Times, April, 1876,) as the most satisfactory prescription, the following, or an appropriate modifica- tion of it, in palpitation : FUNCTIONAL PALPITATION AND OTHER DERANGEMENTS. 1 97 322. R. Potassii bromidi, gr. xv Tincturse digitalis, gtt. v. M. This amount thrice daily. If there is anaemia present, the potassio-tartrate of iron will be found to combine nicely with this prescription. A belladonna plaster should be worn over the region of the heart. Of course, in the treatment of such a neurosal affection, it is well to cut off every form of irritation, and everything which tends to create nervous excite- ment. The mind and body should both be kept as calm and tran- quil as is possible. The alimentary canal should be attended to ; the condition of the reproductive system ought to be carefully scru- tinized, and the habits of life taken into consideration. Where there is a lack of tone in the nervous system, it is well to give the digitalis with hydrobromic acid, in which quinine readily dissolves, so as to furnish a tonic in the mixture. Where there is anaemia, the bromide and the digitalis may be combined with the potassio-tartrate of iron, or a few drops of some preparation of iron may be taken twice a day, after food, with advantage. J. M. DA COSTA, M. D., PHILADELPHIA. Inquiry should always be made as to the cause, for the first step in the treatment is its removal. The cause may be found to be .drinking of coffee, chewing of tobacco, smoking, alcoholic drinks, masturbation, etc. In all cases of functional disorder of the heart, attended with pal- pitation, digitalis is very serviceable, more so than aconite. If there be masturbation as the exciting cause, the following is a useful com- bination : 323. R. Potassii bromidi, (^tr- Tincturas digitalis, ri-'^* M Infusi cascarillje, '• 3 '"'■ *^- A dessertspoonful two or three times a day. HENRY M. BOWDITCH, BOSTON. In the Boston Med. and Surg. Jour., 1883, Dr. BOWDITCH highly praises the following : 324. R. Pulv. digitalis, 8^- '^ Pulv. colchici sem., ^- "* Sodii bicarbonatis, ^- ""• M. et div. in pil. No. 20. 198 DISEASES OF THE CIRCULATORY SYSTEM. These are to be taken three or four times daily at first ; subse- quently to be reduced until only one is taken at bedtime ; the treat- ment to be continued for three to nine months. He has used it for twenty-five years, and has found it to relieve even the most serious cardiac affections. ROBERTS BARTHOLOW, M. D., PHILADELPHIA. The violent and irregular actions of the heart occiiring in hysteri- cal subjects are immediately relieved by the use of the hypodermic syringe. Morphia alone is used. In cases of dyspnoea, dependent upon dilated right cavities, pulmonary oedema and mitral disease, advantage is derived from the following: HYPODERMIC INJECTION. 325. R. Morphiae sulphatis, gr. xvj Atropise sulphatis, gr. j Aquae destillatae, f-SJ- M. Filter. Dose, five minims (equal to one-sixth of a grain of morphia, and one ninety-sixth of a grain of atropia). DR. BEVERLY ROBINSON. (Med. Record, 1887.) Dr. ROBINSON obtains the best results by attending to general hygienic circumstances. He depends on light diet, given at frequent intervals ; and by washing out the stomach, and the use of pepsin and digestants, corrects all reflexes which may arise from improper gastric function. These call out in his exper- ience a very large proportion of the symptoms included under the head of Functional Cardiac Disease. Blisters and thermo-cautery sometimes are the only successful means of relief of some of those forms associated with gastric troubles. For temporary effects coca has seemed to him to be valuable. DR. BOUCHUT, PARIS. 326. R. Assafoetidse, gr. xxxvj Digitalis pulveris, gr. iij Extracti Valerianae, gr. vii. M. Divide into eighteen pills; one morning and evening, to remedy nervous palpitations of the heart. If the blood be impoverished, a ferruginous natural mineral water is a usefiil drink with the meals, mixed with wine. NOTES ON REMEDIES. Aconite, in small doses, often controls nervous palpitations of the heart. Belladonna, in the form of a plaster, frequently does good. FUNCTIONAL PALPITATION AND OTHER DERANGEMENTS. 19^ The Bromides are often of service. According to Dr. Angrisani, of Bologna, bromide of potash has no effect on the muscular fibres or arteries of the heart, but is the most beneficial drug for purely functional palpi- tation, intermittence, irregularity, etc. {DobeWs Reports, 1877.) Cactus Grandiflora is extolled by eclectic practitioners as an unequaled heart tonic in functional disorders. Camphor, in doses of gr. iij-xij daily, is recommended in tumultuous palpita- tion. Cimicifuga, in palpitation with dilated or fatty heart, is particularly service- able. Digitalis is recommended by Prof. Da Costa as more serviceable than aconite, in all cases of functional disorder of the heart. Eucalyptus. In the palpitations frequent in women about the change of life, this is an efficient drug. Hyoscyamus, in large doses, is especially indicated in functional disturbance of the heart arising from emotion. Dr. Harley recommends, in these cases, the hypodermic injection of gr. jV of sulphate of hyoscyamia. Morphia, hypodermically, is recommended by Prof. Bartholow in violent palpitation produced by emotion or reflex irritation. Potassii Bromidum, in doses of gr. v-x ter die, is recommended by Dr. Russell Reynolds in palpitation or fluttering of the heart, arising from disturbances of the vaso-motor system. Senega, in combination with hyoscyamus and ammonia, often proves useful in hysterical palpitations . Veratrum Viride is efficient to reduce the heart's action. EXTERNAL MEASURES. Emplastra of belladonna or of veratria are powerful local sedatives. A caoutchouc bag, filled with pounded ice, suspended around the neck, so that it rests over the heart, is an admirable calmant. Bosture. In many instances, moderate palpitations, not depending on or- ganic disease, may be almost immediately arrested by bending the head downward, and allowing the arms fo hang pendant. The effect is still more rapidly produced by holding the breath a few seconds, while the body is in this bent position. Pressure on the Carotids. This is an excellent measure for palpitations of a nervous character, not dependent on organic disease. The compres- sion should be exercised on both carotid arteries at once, and main- tained only a few seconds. The relief should be instantaneous. Pressure on the Pneumogastric. This measure has been urged by Dr. J. F. A. Adams, of Boston, as giving results very striking and suggestive. In 200 DISEASES OF THE CIRCULATORY SYSTEM. one case, violent nervous disturbance of the heart, with hysterical symp- toms, came on a lady suffering from an attack of acute rheumatism. Compression was made, first of one vagus and afterwards of both. In a few minutes, the agitation had subsided, the heart's action became quieter and more regular, and, finally, all the nervous symptoms sub- sided. A few minutes afterwards, she sank into a steady sleep, and, on awakening was perfectly quiet, and the cardiac symptoms never rc-appeared. IRRITABLE HEART. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. This common condition of the heart, frequently the result of over-exertion, the demands of modern "high-pressure" life, the ex- cessive consumption of meat and stimulants, etc., demands, in the first instance, rest, and the cessation of the habits which have been the exciting cause. The patients should lie dow^n several hours daily. Digitalis, in doses of gtt. viij-x of the tincture, is the most useful drug. Where the impulse is forcible, however, aconite may be employed in place of digitalis. The dose is tinct. rad. aconit. (U. S. Ph.) "Li-ij, ter die. In a few cases, this dose requires to be doubled. In cases of decided increase of the organ, aconite most shows its influence. No medicine can then be compared to it. It may be used steadily, in moderate doses, for months. Belladonna is an efficient agent, especially in instances of irregular action. Where no irregularity exists, but merely rapid action, it rarely shows itself of decided use. It may be advantageously combined with digitalis and iron. Opium has some quieting action, but only of a temporary character. Hypodermic injections of morphia are excellent to relieve the cardiac pain occasionally present. Tonics are often excellent adjuncts to the treatment, but are insufficient to control the disorder. Zinc, tincture of the chloride of iron, and gentian, may be mentioned. Where the attacks of palpitation are violent, Hoffman's anodyne and rest in the recumbent position are called for. Hypodermic injections of morphia and atropia relieve the pain. A belladonna plaster, persistently worn, is often, also, productive of good. Counter-irritation is valueless. The treatment is never a short one. VALVULAR DISEASE OE THE HEART. 201 VALVULAR DISEASE OF THE HEART. ALFRED L. LOOMIS, M. D., NEW YORK. All valvular diseases require rest, the avoidance of strong emo- tions, a nutritious diet, and temperance. If anaemia is present, iron is called for. Digitalis should be employed carefully; "it should never be resorted to in aortic regurgitation while the hypertrophy compensates for the dilatation." Dr. LoOMiS thinks the best mode of administering it is by infusion. The following tonic combination is recommended by Bartho- LOW: 327. R. Pulveris digitalis, 9ij Ferri redacti, Quiniae sulphatis, aa Bj. M. To make twenty pills. One to be taken two or three times a day. There is considerable diversity of opinion in the books as to the use of digatilis in aortic cases, though in other forms of heart dis- ease opinions are pretty well agreed. Some authorities would re- gard aortic insufficiency as a nearly absolute contra-indication to the use of the drug. Dr. G. W. Balfour regards it as the most valu- able remedy in this lesion. Mr. THOMAS Hayden says : " Given as the tincture, and combined with iron and ether, I have rarely known digitalis to cause unpleasant symptoms ; on the contrary, in numer- ous instances it has been followed by the most favorable and satis- factory results. I have in a few instances been under the necessity of suspending the use of digitalis, owing to threatened syncope ; but in the cases referred to there was fatty degeneration of the heart, in some instances with, and in others without, disease of the aortic valves." Mr. Hayden'S prescription is : 10 minims each of tincture of digitalis, tincture of chloride of iron, and spirits of nitric ether, in an ounce of infusion of quassia, thrice daily. Dr. Balfour, however, will not allow the fatty degeneration to be the explanation, as he quotes a very good case in which the drug was most useful, and says, speaking of fatty heart, " I have never seen any reason to withhold digitalis, and have always hitherto been rewarded by considerable and well-marked improvement." He pre- fers the tincture, and orders "rv-xxx every four hours, to be sus- pended if there is any faltering of the pulse or nausea on move- ment. (Edinburgh Medical Journal, February, 1875.) 202 DISEASES OF THE CIRCULATORY SYSTEM. DR. H. PYE-SMITH. (British Med. Journal, 18.90.) In aortic valvular disease digitalis is often uncertain, and at times dangerous, especially where there is no associated venous congestion or oedema. In these cases iron with strychnia is apt to be of service, and often arsenic is valuable. There is often derived the greatest benefit by insuring good condi- tion of the digestive functions and by the avoidance of flatulence. Where there are pain, headache and symptoms resembling aortic aneurism, or attacks resembling angina pectoris, nitro-glycerin and nitrite of amyl are extremely serviceable ; but often leeches over the sternum or repeated bleedings from the arm give great relief- Ether in form of Hoffman's anodyne, strychnine, and aromatic spirit of ammonia, are very useful in cardiac dyspnoea and distress of aortic disease. In advanced cases of ihitral disease, with dropsy, opium is gener- ally contra-indicated, but in aortic disease it may be given in form of laudanum or Dover's powder with great relief. Tincture of hy- oscyamus given in hot brandy and water is often valuable in cases of restlessness and discomfort. Antipyrine is sometimes given for the headache of cardiac disease, but is dangerous. Chloralamid in doses of twenty grains often acts ■well, and as a rule without unpleasant effects ; sulphonal has also been of value in the experience of the writer. Venesection, with absorption of a small amount of blood, is often very effectual in cases of aortic disease when the pain and other symptoms resemble aortic aneurism ; it is also proper when the right heart is engorged, the skin cyanotic, and the pulse small, weak and fluttering. Dr. Pye-Smith does not believe in Oertel's system of cardiac gym- nastics, as such gymnastics are already provided for by the necessi- ties of circulation, and there is no fear of the heart being too idle, but, on the other hand, of its being over-taxed. PROF. S. S. ROSENSTEIN, M. D., LEYDEN. The indication in valvular, disease is to develop and maintain com- pensatory action of the heart, and to moderate over-compensation. The diet should be nourishing, but not stimulating ; coffee and tea should be weak ; distilled liquors avoided ; the exercise be moder- ate. Lukewarm baths followed by a cold rub-down attract the blood to the surface, and thus act favorably. Mentally, an " Olym- VALVULAR DISEASE OF THE HEART. 203 pian calm " should be warmly recommended. To allay the irritabil- ity of the cardiac muscle, cold to the.praecordial region ranks first The patient may carry, for a few hours daily, a gutta-percha bag filled with ice suspended over the heart. Counter-irritants are in- iurious. The sovereign remedy in every stage of valvular disease is digitalis. Dr. R. has found this combination excellent: 328. R. Tinct. digitalis, " valerian., ££ f 5 j " fern acetat. aether., flgjsj j^_ Twenty-five drops thrice daily. (The ethereal tincture of the acetate of iron, G. Ph., is made as follows : 329- R- Liq. ferri acetat., o parts Alcoholis, 2 " ^theris acetic, i part. m. The patient should take this a fortnight, but no longer.) The swelling of the liver and gastric catarrh, which are apt to arise, may be met by the use of quassia, gentian, or rhubarb, and gentle aperients, like the saline mineral waters. When dropsy occurs, which is usually first noticed about the ankles, acetate of potash is called for : ZZ°- R- Potass, acetatis, 5ij Tinct. ferri acetat. ether., tllxlv Syrupi rhe£edos, f. 3v Aquam, ad f. § vj. M. A tablespoonful thrice daily. Squill may be reckoned a tried diuretic in such cases. 331. R. Aceti scillie, f. §j Potassii bicarb., ad saturandum Aquae cinnamom., f. § viij. M. One to two tablespoonfuls thrice daily. Respiration of compressed air sometimes gives great though not lasting relief, especially in mitral affections with stenosis. Digitalis combined with quinia is often also of great value ; it should be given in continued small doses. In the fainting and dizzy fits so often exhibited by patients with aortic stenosis, the prompt application of volatile stimulants, as Hoff.man'S anodyne, wine, or ether, is urgently necessary ; the head should be placed low, while the body lifes horizontal. The active congestion of the brain which occurs in insufficiency of the aortic 204 DISEASES OF THE CIRCULATORY SYSTEM. valves, must be combated by sinapisms or dry cupping to the neck, or small bleedings over the mastoid process. PROF. FiJRBRINGER. (Medicin.'Chirurg. Rundschau, 1 890.) FURBRINGER recommends highly the following prescription in cases of oedema and anasarca arising from cardiac valvular fault : 332. R. Infusi digitalis, f. Sv Caffeinae citratis, gr. xxx Tincturae strophanthi, IHlxxv Liquoris potassii acetatis, f- 3 xv Extracti glycyrrhizas, gr. Ixxv. M. This amount is to be taken in divided doses in two days, at intervals of four or five hours. PROFESSOR SEE, PARIS. This distinguished teacher recommends (Union Medicate, May, 1875,) the following combined treatment in the oedema and anasarca which so frequently complicate cardiac afifections. He claims to have effected their speedy disappearance : 333- B- Extract! scillse, gr. xv Pulv. rad. scillae, gr. iss. M. For ten pills. Six to ten of these a day. Also, 334- R- Potassii bromidi, 3j. This amount to be taken daily, m divided doses. For continuous cardiac dyspnoea he has seen much benefit from iodide of potassium : 335- R- Potassii iodidi, gr.xxx Chloral hydratis, j^j Gum julep, f. 5 iv. M. Take as required every two hours during the day. The Action of Convallaria. The general action of this recently introduced heart tonic may be discussed in this connection. The preparation employed may be the fluid extract, such as is prepared by Messrs, Parke, Davis & Co., of Detroit, the dose of which is fifteen to twenty drops to an adult every three hours until its effect is produced. According to the obseivations of Prof. E. Maragliano, of the diseases in which the good effects of the convallaria preparations VALVULAR DISEASE OF THE HEA.RT. 205 ■were obtained, heart diseases occupy the first place. It acted well in valvular diseases, especially of the mitral orifice, with insufficient activity of the cardiac muscle. In nine of thirteen cases the prepa- rations were decidedly advantageous. They increased the amount of urine, and regulated the heart's action. In many cases conval- laria is preferable to digitalis. In four cases in which it failed, digi- talis also failed. Convallamarin also acts most powerfully in cardiac disease. Dr. CONSTANTIN PAUL considers it a true heart tonic, and adds that it must be employed in large doses. He gives- one teaspoonful of the tincture at once. Dr. E. T. Bruen (Med. and Surg. Reporter, 1883,) says that in valvular disease it is most useful in cases of mitral obstruction. It loses its effectiveness in proportion as fatty degeneration is present. In advanced valvular heart-disease or cardiac failure in the catarrhal nephritic forms of Bright's disease, convallaria has not proven as useful as digitalis. The drug is of great service in cases where palpitation and dyspnoea, rather than deficient cardiac systole, are the prominent features. Broadly speaking, cases of phthisis or asthma in which palpitation and dyspnoea are prominent symptoms, before cardiac failure from advanced fatty change ensues, are much benefited by this drug. Its effect is often brilliant in purely functional heart disorder, especially palpitation with irregular cardiac action dependent on general debility, and in cases of anaemia or hysteria. It is some- times an efficient remedy in the irregular action of the heart caused by tobacco. ROBERT J. graves, M. D., DUBLIN. 336. B- Potassii nitratis, 3j-'j Tinctures digitalis, nixxv Tincturse hyoscyami, "Ixv Misturae amygdalae, f. 3 x. M. A tablespoonful from hour to hour in the oedema which accompanies disease of the heart. DR. BOUCHUT, PARIS. 337. R- Digitalis pulveris, 9'* Morphiae muriatis, P- ' Camphorse pulveris, 3 ^' „ Confectionis rosse, I- ^- ™' . Divide into forty piUs. One to be administered morning and evening, in organic affections of the heart. 2o6 DISEASES OF THE CIRCULATORY SYSTEM. 338. B. Tincture digitalis, f-Sivss Vini colchici, f.3iss Potassii iodidi, 5iiss Syrupi sarsaparillse, f- § iss Aquae destillatae, f- § ijss. M. A teaspoonful three or four times a day in the anasarca of heart disease. The pa- tient should be purged every third day with compound jalap powder. 339- R- Tincturas aloes, f.3j Tinaturae scillse, _ , Tincturse digitalis, aa JUxv. M. For one dose every second or third day, for the dropsies of heart disease. NOTES ON REMEDIES. Aconite is contra-indicated or to be used with the utmost caution, in organic disease, where the power or force of the heart is impaired. Adonis as a heart tonic is unreUable. Arseniosum Acidum. Arsenic is a valuable cardiac stimulant, alone and as an adjunct to digitaUs, where there is a failure of compensation. Belladonna is recommended by Dr. A. T. H. Waters in form of plaster or lotion over the heart, in palpitation combined with valvular disease, the patient at the same time being kept at rest in bed ; rest alone is often efficacious. In severe cases belladonna is superior to digitalis (which see). Caffein has considerable value as a cardiac tonic in the milder forms of loss of compensation. Casca Bark is thought by Dr. T. Lauder Brunton to be a more powerful heart tonic than digitalis, and to be capable of reheving cases of ad- vanced mitral disease where digitalis fails. (British Med. Journal, March, 1877.) Convallaria is used frequently as a substitute for digitalis in valvular cardiac disease, in doses of fifteen to twenty drops of fluid extract every three- or four hours. It is, however, uncertain in its effects, and is apt to produce nausea and vomiting. Digitalis is recommended by Dr. A. T. H. Waters in valvular disease, especi- ally when there is hypertrophy of the heart. Dr. E. Mackey (British Medical Journal, May 31st and July nth, 1868,) thinks that neither mitral regurgitation nor mitral obstruction contra-indicates the use of digiUlis, and gives numerous cases in which it was employed with ad- vantage ; but he regards its employment in aortic regurgitation and in fatty degeneration as contra-indicated or of doubtful safety. In any case where the heart s action is very feeble. Dr. M. considers that the commencing dose of the tincture should be tn,v-x every four or six hours ; this dose may be increased to" n^^xv-xx, or even in,xxx, with benefit; but, as a general rule, such a dose as n^xxx should not be re- VALVULAR DISEASE OF THE HEART. 207 peated more than twice in the twenty-four hours. An equivalent dose is f.^ss of the fresh infusion, or gr. j of the powdered leaves. The patient, before taking such a dose, must be kept recumbent at least half an hour, and kept so for two hours after. Dr. M. hesitates to pre- scribe a larger dose than ni,xv of the tincture to any patient following his occupation, and believes that half-drachm doses of the tincture, re- peated several times at short intervals, especially in the upright posi- tion, may dangerously interfere with the circulation, whether by over- stimulation or partial paresis. But, given in the manner directed, no accumulative action has been observed. Jaborandi. Prof. Rienzi has exhibited powdered jaborandi about 3J daily in divided doses in cases of aortic insufficiency with dyspnoea and pain- ful palpitations. After a day's treatment, the sounds were lessened, the pulse was less frequent, and the painful palpitations had ceased. (Compend. of. Med., 1884.) Morphia has been employed hypodermically by Dr. Clifford Allbut (Prac- titioner, December, 1869,) with marked advantage in diseases of the heart. He gives the injection in the evening, and enjoins perfect quiet afterward. His commencing dose is gr. ^ or J^ of the muriate, in- creased, in ordinary cases, to gr. ]^ for an adult. He finds it valuable in mitral regurgitation, but less valuable in mitral obstruction and in disease of the aortic valves ; but in aortic disease, when the heart is big and pumping, it gives much ease. The urine, however, should always be examined, and the morphia given with caution or withheld, if albumen be found. Prof. Bartholow also recommends morphia, hypodermically, in mitral disease, but is opposed to its employment in narrowing or obstruction of the aortic orifice. Nitroglycerine is of great value in cases of cardiac failure, in urgent cases ad- ministered hypodermically, one drop of a one per cent, solution. Quebracho Aspidosperma is reported to act potently in cardiac dyspnoea, Dr. Mariana Y. Lanion gives the following results from his study of it (London Med. Record, 1883). i. Quebracho diminishes the fre- quency of the respirations and cardiac contractions. 2. Its action appears to be principally directed to the heart, strengthening and reg- ulating its contractions, either directly or by the influence of the ner- vous system. 3. This action is evident and immediate. 4. It is the only remedy which has a manifest antidyspnoeic action. Other reports to the same effect are given in The Newer Materia Medica, 1884, issued by Parke, Davis & Co., Detroit, who prepare the drug for medi- cal purposes. Senega, combined with some other diuretic, is recommended by Dr. Barlow in valvular disease of the heart, to promote the action of the kidneys and relieve the palpitation, especially the palpitation arising from aortic disease. He employs the following formula : 208 DISEASES OF THE CIRCULATORY SYSTEM. 340. R. Spiritfls setheris compositi, f.5ij Tincturae hyoscyami, '■^j*' Decocti senegas, ^'pl'j Misturae camphorse, q. s., ad f. 3 iv. M. Take one-fourth thrice daily. Strophanthus is of importance second only to that of digitalis as a cardiac tonic ; it is to be used where continued medication is required, not having the cumulative effect seen in case of digitalis (although this statement is denied by some observers). It may be administered in doses of ten drops of the tincture (i in 10), or may be given in pill as follows : 341. R. Pnlveris strophanthi seminis, S'-.t Extracti gentianse, gr.j. • M. Ft. massa ex qua ft. pilula. Sig : Such a pill thrice daily. Tinctura Ferri Chloridi is recommended in chronic valvular disease by var- ious writers : given in long-continued small doses, as directed for fatty degeneration. Veratrum Viride is often employed with benefit to the pulse. Zinci Sulphas is favorably spoken of by Dr. Barlow in mitral disease. He employs : 342. R. Zinci sulphatis, gr. iij Extracti lupuli, gr. TJ. M. Make six pills. Take one thrice daily. The dose of the zinc should be gradually in- creased to gr. iij. When there is much palpitation, he advises its combination with camphor. 343- R- Zinci sulphatis, gr. j-iij Camphorse, gr, j Extracti hyoscyami, gr. ij. M. Make two pills. Take thrice daily. When there is much irritability of the stomach, the iodide should be substituted for the sulphate. Diuretics are found beneficial by Dr. Hope, in every stage of valvular disease of the heart. They draw off the serous portions of the blood, diminish the quantity without deteriorating the quality of that fluid, and thus reUeve palpitation and dyspnoea, and obviate infiltration, without ma- terially reducing the strength. PART III. • DISEASES OF THE DIGESTIVE SYSTEM,* Appetite, Loss of^Biliary Calculi — Cholera Asiatica — Colic (Flat- ulence, Ileus, Colica Pictonum) — Constipation, Habitual— Diarrhoea (acute, chrofiic) — Dysentery (acute, chronic) — Dyspepsia — Gastritis and Gastro- Enteritis — Gastric Ulcer — Hematemesis — Hepatitis (acute) — Hepatic Cirrhosis — Intestinal Worms — Jaundice — Liver : Functional Disorders of— Peritonitis — Pyrosis — Typhlitis — Vomit- ing. APPETITE. LOSS OF. Although this is merely a symptom, and not a disease, the physi- cian is constantly consulted with reference to it. Hygienic measures are those which are indicated in simple anorexia, and will generally suffice. Most of the " bitters," as calumba, gentian, quassia, chiretta, cas- carilla, etc., are popular agents to increase the appetite. They exert a slight irritant action on the stomach, and in this indirect way assist both appetite and digestion. They should be taken a short time be- fore food, as their effect soon wears off. Cinchona or quinine is an excellent sharpener of the appetite, and also assists digestion. It is particularly useful in the case of elderly people and inhabitants of towns, who have been "run down" by confinement,'sedentary occupations and impure air. DR. N. GALLOIS, PARIS. 344. R. Tincturae nucis vomicae, gtt. v Extracti gentianae. gr- xv Syrupi aurantii corticis, f- § iss Vini cinchonae, f- § v. M. One-half to be taken half an hour before each of the two principal meals, in order to awaken the appetite. * Note.— Diseases of the Teeth, Oral Cavity and Pharynx, including Tonsillitis, Pharyn- gitis, Caries, Odontalgia, Goitre, etc., are treated of in Napheys' Surgical Therapeutics, Chap. X. 14 (209) 2IO ■ DISEASES OF THE DIGESTIVE SYSTEM. 345. R. Rhei, gr.xxxv Aloes Socotrinse, gr- xx^ Myrrhse, Saponis, aa 9j Spiritfls menthse piperitse, fljij Extract! taraxaci, 9'j- M. Divide into forty-five pills; and order from one to three at a dose, as laxatives, and to stimulate the functions of the stomach. 346. R. Aloes Socotrina;, gr. xyj Ipecacuanhse, gr- vijss Zingiberis, gr- xxv Syrupi, q- =>- M. Divide into sixteen pills; order one a day, before dinner, to stimulate the appetite and regulate the system. 347. R. Fel. bovini purificati, 9iv Ferri carbonatis, 3ss Rhei, Extracti gentianse, aa 9iv. M. Divide into one hundred and twenty pills; order six or ten a day, to combat a want of appetite. DR. REECE, FRANCE. 348. R. Sodii carbonatis exsiccatae, 9j Extracti gentianse, 3ij Zingiberis, gr. xij. M. Divide into thirty-six pills, and order two morning and evening, as absorbents and stomachics. PROF. FONSSAGRIVES, MONTPELLIER, FRANCE. 349. R. Extracti cinchonse ilavse, 3^^ "rtncturae nucis vomicje, gtt. v Syrupi aurantii corticis, f. § iss Claret wine, f. | viij. M. Take several tablespoonfuls at the commencement of the meals, to stimulate the appetite. LONDON HOSPITAL. 350. R. Pulveris anthemidis, § ss Pulveris rhei, Pulveris zingiberis, aa § ij. M. Divide into sixteen powders. Take one a day, an hour before or after meals, to stimulate the appetite and facilitate digestion. DR. HUSS, FRANCE. 351. R. Pulveris nucis vomicae, gr. xv-xx Pulveris quassis, Cretae prseparatae, ii 553. m. Divide into twenty powders, and order one three times a day, half an hour before each meal, to stimulate the appetite and favor digestion. BILIARY CALCULUS. 2 II BILIARY CALCULUS. DR. GEORGE HARLEY, OF LONDON. This author states that it is very easy to prevent the formation of gall-stones, because in the majority of cases cholesterin is their chief ingredient, and the abnormal formation of cholesterin can readily be prevented by foods and medicines. " Let the patient avoid an ex- cess of fatty or fat-forming foods, either liquid or solid." Sugar and starch are to be especially avoided. Alkalies, especially carbonate of soda, will prevent the formation of gall-stones. In connection with the warm bath to favor the expulsion of gall- stones. Dr. Harley recommends opium and belladonna, given every two hours until their physiological effects are produced. Belladonna may be used in form of liniment, plaster or suppository. Gentle friction with the warm hand from right to left, but not from left to right, over the seat of acute pain, together with kneading pressure downwards from gall bladder towards navel, may also be had re- course to ; and during the whole time this treatment is being carried out, let the patient drink freely of alkaline warm water. He usually recommends a teaspoonful of bicarbonate of soda to the tumbler of warm water or milk and water. The administration of a brisk alka- line mercurial purgative ought under no circumstances to be omitted. He uses 352. R. Pulv. hydrarg. c. creta, gr. viij Pulv. rhei, gr. iv Magnesia;, 9j- M. When head symptoms supervene, he gives repeated doses of 353- R- Ammonii chloridi, gr- ^ Pulv. antimonialis, gr- "j Aq. sambuci, 3 ss. M. DR. JOHN A. OUCHTERLONY, KENTUCKY. This practitioner records his observations in thirty-five cases of chole-lithiasis. ( Transactions of the Kentucky State Medical Society, 1877.) The indications are two : first, to relieve the pain during the attack ; and, secondly, to prevent its recurrence. I. For the immediate relief of the patient, hypodermic injections of morphia are most appropriate. Opiates should never be given by the mouth nor in solid form for the relief of gall-stone colic. In 212 DISEASES OF THE DIGESTIVE SYSTEM. some cases where the pain is so atrocious that morphia seems to be inadequate, chloroform or ether may be given by inhalation. Chlo- roform has also been given internally, f.5j every hour, while the pain lasted, and as much after each meal for five days longer. It is as- serted to melt away gall-stones of considerable size. Such large doses of chloroform may, however, produce alarming symptoms, and must be used with caution. The general prolonged hot bath is sometimes of signal benefit. Surrounding the patient's waist with a sheet wrung out of hot water is a good substitute. Leeches to the sides are sometimes effectual when other measures fail. Emetics ought to be rigorously proscribed. 2. To prevent the recurrence of the paroxysm, any gall-stones re- maining in the gall-bladder must be dissolved, and their formation prevented. The diet must be carefully watched. Highly-seasoned food, malt liquors, fats, sweets and rich viands must be forbidden. The meals should be at short intervals, thfee or four a day. As a remedial measure to prevent the formation of the stones. Dr. BUCKLER has proposed succinic acid and peroxide of iron, on account of the large amount of oxygen contained in both of them, which is almost want- ing in cholesterine. These can be combined in the hydrated succi- nate of peroxide of iron, and should be taken continuously for six months according to the following formula : 354. R. Hydrated succinate of peroxide of iron, §vss Distilled water, f. § vjss. M. A teaspoonful after each meal. In almost every case Dr. OucHTERLONY has used this salt with complete success. (Dr. Buckler's article is in the American Journal of the Medical Sciences, July, 1867.) Carlsbad, Vichy, or Marienbad waters, and their counterparts in this country, are useful. A remedy much employed and with good results by the late Dr. Lewis Rogers, of Louisville, is : 355- R- Ammonii muriatis, Extracti taraxaci, ££ § js Aquae, fcgvj. M. A dessertspoonful three times a day. BILIARY CALCULUS. 213 DR. SIEGFRIED ROSENBERG, OF BERLIN. (Therap. Monatsheften, 1889.) The treatment of biliary colic by the exhibition of large doses of sweet oil is not due to this physician especially, having been proposed long since; but in his suggestions as to the manner of its action there is a degree of probability which justifies the use of his name in connection with the method. He states that there is no specific action of the oil directly on the cal- culi which are causing the pain, but that sweet oil or any other fatty substance is perhaps the most powerful cholagogue of which we know. When a considerable quantity of fat is introduced into the stomach, a corresponding amount of bile is excreted for its proper solution, as has been proved experimentally upon animals. This great increase in the biliary flow causes a mechanical pressure tend- ing to gradually distend the ducts, and, too, perhaps exerts a pro- pulsive power upon the engaged calculus. The fact that there is an important influence is too well known to be seriously disputed. Dr. Rosenberg suggests the following method of administration: 356. R. Sweet oil, f-Sv-vij Brandy, f- i ss Menthol, f-3ss Yolks of two eggs worked smoothly in. Sig. — One dose. It had best be taken an ounce at a time in such a way that the whole is consumed in about tbiree or four hours. The patient is kept in bed; morphia may be required if pain becomes intense. DR. JAMES E. JACKSON, PENNSYLVANIA. This practitioner states that the following combination forms the most active solvent for gall-stones, biliary secretions, etc., he has ever tried. In connection with its use the patient should avoid meat and fats, and confine himself to a milk and vegetable diet : 357. R. Chloroformi, ££ f5ss j^thens sulphunci, W 1. 1 ss Olei terebinthinae, *;?.J Sacchari albi, ^2' Mucilaginis acacise, A teaspoonful three times a day. f.§ij. M. DR. DURAND, PARIS, 358. R. Olei terebinthins, ^-llJJ y. iEtheris sulphunci, '• ^ '' Haifa teaspoonful night and morning. This is the celebrated "solvent" of DURAND, endorsed by TrouS- 214 DISEASES OF THK DIGESTIVE SYSTEM. SEAU. It has unquestionable utility as a preventive of the recurrence of an attack. Alkaline drinks, such as Vichy water, or, as Dr. ProUT recommends, bicarbonate of soda, 3ij, in warm water, Oj, aid its action. PROF. STILLER, OF BUDA-PESTH. (Provincial Med. Jour., 1890.) Professor STILLER states that salicylate of sodium has remarkable cholagogue powers, and believes that not a little of its influence over the rheumatic process is con- nected with this. He has found that the drug is of great service in cholelithiasis, both aiding in the solution of the calculus, and also in quickly relieving the pain. He thinks this action to be due to its quickly increasing the quantity of the bile and decreasing its con- sistency, and gradually dilating the ducts as well as exerting solvent action. The dose during the paroxysm is about seven or eight grains four times daily ; the patient is kept in bed and on light but nutritious diet. There may not improbably arise necessity for the use of mor- phia in the paroxysms of pain. The following formula is given (Rev. Gen. de Clin, et de Therap., 1 89 1,) based upon the above as well as upon the experience of oth- ers, in the treatment of the interval. In the paroxysm of the colic the salicylate should be increased. 359- R- Sodii benzoatis, Sodii salicylatis, ii gr. Ixxr Pulveris nucis vomicae, gr. vij. M. Fiat pulvis dividenda in chartulas, no. xx. Sig : One thrice daily for two months. HUCHARD (La Med. Mod., 1891,) modifies this as follows: 360. R. Sodii benzoatis, Sodii salicylatis, Pulveris rhei, ££ 5: Extracti nucis vomicae, or. y. M. Ft. tabllae, no. xx. Sig : One at each meal. NOTES ON REMEDIES. Belladonna. Dr. Murchison highly recommends the extract of belladonna, in half-grain doses, every two or three hours, in the passage of gall- stones. BILIARY CALCULUS. 21 5 Benzoic Acid. 361. JJ. Acidi benzoici, Jij Potassse causticae, 5ss (vel. liq. p. 5ss) Aqua destil., f. § vj. M. Dissolved with heat, and a tablespoonful taken in water tbrice a day. The abgve is highly recommended by Dr. Harley, in the treatment of impacted gall-stones. Bile. The administration of bile, as in the form of the inspissated bile, or enclosed in capsules, is recommended as one of the most powerful cholagogues, and is sometimes successful when ordinary measures fail. Chloral is frequently employed with advantage, on account of its producing muscular relaxation. Chloroform by the mouth, or in the form of inhalation, relieves pain, dimin- ishes spasm, and does not interfere with the onward propulsion of the stone. It is also believed to prevent the formation of stones. D. BouCHUT gives : 362. R. Chloroformi, f.Sijss Alcoholis diluti, f.lijss Syrupi acacia, f.§viij. M. A small wineglassful thrice daily, to persons subject to hepatic colic. Abstinence from fats, oils, fatty food, and strong wine. Dr. ToURASSE prescribes : 363. R. Chloroformi, J-3ss Olei amylgdalse dulcis, f-3] Syrupi acaciae, ■• 3 'ss. M. To be well shaken. A tablespoonful every quarter or half hour, in hepatic colic. Ether, internally, has been recommended on account of its power of dissolv- ing cholesterine, as well as because of its anti-spasmodic properties. A combination of equal parts of turpentine and ether constitutes the well-known remedy of Durand for the solution and cure of biliary calculi. Olive Oil. Olive oil is frequently prescribed with good effect to facilitate the passage of gall-stones through the intestines. It should be given in large doses if expected to be of service, five or six ounces within a few hours. opium in full doses (gr. ij, or gtt. xl of laudanum) by the mouth or rectum, repeated in half an hour, if necessary, generally reheves the mtense pain attending the passage of biliary calculi better than any other remedy. It should be combined with the use of the hot-bath. The administration of ether or chloroform may also be advantageously re- sorted to The hypodermic infection of morphia (gr. X), repeatea, 11 necessary, is particularly useful from the rapidity of its action Podophyllin, gr. y, daily, is recommended by Prof. Bufaum. It should be continued for many months. 2l6 DISEASES OF THE DIGESTINE SYSTEM. Potassium Chlorate has been suggested as having some value aa a cholagogue: and possibly of service in cholelithiasis. It is, however, not, sufficiently stimulant to the flow of bile to produce any mechanical interference, and is probably of little or no value. Saline Mineral Waters, such as Carlsbad, especially the Sprudel Spring there, are extremely useful, if taken steadily, and supported by a strict regi- men. All fat, butter, cheese, rich meats, spices, salt fish and meat, strong tea, coffee, and alcoholic beverages, must be strictly excluded. " Sprudel Salts " may be used instead of the natural water. ■Sodii Phosphas, in doses of 3j-.^j, administered for several months, before each meal, has been found by Bartholow to be extremely efficacious in preventing the recurrence of attacks of hepatic colic. It is believed to act by relieving the catarrh of the duodenum which is present in most of these cases, and, by transference to the gall-bladder, forms a nucleus of mucus and bile, around which the cholesterine cr)'stallizes. Sodii Salicylas, and Sodii .Benzoas, in doses of six or eight grains four times daily, have been commended in the treatment of biliary calculi by Stiller, Binet, and others. Nitro-Muriatic Acid Baths are a valuable remedy. The right hypochondrium may be repeatedly bathed with a solution of the acid, f.giij to a gallon of water, and the whole person rubbed down with it. Or a flannel roller, ten or twelve inches wide, and long enough to encircle the body twice, may be moistened with the fluid and worn around the waist. CHOLERA ASIATICA. DR. ROLAND G. CURTIN, OF PHILADELPHIA. In a series of observations by this eminent physician upon Asiatic cholera in an epidemic in Bleckley Hospital, the disease was found distinctly amenable to the use of sulphuric acid lemonade. A num- ber of cases had appeared in the Insane Department, but when the acid treatment was begun it promptly ceased, and no further cases arose except one, in a man who persistently refused to drink the acid beverage. Later the treatment was suspended and several cases at once appeared ; the sulphuric acid was once more placed in the wards for the use of the patients, and the disease disappeared. Cases already developed appeared to be very favorably influenced by the diluted acid ; and from this experience and that of others, it seems to have a decided prophylactic effect. It is made by adding CHOLERA ASIATICA. ,,_ to clean (best boiled) sweetened water, sufficient sulphuric acid to render it decidedly acid to the taste. PROF. CANTANI. (Therap. Monatshefte, 1888.) Basing his views upon the more recent views of the aetiology of Asiatic cholera, this eminent ob- server recognizes the following indications in the treatment of the disease: (i) Against the deposition or multiplication of bacilli in the intestines; (2) neutralization of the chemical poison developed in the intestine and its rapid removal from the blood; (3) and against the thickening of the blood due to the rapid withdrawal from the body of large quantities of fluid in the dejecta. He practises enteroclysis after each evacuation. To two quarts of water of a temperature of 100° to 104° F., one drachm to half an ounce of tannin is added, with somewhat over an ounce of acacia and about thirty drops of Sydenham's laudanum. In some in- stances a single injection sufficed to cure the case; and the mortal- ity rate is decidedly better than in the ordinary modes of treatment. The third indication he meets by the subcutaneous injection of a saline solution of a temperature of ioo°-i04° F., made as follows: 364. ]J. Sodii carbonatis, gr. xl Sodii chloridi, 3j Aquae destillatae, f. § iv. M. In the report of the Chilian government on cholera, in 1887 and 1888, this method is favorably spoken of. Where the injections were not successful after three or four instances, at intervals of sev- eral hours, and the stools began to get bloody, the prognosis be- came very grave ; and then the following injection was given : 365. R. Pulveris ipecacuanha;, gr. xxx Aqu£e destillatic, Oij. Ft. injectio. (Let stand two hours before use.) For the cramps, dry friction and mustard and turpentine applica- tions, and when severe, ice frictions are recommended. For vomit- ing, ice pellets, iced champagne, tincture of iodine in water, are said to be of service. In the beginning of the cold stage, the Chilian Report recommends ether, camphor and caffein subcutaneously, dry frictions and mustard plasters, hot bottles, no food. Where the cold stage is established and asphyxia becoming evident, large saline 2l8 DISEASES OF THE DIGESTIVE SYSTEM. hypodermic injections of about the same character as the above are commended, the amount varying from one to six ounces according to the state of the pulse. If this failed, injecting warm salines into the peritoneal cavity was found to have a good effect in some cases. Ice frictions, ice-bags to head and spine, are found of value in the third stage where blood stasis is beginning. Where suppression of urine is marked, simple diuretics are indi- cated. In the beginning of the attack the Chilian Report recommends a full dose of calomel followed after an hour by castor oil. Diet is carefully restricted. The diarrhoea continuing, stimulants and car- minatives and acid lemonades are commended, muriatic or sul- phuric acid. THE MEDICAL STAFF, U. S. ARMY. The classical work on The Cholera Epidemic of i8yj, in the United States, mainly prepared by Dr. ELY McClellan, U. S. A., contains the well-digested experience of practitioners during the last cholera epidemic in this country. We quote some of the most successful measures adopted. Dr. R. W. Mitchell, of Memphis, Tenn., writes: "When satis- fied that I had cholera to contend with, as indicated by rice-water discharges, vomiting, cramps, and shrinkage of extremities, I ceased medication by the stomach, and used the formula given, hypo- dermically : 366. R. Acidi sulphurici, f. 3ss Morphise sulphat., gr. ^ Spititfls vini gallici, f. 3 iss Aquae destillato:, f. § iij. M. "The above was injected under the skin of thje arms, legs, and over the stomach, every hour until the symptoms of the disea'se were relieved." Dr. G. B. Thurston, of Memphis, Tenn., writes: "The general treatment that I adopted was about as follows : Calomel and opium in alterative doses, say in two of the former to one of the latter, re- peated every hour for several hours. In conjunction with this, used the following : 367. K. Extracti cannabis indicae, gr. xvj Camphorae, 5ss Chloroformi, f.§ss Olei terebinthinae, f.3ij Mucilag. acacise, Syrupi simplicis, aa f . § ss Aqua; cinnamomi, f-§j. Dose, a tablespoonful every one or two hours." M. CHOLERA ASIATICA. 210 Dr. J. T. JONES, of Nashville, Tenn., reports that, in the cold stage of cholera he has used creasote with greater success than any other article of the materia medica, and suggests the following formula: 368. R. Creasoti, Aquae camphoree, ^ ^ Infusi gentianas compositi, aa f.3vi. M At a dose, and repeated every two hours. Dr. S. T. Chandler, of Campbellsville, Ky.. who treated, during the epidemic of cholera in 1854, some sixty to seventy cases of the disease in its various stages, records his experience as having been largely in favor of the use of dilute sulphuric acid, in full doses, and repeated every fifteen to thirty minutes, until the vomiting' and purging are arrested. In the epidemic of the year 1873, the same plan of treatment was adopted, and with like results. "The acid relieves the nausea, arrests the vomiting like a charm, and gradually the dejections are stopped." Dr. McClellan adds, that the necessity of instituting treatment at the earliest moment after the occurrence of a diarrhoea, was most generally recognized throughout the area of infection. Whenever physicians, during the progress of the epidemic, ceased the attempt to diagnose between cholera, cholera-morbus and diarrhoea, and treated all cases that occurred as cases of cholera, the lists of mor- tality were reduced ; while, on the other hand, increasing mortality was shown whenever too great reliance was placed upon diagnostic powers. The evidence is conclusive that the exhibition of opium, followed by alterative doses of calomel, and absolute rest in the recumbent posture, almost invariably arrested the disease when in the premoni- tory stage. In the advanced stages, the entire range of the Pharm- acopoeia seems to have been brought into use, with no better results than had been obtained in previous epidemics. The experience of the writer is strongly corroborative of the bene- ficial results which may be obtained from the use of sulphate of iron and dilute sulphuric acid as prophylactics during an epidemic of cholera ; and, further, that the most successful treatment of the dis- ease is to be found only in all that is implied in the word sanitation. Dr. John M. Woodworth, Supervising Surgeon U. S. Marine Hospital Service, records the experience of his department in the following language: " Beginning with the year 1814, the cholera literature down to the present time abounds in proofs, clinical, phys- 220 DISEASES OF THE DIGESTIVE SYSTEM. iological, pathological and meteorological, of the efficacy o{ sulphuric acid; and there can be no doubt, despite the dicta of the last Inter- national Sanitary Conference, that we possess in the mineral acids a certain means of prophylaxis against cholera. The lessons of the epidemic of 1873 point strongly to the value of sulphuric acid even as a therapeutic agent against the disease. According to Dr. Mc- Clellan, mortality among cholera patients treated with acids was only eight per cent, whilst the lowest mortality rate where other remedies were used was twenty-three per cent., and the highest fifty- nine per cent. SURGEON-MAJOR G. C. ROSS, BRITISH MEDICAL SERVICE IN INDIA. (Indian Medical Gas, 1890.) This physician recommends that the disease be met with subcutaneous injections of atropine and morphine. The former of these alkaloids is known to be antagon- istic to muscarine, an alkaloid producing much the same train of symptoms as met in Asiatic cholera and found in cultures of the cholera spirillum. As intestinal disinfectants, phenol and sulphuric acid are recommended. The diet of the patient should be rice water and ice. DR. WILLIAM STEVENS, LONDON. This author, in two epidemics, claims to have had very successful results from the saline treatment, in his hospital and prison patients. Cases presenting premonitory symptoms — diarrhoea and vomiting — were removed into an observation ward, where an even temperature was constantly maintained. A Seidlitz powder was immediately ad- ministered ; if sinking was felt, without purging, three or four tea- spoonfuls of Epsom salts were added to the powder. On these agents acting, plenty of thin beef tea, well seasoned with salt, was given ; if there was any pain, a sinapism was applied to the gastric region ; and thirst was relieved with Seltzer water, soda, or pure water ad libitum. Most of these cases were thus cured. If, however, cramps, coldness or shrinking of the pulse came on, the patients were considered as cholera cases in the second degree. The follow- ing was then administered : 369- R- Sodii chloridi, Jij Sodii carbonatis, Jjj Potassii chloratis, g;; ■ Two tablespoonfuls in water about every half-hour. CHOLERA ASIATICA. 221 If there was much irritability of stomach, a large sinapism was applied ; if much heat or burning pain, an additional quantity of carbonate of soda was added to the mixture. In cases in the stage of collapse, a strong solution of the same salts, dissolved in hot water (ioo° F.) was thrown into the bowels, and repeated every two or three hours. Sinapisms were also applied to the stomach, be- tween the shoulders, etc. ; and in the cold stage, frictions with warm towels were used. A pure air for the patient to breathe was con- sidered of the greatest importance. In mild cases, the " wet-sheet-envelope " will favor reaction, but it has only proved mischievous in severe instances. When the vomit- ing is severe, or the thirst insatiable, nothing gives more relief than permitting ice to be continually sucked. The patient is also to be isolated as far as possible. He is to have plenty of fresh air ; and care must be taken that the water he drinks is uncontaminated — particularly, that it has not been drawn from a well near any sewer. Moreover, his excreta should be received in a pan containing a dis- infecting fluid, and then at once thrown away. The greatest caution will subsequently be required for many days as to diet ; not a few deaths have occurred from the too early use of animal food. As a rule, broths and farinaceous substances only should be allowed, without any solids whatever, until the renal secre- tion has been fully re-established, and all the symptoms have vanished. WILLIAM SEDGWICK, M. R. C. S., ETC., LONDON. Our author strongly recommends (the Lancet, August 19, 1871,) dilute phosphoric acid in half-drachm doses, combined with syrup of orange, and largely diluted with ice-water. In cases of choleraic diarrhoea, and in the early stage of confirmed cholera, this remedy appears to be capable of checking the progress of the disease with greater certainty than sulphuric acid. . GEORGE JOHNSON, M. D., F. R. C. P. (Professor of Medicine in King's College, London ; Physician to King's College Hospital, etc.) In the treatment of cholera and chol- eraic diarrhoea, which is, in fact, cholera in a mild form, the main principle to bear in mind is, that the discharges are as essentially curative as is the eruption of small-pox. The discharges are not to be abruptly stopped by opiates. Experience has abundantly proved 222 DISEASES OF THE DIGESTIVE SYSTEM. that this is a pernicious practice. Neither are they to be permitted to accumulate in the alimentary canal. There is one remedy which is almost universally applicable in all forms and stages of the disease, and that is an abundant supply of cold water, to flush the intestinal sewer and to wash out the poisonous discharges. A copious im- bibition of pure cold water will suffice for the cure of most curable cases. Palpitation and percussion of the abdomen reveal the fact that there occurs not unfrequently a painful and sometimes a paralyzing over-distention of the bowel by rapidly effused morbid secretion. This, if not promptly relieved, may even go to the extent of causing a fatal obstruction. More especially is this likely to happen when the sensibility of the bowel has been deadened by opium. The plan to prevent and to remove this accumulation is to give some quickly- acting yet unirritating evacuant dose. For this purpose, castor oil is, on the whole, better suited than any other remedy. He directs, as early in the premonitory diarrhoea as possible, a tablespoonful of castor oil in a mixture of orange or lemon juice and water, or cold water, or other convenient vehicle. If this be vomited, it should be again given, and the patient directed to lie still and take no more liquid for half an hour, by which time the oil will have passed from the stomach into the bowels. Within an hour or two, the oil will usually have acted freely, when a tablespoonful of brandy, in thin arrowroot or gruel, is given ; and if there be much feeling of irrita- tion, with a sense of sinking, gtt. v— x of tincture of opium, in cold water. In this manner, most cases of choleraic diarrhoea are promptly arrested. Rhubarb (gr. xv of the powder, or f.3ss of the tincture) may be employed, if objections exist to castor oil. If vomiting be present, it should be encouraged by copious draughts of tepid water; and if nausea exists without vomiting, especially if the stomach is supposed to contain undigested or unwholesome food, or morbid secretions, an emetic is advised (gr. xx of ipecacuanha, or a tea- spoonful of mustard, or a tablespoonful of common salt). The time to give opium, if at all, is in small doses, to soothe the bowel, after the expulsion of the poisonous secretions. Opiates are useless, or even dangerous, when the blood is poisoned, or when the bowel contains offensive morbid secretions. Opiates, in the early stages of diarrhoea and cholera, would be more frequently and de- cidedly injurious, were it not for the fact that their absorption is prevented by the rapid current of liquid which is being passed from CHOLERA ASIATICA. 223 the blood into the alimentary canal ; therefore, they are quickly ex- pelled, together with the morbid secretions, and they are powerless to arrest the discharges. (The British Medical Journal, August 19, 1871.) Sir Thomas Watson, Bart., M. D., etc., states, in the last edition of his Practice, that he firmly believes that the doctrines advanced by Dr. JOHNSTON are well founded, and approves his rules of treat- ment. No doubt the true indication of treatment is to stop the flow as soon as possible ; but this may sometimes be best effected (as also in crapulous diarrhoea, and in the summer cholera of Syden- ham,) by carrying off the offending matter. JOHN MURRAY, M. D., Inspector-General of Hospitals, Indian Medical Service. When irritating or indigestible food in the bowels is the cause, as is fre- quently the case, of the early diarrhoea, it should be removed, if it has not previously been discharged in the evacuations, and a recur- rence of the looseness guarded against. For this purpose, our author recommends the following cholera pill : 370- R. Pulveris opii, gr. j Piperis, gr. ij Assafcetidae, gr. iij. M. To make one pill. It appears to check the looseness and stimulate the secretions, and does no harm if needlessly exhibited. It should be repeated should the looseness continue. It will cure most cases, and in all, restrain the symptoms until regular medical advice can be procured. It may be distributed to every house, and be available in a few minutes, whereas the delay of a few hours may allow the disease to advance beyond control. These pills have been distributed in tens of thou- sands, in the towns and villages of India, with most satisfactory re- sults. Some surgeons prefer red to black pepper, and others add camphor to the opium and assafoetida, and report favorably of the combination. They are distributed in the dispensaries and placed in the charge of the police in India. (The British Medical Journal, August 1 2th, 1 87 1.) In a discussion at the thirty-ninth annual meeting of the British Medical Association, between Drs. JOHN MURRAY and GEORGE Johnson, Dr. M. stated that Dr. JOHNSON seemed to confound 224 DISEASES OF THE DIGESTIVE SYSTEM. elimination with purgation, and that nature was best assisted by re- straining the further advance of the disease, of which the most dan- gerous symptom is looseness, whether naturally induced by indiges- tion, by improper food, or by purgative remedies. Dr. JOHNSON said that the main difference between Dr. M. and himself was with regard to the treatment of the early stage of cholera. Dr. M. consid- ering evacuants dangerous and opiates safe, while he (Dr. J.) held an opposite opinion with regard to both classes of remedies. (The British Medical Journal, August 26, 1871.) DR. EDWARD R. SQUIBB, BROOKLYN. 371. R. Tincturse opii, depurat., Spirit, camphorse, Tinct. capsici, ii f. § j Chloroformi purificat., f. 3 "j Alcohol, 95 per cent., q. s. to f. § v. M. Each fluid drachm or teaspoonful contains about one hundred drops, consisting of twelve minims of each of the first three ingredients, and four and a half minims, oi eighteen drops, of the chloroform. Dose, for persons over eighteen years of age, n teaspoonful; for persons fourteen to eighteen years of age, a small teaspoonful; for persons ten to fourteen years of age, half a teaspoonful; for persons six to ten years of age, thirty drops; for persons two to six years of age, ten to thirty drops; for infants, one to ten drops, according to age. To be taken in water. In time of epidemic cholera or diarrhoea, when any person has two movements of the bowels more than natural within twenty-four hours, the second one should be followed by a dose of this mixture ; the dose to be repeated after every movement that follows. If the movements increase in frequency, or in copiousness, after a second dose of the medicine has been taken, a physician should be sent for at once, and a double dose be taken after each movement, until he arrives. Immediately after taking the first dose, the person should %o to bed, and remain there for twelve hours after diarrhoea has entirely ceased. Made a little more dilute to adapt it better to extended popular use, it was largely applied in the last epidemic of cholera by the Metro- politan Board of Health of New York, and by the Boards of Health of some other cities, and appears to have accomplished all that could be reasonably expected from any arbitrary formula. INOSEMZEFF'S ANTI-CHOLERA TINCTURE. According to Dehio (Pharm. Zeitsch.f. Russland, 1889), the fol- lowing is the formula for this famous mixture : CHOLERA ASIATICA. 225 372. R- Tincturae rhei compositse, Hlv " " spirituosis, niij " opii, " Valerianx aetherosi, " menttjai piperiUe, Spiritfls aetheris compositos, aa f.§ij Olei menthse piperitze, Tt^xxiT Extracti niicis vomicce, gr. ivss. M. Dose. — Fifteen to twenty drops. HAMLIN'S CHOLERA MIXTURE. No I. 373- K- TincturjB opii, Tincturse camphorse, aa I part Tinctura; rhei, 2 parts. M. No. 2. 374- R- Tincturje opii, Tincturse capsici, TincturjE cardamom, co., Ginger, aa equal parts. M. RUSCHENBERGER'S CHOLERA MIXTURE. 375- R- Tinctune zingiber!, Tincturre capsici, Tincturtc pij>eritse, Tincturje opii, CHLORODYNE. aa equal parts. 376. B- Chloroformi, Spiritus aetheris sulphurici, Olei menthze niperitee, f.§ss f.Siss gtt. viij Oleo-resince capsici, Extracti cannabis indicie. gtt. ij gr- vj Korphise muriatis, Acidi hydrocyanici diluti, Acidi hydrochlorici diluti, Glyceriiia: et mellis, aa gr. xvj THlxv f-5j I q. s. ad f. § iv. Dose. — Fifteen to twenty drops. M. M. DR. JOHN SULLIVAN, M. D., BRITISH INDIA. In his recent work on The Endemic Diseases of Tropical Climates, (London, 1877,) this writer altogether rejects the treatment of elimination. The plan he has found most successful is : First, to prescribe complete cessation from all labor and fatigue out of doors, and the adoption of the horizontal position on the very first appear- ance of diarrhoea. Secondly, arrest of diarrhoea, " whether it exists in the preliminary state, or whether it takes the form of rice-water evacuations;" and for this purpose he prefers the employment of IS 226 DISEASES OF THE DIGESTIVE SYSTEM. opium or laudanum, by means of suppositories and enemata. And, thirdly, he endeavors to supply the loss of fluid, by giving ad libitum "iced or cold water or tea;" and occasionally some moderately astringent cordial. DISINFECTING CHOLERA DEJECTA. In order to limit the epidemic influence of the disease as much as possible, careful disinfection of the stools should be performed. SCHANZ (Deut. Med. Woch., 1890,) states that in his experience while chlorinated lime is excellent for fluids, it has not sufficient penetrating power to be used where there are solids. He advises that acids be used for this purpose, and suggests the following : Of a mixture of three ounces of crude sulphuric acid (by weight) and one quart of water, one-sixth the volume of the stool should be added. Of a mixture of four and a half ounces of crude nitric acid, with the same amount of water, one-fourth the volume of the stool is re- quired. Of a mixture of eight ounces of crude muriatic acid and the same quantity of water, one-third volume is to be added. Of a five per cent, solution of carbolic acid, one-half volume should be added to the stool. NOTES ON REMEDIES. Acidum Sulphuricum is one of the most effective remedies in the treatment and prevention of the disease, given in form of a lemonade in frequent and large draughts. The other mineral acids are also used in the same manner with similar good effect. Aqua Ammonim, when inhaled or taken internally, largely diluted, is a usefiil stimulant and restorative in the collapse of cholera. Argenti Nitras has been recommended injected into the colon, by means of a long, flexible tube. The following solution is thus injected : 377. R. Argenti nitratis, gr. xyj Aquae destillatse, f. g jy. M. Ten minutes afterward the following enema is to be administered : ,78. R. Tincturae opii, f. 2iv ^™^'' figvj. M. Dr. Waring considers this treatment worthy of trial. In an epi- CHOLERA ASIATICA. 22/ demic of cholera in Assam, in 1053, Dr. Barry used nitrate of silver internally with great success, giving one grain after each stool. Arsenic. Fowler's solution v/ith opium is sometimes valuable. Atropice Sulphas, hypodermically, in dose gr. tbo-m, is recommended by Dr. Harley as one of the most appropriate and useful means of resuscita- tion in the collapse of cholera. It stands at the head of all our stimu- lants in such cases, for there is no medicine which approaches bella- donna in its simple, direct, immediate, and powerful influence in exalting the force and rapidity of the heart's action. Calomel, in small doses (iiy to ii of a grain every half hour), will sometimes check the vomiting. Camphor is recommended by Dr. Sydney Ringer, from personal experience. He gives six drops of a strong alcoholic solution of camphor every ten minutes, until the symptoms have abated, and then less frequently. By this treatment, he generally at once controlled the vomiting and diarrhoea, and often altogether checked them, removed the cramps, and restored warmth to the extremities. An Italian physician. Dr. RuBiNi, of Naples, is said to have treated with success nearly six hundred patients by a solution of camphor in alcohol at 60° over proof. The commencing dose was gtt. iv, every five minutes (in severe cases, gtt. xx, or more), persevered in until reaction set in, the patient being well wrapped up in blankets. It should be given in sugar, and not in water, as in the latter the camphor solidifies and loses its power. Cannabis Indica has been highly spoken of, n^x-xxx of the tincture being administered in repeated doses. Carbo Ligni, in drachm doses, has been employed with repeated benefit. Carbolic Acid, it is staled (Medical Press, January 22, 1868), proved suc- cessful. Chloral is highly effective by subcutaneous injection ; usually combined with morphia in the treatment of the cramps in the early stages. Chloroform, in doses of ni^v-viij every hour or half-hour, often arrests the vomiting and relieves the spasms and cramps in the early stages of cholera. When the vomiting is excessive, a little chloroform, on lint, placed over the epigastrium and covered with oiled silk or gutta percha, will frequently relieve it. Chloroform liniment, alone or with turpen- tine, diligently used, is very effectual against the spasms and cramps. The spasms are also quickly relieved by chloroform inhalations, stopped short of complete anaesthesia. In giving chloroform internally, some prefer to combine it with the carbonated alkalies, soda or potash (grs. xl— Ix) in solution ; others, with the oil of turpentine (hlxx-xxx.) Dr. T. M. LxJWNDi'S, of the Bombay army, advises (British Medical Jour- 228 DISEASES OF THE DIGESTIVE SYSTEM. nal, August 29th, 1868,) the following formula, which he has used for years in the treatment of choleraic diarrhoea, with the best results : 379. R- Chloroformi, lUxv-xx TincturjE opii, TUx-xv SpiritCls vini, f. 3j Aqu£e, f-§j. M. Chloroform, as a remedy in cholera, has the advantage that, being very volatile, it does not, like calomel and solid opium, accumulate in the stomach, and thus produce serious effects when reaction is estab- lished. Hydrargyri Chloridum Mite has, as Dr. Waring remarks, been given in cholera for upward of half a century, in every variety and stage of the disease, in every gradation of dose, from one grain to sixty, in almost every possible form of combination, with the view, by turns, of obtaining its purgative, or its cholagogue, or its stimulant, or its sedative action, and the reported results have been of the most diversified and unsatisfac- tory character. Dr. Ayre has reported great success from the follow- ing plan of treatment, which, probably, deserves the preference, if the mercury be employed at all ; grs. j-ij of calomel, with "l j-v of lauda- num, are given every five, ten or fifteen minutes, omitting the latter when the dose has reached sixty or eighty drops. Perhaps a great measure of the success recorded of this treatment is due to the patient being allowed to drink freely of cold water, the colder the better. During the state of collapse, the fact must not be lost sight of, in ad- ministering calomel and other powerful drugs, that the stomach has lost its power of absorption, exposing the patient to all the dangers of an accumulated drug when reaction sets in. General mercurial in- unction is another plan that has had its advocates. Ipecacuanha, as an emetic, at the outset of the attack, forms part of the elim- inative treatment recommended by some. Small repeated doses (gr. j-ij every fifteen or thirty minutes, until nausea is felt,) has been re- cently advised. The power of minute doses of ipecacuanha to arrest many forms of vomiting is now well known, and would seem to indi- cate its utility in cholera. Morphia, hypodermically. Dr. W. Bates relates a case (Lancet, August 21st, 1879,) treated with success by the subcutaneous use of morphia. It is useless in the malignant form, except to control pain. It probably is never curative in real cholera, if used alone. Oleum Ricini is the purgative par excellence employed by Dr. G. Johnson in the " eliminative treatment ;" and is used at present in the early stages of the disease as a routine. Cleum Terebinthince has been employed internally, as well as externally, with benefit. CHOLERA ASIATICA. 229 Opium, though still much employed in the earlier stages of the disease, alone or conjoined with the acetate of lead, or camphor, or calomel, is no longer regarded, as formerly, as the sheet-anchor in cholera. Its use in the solid form in large and repeated doses, in all stages of the dis- eare, is now nearly abandoned, in consequence of the inutility, and even danger, of its employment. In the liquid form, in very small doses, it frequently arrests the action of other remedies. Paracotcin, hypodermically, has been recently tried with success in Japan. Piper Nigrum is, it is said, often prescribed in cholera by the natives of India, in the form of an infusion of recently-roasted black pepper. A pop- ular Bengal cholera pill is the following : 380. R. Pulveris nigri, Assafoetidos, aa gr. j Camphora;, gr ij. M. For one pill. If given early, it is stated that it frequently arrests the disease. Plumbi Ace/as, in combination with opium, at first proposed by Dr. Graves, of Dublin, is very effectual at the outset of cholera in checking the diarrhifia. Dr. Fleming prefers combining the acetate of lead with a solution of acetate of morphia. Dr. E. Goodeve also prefers admin- istering the acetate in a fluid form, but gives the opium independently. He employs the following : 381. R. Plumbi acetatis, grs. xxx Acidi acetid, TUx Aqu£E destjllatas, f-§vj. M. Two or three tablespoonfuls every half hour or hour. Opium, in doses of one grain, repeated once or twice, is given separately. He limits, as a rule, the quantity of the acetate of lead to grs. x-xv, and of opium to grs. iij, in the first three hours. If the disease shows signs of yielding, the doses are to be diminished or stopped altogether. Poiassii Chloras is frequently employed. It forms part of the " saline treat- ment " of this disease. Sodii Chloridum was formerly given in large draughts of cold water, with the view of inducing emesis, and at the same time supplying the blood with the saline constitutents supposed to be carried out of the system in the evacuations. It is used with the carbonate and the hyposul- phite in the large warm saline subcutaneous or intraperitoneal injec- tions in the algid stage. Strychnia has been used with success. Sulphur was first suggested as a remedy by Dr. A. Blacklock, of the Madras army, in 1848. He recommended, also, as a prophylactic during epi- demics, sulphur internally, and a diet rich in sulphuretted ingredients. Dr. J. Grove (in his work On Epidemic Cholera, 1865,) highly praises this remedy, which he prescribes as follows : 230 DISEASES OF THE DIGESTIVE SYSTEM. 382. R. Sulphuris praecipitati, Sodii bicarbonas, aa § '^ . Spiritds lavandulae compositi, f. § xxir Aquae, f- i Ixxij. M. The soda and sulphur are to be first thoroughly triturated together, in a mortar, the spirit of lavender gradually added, till the whole is well mixed, when the water is added. Dose, two teaspoonfuls, in a Httle water, every two, three or four hours, in simple choleraic diarrhcsa ; but if the case is urgent, every ten or fifteen minutes. In sudden or severe attacks, tn,x-xxx of laud- anum are given with the first dose. GENERAL ^rEASURES. Ice in lumps and iced drinks, given ad libitum, are grateful to the patient and highly beneficial in relieving the burning heat at the pit of the stomach and the intolerable thirst, arresting the vomiting and exciting reaction. Frictions with ice relieve the cramps very considerably. Stimulants. Champagne, ammonia and turpentine are among the best, but weak brandy and water is sometimes retained better than any other stimulant. Turpentine Stupes applied hot successively to the abdomen, the cardiac region and along the spine and extremities, and turpentine frictions and enemas, are valuable aids to the other treatment. Intra— Venous Injections. Some remarkable results have been obtained by the injection of a saline solution in the veins in cases of the collapse of cholera. Unfortunately, the appearances of improvement, which are very remarkable, are not usually sustained. Hodder, of Canada, re- ports three cases wherein he transfused milk in cholera collapse, and two recovered. When milk is used for transfusion, it should be fresh and directly from the cow, if possible, and its temperature should be 100^ Fah. Not more than four to six ounces should be injected at one time, lest the heart be paralyzed by over-distention. Subcutaneous and Intraperitoneal Injections are even more valuable than intra- venous injections. They are commonly administered warm, of sodium carbonate and chloride (3 and 4 per cent, respectively) and in large amounts in order to make up for the fluids lost in the liquid stools. COLIC. In cases of intense abdominal pain of a colicky type, the first point to which the physician should attend is the exclusion of a strangulated hernia as the cause of the pain, or any other similar COLIC. 231 intestinal obstruction. This excluded, the indications are the pre- vention of pain, the expulsion of offending matter from the bowel, the prevention of enteric inflammation. MR. JONATHAN HUTCHINSON, LONDON. In all cases of unusually severe colic, the possibility of intestinal obstruction must be considered. In such cases the following rules for treatment should be observed : 1. In all early stages, and in all acute cases, abstain entirely from giving either food or medicine by the mouth. 2. Use anaesthetics promptly. Put the patient under the full in- fluence of ether ; examine the abdomen and rectum carefully before tympanites has concealed the conditions ; administer large enemata in the inverted position of the body ; and, if advisable, practice ab- dominal taxis. If you do not succeed at first, do it repeatedly. 3. Copious enemata, aided perhaps by the long tube, are advis- able in almost all cases, and in most should be frequently repeated. 4. Fluid injections may be sometimes replaced by insufflation of air in cases of invagination, since air finds its way upwards better, and is more easily retained. It is, however, somewhat dangerous, and has, perhaps, no advantages over injections with the trunk in- verted. 5. Insufflation is to be avoided in all cases of suspected stricture, since the air may be forced above the stricture, and there retained. 6. Saline laxatives are admissible in certain cases where impaction of faeces is suspected, and in cases of stricture where fluidity of faeces is advisable. 7. Opium (or morphia) must be used in proportion to the pain which the patient suffers. It should be administered by the rectum or hypodermically, and should be combined with belladonna. If there be not much pain or shock, it is better avoided, since it in- creases constipation and may mask the symptoms. 8. A full dose of opium administered hypodermically v/ill put a patient in a favorable condition for bearing a prolonged examina- tion under ether, and attempts at abdominal taxis. 9. In cases of uncertain diagnosis, it is better to trust to the chance of spontaneous cure, or relief by repeated abdominal taxis, than to resort to exploratory operation. 232 DISEASES OF THE DIGESTIVE SYSTEM. CHARLES MURCHISON, M. D., F. R. S., LONDON. Flatulent colic will often be relieved by the various ethers and the essential oils of peppermint, anise and cajuput, by vegetable char- coal, galbanum and assafoetida. When, however, it is due to de- composition, from deficient or deteriorated bile, those remedies will be found most useful which act by checking decomposition, such as creasote, turpentine or carbolic acid. 383. R. Acidi carbolici fluidi, Spiritfls chlcroformi, aa f. 5 "j . Aquae menthse piperita;, f-SJ-iij- M- Dose — a tablespoonful. Or, a pill containing one drop of creasote. Flatulence, and other dyspeptic symptoms arising from want of bile in the bowels, are also greatly relieved by the use of purified bile from the ox or pig, which may be given in doses of from three to six grains, about two hours after meals. As it is not desirable that the bile should come in contact with the stomach, it is well to give it enclosed in capsules, or in pills coated with a solution of tolu in ether. The following recipe will be found useful for the same purpose: 384. R. Sodii chloratis, gr. x Aqua; menthae piperitse, f. § ss. M. For one dose. DR. D. L. PHARES, in the Transactions of the Mississippi State Medical Association, 1878, directs attention to the mechanical treatment of colic. This consists in simply supporting the patient in an inverted position — in other words, in standing him on his head. In some instances, cases that have for hours or days resisted all ordinary treatment, have by this simple means been relieved and permanently cured in from one to five minutes. Cases attended with most intense pain, vomiting and other phenomena of so-called "bilious colic," have been thus cured. DR. SAMUEL FENWICK calls attention to the possibility of the colic being due to lead poisoning, and where there is a likelihood the gums should be ex- amined, and the urine analyzed for the purpose of detecting the lead. (See Plumbism.) COLIC. 233 Where the colic seems to be due to some offending portion of the diet, a dose of calomel followed by castor oil. Or, if there be much vomiting, calomel and opium may be given, followed by an aperient draught several hours later, as 385. R. Magnesii sulphatis, 3ij " carbonatis, 9j Syrupi zingiheris, f. 3j Aquae aiiethi, f. 5xj. M. Or a turpentine and castor oil enema may be administered. If flatulence is probably the cause of the colic, 3S6. R. Magnesii carbonatis, 3'ss Ammonii carbonatis, 3ss Aquje menthce viridis, f. § vss Tincturoe lavandulae, f. 3ij Spiritfls carui, f. 3.j Syrupi zingiberis, f-3ij M. Tablespoonful to be taken occasionally. During the attack hot applications and some decided sedative will in all probability also be demanded. 387. R. Spiritds setheris, f. 3s» Liquoris morphize muriatis, lllxv Aquae menthae piperitoe, f. § j. Or 388. Jt. AquES camphorae, f. §j .Spiritfls aetheris, f. 3 ij Tinctura; cardamomi compositae, f. 3 iv Spiritus anisi, f. 3yj Olei carui, Hl'^ij Syrupi zingiberis, f-3ij Aquas nienthae piperitae, f. § vss. M. One or two tablespoonfuls at a dose. DR. EDWARD MONTGOMERY, ST. LOUIS. This writer (Half-Yearly Compendium, January, 1878,) recom- mends in cases of faecal impaction, hot poultices to the abdomen, warm water and saline injections, and after the evacuation of the lower portion of the alimentary canal by enemata, purgatives by the mouth. In young, robust patients, at the early period of the dis- ease, one-tenth of a grain of tartar emetic and one drachm of sul- phate of _ magnesia, every hour, will very often aid in breaking up and removing the obstruction. As it is very common for these cases of intestinal obstruction to be associated with conditions of torpor, or even paresis of portions 234 DISEASES OF THE DIGESTIVE SYSTEM. of the bowel, the administration of the following pill will be found of great service : 389. R. Strychniae, P.j Ext. belladonnae, Podophyllin, aa gr. iv Pulv. ferri sulphat., Alces Socpt., aa gr. XX Syrupi simp., q. a. Divide into twenty pills; one to be taken every eight hours. M. Even after the removal of the impacted mass, this pill will be found valuable in preventing a relapse, and in promoting regularity of the bowels afterward. PROF. DUJARDIN-BEAUMETZ. (Medical News, 1891.) The following mixture is attributed to this physician : 390. R. Strong chloroform water, f. Siv Decoction of orange flowers, f. § iv Tincture of capsicum, ■ f. 3 ij M. A teaspoonful every fifteen minutes until the pain is relieved. PHILADELPHIA HOSPITAL. The following prescription was a favorite among the house staff in Blockley, where it was known as "Oh! Be Joyful!" It was origi- nated by Dr. J. LuDLOW, and is somewhat similar to chlorodyne : 391- B- Chloroformi, f. Sij Morphise acetatis, gr. iij Olei anisi, Olei menthje piperita;, aa gtt. xyj Syrupi acacize, f. | ss Aqu33 camphorje, q. s. ad f. § iv. M. Teaspoonful when necessary. Also 392. R. Tincturae capsici, Tincturae opii, Tincturte rhei, Essentiee menthse piperitje, Spiritus camphorse, aa. M. Fifteen to thirty drops, according to age, every half hour. Chlorodyne (No. 376) is also of excellents ervice in the treatment of colic. COLIC. 235 GERMANTOWN HOSPITAL. 393- R- Tincturce opii, Tincturse rhei, Sjjiritfls menthae piperita;, Spiritfls camphorse, Spiritfls chloroformi,. Tincturoc capsici, aa lHv Tincturoe catechu compositse, q. s. ad f. 3j- M. Dose. — A teaspoonful. NOTES ON REMEDIES. Ammovii Carbonas, in doses of gr. v-viij in some aromatic water, frequently proves useful, especially in the flatulence or atonic dyspepsia of hyster- ical females. Anthemis, in strong infusion, or gtt. ii-ii; of the volatile oil, frequently affords relief after the failure of other remedies. Assafatida, in enema, is of especial value in the flatulent colic of hysteria. Belladonna is probably the most efficient remedy in intestinal obstruction ; gr. j-ij of the extract every hour, together with opiate fomentations to the belly and warm applications. The remedy should take effect in six or eight hours. Carbo Ligni, inclosed freshly prepared in gelatine capsules, each containmg gr. X of heavy vegetable ivory charcoal (dose, two, i. e., gr. xx,) is a valuable remedy, from its gas-absorbent property. If administered in this manner, the large nauseous doses so frequently prescribed are avoided. Caryophyllum in infusion, or the volatile oil (gtt. iij-v) is useful. Cinnamomum is a pleasant and excellent carminative. Creasotum , in doses of gtt. j in pill thrice daily, will greatly relieve the dis- tressing flatulence of hypochondriasis. Fel Bovinum. Dr. W. Murray says in the Lancet, September, 1878 : "Were I called to a desperate case of obstruction of the bowels, I should first of all push the belladonna treatment to its fullest extent, and while the patient is fully under the influence of the belladonna, I should ad- minister, by enema, eight ounces of ox-gall diluted with eight ounces of water containing a few crystals of washing soda." Nux Vomica is valuable in obstinate flatulence. Dr. Barlow recommends the following useful formula : 394- R. Extracti nucis yomicce, gr. iss Argenti nitratis, gr. ij Extracti lupili, gr. xij. M. Make six pills. Take one thrice daily. This formula is particularly serviceable when there is also pyrosis and heartburn. Oleum Carui is often of benefit, in doses of gtt. ij-v on sugar. 236 DISEASES OF THE DIGESTIVE SYSTEM. Oleum Menthx Piperita, with or without a few drops of laudanum, is a pleas- ant carminative. Oleum MyrisHccB, in doses of gtt. ij-v, affords relief. Grated nutmeg may be given in a little warm brandy and water. Oleum TerebinihincB. Dr. J. Copland remarks that, notwithstanding con- stant or even feculent vomiting, advantage will sometimes be derived from one or two tablespoonfuls of the unrectified oil of turpentine, taken with aromatics. He has seen the vomiting cease and the dis- tention of the abdomen rapidly subside immediately after this dose which should be repeated if rejected at first. Potassii Permanganas. Dr. R. Bartholow has found marked advantage from the use of this substance in the flatulence and dyspepsia so con- stantly attendant on obesity, as follows : 395- R- Potassii permanganatis, gr. ''j AquiE destillatte, f- § ij- "*• Keep in a glass-stoppered bottle. Dose, a teaspoonful thrice daily. Rheum. 396. R. Magnesii carbonatis, 3j Pulveris rhei, gr. xxx Tincturie rhei, f- 3 iij Tincturje opii, "Ixv SpiritQs anisi, ^'-.yj SpiritCls menthae piperitse, f- 3ij_ Aqu£e destillatJE, f- 5 YJ. This is a popular remedy in the west of England, in intestinal pains. From three to SIX tablespoonfuls a day. Spiritus Etheris Compositus is useful, particularly in the flatulence of hyster- ical females. Spiritus Etheris Nitrosi, in doses of a teaspoonful in a cupful of any conveni- ent vehicle, is a popular and efficacious remedy. Zinci Sulphas has been recommended in "flatulent affections of the bowels, especially of the colon. The following formula has been employed : 397- R- Zinci sulphal is, gr. xviij Pulveris opii, gr. iij Mucilaginis, q. s. M. Make six pills. Take one four or Sve times a day, after a meal. When the stomach can dispense with the opium, substitute extract of gentian or rhubarb. Galvanism is often very serviceable in obstructiop. Drs. Beard and Rock- well recommended that the positive pole be applied along the spine, while the negative pole is passed gently over the abdomen, following the direction of the ascending colon. A case, accompanied with faecal vomiting, is reported (Dublin Quarterly Journal of Medicine, Novem- ber, 1864,) as successfully treated by the application of galvanism to CONSTIPATION HABITUAL. 237 the mucous surface of the intestine. A sponge, with the metallic handle to which it was attached, was passed up the rectum two or three in- ches, whilst the other sponge was applied to the abdominal walls. The effect was immediate, the constipation being at once relieved and the patient recovering from an apparently hopeless condition. CONSTIPATION. HABITUAL. The habit of constipation may be broken up by massage, change of diet, enevtata, laxative mineral waters, or drzigs. In regard to massage, or the movement cure, the following little operation, executed by the patient upon himself, when properly per- formed, is valuable : Place the tips of the fingers of the right hand exactly over the csecal region, with very slight pressure ; carry them upward, along the ascending colon, to the right hypochondrium ; continue the movement without any intermission over the region of the transverse colon to the angle of junction with the descending colon ; stop not, but proceed downward, gently and steadily, to the iliac region of that side; instead of the previously very gentle pressure, the finger must now be pressed firmly and deeply (without pain) into the pelvic cavity, and there retained for about fifteen seconds ; then remove the hand altogether, rest a few seconds, and repeat the procedure. This may be continued for the period of from a few minutes to a quarter of an hour or more. Some little care and tactile dexterity are needed to do this properly; and where the hand is dry, or the cuticle thick and hard, it is advisible to slightly moisten the ends of the fingers. When the right hand is tired, the left can be used, and so alternately, but it is better not to alternate them too rapidly. If there be failure, it must not necessarily be given up. Invalids them- selves will often fail ; almost invariably, if their bowels are extremely intractable. But now the aid of a friend for passive movements may be invaluable. The medical adviser can give instructions regarding the precise anatomical relations of the parts involved, and the method of performance. The proceeding should usually extend over a period of from five or six minutes to occasionally twenty-five minutes. 238 DISEASES OF THE DIGESTIVE SYSTEM. DR. ROBERTS BARTHOLOW, PHILADELPHIA. A proper regulation of the diet is of great importance in the treat- ment of habitual constipation. This usually depends on deficient se- cretion, or torpor (or paretic state) of the muscular layer of the in- testines. Corn-bread, cracked wheat, oatmeal, bread of unbolted flour, fruits, aud such vegetables as green corn, tomatoes, and celery, are indicated. Those troubled with habitual constipation, to a mod- erate extent, may overcome it by the daily use at dessert of a' few almonds and raisins, about six of each. Hemorrhoids, due to con- gestion of the portal vein, or to constipation, are much benefitted by the grape-cure, or a diet of fruits and succulent vegetables. PROF. NOTHNAGEL, OF VIENNA. (Wien. Med. Presse, 1890.) NOTHNAGEL regards as the important elements of treatment of habitual constipation, massage of the ab- domen, electricity and abundant exercise. He does not think that the patient can take the place of a masseur in carrying out the first of these ; but suggests as a fair substitute that a metal ball weighing from three to six pounds, and covered with cloth to prevent chilling, should be rolled along the course of the large intestines every morn- ing for about five or ten minutes, beginning always in the right iliac fossa. He warns that there be no expectation of great results for several weeks or months, but believes that in the end there is real good derived from the practice. He suggests further the use of the faradic current, and states that a strong current over the colon is sufficient. Systematic calisthenic exercise should be insisted upon, considerably more than the accustomed amount, with riding and walking as well. NOTHNAGEL prefers enemata to drugs ; but when the patient is able, a visit of some weeks at one of the mineral water cures is better than either. His most satisfactory enema, as a rule, is glycerine, one-half to one drachm being thrown into the rectum; or glycerine suppositories may be used. Acid fruits should be freely taken in the dietary : and the food should be nutritious and easily digested. Where recourse to drugs is necessary, NOTHNAGEL frequently pre- scribes as follows : 398. R. Podophyllin, gr. iiss Extract of aloes, Extract of rhubarb, aa gr. xlv Extract of taraxacum, sufficient to make a mass. M. Make a mass, from which forty pills are to be made. 6ig : One or two of these at bedtime. CONSTIPATION, HABITUAL, 239 J. M. DA COSTA, M. D., PHILADELPHIA. 399- R- Podophyllin, Extracti belladonnae, aa gr. j Capsici, gr. v Pulveris rhei, 9j. M. For twenty pills. One three times a day. Belladoitna is undoubtedly a stimulant to the muscular fibres of the intestines. It acts on them as it acts on the bladder ; it stimu- lates to contraction. It also increases the action of purgatives, en- abling the physician to get along with smaller quantities of purga- tive medicine. Podophyllin is useful in torpor of the upper portion of the bowels, to increase the secretion of the liver. 400. R. Tincturse gentianse compositae, f-§Jij Tincturae rhei dulcis, f. § j Tincturse belladonna;, f.Siss. . M. Dessertspoonful thrice daily. 401. R. Extracti gentianse, 3j Extracti nucis vomiae, Podophyllin, ' aa gr. iiss Olei cajaputi, gtt. xx. M. For twenty pills. One twice a day, as a tonic for chronic constipation, 402. }^. Extracti helladonnse, gr. iss Pulveris rhei, gr. xxiv Pulveris zingiberis, gr. xij. M. For twenty-four pills. One four times a day. DR. J. MORTIMER GRANVILLE, OF LONDON. The following are recommended by Dr. J. MORTIMER Granville in the British Medical Jotirnal, May 26, 1883 : When there is a lax and torpid condition of the muscular coat of the alimentary canal, evidenced by flatulence, etc., he uses the fol- lowing : 403- R- Sodii valerianatis, gr. xxxvj Tincturre nucis vomicx, Ttllx Tincturae capsici, IHxlviij Syrupi aurantii, f. S iss Aquam, ad f. § yj. M. Fiat mistura, cujus sumatur cochleare magnum ex aequa ter die semihorS ante cibum Where there is a deficiency of glandular secretions, generally, throughout the intestine, manifested by a peculiarly dry and earthy character of the dejecta when the bowels do act, he gives : 404. R. Aluminis, 3"j Tincturae quassise, ^- ^ J .. Infusi quassiae, f. S vij. M. Fiat mistura, cujus sumantur cochlearia duo magna ter quotidie, post cibum. 240 DISEASES OF THE DIGESTIVE SYSTEM. The third form, which depends chiefly on interruption of the natural habit of periodic discharge, often results from repeated fail- ure to move the bowels, in consequence of one or other of the two preceding forms of this trouble. This may generally be relieved by directing a perfectly regular attempt to go to stool, and by the use of the following draught, taken the first thing after rising from bed — not on awaking — in the morning, as nearly as possible at the same hour. It will be observed that it is not an aperient, in the ordinary sense of the term. It is, as a rule, neither necessary nor desirable to continue it for longer than a fortnight. In most instances, it will be found to re-establish the normal habit in a week or less. 405- R- Ammoniae carbonatis, 5j Tincturae Valerianae, §j Aquas camphorx, § v. M, Fiat mistura; capiat partem sextam in modo dicto. S. S. BIRCH, M. D., LONDON. 406. R, Extracti rhei alcoholici, 3ss Extracti taraxaci, gr. xxiv Quiniae sulphatis, gr. ij. M. Divide into twelve pills. One should be taken either on arising in the morning or at dinner- time, or even at both periods, when the constipation is very obsti- nate. This is a very gentle stomachic and tonic evacuant, particu- larly useful for the delicate. In addition, when there is torpor of the liver, deficiency or perversion of the biliary secretion, the patient should be ordered : 407. R. Hydrargyri cum creta, gr. i_j Sacchari albi, gf_ y_ j^{_ For one powder. This is a sufficient dose, when given alone, at bed-time, for two or three successive nights, or, in very sensitive persons, every second or third night. But the hydrargyrum cum creta is often prepared imperfectly, and then causes considerable annoyance and dissatisfac- tion to the practitioner. PROF. WILLIAM THOMPSON, M. D., NEW YORK. This writer observes {Medical Record, May, 1877,) that obstinate constipation is owing to deficient action of, i, the small intestine; or, 2, the large intestine. CONSTIPATION HABITUAL. 24 1 I. Deficient action of the small intestine is often owing to deficient secretion. Constipation from this cause is common in the Northern States, as a sequel to diarrhoea, and is often met with in the Southern States, as the result of malarial poisoning. There is, in these cases, no extraordinary accumulation and impaction, but a sluggish action of the bowels, medicine being required to produce the stools in four or five days, which are, even then, moderate in amount and quite dry. In most cases, there is present a dull pain, or, rather, an uncomfortable sensation, at the back of the head, which is best relieved by a free discharge of bile. The tongue is not large and flabby, but usually small, with a little redness at the tip and along the edges. The se- cretions of the mouth are viscid, indicating the condition of defective secretion that prevails all along the canal. Mild cathartics, in these cases, are injurious, and active purgatives still more so. What is wanted, is the presence in the intestine of a small increase of lubricating liquid, and this is obtained by causing the patient to take a great deal more water than customary — drink- ing on rising, for example, two tumblerfuls of water; and, as a rule, those who drink a considerable quantity of water are not constipated. Its laxative action may be insured by the addition of some saline, as carbonate of soda or salt, the water to which this is added not pass- ing so readily through the mucous membrane into the general system, and thus more readily exciting peristaltic action. A half drachm oi sulphate of magnesium, dissolved in a pint of water, will, for this reason, act sufficiently as a cathartic. A curious fact is, that the addition of a small dose of quinine to salines, increases their power of acting on the intestinal canal. 408. IJ. Magnesii sulphatis, ?,] Quiniae sulphatis, gr- j- M. To be taken in a tumbler of water, every morning. This dose rarely fails to produce all the laxative effect required in every form of deficient secretion, as, for instance, in constipation fol- lowing fever, where we wish to obtain free evacuations. Patients should be told not to expect much effect for a week or two ; but, if they can be induced to persist in the daily use of large quantities of water, great benefit will almost always follow. When flatulence is present, and defective innervation, the follow- ing pill is excellent: 16 242 DISEASES OF THE DIGESTIVE SYSTEM, 409. R. Pulveris assafcetidse, gr. iv Extract! nucis vomicae, gr- ss Saponis, gr- ix- M. For three pills. To be taken daily. Such a combination is suitable in persons of a sedentary habit, with a tendency to headache and a dull, sallow color. 2. Deficient Action of the Large Intestine. This also may depend upon deficient secretion, or defective innervation ; but far more fre- quently on the latter. One of the worst forms of this is when the constipation depends upon deficient nerve-power in the rectum alone, and which, if overlooked, may give rise to rectal abscess. The patients have little knowledge that they should have a movement, and when the sensation does occur, they have little or no power of expelling the faecal accumulation. One of the most common causes of this condition is chronic in- flammation set up about haemorrhoids. The relaxed condition which follows the defective innervation renders prolapsus of the rectum very probable. These patients are remarkable for being generally low-spirited, so that even insanity may be induced by such a state of the rectum, disappearing when this has been relieved. In treating these cases the first indication is to keep the rectum empty; and when accumulations do take place, they are best removed by enemata. These, however, should never be prescribed as a regular treatment, for if the habit is acquired of emptying the bowels daily by their aid, they can never be dispensed with. When the accumu- lation which has caused the enema to be employed, has been thor- oughly removed, other means should be restored to for restoring the innervation of the bowel ; and in these cases the injection of strychnia into the submucous tissue is an exceedingly valuable remedy. If necessary, a fold of the mucous membrane may be drawn down, and the injection inserted. It will frequently cure the worst forms of prolapsus of the rectum, as well as that condition in which there is simple debility with hypertrophy of the mucous membrane. In other forms of constipation there are accumulations of scyba- lous matters in the upper part of the rectum and in the transverse colon. When these last are dislodged they come down into the sig- moid flexure ; and mineral waters, such as the Kissingen, are useful in effecting such dislodgment, loosening the scybalse without de- pressing the patient. The water may be taken in the morning ; a suppository of stramonium or belladonna (suflScient to cause a little CONSTIPATION HABITUAL. 243 dryness of the throat and slight dilatation of the pupil) may be in- troduced in the evening. Constipation may be met with during the recovery from pneumonia and other febrile affections, arising from accumulations at various parts of the canal. Compound jalap powder is a very effective means for preventing such accumulations. One of the nrast valuable additions to the list of remedies for chronic constipation is cascara sagrada. Its especial value lies in its tonic action upon the bowel, and the fact that its exhibition is not followed by the usual marked constipation which is often seen after the action of aperients. It may be given in the form of the elixir or cordial (Parke, Davis & Co.) in fluid drachm doses, or as follows: 410. R. Extracti cascarse sagradsE fld., gtt. xxx Syrupi yerbse santae, Aquae, aa qs. ad f. Sss. M. Sig; — One dose, to be taken before breakfast. The following wines are also commended, given, each of them, in doses of a wineglassful in the morning: 411. R. Extract! cascane sagrad£e fluidi, f. 5j Vini Xerici, f. § ix. M. Filtra. Or, 412. R. Cascara sagrada (crude), §i Sherry wine, f. § x. Macerate for eight days, press and filter. THOMAS HAWKES TANNER, M. D., F. L. S., LONDON. 413. R. Zinci valerianatis, gr. xij-xxiv Extracti belladonna;, gr. iij-yj Extracti gentianee, gr. xxiv. M. Make twelve pills and silver them. One to be taken three times a day, in nervous cases of habitual constipation, and in spasmodic contraction of the sphincter ani. PROF. W. H. VAN BUREN, M. D., NEW YORK. 414. R. Extracti aloes, 5ss Extracti nucis vomicae, gr. yj Extracti hyoscyami, 9j Pulveris ipecacuanhse, gr. j. M. Divide into twenty pills. One to be taken at night. This receipe, termed the " Pil. Salutis," is of special value in the constipation of females. DR. LUTAUD. Dr. LUTAUD (Med. News, 1890,) recommends the following in obstinate constipation occuring in women : 244 DISEASES OF THE DIGESTIVE SYSTEM. 415. R. Citrate of iron and ammomum, gr. xxxj Fluid extract of cascara sagrada, Ttlxxxij Saccharin, gr. viij Water, f- S "ss. M, Sig : — A half teaspoonful thrice daily before meals. DR. METTAUER'S alkaline MIXTURE OF ALOES. 416. R. Aloes, 2j ounces Bicarbonate of soda, 6 ounces Compound spirit of lavender, 2 fluid ounces Water, 4 pints. M. Macerate for two weeks, and filter. Dose — from one fluid drachm to one fluid ounce, hair an hour after meals, for persons of a costive habit. It has been observed that aloes is useful in habitual constipation due to atony of the colon, the result of fever and debilitating dis- eases, old age or sedentary habits. It may be combined as indicated, with aromatics, hyoscyamus, ipecacuanha, nux vomica or quinine. Dr. Spender recommends (Medical Times and Gazette, February 19, 1870,) the following pill: 4' 7- R. Extract! aloes aq., gr. ss— j Ferri sulphatis, gr. iss-ij. M. For one pill, to be taken thrice daily, immediately after the principal meals, and con- tinued regularly for a few days till the occurrence of the first loose motion, after which one only is to be taken night and morning. At the end of a week or two, another pill may be omitted, and within a month a single pill once or twice a week suffices. Dr. W. Craig, of Edinburgh, prefers aloin. He has never seen any bad effects follow its use ; and, from its small dose, absence of griping, and certain action, he holds it should always be used in preference to the crude drug. He gives : 418. R. Aloinae, gr. ji Ferri sulphat. exsic, gr. iss Quiniae sulphatis, gr. j Extr. nucis vomicae, gr. ss Extr. gentianas, q_ ,,_ ji_ For one pill. DR. C. P. NOBLE. (Medical News, 1891.) Dr. C. P. NOBLE publishes the following as a very reliable purgative enema : 4I9- R- Sulphate of magnesia, 5 y Glycerin, ^i-^ Oil of turpentine, f 5 ss Water. flgij y^ CONSTIPATION HABITUAL. 245 PROF. ROBLEY DUNGLISON. 420. R. Magnesii sulphatis, §j Potassii bitartratis, 3j Ferri sulphatis, gr. x. M. For one powder. Add to a quart of water and take a wineglassful, on rising every morning. The recipe was frequently recommended in his lectures by the late distinguished professor of physiology. JOHN FORSYTH MEIGS, M. D. 421. R. Confectionis sennse, Si Potassii bitartratis, 3ij Sulphuris prsecipitati, Ferri subcarbonatis, aa 3j Mellis despumati, q. s. Make an electuary. Teaspoonful after meals. M. PROF. METCALF, M. D., NEW YORK. 422. g. Extracli aloes (purif.). Extract! hyocsyami, aa 3j Extracti nucis vomicse, gr. xij Olei anisi, g". x. M, Divide into sixty pills. One to be taken after each meal, particularly for constipa- tion in women. PHILADELPHIA HOSPITAL. 423. K- Magnesii sulphatis, Ferri sulphatis exsiccati, Acidi sulpburici diluti, Aqu£e, Sig: Half teaspoonful in water before breakfast. 5i' gr. xxxij f.|ss Oj. M. Also 424. R. Extracti ignatiae amarse, Pulveris podophylli, Pulveris aloes socotrinse, Pulveris rhei, Sulphatis quininae. Ft. massa ex qua fiant pilulse No. xx. Sig : One every night. aa aa gr. XX 3j M. Also 425. R. Resinre podophylli, Extracti colocyntbi compositi, Extracti nucis vomicae, Ferri sulphatis exsiccati, Ft massa ex qua ft. pil. No. xii. Sig : One at bedtime. gr-i] gr. xvu) gr. iij gr. xij M. 246 DISEASES OF THE DIGESTIVE SYSTEM. Also 426. ]J. Resinse podophylli, gr. ij Extract! colocynthi compositi, gr. xx Extract! hyoscyami, gr. iij. M. Ft. pilulae No.xii. Sig: One at night. Also 427. R. Massse hydrargyri, Extracti colocyn'hi compositi, ia 9j Pulveris jalaps, gr. x Extracti hyoscyami, 3ss. M. Ft. pilulae No. xx. Sig : One in the morning. FOR NERVOUS CONSTIPATION. 428. R. Pulv. ferri sulphatis, gr- 'J Aloes socotrinse, gr. J Ext. belladonnae, gr. j j— J. M. Ft. pil. One to four pills daily. NOTES ON REMEDIES. Akuritis Triloba. The oil of the aleuritis nut has been highly recommended as a substitute for castor oil. It has the further advantage of not being disagreeable to take, having the flavor of the hazel-nut. An adult is easily purged with a dose of fifteen grammes. It is an excellent aperi- ent, and its effects on the intestine are identical with those of castor oil. About three hours are required for its action, which takes place without pains or colic. 429. R. Olei aleuritis, f.§ss Sacchari albi, § ss Pulv. acacix. Aquae, ia 3 iij.] M. For one dose. In rebellious cases of constipation and in abdominal pains, good re- sults have been obtained by making frictions on the abdomen with the following liniment : 430- R- Olei aleuritis, f. § ss Tincturse cantharidis, f. 5 iij Ammoniae carbonatis, 3 iij M, For a liniment. Aloes and Aloin. The following formula is highly recommended : 43'. R. Ext. aloes soc. aquos., gr. ij Ext. nucis vomicae, gr. ss Ipecac pulv., gr. ss. M. Ft. Pil. To be taken each day with dinner. CONSTIPATION HABITUAL. 247 432. R. Aloes, gr. XT Resin of scammony, gr. vij Resin of jalap, gf-vij Calomel, gr, vij Extract of belladonna, gr. iii Extract of stramonium, gr. iij. M. Ft. massa ex qua ft. pil. No. xxv. Sig: One or two Jpills a day. Arseniosum Aciduvt is said by Dr. Isnard, of Marseilles, to be particularly useful in the constipation of aged people and sedentary persons. Belladonna is especially called for where there is atony or paralysis of the muscular coat of the intestines : gtt. v-x, thrice daily, of the tincture, will often overcome the most obstinate constipation from this cause. Benzoini Tinctura, in doses of gtt. xx, thrice daily, is said, in cases of consti- pation apparently depending upon stricture of the colon, to keep up the peristaltic actions without irritating the bowels. Calcis Saccharas. Dr. J. Cleland, of Edinburgh, first introduced this aperi- ent through the Edinburgh Medical Journal, August, 1859, to the profession. He prepares it as follows : 433- R- Slake of quicklime, § viij Rub up with it of white sugar, 5 v Add of water, f. 5 xx. M. Stir and filter. The product should be perfectly clear, with only a slightly yellowish tinge. Each ounce, by weight, should contain 18 grains of lime. Dose, IUxv-xxx, orf.Sj. Dr. C. finds this saccharate of lime a very valuable means of over- coming gradually that chronic constipation which so frequently accom- panies dyspepsia, and that persons who for years have been in the con- stant habit of using aperient medicines have been able to abandon them, in a great measure, after taking this remedy for some time. Camphora. In constipated persons, who suffer much from difficult defecation, the following enema is very highly recommended : Take a tumbler and fill it half full of water, at the temperature of the room ; pour in a few drops of tincture of camphor — just enough to give the water a slight sapidity — then fill the glass with water. Inject this slowly into the rectum, till about sixty or eighty grammes have been introduced. At first, no effect is perceived, but in about ten minutes, the desire to defecate becomes irresistible. The effect becomes energetic in pro- portion to the quantity of tincture of camphor added. After the de- fecation, it is well to repeat the injection of a small quantity of the same mixture, and retain it in the rectum, which can readily be done, so as to prevent constipation on the following day. Cascara Sagrada, othenvise known as the Rhamnus Purshiana, is a well- established, generally efficient remedy in habitual constipation, the fa- 248 DISEASES OF THE DIGESTIVE SYSTEM. vorite remedy foi constant constipation among the practitioners of this country. Of the fluid extract, f.^ss daily is a dose ; of the cordial gss-j. Cocillana is used in obstinate constipation in doses of ten drops of the fluid extract. Colchicum, in doses of gtt. v of the tincture of the root several times daily, has been highly recommended in obstinate constipation. Colocynth. Dr. Crichton recommends (British Medical journal, Novem- ber 28th, 1868,) the Prussian tincture of colocynth, in doses of niv-x in a little water, taken about an hour before breakfast, as an efficient remedy. The formula of the Prussian tincture is as follows : 434- R- Colocynthidis pulpse, §j lUicii anisati, 3] Alcoholis, f- 3 XX- »*• Dr. Birch recommends colocynth combined with hyoscyamus, in the con- stipation of old age. Fel Bovinum Purificaium. When there is torpidity of the liver and defi- ciency of the biliary secretion, ox-gall may prove useful by supplying the deficiency. Either of the following formulas may be used : 435- R- Ffi' bovini purificati, 3ij Olei carui, "Ix Magnesiae carbonatis, q. s. M. Make thirty-six pills. Take two twice daily. Or: 436. R. Fel bovini purificati, Pilulse assafcKtidte compositse, aa gr. xxx Extract! aloes, gr. xx Saponis duris, gr. x Pulveris ipecacuanhse, gr. viij. M. Make thirty pills. Take one to two daily, before dinner. Ferri Carbonas has not, in the opinion of Dr. Graves, been duly appreciated as a remedy in habitual constipation. He has succeeded in curing with it alone, a patient who had long been subject to extreme consti- pation, and who had been reduced to the necessity of taking an im- mense dose of purgatives almost every week. Magnesite Sulphas, in small, frequently-repeated doses, with the addition of a few drops of diluted sulphuric acid, will sometimes subdue obstinate constipation after the failure of other means. Muscarine. Bartholow recommends the following : 437. R. Muscarine, gr. it Ext. belladonnse, Ext. nucis vomicae, aa gr. iij Enonymin, 3ss. M. Ft. pil. No. xii. S. — One pill morning and evening. CONSTIPATION HABITUAL. 249 Muscarine is strongly indicated when the digestion of starches and fats is imperfect. Nitricum Acidvm in the opinion of Dr. Graves, is a very rehable remedy in habitual constipation, and combines tonic with aperient qualities. Pipitzakoic Acid. This acid, obtained from the root of the pipitzahuate, a Mexican plant, is stated to be an excellent and safe purgative. The remedy was first introduced in the Annalen der Chemie, 1855, and in 1883 into Germany more prominently. Pix Liquida, persevered in for some time, often effectually removes constipa- tion. Physostigma. Bartholow recommends the following : 438. R. Tinct. physostigmatis, Tinct. nucis vomicae, Tinct. belladonnae, aa 5Jj- M. S. — Thirty drops in water nioming and evening. 439- B- Extract, physostigmatis, Extract, belladonnse. Extract, nucis vomicse, aa gr. v. M, Ft. pil. No. X. S. — One pill at bed-hour. 440. K. Ext. physostigmatis, Resinae podophylli, aa gr. iij. M. Ft. pil. No. vi. S. — One pill at bed-hour. Podophyllin is useful when there is torpor of the upper portion of the bowel It may be continued indefinitely, in small doses. Dr. Horace Dobell recommends the following formula as one of the most satisfactory he has ever tried : 441. R. Podophylli, gr-.ij Essentiae zingib., 3 ij Alcoholis, 5 ij- M. A teaspoonful at bed time, in a wineglass of water, nightly, or every second or third night. Rhaninus Frangula and Rhamnus Purshiana ( Cascara Sagrada) are val- uable as laxatives in constipation from dyspepsia. Rheum. Dr. F. W. Paw recommends the following pill in habitual constipa- tion : 442. R. Pilulx rhei comp., gf- ;H'J Pulveris capsici, P- ]• "*■ To be taken with the food, and repeated daily, as occasion requires. In the constipation of anajmic females, Dr. Ashwell recommends the following mixture : 250 DISEASES OF THE DIGESTIVE SYSTEM. 443. R. Pulveris rhei, __ _ Magnesii carbonatis, ^ 3 5' Confectionis aromaticae, fk^ Aquae cinnatnomi, c'x^ Ml Tincturee cardamomi compositse, '• O}- "■• Make a drink. To be taken at bed-time, every three or four days. Jiutm Oleum is one of the best purgatives which can be employed in habitual constipation, acting speedily, without much griping, and causing less subsequent constipation than any other purgative given to remedy this state. Senna, particularly in the form of confection, is a mild, efficient purgative, causing little excitement, and leaving no subsequent constipation. Stramonium. Prof Armor (American Practitioner) has been in the habit of using stramonium in the form of suppository, and is pleased with the results. Half or three-fourths of a grain of the extract may be com- bined with a sufficient quantity of cocoa butter. It is admirably adapted to obstinate constipation of nervous females, who suffer, at the same time, from pelvic irritations from various causes. Tabaci Vinum. In habitual constipation, due to a relaxed state of the mus- cular layer of the bowel, five minims of the wine of tobacco, admin- istered at bedtime, will not infrequently afford relief. Nux Vomica or Strychnia is often of equal benefit. Dr. Copland recom- mends the following pills : 444. R. Extracti nucis vomicae, S^*.."j Extract! colocynthidis compositi, Bij Saponis castiliensis, gr. xij. M. Make twelve pills. Take one every night, for a few weeks. It is also indicated in those cases in which there is inaction of the muscular layer, and consequently great fecal accumulations. It may be most advantageously combined with purgatives. Bartholow recommends the following : 445. R. Tinct. aloes et myrrhse, 3'^ Tinct. nucis vomicae, 3 ij- M. S. — Fifteen to thirty drops two or three times a day. Veratrum Viride, in doses of gtt. iij of the tincture four or five times daily, is said (Practitioner, November, 1868,) to be useful in some cases of obstinate constipation. Massage along the line of the colon toward the rectum, if persisted in daily for some weeks or months, is a valuable means of correcting a con- stipated habit. Electricity. Dr. Althaus and Drs. Beard and Rockwell have reported a number of cases of habitual constipation which yielded readily to faradization of the bowels after the failure of other remedies. DIARRHOEA, ACUTE AND CHRONIC. 251 DIARRHCEA. ACUTE AND CHRONIC. As the term diarrhoea is appHed to a condition characterized by- fluid faecal discharges accompanied with intestinal pains, its treat- ment must always have reference to the exciting cause of the dis- charge. Frequently it is not advisable to check it, as it is a natural effort to carry off irritating matter from the intestinal canal. In- deed, it is often better to assist this effort by gentle laxatives and judicious diet, as for instance on the plan recommended by DR. CARRlfeRE. The grape-cure, which is a treatment much in vogue in some parts of France and Germany, consists, according to Carriere, of a diet exclusively of grapes. They are taken many times a day to reple- tion. It is usual to commence with a pound, and progressively to increase the amount to two, three, six and eight pounds, a limit which is not exceeded. The first grape repast, which may be the most abundant, is in the early morning, but not, as are the others, eaten in the vineyard. Another is taken at the time of the morning meal (^corresponding to our breakfast) ; the next after the morning walk, at noon, consisting of bread and water (because there is not a requi- site amount of nitrogenous matter in grapes) ; another before the usual dinner hour (evening), and finally, before retiring. The treat- ment is continued during the five or six weeks of the duration of the grape crop. A method of treating diarrhoea, long practiced in Russia, consists in the use of a pulp of raw meat. A bit of fillet of beef is deprived of all fat and aponeurotic fibre, minutely divided, and beaten in a mortar until all trace of fibre has disappeared. It is then pressed through a fine sieve and mixed with sugar, conserve of roses, or some suitable aromatic, or seasoned with salt and pepper to the taste. It may be administered in this form, with fruit jelly, or spread on thin pieces of bread. A beefsteak, hastily broiled on a hot fire, so as to retain its juices, may be treated by the same method ; or the raw beef scraped to a pulp, rejecting the fibre, may be thrown on to a hot skillet for a few seconds, to give an odor and appearance of cooked meat. This method, which has been used especially in the treatment of diarrhoeal diseases of early life, is equally efficacious in the chronic diarrhoea of adult life. The chief objection to this mode of alimentation is the great frequency with which tape-worm follows. . 252 DISEASES OF THE DIGESTIVE SYSTEM. A milk diet has proved very efficacious. DAVID YOUNG, M. D., FLORENCE, ITALY. This writer ( Practitioner, Uiirch, 1875; December, 1876,) states that in nearly every form of diarrhoea he trusts almost exclusively to diet and one or two forms of castor-oil emulsion. For instance: 446. R. Oleiricini, IUxxiv Spt. chloroform!, f§-^* Sol. morph. mur., '• 3j Pulv. acacize, r z'** Synipi, , ,i?* Aquam, ad f. 5 iv. M. A small dessertspoonful every hour and a half till the bowels are quieted. He adds the following rules : 1. When the diarrhoea is chronic, and the stools contain mucus, he increases the dose of castor-oil to from four to six drops. 2. If the pain is very severe, six drops of morphia (Sol. B. Ph.) may be given with each dose, but he has never had occasion to give more. 3. If the mixture is carefully prepared it is pleasant and readily taken, and the taste of the oil is so completely covered that in only two or three cases of the large number in which he had given it, was the mixture suspected to taste like castor-oil. 4. The mixture does not keep well, especially in warm weather, but the addition of four grains of quinine to a three-ounce bottle will keep it fresh for several weeks. In muco-enteritis, or dysenteric diarrhoea. Dr. YouNG has derived decided advantage from the employment of arsenic. It is especially indicated where the stools are slimy, contain much mucus and blood, and are attended with great prostration of strength. Two drops of the liquor arsenicalis (B. Ph.) are given every two or three hours. If the movements occur soon after food, the arsenic should be taken before meals ; if not, in the usual way, after food. DR. O. T. OSBORNE, NEW HAVEN; (New York Med. Jour., 1888.) Dr. OSBORNE gives salol every two hours in acute diarrhoea until the stools cease. The indications for the drug in intestinal troubles are vomiting, cramps, summer diarrhoea of children ; and Dr. O. has found it of service in pro- longed diarrhoea and in one case of dysentery. He has used it most frequently in the diarrhoea and vomiting of children, and in every 447- R- *^'" ricini, Pulveris acaciae, 5) Tincturae opii, Syrupi, Aquae carui. TUviij f.Sij q. s. ad f. § ij. Dose — ^A tablespoonful for a child six years old. DIARRHOEA, ACUTE AND CHRONIC. 253 case with success, the stools becoming infrequent immediately, as- suming their natural color and losing their offensive odor. To a child under two years he gives three-fourths of a grain ; from two to five years, one and a half grain ; from five to twelve, three grains ; and above twelve years, four and a half or five grains. DR. THOMAS HILLIER, LONDON. U. A useful oleaginous mixture in dysenteric diarrhoea. Poultices and hot fomentations help to relieve the pain. DR. GEORGES HAYEM. (La. Med. Mod., 1890.) Hayem calls attention to the value of lactic acid in the treatment of diarrhoea of both adults and children. In small doses it seems to increase digestion ; in moderate quantities it is probably absorbed and changed in the blood ; but after large doses, more than two and a half drachms daily, it appears in the urine and faeces. These large doses do not produce any unfavor- able symptoms, however. 448. R. Acidi lactici, 3iiss-3iy Syrupi, f. § vj Aquae, f. § vij. M. Sig. : Half a tumblerful to be taken between each meal. Mr. R. P. White, of Dublin, speaks in the highest terms of a tur- pentine emulsion in all cases of severe diarrhoea, even those in typhoid fever. 449. R. Olei terebinthinne, Liquoris potassae, aa f-3ij Mucilaginis acaciae, f. 3i" Syrupi papaveris, Syr. flor. aurantii, aa f. 3 viij Aquam camphorce, ad f. % viij. M. Shake well, and take a tablespoonful every four hours. After the acute phase of the attack is over, the time has come for opiates and astringents. 2 54 DISEASES OF THE DIGESTIVE SYSTEM. DR. WILLIAM AITKEN, M. D., EDINBURGH, says that one general rule may be acted on in the cure of diarrhoea, which is, that in the adult, whatever be the form of the diarrhoea, if the stools be dark at first and then become light-colored, purgative medicines are no longer beneficial, and in no instance ought they to be continued longer than is sufficient to remove any irritative substance accumulated in the alimentary canal. Often a tonic is re- quired : 450. R. Salicin, gr- v-x. For one powder. To be taken every four or six hours. In cases of diarrhoea with clear tongue, which will not yield to opiates, astringents, or stimulants, either singly or combined, and which probably depend on a want of tone in the intestine, the above recipe has often stopped a discharge that appeared fast hurrying the patient to his grave. DR. JOSEPH NEFF, OF PHILADELPHIA. This physician has had very favorable results in chronic diarrhoea of a simple character from the use of the following : 451. JJ. Acidi nitrosi, ITlv Tinctutje opii deod., jliv Xini;turx nucis vomicae, IHv Aquae camphorae, q, s. ad f. § ss Syrupi et aquje, aa q. a. adf. fj. M. . Sig: One dose; same every three or four hours. In chronic diarrhoea with lientery. Dr. Neff is in the habit of pre- scribing with good results the following: 452. JJ. Massae hydrargyri, gr. iv Tincturae nucis vomicae, f. 3'j Morphize sulphatis, gr. ij Syrupi catechu, ^ § ij Aquae camphoris, q. s. ad f. § viij. M. Sig: Tablespoonful four times daily. DR. McCONNELL. (Practitioner, 1888.) Dr. McCONNELL advises in the chronic diarrhoeas of dyspepsia the following : 453- ■ B- Tincture of cannabis indica, IIlx gr-Jt Subnitrate of bismuth, ^ Spirits of chloroform, IHxx M ucilage o f acacia, f. 5 ss Cinnamon water, f-ij. M. Sig: One dose. DIARRHCEA, ACUTE AND CHRONIC. 255 DR. J. M. DA COSTA, M. D., PHILADELPHIA. In cases in which there exists persistent irritability of the bowels, influenced by the taking of much food which cannot be digested, and in which there are gastric symptoms in connection with the dysen- teric affection, the subnitrate of bismuth will be found very service- able. In order that it shall produce an effect, it is necessary that it shall be administered in sufficiently large doses, not less than 20 grains. The dose may gradually be increased to a drachm. 454. R. Bismuthi subnitratis, 9j Acidi tannici, Pulveris ipecacuanhiE compositae, aS gr. iij. M. For one powder. To be taken three times a day, in chronic dysenteric diarrhoea. SIR J. FAYRER. F. R. C. P., BRITISH INDIA. This author believes that in the treatment of chronic diarrhoea, diet is the most important element — more so than drugs. He gives the following rules : All irritating or indigestible or solid food must be at first prohib- ited, and only that which is most easily absorbed and assimilated allowed. Milk alone, or, better, diluted with about one-fourth or one-third part of lime-water, given in small quantities and at fre- quent intervals, say a wineglassful every second or third hour, in some cases more frequently, will generally be found to answer well, and may be continued for a time to the exclusion of all other food. Milk, undiluted, will seldom agree, as may be seen by its causing increased irritation, frequency of action, and the passage of undi- gested caseine. Beef tea, raw beef juice, or other plain animal broth,, free from all extraneous matters ; a raw egg beaten up with milk, to which a teaspoonful of brandy may be added, will sometimes be tol- erated ; arrowroot, tapioca, or other plain farinaceous food, will sometimes, but not always answer. Tea and coffee, as a general rule, disagree, and should be avoided. Stimulants, especially for those who have long been habituated to their use, are often needed ; the best are a little whisky or brandy diluted with Vals or Vichy or potash water; but these should be laid aside for plain water if they, as they sometimes do, increase the action of the bowels. Or a little very good port wine may be tried ; as a general rule, all other wines are unsuitable. Regularity in the times of administration and in the quantity of 2 56 DISEASES OF THE DIGESTIVE SYSTEM. nourishment given is most essential. The greatest care should be taken not to give too much of anything at a time, and at once to discontinue whatever appears to disagree. It is necessary that the patient should be kept warm, and at an equable temperature day and night. The body should be covered with flannel or woolen next the skin, and a flannel bandage should surround the abdomen. Chills and damp are especially to be avoided; exposure to them may seriously aggravate the mischief; during cold weather the patient should not leave the house. JOHN FORSYTH MEIGS, M. D. 455. JJ. Pulveris opii, S'- V Fxtracti nucis vomicae, gr. iij Cupri sulphatis, gf- J- **• Divide into twelve pills. One three times a day, in chronic diarrhcea. The value of this pill has been proved by army experience. CHARLES MURCHISON, M. D., F. R. OS., ETC. 456. R. Acidi tannici, 9'' Tincturae opii, "l^l Glycerini, f.^ss Aquse menthae piperitae, ad f. § iv. M. A tablespoonful in a tablespoonful of water every four hours. After the diarrhoea is checked, order : M. DRS. BURKART AND RICKER, STUTTGART, GERMANY. These writers bave lately called attention to what they deem the •extraordinary powers of cofo bark, and its active principle, cotoin, in diarrhcea, intestinal catarrh, and dysenteric disease. The remedy was employed in the form of powder, tincture, and the active prin- ciple, cotoin. The taste of the powdered bark and tincture is par- ticularly disagreeable, increasing the flow of the saliva in a marked degree. In moderate doses, they generally produce a burning sen- sation in the stomach, and, very frequently, eructations and vomiting, making both these forms of exhibition extremely undesirable. The employment of cotoin is free from these objections, for very small doses produce the desired effect, without inducing secondary dis- turbances or disagreeable sensations of any kind. 457. R. Acidi nitro-muriatici. f.Siss Tincturee opii, ruxl Syrupi, f.Bss Aquse, ad f. S iv. A tablespoonful in water, four times a day. DIARRHOEA, ACUTE AND CHRONIC. 257 ■ 458. R. CotoTnEe, gr. j Aquae destillate, f. g i^ Alcoholis, gtt. X Syup'. f.ij. M. A tablespoonful every hour. Some of the cases were of long standing, some were severe attacks of cholera morbus, and others had been but little benefitted by tan- nin, opium, or lead acetate. The above mixture produced speedy- improvement — generally in a few hours — and complete recovery in from twelve hours to six days. Paracotoin is another derivative which is used in the same connec- tion ; dose, four or five grains. Cotoin and paracotoin are said not to cause the objectionable symptoms of nausea, vomiting and pain which occasionally arise from the bark. DR. H. F. VICKKRY. ( Therap. Gaz., 1 890.) Dr. H. F. Vickery publishes a paper on the treatment of chronic diarrhoea, which, although it offers no claim for originality, yet calls attention to a number of points which are doubtless overlooked by the majority of practitioners. He shows that in the treatment of chronic diarrhoea four general principles should be attended to. First, the diseased parts should be given rest ; second, any tendency to abnormal fermentation should be cor- rected ; third, no fsecal accumulation should be permitted ; fourth, pain should be relieved. Taking these four indications in order, he shows that rest for the bowels means the ingestion of such kinds and amounts of food as will tax intestinal digestion least. Of course, it is not meant that the patient should be put on a starvation diet, for although this suc- ceeds in acute diarrhoea, it is not so in chronic. The principle which Dr. Vickery recognizes, although he does not emphasize it, is that substances which are digested in the stomach are suitable in such cases, while those which are dependent upon intestinal diges- tion should be avoided. He therefore recommends meat-broths and aseptic milk, while oily bodies and starchy foods should be avoided. In the second place, as the intestines, even in health, swarm with bacteria, and the natural processes of intestinal digestion border close on putrefaction, some antiseptic is almost always useful as an ingredient in the prescription for chonic diarrhoea. Subnitrate of bismuth probably acts to some extent in this way, besides soothing the mucous membrane. Michailoff, of St. Petersburg, has re- 17 258 DISEASES OF THE DIGESTIVE SYSTEM. cently reported the cessation of a diarrhcea which had lasted thirty years under the employment of salicylate of bismuth. Dr. ViCKERY also used carbolic acid (^ grain in each dose), beta-naphthol (% to I grain), and salol {2% to 5 grains). Thymol has also been praised (2 grains three times a day), but in the one case in which the anthor tried it he suspected it of causing headache, although the diarrhcea improved while it was being taken. The danger from faecal accumulation in chronic diarrhcea seems to be one which is rarely recognized, although. DR. ViCKERY states that the accumulation of faecal masses may cause mischief. This undoubtedly would be true if it occurred, and although there may be, of course, a fluid discharge from the bowels, and hard masses still remain in the intestine, such a state of affairs is of but excep- tional occurrence, and its recognition and removal of the faecal ac- cumulations will in nearly all cases cure the affection. This factor in the causation of diarrhcea is well worthy of atten- tion, and a paper by DR. C. P. Putnam in the Boston Medical and Surgical Jonrnaliox March 6, 1890, especially emphasizes the im- portance of bearing in mind that in some cases retention of faeces may be an important element in rendering diarrhoea persistent. Of course, where the diarrhcea is known to be due to the presence of some offending substance, no one hesitates to administer a cathartic ; thus castor oil, or rhubarb, or calomel, is used frequently, and with much advantage, in diarrhoea from indigestion in children. Dr. Putnam refers to three typical cases, occurring in an infant, a young woman, and a youth, illustrating different evidences of diarrhoea be- ing kept up by the retention of faeces. The practice of giving opiates for diarrhoea, irrespective of its cause, is highly objectionable, and may be even dangerous. The number of discharges is of comparatively little importance, in offer- ing indication as to the character of the treatment, as compared to their quality. Extremely offensive stools, as indicating a process of decomposition in the intestines, is to be regarded as an indication for the administration of a laxative, and it will be found that the administration in some cases of a few calomel powders will produce much more rapid and permanent improvement than the routine treatment with astringents and opiates. Pain may be overcome by the use of a few drops of laudanum, or a drachm of paregoric, to each dose of medicine, omitting it as soon as may be. Sometimes the bowels are lame, so that motion is pain- DIARRHCEA, ACUTE AND CHRONIC. 259 ful. Sometimes changes of temperature affect the patient disas- trously. For both these conditions a flannel swathe is useful. And in severe cases, rest in bed is demanded. Where the frequent dejection of small amounts of mucus and blood, with tenesmus, indicates the predominance of colitis, rectal irrigations through a soft tube passed high up are both rational and efficient. Two or three pints of simple cold water used in this may- do good. In it can be dissolved sulphate of zinc or alum to the amount of one grain to every four or six ounces of water ; or two grains of nitrate of silver to a pint may be injected every one or two days, if allowed to come away at once. DR. EDWARD R. SQUIBB, BROOKLYN. The following is a favorite prescription of this physician, in diar- rhoea : 459- R- Tincturre opii, Tincturae camphoKc, Tincture capsici, Chloroformi purilicati, Alcoholis, A teaspoonful as required. aa f.§i f.Siij q. s. aJ f. § V. M. The following formula is quoted from the Canada Medical Review, 1890: 460. R. Vini opii, Tinctune valeriaras, Aetheris, Olei menthoe piperitse, Extract! ipecacuanhos fluidi. Alcohol, Dose : Thirty drops every three hours. q. s. f. § iss f.§ss mix nixv ad f. § iv. M. NOTES ON REMEDIES. ACUTE DIARKKCEA. Acetum. — Pure cider vinegar has been recommended by Dr. T. C. Stel- WAGEN, of Philadelphia, as a safe and efficacious remedy in all forms of diarrhoea. It should be taken without water, an adult dose being about two oz. It can also be given to children in chronic forms of the disease with advantage {Reporter, 1S84). Acidum Nilrosum. When there are painless, watery stools, of a light color, and alkaline in reaction, Hope's mixture has long been used with ad- vantage. The following is the formula : 461. R. Acid, nitrosi, Tinct. opii, AqujE camphorse, S. — One-fourth to be taken every three or four hours. f.3j gtt. xl f.Sviij. 26o DISEASES OF THE DIGESTIVE SYSTEM. Camphor is regarded by Dr. Ringer as one of the most efficacious of reme- dies in summer diarrhoea, but it must be employed at the very com- mencement of the disease, or it will fail of its effect. Capsicum is regarded by Dr. Copland as almost a specific in diarrhoea aris- ing from putrid matter in the intestines, and especially when occasioned by fish. Carbolicum Acidum has been recommended in the diarrhoea caused by eating unripe fruit, etc. Lactic Acid is warmly recommended in large doses (gr. v-vii.) by Hayem. Leptandrin is valuable when the stools are destitute of bile and the mucous membrane is irritable. In such cases, the stools, under its use, are said to assume their natural color and consistence. Magnesii Sulphas. A dose at the outset often brings prompt relief. Oleum Ricini. (F. 446, 447.) Opium is a most valuable remedy in diarrhoea. In cases due to the inges- tion of indigestible food, etc., an aperient should be first given, to re- move the irritating matter ; then, if the diarrhoea persist, opium, in mixture, or pill, or enema, will often arrest it. Dr. Waring recom- mends, in the so-called summer cr autumnal diarrhoea, the combina- tion of laudanum (itlx— xx) with dilute sulphuric acid (ttlxv-xx), as often successful. Rheum is often of great benefit by its property of first removing irritant mat- ters from the bowels, and then acting as an astringent and tonic. The following is an excellent formula for general use, which by itself will often effect a cure : 462. R. Pulveris rhei compositi, 5j Sodii carbonatis, gr. xx Tincturee opii, lUx-xv Aquae menthse piperitse, f. 3 x. M. Make a drink. If, after its operation, the diarrhoea continues, chalk mixture and opium may be given. Salol has been prescribed with benefit where the diarrhoea arises from fer- mentative changes in the bowel. Sodii Bicarbonas, in full dose (Bij-3J), combined with tincture of ginger (f. 3ss-f. 3j) and aromatic spirits of ammonia (f. gss-f. 3j) and a lit- tle laudanum, is of great service in diarrhoea attended with colic and gastric irritability, and flatulence, especially when this is consequent on the ingestion of unwholesome food. Tannic Acid and vegetable astringents containing it, especially rubus, kino, and catechu, are much used in simple diarrhoea. Enemata are often of great service, either mucilaginous or containing opium, ipecacuanha, or astringents. Cold water enemata are highly recom- DIARRHOEA, ACUTE AND CHRONIC. 261 mended by Winternitz. Enemata containing some antiseptic, as creoline, are often of value. SUB-ACUTE AND CHRONIC DIARRHCEA. Alum, in doses of 3SS-3J, daily, or in enema Oj-vj), is often of benefit in diarrhoea dependent upon a relaxed condition of the intestinal mucous membrane. The following formula is useful : 463. R. Aluminis, gr. x Pulvcris kino compositi, gr. 1 Confectionis rosre, q. ». M. Make pill. Take every sixth hour. Argenti Nitras is of service in chronic diarrhcea when the stools are watery or mucous. Arsenic is highly spoken of by Dr. Ringer in chronic diarrhcea. He gives one to two minims of Fowler's solution before each meal. Bartholow recommenda it, with tincture of opium, when undigested food is passed soon after meals, and in chronic diarrhcea. Bismttthi SubnitraT, (See F. 454) Professor Alonzo Clarke recommends as particularly excellent in chronic diarrhcea : 464. R. Eismuthi subnitratis, gr. v Morphise sulpbatis, gr. [V. M. This much, two, three or more times daily. Cakis Carbolas, in one-grain doses, combined with henbane, has been suc- cessfully employed by Dr. Habershon (Lancet, January 4th, 1868,) in diarrhoea attended with flatulent distention of the colon. Calcis Phosphas, in doses of gr. j-ij, several times a day, is praised by Dr. Ringer as of great value in chronic diarrhoea, effecting both a general and local improvement. Camphor as in Hope's mixture (F. 461) is of great value. Cannabis Indica in the form of tincture is often used in combination with bismuth or vegetable astringents in diarrhoea. Carbazoiate of Ammonia, in grain doses, thrice daily, has proved successful in very chronic cases. Cascarilla is much used in Germany in the advanced stages of diarrhoea. Catechu, when there is no inflammatory action, is useful (in doses of gr. x-xv of the compound powder, orf. |j-ij of the infusion) in diar- rhoea depending upon a relaxed state of the mucous membranes of the intestinal cannal. Cinnamcmum, in combination with chalk and opium, is often of benefit in chronic diarrhoea. 262 DISEASES OF THE DIGESTIVE SYSTEM. ■Goto and Cotoin. These preparations act as useful astringents in both acute and chronic cases. Dr. J. B. Crandall, of Ohio, recommends : 465. R. Fl. ext. coto bark, r z ■• Comp. tr. cardamom., aa f. 3 ij Mucilag. acaciae.. Syrup, aa , f-|s».. Cinnamomi aquze, q. s. ad. f. 5 vuj. M. Sig. — A tablespoonful every three hours. Creasotum is occasionally effectual. The following formula may be used : 466. E. Creasoti, "IH^^ Spiritfls ammonix aromatici, Plxv Aquae, f.giss. M. Where there is much pain, paregoric may be added. Or the following : 467. R. Creasoti, f.3is» Pulv. opii, Pulv. capsici, aa 3j Pulv. kramerise, q. s. M. Make sixty pills. One every hour or two until the violent symptoms are relieved. Cupri Sulphas, combined with opium, is often very serviceable. Dr. Waring recommends the following formula : 468. R. Cupri sulphatis, gr. ^-ss Pulveris ipecacuanhae compositi, gr. vj. M. Make powder. Take thrice daily. Dr. John Fors\th Meigs combines it with opium and nux vomica ; Dr. Tanner, with opium and gentian. Cusparim Cortex may be given with advantage in the latter stages of diar- rhoea. Erigeron Canadensis. Dr. J. W. Moorman, of Kentucky, says there is no better remedy in diarrhoea with debility, than the oleum erigerontis, gtt. XV, every four hours, till relieved. It is best given in sugared water, and in full doses. (American Journal of Medical Sciences, 1865.) Ferri Pernitratis Liquor, in doses of gtt. x-xv thrice daily, is a valuable as- tringent and tonic. Dr. Kerr recommends the persesquinitrate. To prepare it, he mixes one ounce and a half of nitric acid with seven and a half of water, and puts into the mixture half an ounce of iron wire. The solution is then poured off from the remainder of the wire, and water is added to it, till the whole amounts to thirty ounces. The liquor ought to be transparent and of a beautiful dark -red color. Ferri et Po/assii Tartras. The following formula is recommended by Dr. E. GooDEVE, in chronic diarrhoea, attended with anaemia .: DIARRHCEA, ACUTE AND CHRONIC. 263 469. R. Ferri et potassii tartratis, 9i-ij Tincturee opii, f. 3 iss_iij Aquse cinnamomi, . f. g iy. j^j A tablespoonful in water thrice daily. Guarana. (Therap. Gaz., i8go.) Dr. Boughter reports very gratifying results in chronic diarrhoea from the use of powdered guarana. Hcemaioxylon, in decoction, in the form of an extract (gr. x-xxx) is a use- ful astringent and tonic after active inflammation has subsided. Hydrargyri Chloridum Corrosivum. In intestinal catarrh, especially in children, the use of the following prescription with a milk diet, often produces " marvelous" results : 470. R. Hydrarg. chlor. corrosivi, gr. \-\ Aquae, f. § iv.' M. A teaspoonful every two or three hours. Ice and other cold applications to the abdomen may often be of service in acute diarrhoea. Kino, in doses of gr. xij— xx, with or without opium, is a valuable astringent in chronic diarrhoea, especially that connected with follicular de- rangement. It is also frequently prescribed even when febrile symp- toms are present. Krameria is much employed by Spanish physicians, in chronic diarrhoea, and is especially useful when the stools are mucous and slimy, and when there is no inflammatory action. Matico, in infusion, is usually of benefit in chronic diarrhoea. Muriatic Acid, combined with tincture of nux vomica, and given before meals, is found of benefit, by Dr. William Fox, in the nervous disorder of digestion, associated with diarrhoea. Myristica, in mild cases of asthenic diarrhoea, is recommended by Dr. Per- EiRA as a substitute for opium, with warm brandy and water (if not contra-indicated) as a vehicle. Nitricum Acidum Diluium, in doses of ttlv-xv, combined with laudanum (iTi^xv-xx), in a little vegetable infusion, has been recommended in chronic diarrhoea. Nux Vomica is highly praised by Prof. Graves, in obstinate chronic diar- rhoea, which resists ordinary remedies, and in that form, especially, which accompanies exhaustion after fevers. It may be combined with opium and sulphate of copper. Opium is frequently given, alone or in combination with other remedies. Dr. Spender says it is now and then absolutely necessary, and it should always be prescribed in comparatively small and frequent doses, so as to obtain the least physiological with the most medicinal effect. Let the wine of opium be given to an adult, in the quantity of 264 DISEASES OF THE DIGESTIVE SYSTEM. three or four minims (with an ounce of chloroform water), five or six times in the twenty-four hours ; and the remedy ought, invariably, to be left off by degrees. In ordinary choleraic diarrhoea or cholera morbus of adults, no remedy will so promptly reliave the cramps and pain, and check the purging, as the hypodermic administration of tnorphicB sulphas, gr. }i-}i- Plumbi Acetas, by the mouth or in the form of an enema, is often an effectual remedy. Potassii Chloras is recommended by Dr. Copeland in chronic mucous diar- rhoea, with whitish, grayish, or mucilage-like stools, arising from the absence of bile, etc. Professor Bonfigli lately urges it in vaso-paralyt- ic diarrhoea. In grave cases of cachexia, connected with great ner- vous depression, the diarrhoea diminishes, but does not completely cease. In obstinate cases, there are alterations of the vascular pari- etes (amyloid or fatty degeneration), or ulcerative lesions of the mu- cous membrane. These require an energetic and prolonged use of the remedy. It is of no use if the diarrhoea is kept up by an active process of the mucous membrane, catarrhal enteritis, etc. Quercus Cortex, in decoction, is sometimes serviceable. Acorns, roasted and 'powdered, have also been used. Salicin, in cases of chronic diarrhoea dependent on want of tone, is recom- mended by Dr. Aitken. It should be administered in a dose of five or six grains, perhaps combined with a grain of ipecacuanha. Let them be mixed into a couple of pills, and taken three or four times a day. This plan seldom fails to appease an obstinate diarrhoea. Sarracenia Flava, is a popular agent in chronic diarrhoea. One physician reports uniform success with it. (Therapeutic Gazette, 1880.) Tannin, with opium, sometimes proves of surprising efficacy in cases of chronic diarrhoea which have resisted all ordinary treatment, and which are not dependent on obstructive disease of the heart or liver. It is especially useful where there is an irritable, weakly mucous mem- brane. It may be given in the form of a pill or mixture. Terebinthince Oleum in Stupes, applied to the whole abdomen and allowed to remain on as long as the patient will endure them, is often of great benefit. Internally, see F. 449. Zinci Oxidum,va. doses of gr. iij-x, thrice daily, has been recommended by Dr. Waring-Curran. Dr. Bonamy, of Paris, has employed the method indicated by M. Gubler, that is to say, 20 grains of oxide of zinc, mixed with 71^ grains of bicarbonate of soda, and divided into three or four doses, to be taken every three hours. M. Bonamy has not observed any vomiting. He sums up the advantages of the treatment thus : ist. Superiority of Action ; since all the cases of diarrhoea in DYSENTERY, ACUTE AND CHRONIC. 265 which oxide of zinc was employed with success, had resisted other means of treatment ; and since the diarrhoea re-appeared as soon as the oxide of zinc was replaced by another agent. 2d. Rapidity of action; diarrhoea dating for several months was favorably modified after the administration of the first dose. Zinci Sulphas, combined with ipecacuanha and opium, occasionally proves of advantage. Blisters. A small blister to the abdomen is often veiy effectual in obstinate subacute diarrhoea. Enemata of cold water have recently been found very useful by Dr. M. J. B. Messler. (American Journal Medical Science, 1v\^, 1878.) DYSENTERY. ACUTE AND CHRONIC. ACUl'E DYSENTERY. DR. LEMOINE, OF FRANCE. (La Bull. Med., 1890.) At first a solution of 5 parts of corrosive sublimate to 1,000 parts of water is employed, six or eight drachms being injected two or three times daily. Later, the same quantity of a 3 to 1,000 solution is injected morning and night. Lemoine has obtained very gratifying results from this method of treatment; he has never seen mercurial poisoning from it, and has never been able to detect even traces of mercury in the urine. The injections act as an antiseptic, bathing the mucous membrane, clearing the ulcerations and preventing absorption of the products of putrefac- tion. It is possible that the good effects are really due to the action of the drug upon the parasite which is commonly found in the in- testines in dysentery and which is supposed to bear a causal rela- tion to dysentery. DR. A. W. D. LEAHY, OF INDIA. (London Lancet, 1890.) This physician has obtained almost uni- form success in dysentery from the use of epsom salts in a large series of cases of dysentery. The plan recommended is to take a sufficient quantity of magnesium sulphate to saturate seven ounces of water and to add to this saturated solution one ounce of dilute sulphuric acid. Sulphate of morphia may be combined with it, or starch enemata with laudanum may be employed. In the earlier 266 DISEASES OF THE DIGESTIVE SYSTEM. Stages this solution acts like a charm, according to the writer ; fever disappears, mucus and blood no longer are present in the stools, which become copious, faeculent, and bilious ; tenesmus ceases ; the patient's anxiety disappears ; the skin acts well, and sleep follows the administration of the first few doses. The more chronic the case the less, however, does this remedy appear as efficient. Dr. Leahy gives of the saturated solution of epsom salts a drachm with ten drops of dilute sulphuric acid every hour or two, until the above favorable symptoms become manifest. After the stools have become normal in appearance and the patient has only two or three in 24 hours, an ordinary astringent mixture of acid with laudanum or tincture of Indian hemp, or a pill containing extract of opium, is usually all required to complete a cure. DR. ALFRED STENGEL, OF PHILADELPHIA. (Med. News, 1890.) This well-known practitioner of medicine, in the report of a number of cases of dysentery in which he had found the amceba coli present, apparently as the causal agent, expresses the highest opinion of epsom salts in these cases of acute dysentery. He recommends the following mixture : 471. R. Magnesii sulphatis, gr. xl Tinctune opii deod., gtt. v Sy rupi limonis, f, 5 ss Aqns, adfiSij. M. Sig. — One dose. This is to be given every hour until the stools change in character to fbeculence; then every two hours. DR. F. RAWLE, OF ENGLAND, Recommends the following treatment in the British Medical Journal, January 27, 1883. First, having placed the patient between warm blankets, he pro- ceeds to inject a pint and a half of warm water, at a temperature of 90° Fahr. This is seldom retained longer than a few minutes, but is pronounced very grateful to the patient. When the water has soothed the mucous membrane of the colon and rectum, and brought away any effete matter, he then proceeds to administer a small injection of two ounces, by measure, with a gum-elastic bottle. The form he administers is the following: 472- R. QuiniEB disulphat., „ ^ Tinct. camphorse comp., f 5 j^ Decocti amyli. q.s.adfiiij. M. iieat, and when about milk-warm, inject. DYSENTERY, ACUTE AND CHRONIC. 267 It is generally retained, but if ejected, it may be repeated after an hour or two. This he has found of great service, and very grateful to the patient. He does not stop to inquire how it acts, but the effect is like magic. If griping pains be felt over the region of the epigastrium, he administers half-drachm doses of chlorodyne, in some aromatic water, mint, caraway, or aniseed. The diet, of course, should be of the most soothing kind : jellies, isinglass, lin- seed, toast and barley water, ad libiUim. Ipecacuanha is of little service. He has used with advantage warm turpentine stupes on warm flannels, over the hypogastrium. DR. CARL SCHWALBE, COSTA RICA. In the Deutsches Archiv fur Klinische Medicin, March, 1875, this writer gives a very judicious treatment of acute dysentery as it occurs in hot climates, by pursuing which he had the good fortune not to lose a case. He advises, whenever a diarrhcea sets in during a heated term, or immediately after a marked fall in the tempera- ture, to suspect the possibility of dysentery, and at once to admin- ister a large enema of lukewarm water, 100 Fah., after it has been thoroughly boiled. This should be repeated until one and a half to two gallons have been thrown up, and the colon thoroughly emptied. After the onset of the dysenteric symptoms, these copious clysters should be repeated thrice daily. Against the tenesmus, when very annoying, Dr. SCHWALBE uses : 473- K- Atropiae sulphatis, gr. j Aquse destillatse, f- S j- M. Two or three drops every half hour, in water, until the pupil enlarges and the throat feels dry. When there is much intestinal pain the following recipe proves of value : 474- R- Acidi muriatici diluti, f. 3ij Morphise sulphatis, gr. ij Aquae destillatx, f. § iij. M. A teaspoonful three or four times daily. Mustard plasters should be applied to the abdomen. The diet should be fluid and nutritious. White of eg^ water, made by shak- ing thoroughly the whites of four eggs in a pint of boiled and cooled water, is especially serviceable. Dr. John G. Earnest, of Atlanta, Ga., adds his testimony to the efllicacy of hot water injections. Beginning with tepid water, the 268 DISEASES OF THE DIGESTIVE SYSTEM. temperature is gradually increased until the limit of toleration is reached. In conjunction with the hot water treatment, the author uses ipecac in full doses (twenty to thirty grains) and small doses of morphia hypodermically. KOYCiim (St. Louis Med. and Surg. Jour., 1891,) has also derived signal success by the use of large enemata of water warmed to 102° F. He used six pints of water at each enema ; the injected fluid was retained for five or ten minutes. He is in the habit of adding ten or more grains of carbolic acid to each enema, but does not think the addition is particularly advantageous over simple water. DR. MINORBI. (L! Union Med., 1890.) MiNORBl has used the following treat- ment with success in acute dysentery. The treatment consists in the insertion into the rectum of suppositories : 475- R- Naphthalin, Cacao butter, aa 3 iiss Where there is ulceration or any other condition rendering the use of a suppository painful, he uses this injection : 476. R. Naphthalin, gr. kxv Olive oil, f.Svj. At first these injections should be made every half hour, but ordinarily it is sufficient to repeat them three or four times in twenty-four hours. ROSSBACH employs naphthalin in this condition after the follow- ing manner: 477. R. Naphthalin, gr_ x " Boiling water, f 5 jy Decoction of marshmallow, Qj. M. Sig. : To be used as an injection at 100° F. PROF. W. C. MACLEAN, M. D., ENGLAND. Ipecacuanha should be administered in large doses as early in the disease as possible. From grains xxv to xxx should be given, in as small a quantity of fluid as possible. Some advise the administra- tion half an hour previous of ni,xxx of laudanum, or a few drops of chloroform. The patient should be kept perfectly still in bed, and abstain from fluid for at least three hours. If thirsty, he may suck a little ice, or may have a teaspoonful of cold water. Under this man- agement, nausea is seldom excessive, and vomiting rarely trouble- DYSENTERY, ACUTE AND CHRONIC. 269 some, usually not setting in until two hours after the medicine has been taken. Sinapisms or turpentine stupes should be affixed to the abdomen. In from eight to ten hours, according to the urgency of the symptoms and the effect produced by the first dose, ipecacuanha, in a reduced dose, should be repeated, with the same precautions as before. The effects of this treatment are surprising, and soon mani- fest; the tormina and tenesmus subside, the motions quickly become feculent, blood and slime disappear, and often, after profuse action of the skin, the patient falls into a tranquil sleep, and awakens re- freshed. The treatment may require to be continued for some days, the medicine being given in diminished doses, care being taken to allow a sufficient interval to admit of the patient taking some mild nourishment suited to the stage of the disease. As the disease abates, the dose should be reduced, but it is well to administer grs. x-xij at bedtime for a night or two, after the stools are, to all ap- pearence, healthy. McDowell, of the East India service {Brit. Med. Jotir., 1887), says that since the introduction of the ipecacuanha treatment, dys- entery has lost much of its horrible aspect. He gives a preparatory dose of twenty drops of laudanum an hour before the administra- tion, and applies a mustard poultice to the abdomen. At bedtime twenty to twenty-five grains of ipecacuanha are given ; this is re- peated each evening, no fluid being taken after the administration. By the third day the good effect is usually visible, and the patient as a rule proceeds to recovery. Fomentations, turpentine stupes, or chloroform liniment, to the ab- domen, lessen tormina and diminish suffering. If a little diarrhoea without the dysenteric odor remain, it may be checked with a small quantity of an astringent mixture ; but astringe7its , in any shape, dur- ing the acute stage, are not only useless, but dangerous. The hot bath is of great service in the mild forms of dysentery. It should be brought to the bedside, and kept at a high temperature, the patient remaining in until he feels faint. He should then be quickly and carefully dried, put to bed, and given ipecacuanha (gr. xv-xx), which may require to be repeated in eight or ten hours, the patient abstaining from all fluid for some hours after taking the medicine, and turpentine stupes being applied to the abdomen. This simple form of treatment, if it be resorted to early, will suffice in a great many cases of the mild form of dysentery which follows chills, without much charging the system with malaria. 270 DISEASES OF THE DIGESTIVE SYSTEM. DR. LIDDELL. This writer (Am. Jour. Med. Set., Jan., 1877,) believes that saline purgatives are of great value in the following cases: (i) Those in which the bowels are habitually constipated, for example, females and people of sedentary habits, for such cases are generally burdened with intestinal obstructions, which can be got rid of only by repeated doses of purgative medicine. (2) Cases of bilious dysentery. (3) Cases where portal congestion is present. (4) Cases complicated with malarial fever, or with malarial intoxication and ague-cake; and (5) Cases of chronic dysentery. In all cases the doses should be repeated until bilious and feculent matter appears in the stools. In such cases, he exhibits cream of tartar, in doses of three and four drachms every three or four hours, until large watery motions, tinged with bile, are produced, and the relief, as to ail the distressing and dangerous symptoms of the disease, was usually " something won- derful." CHRONIC DYSENTERY. DR. B. F. THOMPSON, OF THE SEAMAN'S HOSPITAL, GREENWICH, After trying many drugs, finds them all inferior to ipecacuanha. (British Medical Journal, January, 1876.) He believes the disease is best treated by rigidly keeping the patient at rest in bed, in a supine position ; by carefully regulating the temperature of the room to about 62° Fahr. ; by restricting the diet to few and simple foods, chiefly milk and mutton ; and by administering, at frequent short intervals, every three hours, small doses (three to five grains) of the powdered ipecacuanha. If nausea is produced, the dose is dimin- ished or omitted for a time, as it is very desirable to avoid inducing any disinclination to food. Alcohol, in any form, very decidedly aggravates the symptoms, and it must be always strictly forbidden. W. E. WHITEHEAD, M. D., ASSISTANT SURGEON, U. S. A., also recommends ipecacuanha in chronic dysentery. He directs the following treatment: A hot salt-bath daily, or several times a week, just before going to bed; such nourishing food as best agrees; flannel next the skin; a well-ventilated, dry and warm sleeping room ; and 478. R. Pulveris ipecacuanhae, 3;;,. For twelve powders. One to be taken morning and evening, on an empty stomach. DYSENTERY, ACUTE AND CHRONIC. 271 As improvement takes place lessen the dose of ipecacuanha to ten grains twice a day, and then to eight grains at bedtime. After the ipecacuanha is stopped, it may be followed with advantage by ten drops of the muriated tincture of iron morning and night. Other testimony to the value of ipecacuanha in chronic dysentery has been recently given by Dr. A. A. WoODHULL, U. S. A., and others. MR. R. DONALDSON, BRITISH INDIA. This writer, in the Indian Medical Gazette, June, 1876, recom- mends the compound tincture of benzoin as a most efficient remedy in dysenteric affections. He says that, in Burmah, dysentery is a very common affection, and in the European, as well as in the native, ex- hibits a marked tendency to become chronic. In many of these cases, ipecacuanha appears to have little or no effect; any per- sistence in the treatment by large doses of this drug, far from being productive of good, is fruitful of positive mischief. The stomach is rendered so irritable by it, that the patient is unable to retain nour- ishment; and he then suffers from exhaustion, the combined effect of the disease and innutrition. In these cases, the tincture of ben- zoin, given in combination with astringents — notably with logwood — has been fonnd extremely useful ; often, indeed, acting like a charm ; and it may be truly said of it, that its powers of healing diseased mucous membranes equal its performances when applied externally to wounds. The formula recommended is : 479- R. Tincturce benzoini comp., f. 3ss Tincturos catechu comp., f. 3j Tincturoe opii, TUx Extracti hsematoxyli, gr. x Aquam, ad f.gj. M. For a draught : to be given thrice daily. If necessary, the remedy may be adminis- tered by the rectuui. DR. RICHARD B. MAURY, MEMPHIS, In the Atlanta Medical and Surgical Journal, December, 1872, and later in the New York Medical Journal, March, 1876. The patient is placed in the left lateral position, used for making uterine exami- nations, and the interior of the rectum is exposed to view by means of a small Sims', or other appropriate speculum. This reveals one or more superficial ulcerations of the mucous surface. These are carefully cleansed with cotton-wool, and a solution of nitrate of sil- ver, oij to f.5j of water, 's thoroughly and earcfully applied to the 272 DISEASES OF THE DIGESTIVE SYSTEM. ulcerated surface. The treatment causes considerable pain, which should be relieved by morphia hypodermically ; and the patient be kept in bed. The improvement is immediate ; the movements be- come less frequent, and the sanguineous discharge ceases. In from four days to a week the caustic application should be repeated, which is often sufficient to effect a permanent cure. The following specific directions are given : Proceed deliberately and carefully, as in any other surgical pro- cedure. Always etherize the patient, and always stretch the sphinc- ter ani. When properly done these are both perfectly safe meas- ures. The patient being etherized, the operator is enabled to explore the rectum, and make his applications deliberately and thoroughly. Paralyzing the sphincter is not only necessary to com- plete and satisfactory explorations, but the quieting influence se- cured thereby to the rectum can hardly be over-estimated. Put the patient in Sims' position for uterine examinations, and use Sims' vaginal speculum for examining the anterior and lateral walls of the rectum, and the bivalve with hinges on one side for examining the posterior wall. If much disease is discovered on examination, the surgeon may use nitric acid. If ulceration is superficial, and the mucous mem- brane not much hypertrophied, the nitrate of silver does wdl. The patient should be required to remain in bed for a week or two, on a milk and meat diet. DR. H. C. WOOD, PHILADELPHIA, Recommends large rectal injections of nitrate of silver: 480. R. Argenti nitratis, 5: Al"^' Oiij. M. For one injection. No force should ever be used. The patient should be brought to the edge of a hard bed, his buttocks resting upon a hard pillow in such a way as to elevate the pelvis, and cause the injected fluid naturally to flow downward and inward. A well-oiled, smooth, somewhat flexible, hard tube, with openings in the sides (an oeso- phageal tube will answer well), and with a closed end, must then be gently and slowly introduced from eight to twelve inches in the rectum. The free outer end of this may be fastened to a flexible md.a-rubber tube, in the end of which a funnel is inserted. This DYSENTERY, ACUTE AKD CHRONIC. 273 being elevated five or six feet, the water warmed to the temperature of the body is poured in, and by its own weight, with irresistible gentleness, forces its way into the gut. Other writers assert that this extensive irrigation with simple warm water is all-sufficient. (Alois Monti.) The securing of an even and easily-regulated hydrostatic pressure is an essential feature of this method. Still more essential is the dis- tension of the rectum with Jluid before attempting to pass the tube through the sigmoid flexure. This precaution secures the smoothing out of the folds of mucous membrane, and straightens the curves of the flexure, thus rendering the passage of the tube perfectly safe and easy. NOTES ON REMEDIES. ACUTE DYSENTERY. Acidum Salicylicum, combined with opium, is recommended by Cimbali (Internal. Clin. Rundsch., 1890) ; he gives seven grains of the for- mer with one-fourth grain of the latter every five hours. Aconitum, gtt. ij of the tincture of the root, every hour, in acute sthenic cases, has been much praised. Argenti Nitras, in doses of gr. ss-iss daily, reduced to fine powder, and con- joined with Dover's powder in the form of pill, is highly recommended by Dr. Waring and others, in the advanced stages of acute dysentery. Belladonna, both internally and externally, is often extremely efBcacious. Bismuthi Subcarbonas, 3J-ij, suspended in mucilage, f .^i-ij, with laudanum, f.gss, forms an excellent enema. The lower bowel should first be gently washed out with warm water. Carbolicutn Acidum. Considerable success in the treatment of dysentery is reported by Dr. A. M. Ragl.4ND, of Texas, ( Va. Med. Monthly, Oc- tober, 1876,) by the use of the following: 481. R. Acidi carbolici, gtt- x Syrupi rhei aromatici, f. § j Olei limonis, Olei sassafras, aa gtt. t. M. A teaspoonful every two or three hours. If tormina and tenesmus are present, add ten drops of laudanum to each dose. Creasotum has been found by Dr. J. R. Gushing, of Chicago, a valuable anti- dysenteric remedy. 482. R. Creasoti, gtt. xi Acidi acetici, S"-..^ Morphise, gr.ij Aquae, f-3y> "• A teaspoonful every two hours until relieved. 18 274 DISEASES OF THE DIGESTIVE SYSTEM. In connection with this, he was accustomed to cover the bowels with cbths saturated with the following liniment : 483. R- Aquse ammonise, Olei sassafras, 3* ^ ^ ?? Tinct. opii, i-Oij Olei olivK, ._ Olei petr.>lei, aa f-Sy. M. For a liniment. (Chicaso Medical Journal, January, 1875.) The same agent is strongly recommended by Dr. H. von Swerin- GEN, of Indiana, (1884.) Creolin is recommended in enemata for the purpose of antisepticism. Ergot. Bartholow recommends the following : 484. R. Ext. ergotse fluidi, f- 5 "»* Tinct. opii deod., i- % ss. M. S. — Teaspoonful three times a day. 485. R. Ergotinse (or aq. ex.), Bj Ext. nucis vom., gf. ' Ext. opii, gr. v. M. Ft. pil. No. XX. S. — One every four or six hours. Ergotine, in doses of gr. vj, in emulsion, or in bland enema (gr. xij-xv), has been used with excellent results by Dr. Gross. {Practitioner, Novem- ber, 1868.) One of the effects noted under this treatment, was the speedy reduction in the quantity of blood voided. Gambogia. MAr,GAiGNE and Betz have found minute doses of gamboge (gr. %, three times a day,) valuable in dysentery. Hydrargyrum, formerly always resorted to in large doses in acute dysentery, has now fallen into comparative disuse, except as an occasional aper- ient, and ipecacuanha has taken its place. Particularly in the asthenic and scorbutic forms of dysentery, mercury, in every form, should be avoided. If, in exceptional cases of acute dysentery, it be employed, the following formula, for many years very generally used in Southern India, may be given : 486. R. Pilute hydrargyri, gr. ij— iij Pulveris ipecacuanhse radicis, gr. i-ij Opii, gr. \. M. Make pill. Take one every four or five hours. The following is also an effectual combination : 487. R. Hydrargyri chloridi mitis, gr. ss MorphiiE sulphatis, gr. \ Quinise sulphatis, gr. ij. M. Make pill. Take one every two or three hours. The bichloride in proportion of i : 5000 or i : loooo has been used in enematas for the purpose of intestinal antisepticism. DYSENTERY, ACUTE AND CHRONIC. 275 Jodinium. Dr. Paris recommends : 488. R. lodiDii, i^ Potassii iodidi, ~ ^^ Aqvui; destillatje, i z j:_ w To be employed as an enema in dysentery. It is sometimes necessary to administer It twice in the course of the twenty-four hours, and to continue its use several days. One of the principal effects of the iodine enema is to relieve, promptlv the tenesmus. ' r /> ">- Ipecacuanha, justly called " radix anti-dysenterica," is of the highest value in dysentery. Although, from its introduction, (by Piso, in 1658), its power in this disease has been more or less recognized, it was not— in consequence of the practice of conjoining it with other remedies sup- posed to possess similar virtues— until 1858 that its real value was demonstrated by Mr Docker (Zancef, July and August, 1858), who re-introduced the original plan of Piso and Helvetius, of giving it alone, in large and effective doses. The following facts now seem to be established : that acute dysentery can be successfully and speedily treated by large doses of ipecacuanha ; that this remedy is more effect- ual in the acute than in the chronic forms ; that large doses (gr. xxv- xxx) may be given with perfect safety, without fear of hyperemesis or other ill effects. The mode of treatment, in the main, now gen- erally practiced, is that detailed by Dr. W. C. Maclean, in the article on dysentery in Reynolds' System of Medicine, a condensed statement of which has already been given. Dr. T. J. Happel (Med- ical and Surgical Reporter) has had good results with the following formula : 489. R. Pulv. ipecac co., 9j " ipecac, Qiv. M. Ft. chart. No. iv. S. — One after each action till relieved. BouDiN (L' Union Med., 1890,) has found the following combina- tion of great value : 490. R. Ipecacuanha, gr. v Calomel, gr. iss Extract of opium, gr. j. M. To be made into three pills, and one given every hour. Limonum Succus should form an essential part of the treatment when the state of the gums or other circumstances lead to the belief in a scor- butic taint. A mixture of equal parts of lime juice, decoction of cin- chona, and port wine, was employed with good results in the British army, in the first Burmese war. Magnesii Sulphas. This is coming to take the place of ipecacuanha rap- idly in the treatment of dysentery, the opinion of the profession within the past several years being almost uniformly favorable. 276 DISEASES OF THE DIGESTIVE SYSTEM. Opium fulfills three important indications: i. Allaying pain and muscular excitement ; 2. Moderating the peristaltic motion of the intestines ; and 3. Promoting the cutaneous secretion. It is considered by Dr. Waring as, on the whole, however, inferior, especially at the onset of an acute attack, to ipecacuanha. A preliminary dose of opium is often of great service in enabling the stomach to retain ipecacuanha, and in preventing its emetic operation. The dose of solid opium may be increased from gr. j to gr. iij-iv, three or four times a day, not only without inconvenience, but with benefit, there being a marked tolerance of opium in this disease. The signs that its administration has been carried as far as is consistent with safety, are nausea and vomiting, tympanitic distension of the abdomen, and scanty stools. Tormina and tenesmus are best relieved by opiate enemata. Fre- quently morphia, hypodermically, acts much better than by the mouth, reHeving the vomiting, pain, and tensemus, as if by magic. Plumbi Acelas, in doses of gr. iij-iv, in combination with Dover's powder (gr. iv-v), may be given with advantage in the advanced stages of acute dysentery, especially when the stools contain much mucus. The fol- lowing enema may often be advantageously employed : 491- R- Plumbi acetatis, gr. x Acidi acetici diluti, IHx Morphife acetatis, gr. \ Aquae tepids, f. § iv. M. Potassii Chloras. Injections of this salt have been strongly advocated : 492. g. Potassii chloratis, 3ss Glyceiini, f. § ss AquK, f. § iij_iv. M. For an injection. Two or three a day, the patient to retain them as longas possible. Quinice Sulphas, in full doses (not less than 3j, in solution,) should be given in malarial dysentery, and repeated until cinchonism is induced. Ipe- cacuanha should then be given as directed. Soda ChlorinaicB Liquor. Dr. E. M. Morse, (California Medical Gazelle, September, 1868,) has met with marked success by throwing up into the rectum and colon from two to five pints of Labarraque's solution of chlorinated soda, largely diluted, in chronic simple uncomplicated dysentery, by which are meant those cases not kept up by organic dis- ease of the heart, or phthisis pulmonaTlis, nor dependent on immedi- ate obstruction of the liver or spleen. The right strength for the first enema is twenty parts of water to one of Labarraque's sohition. Sulphur appears to exercise,a favorable influence in some cases of chronic dysentery. Tannin, in combination with opium and ipecacuanha, is often of service. DYSENTERY, ACUTE AND CHRONIC. 277 Turpentine. Bartholow recommends the following in chronic dysentery : 493- R- 01. terebinthinas, f.3j 01. amygdal. express., f. § ss Tinct. opii, f.5ij Mucil. acacise, f. 5v AquEe lauro-cerasi, f. §ss. M. S. — A teaspoonful every three, four or six hours. The same formula is useful in acute dysentery, after the subsidence of the more acute symptoms. Zinci Oxidum, in doses of gr. iij-v thrice daily, is recommended by Dr. VVar- ING-CURRAN. Zinci Sulphas, combined with ipecacuanha and opium, has been employed with success. Water Belt. Dr. VV. Maclean recommends the use of a water belt over the abdomen for some hours daily. It acts as a fomentation, and the steady, uniform pressure it maintains seems to favor the absorption of the fibrine effused between the intestinal coats. If there be much un- easiness about the anus, a water compress over the part often affords more relief than an opiate enema. The cold hip-bath daily, for a few months, is of service. Mineral Waters. The Oak Orchard Water, of Lockport, New York, and the Rock Alum and similar springs of Virginia, possess astringent and tonic properties often of very decided benefit in cases of chronic dysentery. EXTERNAL MEASURES: Turpentine Stupes are highly serviceable in lessening tormina and tenesmus. Leeches to the verge of the anus often afford great relief to the tormina and tenesmus, and, by unloading the portal and hemorrhoidal veins, exer- cise a favorable influence in the course of the disease. Bandage. A large flannel roller around the bowels acts in ■ preventing the peristaltic action of the intestines. Position. The tenesmus is frequently relieved by placing the patient in the prone position, with pillows under the abdomen, so as to elevate the buttocks and rectum. CHRONIC DYSENTERY. Acidum Nitro-muriaticum Dilutum (in lotion of f..?j to aquae Oj) applied to the abdomen, is of benefit, especially where there is hepatic disease. Alum is much less employed in chronic dysenf^ry now than formerly. It may be given in combination with Dover's powder. Ammonii Chloridum. Dr. William Stewart {^Madras Monthly Journal of Medical Science) has found chronic dysentery, associated with chronic disease of the liver, yield to a few twenty-grain doses of the chloride of ammonium, after ipecacuanha and other remedies had failed. 278 DISEASES OF THE DIGESTIVE SYSTEM. Argenti Nitras is of great service in chronic dysentery. It should be given in the same maimer as directed for the advanced stage of the acute affection. Arsenic. When chronic dysentery is dependent upon the changes induced by chronic malarial infection, arsenic is often beneficial. Benzoinum has proved successful in the hands of Dr. Chipperfield, of Madras, {Madras Quarterly Medical Journal, January, 1867,} given as follows : 494. U. Tincturae benzoini compositae, f. 5 j-ij Tincturae opii, ITlxx-xI Pulveris acaciae, S''- "^ Aquam carui, ad f- S vj. M. Dose — One-fourth part every four hours. Bismuthi Subnitras is highly praised in subacute and chronic dysentery by Trousseau and Recamier. Carbo Ligni was recommended by Prof. Nathaniel Chapman, who found it, internally administered, to remove the acrid and offensive character of the stools. Cupri Sulphas, combined with opium, is often highly serviceable in chronic dysentery. Eserine, in doses of gr. sV by hypodermic injection, has controlled obstinate chronic diarrhoeas in the hospital of Berlin {^Neurol. Centralblatt, 1883). Fermentum has been recommended for removing the fcetor of the stools and diminishing their frequency : 495- R. Fermenti, f. Sx Camphorae, gr. xxx Spiritds aetheris nitrosi, f. § ss. M. A tablespoonful every two or three hours, according to the severity of the symptoms. Hcemaioxylum, in decoction or extract (gr. x-xxx) is an excellent tonic as- tringent, but inadmissible so long as any active inflammation exists. Hydrargyri Chloridum Corrosivum gr. j to water Oj, f. 3J ier die, will often be found to relieve and cure the most obstinate cases. Ipecacuanha, in the form of Dover's powder, is often of the greatest benefit in chronic dysentery, given at bedtime in full dose (gr. x-xij), or in small, frequently-repeated doses, in combination with nitrate of silver. Liquor Ferri Chloridi, in doses of gtt. iij-vij, well diluted with water and syrup, is frequently employed in France. The same doses in enema, combined with opium, are often serviceable. Liquor Ferri Nitratis is of great benefit, particularly in those anaemic from loss of blood and the depraving influence of malaria. DYSPEPSIA. 279 Liquor Ferri Subsulphatis, diluted, in enema, has been recommended. Nickel Sulphate. In obstinate diarrhoea. Dr. J. M. Da Costa has obtained good results from this substance in doses of gr. i-ij thrice daily (Med. News, 1884). He considers it worthy of more attention. Opium is of great value in chronic dysentery, and may be given combined with nitrate of silver, sulphate of copper, or sugar of lead. Plumbi Acetas, though less effectual perhaps than nitrate of silver or sul- phate of copper, may be employed at an earlier stage than either of those salts. Fotassii Bitartras is one of the best purgatives which can be employed when laxatives are indicated. M. Gubler has found this the most useful in the diarrhoea of phthisis, whenever ulceration of the uterus is sus- pected. He gives it in powders in the following form : Oxide of zinc, thirty grains ; bicarbonate of soda, ten grains ; in four powders, two or three daily. DYSPEPSIA. JOHN SYER BRISTOWE, M. D., LONDON. The first thing to be done is to seek the origin of the dyspeptic symptoms. See that the teeth are in good order; that the patient masticates wfell ; that he gives ample time to eating ; that the hours of meals are regular; that the food is wholesome, plain and digest- ible. Note, also, the condition of the stomach, and decide vi^hether the dyspepsia is primary or secondary to some other affection. In all cases of chronic dyspepsia, hygienic treatment, moderate exercise, regular hours, ventilated rooms, and change of air and scene, are of extreme importance. DIET IN DYSPEPSIA. In a leading article in the Dietetic Gazette, 1889, the following very sensible advice is given. Although dyspepsia has been classi- fied into a number of varieties, so far as the dietary is concerned there can be but little difference in these forms. It is a frequently repeated question applied to the physician, "What may I eat?" It is decidedly unwise to put off the inquiry by general instructions to drink and eat "what agrees with him." The general catarrhal con- dition of his mucous membranes can best be cured by copious draughts of hot water before meals. Washing out the stomach is rarely called for. 28o . DISEASES OF THE DIGESTIVE SYSTEM. The diet should follow closely the following table : May take : Soups, etc. — Thin soups, beef tea!, broths. Fish. — Raw oysters. Meats. — Beef, mutton, lamb, chicken, game, venison, chopped meat, meat pulp. Eggs. — Poached, soft boiled, raw or whipped up with water, milk, liquor or wine. Bread and Farinaceous Articles. — Bread sparingly, corn bread, rice cakes, stale bread and butter, macaroni, sago, tapioca, dry toast. Vegetables and Fruits. — Green vegetables, as spinach, turnip tops, cresses, salad, celery, sorrel, lettuce, string beans, dandelion, chi- cory, asparagus ; oranges, ripe peaches and pears. Drinks. — ^Water, abundantly; hot water an hour before meals; koumiss, butter-milk, matzoon, milk and lime-water, milk and selt- zer ; tea and coffee, sparingly ; claret, dry wines. Thoroughly masticate all foods. Avoid: Rich soups, all fried foods, veal, pork, hashes, stews, turkey, sweet potatoes, all starches and saccharine articles except as allowed, all gravies, made dishes, sauces, desserts, pies, pastry, pud- dings, ice cream, sweet wines, malt liquors, cordials, uncooked vege- tables, white potatoes, cooked oysters. In addition, about ten grains of a good pepsin and thirty drops of dilute hydrochloric acid after meals should be prescribed, and the bowels kept open. The above table, while to be strictly followed, may, as peculiar conditions arise, be modified or extended. DR. HENRY GIBBONS, SAN FRANCISCO. This physician also strongly recommends the use of five drops of chlorhydric acid in a teaspoonful of water, after eating, when the stomach feels burdened. Not only in his own case, but in a very large proportion of dyspeptic affections among patients, he has found it a most valuable remedy. From three to five drops is the proper quantity, and it may be taken either regularly before or after each meal, or on special occasions — pro re nata. It is the best thing he has ever given for cardialgia, or any affection of the stomach arising from excessive acidity. It should not be too much diluted, nor should it be sweetened. DR. I. BURNEY YEO, LONDON. In regard to the flatulent form of dyspepsia, this experienced DYSPEPSIA. 281 practitioner considers that, in the first place, it is necessary to main- tain for some time a lax condition of the bowels. In order to get rid of the tendency to the accumulation of gas in the upper part of the intestinal canal, it is absolutely necessary that not even a tem- porary block should be allowed to exist in the lower regions ; hence the value in such cases of a mild course of laxative mineral waters, as Carlsbad, etc., which secures two or three loose evacuations; be- fore any food is taken. Even in cases of organic constriction, it often proves of the greatest service. There are some patients with whom no aperient produces so much relief as castor oil, the comfort of each day depending on a dessertspoonful of this medicine, taken in the early morning. The Hunyadi water also answers well, and is often efficient in small quantities. No breakfast should be taken until the bowels have been freely relieved. With regard to food and drink, tea, coffee, cocoa, and all hot and sweet beverages, must be entirely banished from the dietary. In such conditions tea or coffee will almost immediately disturb the heart's action. Malt and sherry are also under the ban. Sound claret and water, or milk mixed with some alkaline effervescing water, are the safest beverages ; but much fluid of any kind is hurtful. Oat- meal porridge is still better. Animal food should be restricted to roast or boiled mutton, the lighter kinds of fish, and a little broiled fat bacon. Fruit, jellies, and marmalade, should take the place of butter. Of drugs, he has found great use in a pill of creasote, carbonate of magnesia, and extract of hop, taken immediately after every meal ; and when this has failed, he has seen excellent results from a few grains of ox-gall, made into a pill with powdered rhubarb, and taken after breakfast and dinner. One of the finest preparations in dyspepsia with flatulence, is the following: 496. R. Sodii sulphiLis, 3) Tincturae nucis vomicae, f. S'' Aquae, f-i>v. M. j A teaspoonful thrice daily, after meals. Dr. Paul CheRON (Prov. Med. Jour., 1890,) prescribes in flatu- lent dyspepsia the following powder : ■ Equal parts. 497- R- Magnesia, Calcium phosphate. Powdered charcoal. Sulphur, Sig. — A teaspoonful to be taken in water when necessary. 282 DISEASES OF THE DIGESTIVE SYSTEM. DR. WILLIAM BRINTON, LONDON. This writer gives the following useful hints in regard to the salts of iron, in dyspepsia. They are generally beneficial, not only in proportion to the anaemia and general derangement of nutrition present, but in proportion to the patient's deprivation of a due share of light, air and exercise, which is the cause of so much of the dys- pepsia of civilized life. Hence, iron is more useful in females than in males ; more in the sedentary dyspeptic than in the florid and over-fed. Where great nausea and irritability exist, it should gen- erally be avoided. It should always be given immediately after a meal, excepting after tea. The effervescing citrate will generally be borne by the most delicate stomach. Neither this nor any other salt of iron should be given in doses sufficiently large to cause nau- sea or flatulence. The carbonate, phosphate, sulphate and chloride form a scale of increasingly irritative preparations, and therefore demand not only a diminished dose, but an increased dilution. Thus, while we may give gr. x of the citrate as a common dose, gr. ij of the citrate, and "Lvij-viij of the tincture of the chloride, with half a wineglassful of water, are as much as most dyspeptics will safely bear. The oxide and other comparatively insoluble prepara- tions should be avoided. The efficacy of the salts of iron, in dys- pepsia, often appears to be increased by conjoining them with the sulphate or oxide of sine. Cathartics, according to Dr. W. Brinton, are of great service in dyspepsia in emergencies ; of little service, almost hurtful, as prom- inent features in treatment, which ought always to aim at such a tonic effect as is incompatible with habitual purgation. They should be given in the smallest doses, on an empty stomach, either before dinner, in the shape of a slowly-acting pill, or early in the morning, in that of a more rapidly-acting liquid. The pill form is preferable, as a rule, especially when the aperient is often repeated, the liquid aperients, especially the saline, often acting injuriously on an irri- table stomach. Castor oil, however, is, in many constitutions, an exception to this rule. DR. ARTHUR LEAKED, LONDON. This author has brought forward some new views on the subject of dyspepsia, (Brit. Med. Jour., May, 1879,) to wit, that the cause of most cases is not defective or impaired secretions, but a diminu- tion of the contractile movements of the stomach. He recommends DYSPEPSIA. 283 that the principal meal should be taken early in the day, before the nervous system has been exhausted by nervous or bodily exertion. Strychnia is of great value in impaired gastric peristalsis, but care must be used in its administration, and a dose of iV of a grain should be but rarely exceeded. It should never be given in the form of pill. Thymol has been found useful in checking flatulence by hinderino- fermentation, and charcoal capsules are recommended for the ab- sorption of the gases when the stomach is unable to expel flatulency in consequence of temporary paralysis from over-distention. M. CHARTERIS, M. D., GLASGOW. Of the many symptoms of dyspepsia, the more prominent may be met as follows : For the loss of appetite, a bitter infusion, as : 498. R. Ammon. sesquicarb., 3j Potass, bicarb., 3 is* Infusum chirettse, ad f. § vj. M. A tablespoonful thrice daily. For the flatulence, belching, and wind on the stomach, we may order a warm carminative, as : 499- K- Tinct. cardamom, con'.p., f. 3 iv Acid, hydrocyan. dilut., Hlxl Spts. ammon. aromat., f. 3 >i Tinct. zingib., f. 3>'i Spt. chloroform., f. .5 'j Aquje carui, q. s. ad f. § vj. M. A tablespoonful occasionally. When the belching is accompanied by "rotten-egg" flavor, show- ing the evolution of sulphuretted hydrogen, charcoal biscuits should be ordered, and creasote or carbolic acid. For simple heartburn, black sugar is efficacious, or eating an apple, or some liquor bismuthi. When there is gastrodynia, or cramp of the stomach, a brisk purgative, followed by carminatives with a mustard-poultice, gives relief Waterbrash or pyrosis is often brought on by some article of diet, as oatmeal. As a remedy, pulv. kino comp. can be recommended, and Friederichshall or Pullna waters. DR. JOHN S. MAIN, OF ENGLAND. The cerebral form of dyspepsia is well seen, in many cases, where 284 DISEASES OF THE DIGESTIVE SYSTEM. a healthy man, with a good appetite, suddenly receives bad news when sitting down to a meal. But of all conditions acting on the brain in this manner, and through the brain on the stomach, no one is more injurious, or more jarring to the cerebral elements, than un- certainty, and the worry caused by the same, more particularly in preternaturally irritable subjects. The mind, in such cases, preys upon itself ; the cerebral elements seem to get jarred and out of gear; and with this condition the stomach sympathizes. Such cases are most commonly met with amongst those who are engaged in the hottest part of the "battle of life," or "struggle foi- exist- ence;" and, again, amongst those chiefly whose business or profes- sion leads to much anxiety, uncertainty or overstretching of the mental powers. He has found that the only treatment capable of doing these cases any permanent good, is a change, in the wide sense of the term — a relaxation from business or study ; and as re- gards medicines, not such as are meant to act on the stomach directly, but those meant to act on the cerebrum. Amongst these, he has found the most useful to be the bromide of ammonium or bromide of potassium — preferably the former — given in a sufficient dose at bedtime to secure a good night's sleep, this being often very indifferent, and so tending to complicate the case ; and, combined with this, to be taken three or four times during the day, such med- icines as are known to have a building-up effect on the nervous sys- tem — amongst these, the most useful being phosphorus, or the hypophosphites, and cod-liver oil. Arsenic and quinine are often also useful, and a generous diet is always indicated. Unless the stomach has passed into a state of disease (which it may do, if overtasked when in this weakened state), any of these medicines are generally well borne. It will be well to bear in mind, however, that if the mucous membrane of the stomach be in a state of irritation, quinine, arsenic, phosphorus, the hypophosphites, and sometimes even cod-liver oil, are generally inadmissible. CLIMACTERIC DYSPEPSIA. MR. PRANGLEY, OF ENGLAND. This usually occurs in women about the change of life. The treatment consists in the administration of bismuth, bicarbonate of potash, and ammonia, adding valerian, if the nervous symptoms predominate, followed by quinine, strychnia and dilute nitro-muri- atic acid. DYSPEPSIA. 28; The following is the treatment adopted at THE DEMILT DISPENSARY, New York, as described by Dr. D. Lewis, in the New York Medical Journal : When there is constipation, they have found the rhubarb and soda mixture most useful : 500. R. Pulv. rhei, 5j Sodii bicarb., '^\%% 01. menth. vir., gtt. iv Aquse, f.giv. M. A tablespoonful before meals. The alkaline mixture probably owes its efficacy to its stimulating action upon the gastric glands — a property of alkalies .which has been amply demonstrated by many experimenters. When an ad- ditional laxative is necessary, a compound rhubarb pill is ordered at bedtime, or, what is preferable in many cases, the pill of aloes, belladonna and strychnia: 501. R. Ext. aloes, gr. ijss Ext. belladonnae, Ext. nucis vom., aa gr. \. M. One at bedtime. In contrast with such cases are those patients who are anaemic, and complain of the symptoms common to that condition — loss of appetite, palpitation of the heart, intercostal neuralgia and head- ache. In some instances, this condition is a natural sequence of prolonged dyspepsia, but is more commonly dependent upon other causes, such as bad hygiene, overwork, or malarial influences. Tonic treatment is here indicated, and the following prescription is usually effective : 502. ]J. Quiniae sulph., pr. xij Tr. ferri cbloridi, f. 3 iijss AquK, f. i iv. M. A teaspoonful in a wineglass of cold water, half an hour after meals. An aloes and belladonna pill is occasionally required at bedtime. When there is irritability of the stomach (probably gastritis) with nausea and vomiting, a bismuth mixture is often ordered : 503. R. Bismuth, subnit., 3'v Acid, nitric, dil., f.Si'j Tr. nucis vom., f.S'ss Aq. menth. pip., f. I iv. M. A teaspoonful after meals. Shake well before using. 286 DISEASES OF THE DIGESTIVE SYSTEM. Since it has been pretty clearly demonstrated that bismuth acts mechanically by adhering to the mucous coat of the stomach, it is evident that a large dose ahould be administered. But the very large doses given by LUSANNE, Menneret, and others (who gave 5j per diem), no doubt hinder the excretion of gastric juice, thereby causing the cachectic symptoms which those observers found to fol- low its prolonged use. NOTES ON REMEDIES. ■ Aloes, in doses of gr. ij— iv, combined with ipecacuanha (gr. j— ij,) two or three times a week, is useful in the dyspepsia of persons of relaxed habit, or those'debilitated by long illness, especially if it be probable that the duodenum is implicated. (F. 501.) Aqua Calcis, in doses of f. gij in milk, is useful in dyspepsia connected with acidity of the stomach ; also when the urine shows a strong acid re- action, and when vomiting is a prominent symptom. Aqua Chlorofornii,m the proportion of one part of chloroform to 2000 parts distilled water, has been found by Professor Lasegue to be eminently suitable in painful digestion arising from dilatation of the stomach and similar conditions (Gaz. des Hopitaux, 1883). Argenti Nitras is useful in many obstinate cases of dyspepsia attended with morbid sensibility and hypochondriasis. The following formula may be used : 504. 5^. Argenti nitratis, gr. ss Extract! hyoscyami, gr. ij— iv. M. Make one pill. Take every night. The quantity of the nitrate may be gradually increased to grs. ij-iij daily, and this may be continued with safety for six or eight weeks, but not beyond that time. It may sometimes be advantageously com- bined with small doses of quinine. The diet should be carefully di- rected. Or the nitrate may be given in solution : 505. R, Argenti nitratis crystallini, gr. vj Aquse destillatae, f. § ;;;, m_ A tablespoonful to be taken at bedtime, on an empty stomach, and repeated every night, or every second, third or fourth night, according to the severity of the symp- Ar^enti Oxidum was much employed by Dr. Goiding Bird in gastralgia, gas- trodynia, and in those forms of dyspepsia attended with irritable stomach and pain after food. He regarded it as a valuable sedative and tonic, possessing all the virtues without the inconveniences of the nitrate. Dr. J. Eyre used it with advantage in pyrosis. It must be remembered that it cannot in these cases be combined with creasote, DYSPEPSIA. 2S7 for violent decomposition, attended with heat, and even flame, follows the mixture of these substances. Arsenic is a valuable remedy in gasirodynia, particularly when of a neuralgic character. Fowler's solution should be given after a meal, commenc- ing with small doses (ni,iij), and gradually increasing them, adding a few drops of laudanum when large doses are reached, to prevent purg- ing. Dr. Ringer recommends Fowler's solution ("ij-ij) shortly be- fore each meal, in many forms of chronic dyspepsia. He finds it very effectual in checking the morning vomiting of drunkards. Aurantii Amari Cortex, in tincture or infusion, is an elegant tonic in dys-. pepiia. Assafaetida , in combination with bittter tonics and mild aperients, is useful in dyspepsia attended with hypochondriasis and other mucous affec- tions. Bismuthi Subnitras is of great value in atonic dyspepsia. Dr. W. Brinton finds it particularly useful in the " morbid sensibility of the stomach " of old writers. Dr. Wilson Fox especially recommends it in the milder forms of gastric inflammation. He finds that in pyrosis, when combined with opium, it seldom fails to relieve, but that in order to effect a cure a more direct astringent, like kino, is required. Professor R. J. Graves considers it one of the best remedies we possess in gas- trodynia. Calumba, in infusion, is a valuable vegetable bitter tonic in atonic dyspepsia. It may be given at an earlier period than other remedies of the same class, and forms an excellent vehicle for other appropriate remedies. Capsicum is especialy useful in the atonic dyspepsia of hard drinkers and long residents in hot climates. The following formula may be era- ployed : 506. R. Pulveris capsici, gr. iJ-i'J Pilulae rhei compositae, gr- v Pulveris ipecacuanhae radicis, gr- ss. M. Make two pills. To be taken daily, an hour before dinner. Carbo Ligni, enclosed freshly prepared in gelatine capsules, is a valuable remedy in dyspepsia attended with obstinate flatulence and gastro- dynia. Cardamomum, in the form ot the compound tincture, is highly serviceable m the dyspeptic affections of old persons. Caryophyllum, in infusion, or volatile oil (gtt. iij-v), is of benefit in atonic dyspepsia attended with a sense of coldness in the stomach and much flatulence. Cascara Sagrada. In the constipation so frequentiy associated with dyspep- sia, one of the moa efficient remedies is the fluid extract (dose f. 3ss) 288 DISEASES OF THE DIGESTIVE SYSTEM. of this drug, or its cordial (dose, f. |ss-j). A tonic dyspepsia with inefficient hepatic action are conditions which especially indicate its use. The cascara is prepared by Patke, Davis & Co., of Detroit. A formula recommended is : 507. R.. Fluid, extract, cascarse, ^•^!.. Syrupi simplicis, f. Siij. M. A teaspoonful three or four times a day. Cerii Oxalas was much employed by the late Prof. Simpson in irritable dys- pepsia, attended with gastrodynia, pyrosis and chronic vomiting. Coloyncih is useful in forms of dyspepsia and gastrodynia when no inflam- matory symptoms are present. The following formula may be em- ployed : 508. R. Extract! colocynthidis compositi, Bjj Pilulse rhei coraposicse, £?j Saponis, gr. vj Olei caryophylli, gtt. iv. M. Make sixteen pills. Take one or two every half hour. Eucalyptus is one of the most useful of the so-called stomachics, in atonic dyspepsia. Ferrum. (See above, page 282. J Gallicum Acidum has been recommended in dyspepsia arising from a re- laxed state of the mucous membrane of the stomach. It is useful in pyrosis, unaccompanied by organic disease of the stomach, or of the liver. Gentian, in the form of tincture in an aromatic water, is a valuable stomachic in atonic dyspepsia and in the dyspepsia of gouty subjects. Hops, as a stomachic tonic, is quite as serviceable as many more rare and. costly medicines. Hydrargyri Piliila, in doses of gr. ij-iv, is useful in dyspepsia attended with hepatic derangement, or when the duodenum is supposed to be the seat of the disease. It may be combined with ipecacuanha (gr. j-ij) and with a sedative. Ptyalism must be avoided. Hydrargyri Chloridum Mite is sometimes productive of marked benefit in dyspepsia characterized by hepatic derangement. But its habitual use, even as a purgative, is not without detriment, and its constitutional ef- fects are mischievous. Hydrastis is very useful as a stomachic tonic, and may take the place of ca- lumba in the treatment of atonic dyspepsia. A few drops of the tinc- ture or fluid extract (five to fifteen) taken before meals, daily for some time, will often cure chronic gastric catarrh, and remove the distressing headache which frequently accompanies this disease. It DYSPEPSIA. 289 is one of the best remedies for the stomach catarrh of chronic alco- holism, and is probably the best substitute, if given in sufficient doses, for the alcoholic stimulant, when its habitual use is to be aban- doned. Hydrocyanic Acid, in doses of ni,ij-iv, combined with infusion of columbo, is often signally useful in dyspepsia attended with gastric irritation. Dr. Wilson Fox states that in the irritative dyspepsia of phthisis it is a most effectual remedy. Ipecacuanha, in doses of gr. ss-j, in the form of pill, with gr. iij-iv of rhu- barb, taken before meals, often proves serviceable in atonic dyspepsia, especially when the biliary secretion is deficient or vitiated. Kino is useful in the incipient stages of follicular dyspepsia. It does not ap- pear to constipate the bowels, if diarrhcea be not present. Sir T. Watson recommends it highly in pyrosis, in the form of pulvis kino compositus : 509. R. PqIv. kino, 5 iy Pulveris opii, gr. xv Cinnamomi, 3j. m. Divide into thirty powders. One thrice daily. Dr. Wilson also regards it as the best remedy in pyrosis. Lactic Acid, first introduced as a remedy in dyspepsia by Magendie, has been employed with success by Dr. C. Handfield Jones in cases of irrita- tive dyspepsia, when the digestion has been for a long time painful and imperfect. Its use is not advised at the commencement of a se- vere case, but only after the irritation is somewhat reduced. The dose is Jn,xv-xx, in a tablespoonful of water, taken at meal-times. Its use may be extended to all cases where it is desirable to improve the tone and power of the stomach. But it is essential, in order to obtain good effects, that the acid should be pure and of good quality, which unfortunately is frequently not the case with that which is generally dispensed. Liquor PotasscB. 510. R. Inf. calumbce, f. §i» Liq. potassae, f. 3ss. M. S. — A dessert to a tablespoonful three times a day, before meals. Magnesii Sulphas, in small doses, has been found very effectual in dyspepsia accompanied by costiveness. The following formula may be used : 511. R. Magnesii sulphatis, §j Infusi quassiae, *-*'^*. j, Spiritds ammonise aromatici, £5ij. "^ Drink a wineglassful of this every morning, fasting. 19 290 DISEASES OF THE DIGESTIVE SYSTEM. Or the following may be employed : 512. R. Magnesii sulphatis, 5yi Magnesii carbonatis, 3iss Vini aloes, f-oyj Tincturje humili, f. 3ij Acidi hydrocyanic! diluti, "l^v Tnfusi cascarillse, ^- S ''ij- M. Take three tablespoonfuls thrice daily. Manganesii Oxidum Nigrum, in doses of gr. x-xv thrice daily, has been recommended in certain irritable conditions of the stomach, and forms of dyspepsia. Massage. CsERi {Wien Med. Woch., 1890,) publishes an account of favor- able results obtained in chronic dyspepsia by suitable diet, and a peculiar form of massage. The latter is practiced several hours after dinner when the stomach is full. The operator strokes and kneads the stomach from the fundus to the pylorus, first gently and superficially, then more energetically, for ten or more minutes, the patient lying on his back, with legs drawn up and breathing with open mouth. During the last few minutes the massage is extended to the bowels. Mineral Acids. Bartholow highly recommends muriatic acid after meals, with or without pepsin, in atonic dyspepsia. In an excess of acid of stomach-juice, the mineral acid before meals. In excess of uric acid as well as of stomach acid, nitric acid before meals. Morphia, subcutaneously injected, in doses of one-fourth grain, has been used with excellent success by Dr. Clifford Allbutt (Practitioner, June, 1869), in those forms of dyspepsia characterized by irritability or erethism, or such as is often associated with hysteria, or which arises from great mental exertion or depression. Muriaticum Acidum Dilutum, in doses of Tr^xv-xx, properly diluted, given immediately before, during, or directly after a meal, is highly recom- mended by Dr. Wilson Fox in atonic dyspepsia. It may be combined with vegetable bitters. In nervous disorder of digestion associated with diarrhoea, he combines the acid with tincture of nux vomica, and gives before meals. Pancreatine is highly recommended in conjunction with pepsin, and in cases of intestinal indigestion is more valuable than the latter. Pepsine is especially indicated in dyspepsia connected with deficient secretion of gastric juice. It is particularly useful in gastric disturbances follow- ing the use of animal food, often enabling a patient who has not dared attempt it, to eat of it with impunity. The severest cases oi gastralgia are relieved by it. If it fails after three or more doses, it is probable that the dyspepsia does not arise from a defect of the gastric secretion. Dr. Wilson Fox strongly recommends it, not only in atonic dyspepsia. DYSPEPSIA. 291 but in irritative states of the gastric mucous membrane. It may be advantageouily combined with muriatic acid, at meal times. It may be combined with ether medicines which do not impede its therapeu- tic action ; thus, with muriate of morphia, to relieve violent pain of the stomach ; with strychnia, to stimulate peristaltic movement ; with subnitrate of bismuth, lactate or iodine of iron, etc. Potassii Stclphuretum , in doses of gr. x, alone or combined with an aromatic, is useful when the mucous follicles are supposed to be implicated. Potassii Sulphas, in doses of gr. xv-?,ij, alone or combined with rhubarb (gr. v-x) or aloes, is a safe and efficient aperient in dyspeptic affections. Potassii Tartras is sometimes employed as a mild purgative in dyspeptic af- fections, attended with slight febrile action. Potassii lodidutn, in small doses (gr. j-ij), with bicarbonate of potash (gr vij-x), is recommended by Dr. W. Brinton, in flatulent dyspepsia, in which, whether from a too starchy diet, deficient or hasty mastication, decayed teeth, the abuse of tobacco, or other causes, the salivary ex- cretion seems either deficient in quantity, or faulty (/. e., acid) in quality. Two or three administrations will often induce a marked change. Quassia, in infusion, combined with carbonate of soda, is recommended by Trousseau, in dyspepsia attended by acidity of the stomach, sour eructations, and marked especially by vertigo and a tendency to syn- cope. It is peculiarly useful in the dyspepsia of drunkards. Rheum is often highly serviceable, as it is warm and carminative in its nature, speedy, and neither stimulant nor drastic in its- action. Eight grains made into pills with soap, and taken every night at bedtime, together with some mild bitter infusion, and an alkaU in the daytime, is a very effectual mode of treatment. The following mixture is useful : 513. R. Aloes, 3i Rhei, Glycyrrhizje, aa 3ss Spiritds lavanduUe compositi, f. 3ss Aqu£e calcis, f.gvuj. M. Infuse for twelve hours, and strain. Dose, two tablespoon fuls, two or three times daily. The following formula is of benefit when acidity is a prominent symptom : 514. R. Rhei, |i?.* Potassii carbonatis, 3"J Aqu» ferventis, 3 "J- »• Macerate for twelve hours, strain and add : Tincturte cinnamomi composite, '• 3 ')• Dose, a tablespoonful to a wineglassfuL 292 DISEASES OF THE DIGESTIVE SYSTEM. The old plan of chewing a piece of solid rhubarb is an excellent one, as by this means no more is swallowed than what is dissolved in the saliva, and this is frequently sufficient to keep the bowels regular, and impart tone to the digestive organs without producing subsequent con- stipation. Ricini Oleum, in doses of a teaspoonful daily, given at bedtime, is one of the most valuable remedies in dyspepsia attended with inflammation or vascular excitement of the pylorus and duodenum. The nature of the morbid condition of the mucous membrane of the stomach, is indicated by the effects of castor oil. In atonic dyspepsia, it is borne with the greatest difficulty, causing nausea and vomiting ; in irritable dyspepsia, it acts severely, and with much griping ; but in vascular excitement of the mucous membrane of the stomach, it soothes most admirably, and produces the best effects when it has no aperient action. It may be combined with liquor potassse, or administered in emulsion, in coffee, o*r in a mild- carminative water. Sapo, in combination with rhubarb and essential oil, is useful in dyspepsia at- tended with acidity ; also in pyrosis, given either alone or with opium. Senna. A mixture of equal parts of the infusions of senna and gentian is often beneficial in atonic dyspepsia, especially when attended by con- stipation. Serpentaria is recommended by Dr. A. T. Thompson, in dyspepsia, when the skin is hot and dry. Sinapis. White mustard seeds, in doses of two or three teaspoonfuls, two or three times a day, have been advised in some forms of dyspepsia. Sodii Bicarbonas, in full doses Oij-iij), combined with tincture of ginger (ni,xxx) and aromatic spirits of ammonia (f. .cjss-j,) is very useful in dyspeptic attacks attended with colic and gastric irritability, especially when consequent on the ingestion of unwliolesome food. Either in atonic or catarrhal dyspepsia, it answers admirably combined with a bitter ; e. g. : 5' 5- R- Sodii bicarbonatis, „. x Tinct. cort. aurancii, mxxx Infusum calumbse, ad f 5j_ j{_ Dissolve and mix for a draught. Sodii Hyposulphis is praised by Sir. W. Jenner and Dr. W. Brinton, in flatu- lent dyspepsia. In doses of gr. x-xv, in infusion of quassia, it has proved successful in fermentative dyspepsia. Strychnia or Nux Vomica is useful in chronic dyspepsia, in preventing dis- tention by flatus. It is also serviceable in pyrosis and heart-burn. Tannic Acid, which may advantageously be combined with dilute nitric acid, is often very serviceable in dyspepsia, the symptoms disappearing GASTRITIS, GASTRO-ENTERITIS, AND ENTERITIS. 293 under its use, the appetite improving, and the bowels, far from being constipated, often becoming more free. Taraxacum is much used where the liver is implicated, and in the indigestion of gouty subjects. The following formula may be employed : 516. R. Extracti taraxaci, 3j Potassii nitratis, 5ss Spiritns setheris nitrosi, f 3 j Infusi aurantii, f. § vj. M. Take two tablespoonfuls thrice daily. Wild Cherry is an excellent stomach tonic and may be substituted for ca- lumba in the class of cases in which the latter is considered especially applicable. Zinei Sulphas is recommended by Dr. Golding Bird in dyspepsia associated with irritability of the ner/ous system. Zinci Oxidum has, according to Dr. Wilson Fox, the advantage over the sul- phate in irritable conditions of the nervous system associated with dys- pepsia, when given at bedtime in doses of gr. ij-iij,for producing sleep. GASTRITIS, GASTRO-ENTERITIS AND ENTERITIS. These forms of intestinal inflammation are closely associated, both anatomically and with reference to symptoms and treatment. They are marked off from inflammations of the lower bowel (colitis, dys- entery,) by the usual presence of vomiting and constipation, the ab- sence of hemorrhagic discharge, and tenesmus. ANTISEPTIC TREATMENT OF GASTRO-ENTERITIS. (Medical News, 1890.) The following treatment is quoted from the Revue. Gen. de Clin, et de Tkerap., 1890: 517. R. Creolin. "l/i^ ^ Pulverized sugar, gr. b(xv. M. Divide into ten powders. Sig : One every two or three hours. Or: 518. R. Creolin, S*!".' 'J Syrip. . flii. M. Peppermint water, '• " ' Sig: Tablespoonful every one or two hours. 294 DISEASES OF THE DIGESTIVE SYSTEM. Asepsis of the lower bowel may be secured by enemata, as follows : ?IQ. E. Sodium benzoate, o). „ ^ Water, 0>J- '^• Or: 520. R. Boric acid, 5 1'' Sodium salicylate, 3" Water, Oij. M. Or: 521. R. Resorcin, R^- *') ^, Water, Oi) M. JOHN SYER BRISTOWE, M. D., LONDON. In the treatment of typical acute gastritis, local measures are of great importance. Mustard poultices or hot fomentations to the epigastrium will answer in milder cases; but in severer ones, from twelve to twenty leeches should be applied. Food should be reduced to the minimum, and small pieces of ice should be swal- lowed, or iced milk be sipped. Opiates in large doses are called for, either hypodermically, which is best, or combined with bismuth or magnesia. Lime-water and minute doses of hydrocyanic acid are soothing. Stimulants are not desirable. The treatment is much the same for the milder cases of enteritis. As regards the more severe forms, two principles of treatment may be considered well established. They are : (i) To relieve pain, and prevent the movements of the bowels, by opium. (2) To avoid the administration of purgatives. Constipation for a few days, or even a week or two, is of little consequence. The opiate is best given by hypodermic injection. Leeches, early in the disease, followed by hot fomentations^ will be a valuable measure. For the prostration which rapidly ensues, stimulants and concentrated food are required, but they must be given by enema, as the stomach is generally too sensitive to bear them. DR. JOHN M. WHITE, ALABAMA. In a number of cases of acute gastritis, this practitioner (Medical and Surgical Reporter, March, 1877,) has used the following combi- nation with entire satisfaction : 522. R. Tinct. veratri viridis, gtt, xr Liq. morph. sulphatis (Magendie's,) gtt. xxT Acidi carbolici, gtt. vt Aquae menth. piper., f.|j. M. A teaspoonful every three hours. GASTRITIS, GASTRO-ENTERITIS, AND ENTERITIS. 295 Of course, the employment of ice, leeches, and fomentations should supplement this when possible. DR. ROBERT SAUNDBY. (Prov. Med. Jour., 1890.) Dr. Saundby insists that patients with chronic gastric catarrh should be restricted to three meals daily: breakfast, luncheon and dinner. No food should be permitted be- tween meals. On rising, five or six ounces of hot water, with a tea- spoonful of Carlsbad salts in it if the bowels tend to constipation, are to be sipped, in order to wash the stomach free from decomposing mucus. The diet he gives as follows : Breakfast. — If the stomach is very irritable, no hot drinks ; but a cup of cold milk and water should be substituted. Afterwards a cup of cocoa or chocolate with very little sugar may be taken. Boiled fish, boiled or poached eggs, or a little smoked or salted ham, may be eaten with two small slices of toast, but fats should be taken very sparingly. No fruits, vegetables or sweets. Luncheon. — Two arrowroot biscuits, or small slices of toast; oysters (with lemon juice, not vinegar) ; a mutton chop ; a slice of cold meat, fowl or game ; milk pudding ; aerated water. Dinner. — No soup. Boiled white fish ; stewed sweetbreads, tripe ; lightly-cooked beef or mutton, roast or boiled ; fowl or game ; no pork or veal; no vegetables except a little well-cooked potato; milk or custard pudding, jelly ; no fruit or pastry ; no cheese. No beer or spirits ; aerated water is best, but a glass of claret with aerated water is permissible — no other wine. If there is pain or irritability, bismuth and rhubarb may be given. Where the symptoms are those of sluggish digestion, the following mixture may be ordered. 523. K. Acidi muriatici diluti, f-3'j Acidi hydrocyanic! diluti, '• 5 ) Strychninae, B^-ss Glycerinae, Aquae, f.gss f.gT. M. Sig: Tablespoonful in water one hour after meals. In the treatment oi acute gastritis. Dr. Saundby advises in addition to the restricted diet, a grain of calomel at bedtime, and before each meal a powder composed as follows : 524. R. Bismuthi carbonatis, Sodii bicarbonatis, '^ "SS- 'J Pulveris rhei, ^ ■ u_ Pulveris aromatici, S^- J- 296 DISEASES OF THE DIGESTIVE SYSTEM. If pain is persistent a mustard plaster should be applied. If the patient is subject to recurring attacks a broad flannel band should be worn about the abdomen. HENRY HARTSHORNE, M. D., PHILADELPHIA. In the chronic forms of gastritis counter-irritation of the epigas- trium with blisters will be useful. Internally, the most valuable remedy is nitrate of silver : 525. g. Argenti nitratis, gr. v Pulveris opii, gr. ijss. M. For twenty pills. One thrice daily. Begin with gr. y^ of the silver thrice daily, and prudently raise in a few weeks to gr. 5^. Another useful drug is subnitrate of bismuth, gr. x-xx, thrice daily. The diet must be bland, and the food taken in small quantities and at short intervals. The patient should not drink much water, but quench his thirst with small pieces of broken ice. When other means fail, an absolute skimmed-milk diet will at times succeed. DR. MILLET, FRANCE. For the relief of some of the symptoms of chronic gastritis, this author recommends : 526. g. Extracti hyoscyami, Qij Argenti nitratis, gr. vj Bismuthi subnitratis, gr. xxx. M. Divide into forty pills. One morning and evening, in the variety of gastralgia which intervenes frequently during the course of chronic gastritis. Counter-irritation to the epigastrium. 527. g. Extracti belladonnoe, gr. v Quiniee sulphatis, p, xxx Extracti valerianx, q. s_ u_ Divide into fifteen pills. One thrice daily, in gastralgia. DR. DEBOVE, OF PARIS, Has had skimmed milk evaporated (cream being but slightly digest- ible) and the residue reduced to a fine powder. If this be dissolved in hot water, two or three litres of milk may be injected in the same volume as a single litre. He claims excellent results from this milk powderin gastric affections. GASTRITIS, GASTRO-ENTERITIS, AND ENTERITIS. 297 NOTES ON REMEDIES. Acacia. Solutions of gum arabic are valuable emollients. Argenti Nitras, in chronic gastritis, is praised by many authorities. (F. 525.) Arsenic. The vomiting of chronic gastric catarrh, especially the alcoholic form, is relieved by one or two drops of Fowler's solution taken be- fore meals. Bismuthi Subnitraa has a remarkable effect on relieving pain, vomiting, and intestinal irritation. Dr. William Brinton, of London, recommends : 528. R. Bismuthi subnitratis, gr. x-xx Pulv. kino compos., v-x. M. For one dose every four to eight hours. Calcis Aqua is an important dietetic adjuvant. Creolin, as an antiseptic, is used in minim doses. Hydrargyri Chloridum Mite. In acute gastritis. Dr. Aitken recommends three to five grains of calomel, followed by a dose of castor-oil. Naphthalin. In the dyspeptic symptoms of acute gastritis, this drug has been much lauded by some physicians. Dr. Tichborne (Med. Press and Circ, 1889), gives the following formula : 529. R. Naphthalin, gr. xvj Expressed oil of almonds, f. 3 j Acacia, 3i Syrup of orange, f. 3 i Water, f.3iij- M. The naphthalin should be thoroughly mixed with the almond oil before adding the remaining ingredients. Opium and its derivatives are indispensable in the treatment of gastro-enter- itis. (See above, p. 294.) Sodii Bicarbonas is often called for as an antacid. Tannicum Acidum is an excellent astringent to prevent excessive purging. A convenient formula is : 530. g. Aquje camphorae, •^}} Morphia: acetatis, V- ') Acidi tannici, gr. x-xv. M. A teaspoonful every two hours. Veratrum Viride has been used. (F. 524.) external measures. Bandaging. A wide flannel bandage around the abdomen acts as a sort of splint to the part, and sometimes gives much relief. jB/isters. A small blister over the stomach on the abdomen often gives prompt relief. 298 DISEASES OF THE DIGESTIVE SYSTEM. Cups, dry or wet, are often of service. Fomentations. The continuous use of hot water fomentations, as hot as the patient can bear them, over the region of the stomach, is of great ben- efit in acute cases, according to Dr. William Brinton. Leeches are the most convenient means of abstracting blood when they can be had. GASTRIC CANCER. DR. L. REISS. (Berlin Klin. Woch., 1887.) Remarkable results are published l)y Dr. Reiss from the employment of condurango bark in gastric cancer. He declares that the painful symptoms of the affection, where the autopsy proved the cancerous nature of the malady, were removed by this drug. By the employment of 1 50 grains of con- durango daily for several months, the appetite is seen to be improved very shortly, nausea and vomiting diminished, pain removed and strength and weight increased. But the most remarkable effect is that in a considerable proportion of cases a sensible diminution in the size of the tumor could be established, apparently from some local action on the tumor. Reiss administers the drug as follows : 53'- R- Condurango bark, no grains Water, f.| iij Make a decoction and add : Syrup, f.5T Water, to f. § vj. Dose. — ^A tablespoonful every one or two hours. GASTRIC ULCER. DR. DONALD W. HOOD, OF LONDON. This practitioner, in the Med. Press, 1883, makes the point that all writers on the stomach treat ulcer as a chronic disease, but none of them advise such treatment as would be adopted in regard to an ulcer occurring on the surface of the body. In treating assumed ulcer, he thinks it imperative that the patient GASTRIC ULCER. 299 be kept in a recumbent position, in order that the stomach walls might be in a state of rest. When there is much enlargement of the stomach he generally uses a counter-irritant, and he freely pre- scribes the various preparations of opium in those cases where there is no doubt that the dyspepsia does not arise from hepatic engorge- ment, as he finds that it not only stimulates the bowels, but also makes the patient intolerant of restraint. Such treatment in the early stages of dyspepsia is sure to result well. Where the presence of ulceration is well marked, such treatment should be resorted to as would be insisted on if the ulcer occurred on the surface of the body. He has found this method of treatment productive of the best results in the case of a lady who, at the time of first seeing him, was afraid to take the simplest food lest its in- gestion should cause her pain. On making a careful examination of the abdomen he failed to find enlargement, but in the epigastric region there was a spot most tender on pressure. He ordered her to bed, recommended rich milk and light broth as diet, and pre- scribed six drops of laudanum every four hours. Iodine was sug- gested as a counter-irritant. A simple soap-and-water enema was to be used every other day. From the first the patient's progress was satisfactory. Pain ceased, there was no vomiting, and the bowels acted regularly. She left her bed in fourteen days, and re- cently he received a letter stating that she was quite well. He re- garded the case as representing ulceration or excoriation at that stage in which great good can be done by a decided course of treat- ment. DR. H. LEBERT, VEVEY. A careful study of the treatment of gastric ulcer is given by this writer in the Transactions of the Internatioftal Medical Congress, Philadelphia, 1876. His rules are: 1. Absolute rest in bed. 2. A milk diet, about two quarts per day in divided amounts every three hours, except at night. If it is badly borne, add one-fourth part lime-water or a little bicarbonate of soda. The milk diet should be kept up about six weeks. After this it may gradually be com- bined with light nutritious diet. For the pain, opiates by enema or subcutaneously are required- Haematemesis can be controlled by ice externally and internally, hourly doses of ergot, or of tincture of chloride of iron (gtt. v), or 300 DISEASES OF THE DIGESTIVE SYSTEM. acetate of lead or alum whey. Iced milk is the best anti-emetic; or effervescent powders with bismuth ; or small doses of opiates. Often, when other means fail, iodide of potassium will check the vomiting, as: 532- R. Potassii iodidi, 3i Tinct. cinchonae, f- S j. M. Ten to twenty drops several times daily. Constipation should be prevented by cold enemata, or aloes pills. Perforation demands the most absolute rest and full doses of opiates, (subcutaneously) with ice to the epigastrium. This mode of treat- ment has occasionally proved successful in this very dangerous com- plication. As the patient manifests improvement, a mild ferruginous tonic is indicated. The tincture of the malate of iron is one of the best; or the lactate ; or the following : EFFERVESCENT FERRUGINOUS POWDER. 533. B- Ferri lactatis, gr. xlv Acidi tartarici, 3') Sodii bicarbonatis, 3i>j- ^• Keep in a wide-mouthed bottle, well stoppered. Dose, from a half to one teaspoon- ful in a small wineglassful of water, two or three times a day. PROF. DUJARDIN-BEAUMETZ. (your, d" Hygiene, 1891.) Dujardin-Beaumetz looks on gastric ulcer as due to an infectious cause which lowers the vitality of the stomach wall, and to a hyperacidity of the gastric juice which pro- duces an ulceration in some weakened part of the mucous mem- branes. The indications are the nourishment of the patient and the relief of pain. For the first of these the absolute milk diet is the best ; it may be modified for rebellious patients by the addition of such light and semi-liquid foods as farina, racahout, chocolate and vegetable pastes. The hyperacidity of the gastric juice may be di- minished by the administration of bicarbonate of sodium after meals, about half or three-fourths of a drachm. He also suggests the use of condurango for the relief of pain and vomiting, fifteen grains of the powdered leaves at the meal. Where the pain is marked, hypo- dermic administration of morphia is indicated. DONKIN (Wien. Med. Presse, 1890), thinks the best results are obtained by giving the patient neither food nor medicine by the mouth, and relying on rectal alimentation. He advises at intervals GASTRIC ULCER. 3OI varying with the case, rectal enemata, consisting of two and a half ounces of beef-tea, one-half ounce of brandy and the yelk of an egg. An equal amount of milk may be substituted for the beef-tea, or both may be used ; the egg, too, may be withheld if thought well. The rectum should be washed out before each enema, and if it becomes very irritable a few drops of laudanum with the enema will usually correct this fault. By the mouth he permits absolutely nothing ex- cept occasionally a bit of ice. Morphine may be used hypodermi- cally to relieve the pain. DONKIN has seen good i-esults follow such a procedure, the gastric symptoms disappearing in a few weeks ; he has also used it with effect in obstinate cases of dyspepsia. PROF. H. ZIEMSSEN, ERLANGEN. This writer (Medicinische Central Zeitimg, April, 1872,) recom- mends the use of alkalies, especially Carlsbad water, continued sev- eral months. Most vegetable, and fatty, and saccharine matters are injurious. A milk diet has proved of benefit in numerous instances ; but veal, chicken, ham, white bread, and light claret, are harmless. Morphia, hypodermically, must be employed to combat the cramps in the stomach. As regards the consequences of gastric ulcer, especially of stric- ture of the orifices, the indications are, return of the gastric catarrh, retention of the contents of the stomach with acid fermentation, vomiting after meals, constipation, sinking of the hypogastrium, di- latation of the stomach, which is capable of physical proof, etc. These symptoms require the due application of sounds and of the stomach-pump. The so-called system of dry diet may be adopted with advantage for the obstinate constipation so commonly remain- ing, even for years, as the consequence of gastric ulcers. M. ZIEMSSEN recommends the use of rhubarb before going to bed, to which, if any pain follows its employment, or if great atony exists he adds a tenth of a grain of extract of belladonna, or the extract of nux vomica. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. This author states that it has been proposed to treat ulcer of the stomach by absolute rest of the organ and the introduction of foods by the rectum. It should not be forgotten that the rectum is no an organ of digestion; hence nutrient enemata must contain the materfals for artificial digestion. Furthermore, the mucus and fluids 302 DISEASES OF THE DIGESTIVE SYSTEM. of the rectum are alkaline in reaction. To secure rapid osmosis, therefore, the enemata should have an acid reaction. The following formula is suitable for the purpose : 534. E- Beef-tea, i iv Hydrochloric acid, Itl* Glycerole of jjepsin (Scheffer's), 3'j- M. If the rectum is irritable, ten to twenty drops of the tincture of opium may be added to the injection. If stimulants are indicated, brandy may also be added. The rectum soon becomes intolerant of injections ; hence, the greatest care should be used in practicing them, to avoid sudden distension of the bowel, and frequent introduc- tion of nutrient materials should be avoided. Five times in the twenty-four hours should be the maximum — for artificial digestion is much slower than normal stomach digestion. Leube recommends the following as a nutrient injection : " Take about five ounces of finely-scraped meat; chop it still finer, add to it one and a half ounces of finely chopped pancreas free from fat, then add about three ounces of lukewarm water, and stir to the consistence of a thick pulp." Or the following peptonized formula may be used : "A nutritive enema should be prepared in the usual way — of milk — or of milk with beef-tea or eggs — or of milk-gruel. To half a pint of the warm enema, a tablespoonful of the liquor pancreaticus and thirty grains of the bicarbonate of soda should be added. The enema can then be administered at once." PEPTONIZED MILK. " Fresh milk is diluted with water in the proportion of three parts of milk to one part of water. A pint of this mixture is heated to boiling, and then poured into a covered jug. When it has cooled down to about 140° Fah., one or two teaspoonfuls of the liquor pan- creaticus, and a small pinch of bicarbonate of soda (in solution) are mixed therewith. The jug is then placed under a 'cozy,' in a warm situation, for one hour. At the end of this time the product is again boiled for a couple of minutes. It can then be used like ordinary milk." PEPTONIZED MILK-GRUEL. " Half a pint of well-boiled gruel is added, while still boiling hot, to half a pint of cold milk in a covered jug. The mixture will have GASTRIC ULCER. 303 a temperature of about 125° Fah. The liquor pancreaticus and the bicarbonate of soda are then added in the same proportion as in the preceding process. The jug is placed under a 'cozy,' and kept warm for an hour and a half. The contents are then boiled for a couple of minutes, and the product is ready for use. By this second method, the use of the thermometer is dispensed with." DR. ELOY. (Rev. Gen. de Clin, et de Tkerap., 1890.) Where milk cannot be tolerated, predigested foods are to be used ; and peptonized milk tried. Besides the diet, four indications are to be combated, gas- tralgia, flatulence, vomiting and hemorrhage. For the pain the use of a hypodermic injection of morphine and a hot application or mustard plaster to the epigastrium is demanded ; if pain is only felt on ingestion of food, preventive measures must be adopted, liquid and unirritating foods being permitted, and the fol- lowing exhibited with the meal : 535- R- Muriate of morphine, gr. iiss Cherry-laurel water, f. 3ss. M. Sig : Five drops in water. If constipation exists with the pain, sm'all doses of belladonna may be used, or 536. R. Atropine sulphate, gr. yj Subnitrate of bismuth. 3j- M- Make into ten powders. Sig : One at night and in the morning. Or, as prescribed by BarthOLOW: M. 537- R- Morphine sulphate, gr- } Subnitrate of bismuth, gr- ij- Make into a powder. Sig : Such a powder shortly before meals. If vomiting be persistent, small pieees of ice in the mouth, and ice to the epigastrium, with warmth to the feet, may be employed.. For flatulence it is recommended that a small amount of calcined magnesia be ingested, or that a very small cup of coffee be taken thrice daily. (For the Haematemesis, consult p. 307.) 304 DISEASES OF THE DIGESTIVE SYSTEM. DR. FENWICK, LONDON. This author states {Diseases of the Stomach and Duodenum) that in ulcer of the stomach, whenever the pain is very severe and is at- tended by frequent vomiting, we may be sure that inflammation is going on, and the case must be treated as one of subacute gastritis. Perfect rest should be enjoined. A few leeches to the epigastrium are sometimes required ; but, generally, the use of poultices, turpen- tine fomentations, or dry cupping, is alone necessary. The main point in the treatment is the regulation of the diet. Usually, small quantities of farinaceous food may be given at fre- quent intervals. Arrow-root, milk, and gruel, agree the best. The frequent use of ice often relieves the pain, and obviates the necessity of larger quantities of liquids. Sometimes, as when dangerous haematemesis has previously followed a severe attack of pain, the patient ought to be supported by an enema. For the more acute stages of the complaint, morphia and hydro- cyanic acid, combined with small doses of nitrate of potassium — or, if there be much acidity, with magnesia or soda — are the best med- icines. As the pain lessens and the vomiting becomes more rare, the patient may be allowed to take a little exercise. Rather more lib- eral quantities of food may be given, but of a liquid nature. Blis- ters to the epigastrium generally alleviate the sufferings, and the raw surface may be dressed with morphia. When the pain is mod- erate, bismuth with magnesia and morphia, and lime-water with milk, are beneficial. As the case improves, tonics may be given. If the urine deposits phosphates, the mineral acids, with calumba, may be prescribed. Later, iron — the citrate or the reduced, and afterwards the sulphate — may be given. Dr. Fenwick has often prescribed the nitrate or oxide of zinc, and the salts of copper or zinc, with very good results. During convalescence, a little brandy or pale sherry may be given. In very obstinate cases, residence abroad sometimes affords relief. DR. DEBOVE, OF PARIS. During the first few days, this distinguished clinician (Boston Med- ical and Surgical Journal) washes out the stomach to free it of acid matters it may contain. This operation has never provoked haemat- emesjs, and is considered safe. He uses a soft, flexible tube, so that even if it does hit against the ulcer it can do no harm. He then GASTRIC ULCER. administers, three times a day, three-fourths of an ounce of pow- dered meat, suspended in milk and mixed with one hundred and fifty grams of bicarbonate of soda. This mixture is administered at meal time and by means of the stomach-tube, as it is very disagree- able to take in the ordinary way as food. The patient is given be- sides, a quart of milk a day, rendered alkaline by lime water The patients have been confined to this diet for several months at a time, and this treatment has never given rise to any of the symp- toms which characterize what has been called the "alkaline ca- chexia." NOTES ON REMEDIES. Argenti Nitras, though generally considered of value in ulcer of the stomach, is beUeved by Dr. Brinton to be, as generally prescribed, absolutely inert, so far as the gastric ulcer is concerned. He prefers bismuth. Professor Da Costa sometimes prescribes the nitrate with opium. 538. R. Argenti nitratis, ~. y Extract! opii, er.'x. For twenty pills. One thrice daily. Notwithstanding the strong opinion which Brinton has given ad- versely to the use of salts of silver in the stomach, Bartholow agrees with Fox, that these agents are, in this affection, next in value to bis- muth. The oxide or nitrate may be given in pill form, or the nitrate in solution. 539- R. Argenti nitrat., gr. xv Aq. destil., q. j. Ext. belladonns, gr. x 01. caryophylli, gtt. x Rad. gentian pulv., Ext. gentianie, 5a q. s. et ft. pil. No. xl. S. — One pill three times a day. Arsenic is recommended by Dr. Ringer, who gives one to two minims of Fowler's solution before each meal. Atropine and morphine arrest pain and vomiting, even in very minute quan- tity. Bismuthi Subnitras is highly spoken of by all authorities. It relieves pain and vomiting, as well as diarrhoea, when present. Eucalyptus Globulus has been prescribed with great success by Dr. Benjamin Bell, of Edinburgh, in formidable cases of gastric ulcer. (^Edinburgh Medical Journal, February, 1878.) Cannabis, in extract, often answers admirably as a sedative, and would re- place opium entirely, were its effects more uniform. 20 306 DISEASES OF THE DIGESTIVE SYSTEM. Opium is highly recommended by Dr. W. Brinton in ulcer of the stomach. In his opinion, its efficacy in this affection is not due to its sedative or anodyne properties, but rather to its supporting the strength, buoying the nervous system, and checking the waste or expenditure of the tissues generally. When vomiting is excessive, and resists a combi- nation of this powder with bismuth, opium is best borne in a solid form. Thus given, its effects are often very striking. Large and fre- quently-repeated doses are of great service in perforating ulcer of the stomach. Plumbi Acetas often allays the severity of the symptoms. Potassii lodidi. (F. 532.) Dr. W. Brinton gives this formula as of the best effect in the flatulent dyspepsia of gastric ulcer : 540. R. Potassii iodidi, Sf- j Potassii hicarbonatis, gr. xv Tincturse aurantii, ^- 3 ss Infusi calumbse, f.Svijss. M. For one dose, an hour after eating. Ricini Oleum, in a moderate dose, may often be given in the ordinary way without increasing the pain or vomiting. When the latter is frequent, however, the oil is best given in enema. Turpentine stupes often relieve the pain. When, however, the strength is ex- hausted by constant vomiting, dry cupping is preferred by Dr. W. Brinton, as a more effectual means of relieving the pain. In compar- atively recent cases in the young and well-nourished, blisters are to be preferred. Enemata. Life may be prolonged, and even in some cases preserved, in those ulcerous conditions of the stomach in which it is unadvisable or impossible to give food by the mouth, by the persevering use of ene- mata of beef-tea, milk, raw eggs, cod-liver oil, wine, and in extreme cases, even diluted brandy or opium. The quantity of each should be as small as possible, and should rarely be repeated in less than three or four hours. Ice, in small lumps and raspings, greatly relieves the pain and vomiting. Leeches to the epigastrium often relieve the pain, but their use is of doubtful propriety in the weak and cachectic. Milk Diet. This is referred to above (p. 302) ; ass's and mare's milk are best, but not often procurable. The milk should always be obtained from the same animal, and used warm (95" Fah.,) but not boiled. Half a pint every four hours is a fair average. It should not be taken at a draught, but by spoonfuls, slowly, to prevent curdling in the stom- ach. Crusts of bread or fresh crackers may be soaked in it, or lime- water or soda added to it. ApoUinaris water is a pleasant addition. HyEMATEMESIS. 307 Where the irritability of the stomach is not excessive, arrow-root may- be mixed with the milk and boiled to a thin pulp, to be taken cool. Sago and tapioca are generally less easily borne. Rice flour may be used in the same way. H^MATEMESIS. DR. JACCOUD, PARIS. There is no better treatment than that by ice, internally and ex- ternally. The mineral acids or alum may be given, but their effic- iency is neither as rapid nor certain as that obtained from ice. Dry cups on the limbs and trunk are useful when the hemorrhage is copious. FREDERICK T. ROBERTS, M. D., M. R. C. P., LONDON. The judicious rules laid down by this author, in his treatise on Practice, are : bodily rest, and nutrition by enema, if the case is severe; small lumps of ice should be swallowed at intervals, and a light ice poultice to the epigastrium, followed by sinapisms, if the vomiting is violent. It is of the utmost importance to check the emetic efforts, and if the means just mentioned are insufficient, re- course should be had to a few drops of dilute hydrocyanic acid in cold mucilage ; morphia, internally or by subcutaneous injection ; or an enema containing tincture of opium. Should there be signs of sinking, stimulants are called for, and should be given by enema. The most efficient medicines are gallic acid or acetate of lead, in full doses, combined with opium, or oil of turpentine. DR. ELOY. (Rev. Gen. de Clin, et de Therap., 1890.) For hemorrhage from the stomach the physician should administer ice, tannic acid, acetate of lead and antipyrine. The acetate of lead should be prescribed with morphine, but when tannin is used it should be combined with opium, as shown in the following prescriptions : 541. R. Acetate of lead, gr. iij Muriate of morphine, gr. j Powdered white sugar, 3j> M. Make into ten powders, and give two to five a day, or more. 3o8 DISEASES OF THE DIGESTIVE SYSTEM. 542. R. Opium and tannin, each gr. x Powdered sugar, 3iss. M. Divide into ten powders; one powder every one or two hours as necessary. Antipyrine may be administered for hsematemesis in powders of ten grains, with cocaine : 543- R- Hydrochlorate of cocaine, gr. iss Antipyrine, gr. xlv. M. Divide into five powders, and follow the administration of each by a tablespoonful of wine, as the alcohol' favors the action of the antipyrine. DR. A. HILLER, OF GERMANY. Haematemesis is sometimes due to visceral syphilis, when specific treatment must be instituted. NOTES ON REMEDIES. Alum, in doses of gr. viij, in combination with opium, thrice daily, is useful, though inferior to sugar of lead. Ammonii Chloridum is sometimes employed with advantage. Antipyrine possesses haemostatic influence, according to such observers as Henocque, HucHARD.and Ardnin. It is to be given in doses of five or ten grains every one or two hours. Argenti Oxidum, in doses of gr. ss-j, thrice daily, is highly recommended by Sir J. Eyre. Ergot and Ergotine have been successfully employed by many practitioners. Ferri Nitratis Liquor, in large doses, is very efficacious. Ferri Chloridi Tinctura, gtt. v, in water, every half hour or hour, is recom- mended by Dr. Lebert. Gallicum Acidutn. Dr. W. Brinton recommends the following formula : 544. B- AcidigaUici, ^ij Acidi sulphuric! diluti, lllxl Aquje, f.|ij. M. Dose, a tablespoonful in a little water. Ipecacuanha often appears to exercise a powerful influence. It should be given in the manner recommended in haemoptysis. Magnesii Sulphas. Dr. Barlow considers that, in haematemesis and melaena, it is advisable to clear out the bowels before resorting to astringents. For this purpose,. he employs the following formula : 545. R. Magnesii sulphatis, 3j_ij Acidi sulphuric! diluti, IIlx Altiminis, g^^ ^ Syrupi papaveris, f.3ss Infusi rosse compositi, f.Sxj. M. Make a drink. Take every four hours. HEPATITIS, HEPTIC ABSCESS. 309 Matico has been advised. Plumbi Acetas, in doses of gr. ij-iij, combined with acetate of morphia (gr. ^-ss), is very useful in controlling hemorrhage from the stomach, whether idiopathic or from ulceration. The auxiliaries are the exter- nal application of cold, acidulated drinks, perfect rest, and antiphlo- gistic diet. Sulphuricum Acidum Dilutum, alone or combined with gallic acid, is a very efficient remedy. Tannicum Acidum, in doses of gr. iii-vj, three or four times a day, is a useful astringent and tonic, only contra-indicated by the presence of inflam- matory symptoms. Turpentine deserves a trial after the failure of less nauseous remedies. Ice, in lumps, coming in contact with the bleeding vessels, acts as a powerful astringent. HEPATITIS. HEPATIC ABSCESS. DR. WILLIAM AITKEN. In acute parenchymatous inflammation of the liver, this vi^riter pre- scribes antimbnii et potassii tartras (gr. j^—}(.) every two or three hours, providing it can be given within the first three days, when there is much vascular excitement and a full, bounding, unyielding pulse, with a dry, hot skin, and scanty urine. General blood-letting may be adopted, if there be evidence of obstruction to venous blood- flow through' the right side of the heart. Local depletion, by leeches over the liver and also round the anus, must be at once re- sorted to, followed by fomentations and linseed-meal poultices, with or without mustard or laudanum, over the hepatic region. Saline purgation and alkalies, with or without colchicum, are also to be freely administered. Hot turpentine epithems are most beneficial. In the chronic form, iodide of potassiicm with taraxacum is of great service. Alcoholic stimulants and fermented drinks must be abso- lutely forbidden, and the diet restricted to mild nutriment, such as milk, beef-tea, and farinaceous food generally. DR. J. KINGSTON FOWLER, OF ENGLAND, Considers that the trocar is preferable to incision for evacuating he- patic abscesses, for the following reasons : I . The risk of hemorrhage is much less ; for when the liver is 3IO DISEASES OF THE DIGESTIVE SYSTEM. incised there is often a violent gush of blood. This, it is true, soon ceases ; but these patients are usually not in a condition to bear a loss of blood which a distinguished surgeon, Mr. Lister, describes as "alarming." 2. There is less danger from septic absorption along the track of the wound, as the pus flows through a canula or drainage tube. 3. As a trocar of any diameter may. be used, the opening into the sac may be of any size that is considered desirable. For an explor- atory puncture he prefers one having a diameter of one-eighth of an inch ; but if there is certain evidence of the presence of pus, it is very important to employ an instrument of at least three-eighths of an inch or half an inch in diameter. If a smaller one be used it is liable to get blocked by the solid shreds of liver tissue which these abscesses so frequently contain. PROF. W. C. MACLEAN, M. D., LONDON. This distinguished surgeon strongly opposes the usual treatment of acute hepatitis by venesection, mercurials, and purgatives, given above by Dr. AlTKEN, and recommends, in place of it, ipecacuanha, in large doses (gr. xx— xxx), repeated every few hours, until the symptoms subside : 546. R. Pulveris ipecacuanhae, ' 9j Mucilaginis acacias, q. s. M. Make four pills. The whole to be taken every sixth hour, day and night. Dr. Alfred A. Woodhull, U. S. A., has recently published some cases corroborating the value of this treatment. Dr. MACLEAN considers ipecacuanha, in hepatitis, almost as valuable as in dysen- tery. DR. GEORGE HARLEY, LONDON. The first thing in a case of acute hepatic congestion is to enjoin strict rest. The second is to place the patient on low diet. The third, to freely clear out the bowels. The fourth, to relieve the slight discomfort by the application of hot, thick, and large linseed poultices. The fifth, if there be signs of acute inflammation, to apply a freezing mixture of ice and salt or leeches, or even cupping glasses, over the painful hepatic region. Mercury is here our sheet- anchor, both as a purgative and an antiphlogistic. HEPATIC CIRRHOSIS. 31 1 DR. CYR, OF FRANCE. In his recent work upon the diseases of the liver this experienced physician recommends the following treatment for hepatic conges- tion. Compresses of cold water are to be applied over the liver, and frequently renewed; and in acute cases several leeches should be applied to the anus. At evening a grain or less of calomel should be taken, followed the next morning by a dose of salts. A beverage of milk and Vichy water, or seventy-five grains of chloride of am- monium in a quart of water, maybe given. While the patient is reclining a douche of water of pleasant temperature may be applied. Stewart, of the East India Service, commends the use of chloride of ammonium in such affections. The patient should remain in bed throughout treatment, taking but little food, and that of a farinace- ous character and milk. Barley water may be freely drunk. He would give twenty or thirty grains of the chloride two or three times daily. HEPATIC CIRRHOSIS. PROF. SEMMOLA, OF NAPLES. (Dietetic Gazette, 1891.) In the early stages of hepatic cirrhosis, before the new tissue has hardened into fibres, the milk treatment is regarded by this writer as a positive remedial measure of undoubted curative value, if the process be not specific, when, of course, a specific treatment must be undertaken. Semmola'S method consists in ordering every three hours from three to six ounce* of milk, in- creasing the dose according to tolerance to two or three pints in the twenty-four hours. The invariable effect seems to be the cessation of all trouble formerly accompanying digestion. Absolute absti- nence from all other forms of food for several months is insisted upon as a sine qua non. PROF. ZACHARUM, OF MOSCOW. (Medical News, 1891.) This authority has published some re- markably favorable results obtained in the treatment of hypertro- phic cirrhosis of the liver and grave cases of hepatic colic accom- panied by fever, by the administration of fractional doses of calomel, half a grain every hour until five or six doses have been taken, and 312 DISEASES OF THE DIGESTIVE SYSTEM. after this every two hours until the characteristic purging is pro- duced. If the calomel does not act, it is necessary to follow it by a saline or a teaspoonful of castor oil. It is also useful for the patient to use frequently a gargle of chlorate of potassium in order to avoid the appearance of a mercurial stomatitis, and this should be con- tinued some days after the calomel has been stopped. The in- fluence of this treatment is said to be felt almost immediately, and causes very considerable amelioration of the symptoms. The pain, fever and dyspeptic symptoms disappear, and the urine in catarrhal jaundice becomes clear. Alkaline mineral waters may now be given with advantage. Often this treatment is to be repeated every week or so for several months. DR. J. M. DA COSTA, M. D., PHILADELPHIA. In chronic hepatitis, a certain amount of drain should be kept up from the portal circulation. For this purpose, very small doses of podophyllin, cream of tartar, or Rochelle salts, now one and now another, are useful. A very good pill is the following : 547- R- Podophyllin, gr. tj Capsici, gr. iv Pulveris rhei, gr. xij. M. • For twelve pills; one on alternate nights. In order to reduce the state of induration or enlargement of the liver, the mineral acids may be employed. Or, when the case is not chronic, the salts of soda, as in the following formula : 548. R. Sodii bicarbonatis, § ss Infusi gentianas, f. § vj. M. A tablespdonful three times a day, after or between meals. Should this fail, employ nitro-muriatic acid baths. Sulphur-baths are of advantage ; or those of sulphuret of potassium ; or the use of sulphur ointment, followed by warm baths. SIR RANALD MARTIN, LONDON. Nitro-muriaticum acidum is employed, both externally and inter- nally, with great advantage in chronic hepatitis, and in the advanced stages of acute hepatitis and congestion of the liver. It is most ser- viceable in the form of a bath, for which the following directions are given {Lancet, December 9th, 1865,) by SiR Ranald Martin: i. The proportions of acid are given by the following formula : HEPATIC CIRRHOSIS. 313 549- R- Acidi muriatici, f. | iij Acidi nitrici, f. § ij AquE, f. I V. M. 2. Two gallons of water (about ten bottles) may suffice for a bath. 3. To each gallon of water, add f..5iij of the above acid mixture. 4. The bath thus prepared will keep in use for three days, by adding f.Sss of the acid mixture and Oj of water, morning and evening, to make up for the waste by evaporation. 5. A portion only of the bath to be heated for use, after which it is to be added to the re- mainder, so as to make the whole of a comfortable warmth (96°-98°.) 6. Let both feet be placed in the bath, while the inside of the legs and thighs, the right side (over the liver) and inside of both arms, are sponged alternately. This should be continued for ten or fifteen minutes, morning and evening. 7. While using the bath, a gentle aperient should be taken every morning. Earthenware or wooden vessels should be preferred for foot-baths, and all the sponges and towels should be kept in cold water, as the acid corrodes them. 9. In urgent cases, a general bath, to envelop the whole body, may be used. 10. If the acid bath create much irritation of the skin, the quantity of the acid may be diminished. 11. The influence of the acid is not in the least degree counteracted by opium, even when exhibited in the largest doses. NOTES ON REMEDIES. Ammonii Chloridum has for many years been esteemed in hepatic abscess. According to Dr. William Stuckert, of the British Indian Army (Medical Times, April, 1878), in active congestion of the liver, the special and characteristic action of the medicine will be found to be more marked than in cases of chronic hepatitis. The dose necessary for its full thereapeutic effect is gr. xx, and the only condition which cen- tra-indicates its use in cases of hepatitis is the existence of a dry and hot skin. Under such circumstances, its use should not be commenced till the skin is rendered moist and perspirable by the administration of some simple diaphoretic mixture in repeated small doses, say g ij liq. amro. acet. with v\_-v tinct. hyoscyam. in each dose, every half hour. In congestion of the liver (or acute hepatitis, when the skin has been made moist or perspirable by the above means) the chloride should be at once commenced in twenty-grain doses, twice or thrice daily. Colchicum is advised by Dr. Copland to increase the biliary secretion in chronic inflammation or enlargement of the liver, and to promote the resolution of the former and the diminution of the latter state. 314 DISEASES OF THE DIGESTIVE SYSTEM. Hydrargyri Bromidum has been administered with relief in chronic hepatitis with enlargement. Hydrargyri lodidum Rubrum, in ointment, is recommended by Dr. W. Ma- clean, in malarial enlargements of the liver and spleen, to be rubbed in for ten minutes, in the morning, and the patient exposed to the powerful heat of a fire as long as he can endure it. Hydrargyri Chloridum Mite. Mercury is much less employed than formerly in chronic hepatic affections, it having been superseded by nitro- muriatic acid and iodide of potassium. Iodine and its preparations are beneficial in chronic hepatic affections, but their indiscriminate use is to be avoided. Nitricum Acidum, with sarsaparilla or taraxacum, is often productive of good in chronic hepatitis, especially of old persons, where mercurials have been largely used. Nitro-muriatic fomentations and baths may be employed at the same time. Potassii lodidum, combined with taraxacum, is of value in chronic inflamma- tion and enlargement of the liver. Dr. Copland has found that it is chiefly when enlargement, obstruction or torpor of the liver occurs after periodic fevers, or in the scrofulous diathesis, that iodide of potassium, employed internally or externally, or both, and in conjunction with other deobstruents, as liquor potassse, or alternated with purgatives, is of most benefit. Taraxacum is an efficient remedy in chronic inflammation of the liver ; where mercury is advisable, rendering it more efficient, and under certain circumstances, taking its place advantageously. Sir Ranald Martin has found, in indolent enlargements of the liver, accompanied with torpid action of the viscus, that mercury is of little service, and that he has derived more advantage from the following formula, conjoined with a spare diet and the external application of cantharides : 550. JJ. Extracti taraxaci, gr. xxxvj Extract! aloes, gr. xij Extracti acetici colchici, Pulveris ipecacuanhae, aa gr. vj. M. Make twelve pills. Take two every night. INTESTINAL WORMS. T^NIA— TAPE WORMS. The varieties of tape worms are often so difficult to dislodge, that the therapeutic resources of the physician are severely tasked. The principal remedies are mentioned below : INTESTINAL WORMS. 315 PROF. KAISER. Kaiser (Med. Clin, Rundsch., 1889,) gives the following as a new tseniafuge : 551. R. Oleidglii, gtt.j Chlorofonni, f. 3 ) Glycerini, f. 3x. M. Sig : To be taken in two portions half an hour apart. Fast the evening before taking. DR. MIROVITCH. (Mercredi Med., 1891.) This physician regards naphthaline as a powerful tseniacide, being superior to other anthelmintics both in certainty of action and in the absence of any toxic effect. For chil- dren the following formula is recommended : 552. R. Naphthaline, gr. iv-vij Castor oil, f. § ss Essence of bergamot, g"- ij- To adults, fasting, the author gives fifteen grains, followed at once by an ounce of castor oil. The diet for several days before the ad- ministration of the drug should be well salted and highly seasoned and acidified. DR. J. G. BROOKS, OF KENTUCKY. 553- R- Ext. male fern., f. 3) Emul. ol. ricini, (50 pr. ct.) f. § iij. M. S. — All to be taken at once, after twenty-four hours fast. DR. CARRE, FRANCE. 554. IJ. Pulv. kousso, 3vij Olei ricini (hot) § iss Strain, and pour on the residuum Aquae buUientis, S iss. Filter and combine the two percolates by means of yolk of egg in an emulsion, and add gtt. xl ether sulphuric. Sweeten and arom- atize. For one dose. DR. W. A. RAPE. (Daniel's Med. Jour., 1890.) Dr. W. A. Rape advises the fol- lowing treatment for tapeworm. Half a drachm of chloroform is to be given in some bland acceptable vehicle, to be followed in half an hour by 3i6 DISEASES OF THE DIGESTIVE SYSTEM. 555. R. OleitigUi, ftt.iv Oleiricini, f-3iv Glycerini, f.3iv Aquje destillatse, ad f. § iv. M. Sig: Two teaspoonfuls three hours apart, regularly, until the worm is expelled. Give salicylic acid in small doses every three or four hours during the day for three or four days, being careful to keep the bowels open. The patient should fast for 24 hours previous to beginning the treatment. DR. CAMP. (Dietetic Gazette, 1891.) Dr. Camp proposes to give a half ounce or more of castor oil at night, and follow it with thymol in the morning. Twelve ten-grain doses of thymol are given at intervals of fifteen minutes. After the last dose of thymol a second dose of castor oil is administered, when the expulsion of the worm may be expected. It is suggested that no supper be eaten the evening previous to the thymol treatment. At the time of expulsion the patient should sit in a bowl of warm water, so that the passage of the worm entire be facilitated. PROF. MOSLER. The chief characteristic of this practitioner's treatment is the in- jection of large quantities of warm water into the colon, after the administration of the anthelmintic. The diet is first regulated, food being given which is supposed to be distasteful to the tape-worm — bilberry tea, herrings, sour cucumber, salted meats. The intestine having been, as far as possible, emptied by laxatives, a dose of the extract of pomegranate bark is administered, prepared from the fresh bark, and then a large quantity of warm water is injected into the rectum. The theory is that the worm, previously brought down into the colon, is prevented by the water from attaching himself to the wall, and is brought away by the liquid on its escape. It is as- serted that in every case in which this treatment was adopted, the head of the worm was removed. DR. M'PHAIL, VA. After keeping the patient on a light diet for the preceding twenty- four hours, give from 3ss-j of the oil of male fern in gij of thin mucilage, and ten minutes afterwards, a goblet of sweet milk. Two hours after the above dose, give 5j of castor-oil combined in muci- Il^ESTlNAL WORMS. 317 lage, with 5j-iv of spts. turpentine. This always does the work, and with remarkably little discomfort to the patient. ( Virginia Medi- cal Monthly, 1876.) SIR THOMAS WATSON, M. D. This eminent physician gives the preference to oil of turpentine, va, large doses — f.gss-ij, in combination with castor-oil ; or castor-oil may be administered afterwards, to assist its purgative effect. The patient should take it in the morning fasting, and no drink should be admitted into the stomach until the medicine begins to operate, lest sickness and vomiting should be provoked. The worm generally is voided dead within an hour or two. The bowels should be kept open with castor-oil, so long as the urine retains the violet smell which indicates the presence of turpentine in the circulation. MR. A. J. SCHAFIRT, WASHINGTON, D. C. In a number of cases, this pharmaceutist employed no preliminary provisions beyond forbidding the patient to breakfast the day of treatment, and giving him a full dose of Rochelle salts the preceding night. At ten o'clock in the morning, the following was taken at one dose : 556. K. Granati ladicis, § ss Peponis seminum, §j Extract, filicis ether., f. 3j Pulv. ergotse, 3ij Pulv. acaciae, gtt. ij. M. The pomegranate-bark and pumpkin-seed were thoroughly bruised, and, with the ergot, boiled in eight ounces of water for fif- teen minutes, then strained through a coarse cloth. The croton oil was first well rubbed up with the acacia and extract of male fern, and then formed into an emulsion with the decoction. In each case, the worm was expelled alive and entire within two hours. No unpleasant effects followed. In each case, the worm was passed with the head firmly fastened to the side of its body, at about the widest part, from which it was with difficulty removed, and the worm was twisted and doubled into various knots. DR. FORBES DICK, OF ENGLAND, says that the male shield fern, properly administered, will expel not only the segments but also the head of the tape-worm. He says that 3l8 DISEASES OF THE DIGESTIVE SYSTEM. the adult dose of the Pharmacopceial liquid extract, as an efficient vermicide in cases of taenia, is not, as laid down in the British Pharmacopoeia, from fifteen to thirty minims ; nor, as usually admin- istered to soldiers, one drachm ; nor even, as SQUIRE and others allow, eighty or ninety minims, but two drachms. The mode of ad- ministration should be as follows : A full mid-day meal may be eaten, and a little bread, with tea, at 5 p. m. At 10 or 11 p. m..a binder is to be applied to steady the stomach ; and on lying down in bed the following is to be taken. (Neither prolonged fasting nor filling the big bowel with fluid seems to be necessary.) 557. B. Extract! filicis liq., " 3ij Spiritfls chloroformi, tUxxv Pulveris acacise, gr. xx Aquae, qs. ad f. § ij. M. In the morning half an ounce of turpentine beaten up with the yolk of an egg should follow. . The above large dose of the male shield fern is occasionally vomited, but he has failed to discover any deleterious effect contra-indicating its use. When vomiting hap- pens, which is rare, on the following evening the same quantity should be taken in two doses, at half an hour's interval. The half an ounce of turpentine is more liable, especially in the tropics, to produce irritant symptoms. If active exercise be taken under a tropical sun after this dose, strangury follows, which there indicates the propriety of rest, to limit perspiration and prevent concentration of urine, and the drinking of bland fluids. La Mere (La Sent. Med., 1 890) gives the following formula for the administration of filix mas : 558. K- Extract of male fern, giss Calomel, gr. vij Distilled water. Syrup of gum arabic, £5 f. § ss. Powdered gum arabic, suflScient to make an emulsion. Before this mixture is taken it should be well shaken, and the patient directed on the day previous to its use to subsist entirely on a milk diet. It is stated that the worm will be expelled in from thirty to forty minutes after the administration of this medicine, if these directions be carefully carried out. In children from six to twelve years of age, one-half this quantity should be given. INTESTINAL WORMS. 319 NOTES ON REMEDIES. Ailanihus Glandulosa. The powdered bark (gr. vij-xxj is an active anthel- mintic in tape-worm. Alumen, given in milk, is a remedy of some avail. Aspidium Marginale. Dr. Cressler has obtained excellent results from the use of the oleo-resin of Aspidium marginale as a txnifuge. The oleo- resin is put in capsules of about grs. x each, and administered after a total abstinence of twelve hours from food. A dose of castor oil is administered about one or two hours afterward. The Aspidium mar- ginale is related to the male fern. — Unido Medica, 1883. Benzine has been tried with success by Dr. Mosler and other German physi- cians. Dose, sixty to one hundred drops, in capsules. The after- eifects are sometimes unpleasant. Brayera, if well preserved, is highly recommended by Dr. J. Martin (Medi- cal and Surgical Reporter, Oct. 20, 1883). The patient fasts for about twenty hours, and then takes one ounce of the herb, well boiled in one and a half pints of skimmed milk, in two equal doses, two hours apart. Carbolicum. Acidum has been used by Dr. Rumbold, of St. Louis. 559- B- Acidi carbolici, gr. xx Aquae destillatae, f. § viij. One-third every two hours. Others have not found the worm affected by this agent. Cocoa Nut. The meat and milk of the cocoanut are used upon, an empty stomach for the purpose of causing the expulsion of tape-worms ; and it is said that in tropical countries the unripe nut is undoubtedly a powerful anthelmintic. Copaiva. Dr. S. Card has recorded a case (N. V. Med. your., May, 1.876,) of the expulsion of a worm by the balsam copaiva, when nearly all other reputed remedies had failed. Creasotum. This is recommended by Dr. Henry Brickwell, of England, in doses of gtt. j-iij, three times a day for a week, followed by a brisk purge. Eupatorium Perfoliaium. The decoction of this plant is reported by Dr. H. S. WiLKiNS (Medical and Surgical Reporter, April, 1874,) to have ex- pelled, promptly, a tape-worm. Ether Sulphuricus. Dr. Lortet, in 1867, suggested ether (f.jvat a dose), followed, in two hours, by olei ricini, f.gj. He and various observers since report successful cases. Filix Mas is an old and esteemed remedy. The fresh root must be used. 320 DISEASES OF THE DIGESTIVE SYSTEM. 560. ]J. Extr. filicis maris seth., Pulv. rad. filicis, aa gr. xxx. Make thirty pills. Take ten at night, ten the next morning, and an hour after, the remainder. (Kraus.) Trousseau's method was to place the patient on a milk diet for a day; the next morning he prescribed gj of the oleo-resin, in four equal doses, a quarter of an hour apart ; the third day, the same quantity, followed by a brisk purgative. Granaii Radicis Cortex. The pomegranate enjoys a wide reputation against tape worm. 561. R. Granati rad. cort., iiij Sodii bicarb.. 3 j Aqufe, Qj M. Macerate six hours, and boil to Oss. Take in the morning, fasting, in three equal doses, following the last with olei ricini, ij. Or: 562. R. Extr. granati rad. cort., 5v Extr. fil. maris aether., 3 ij- M. Make thirty capsules. Take them within two hours. The bark of the pomegranate root is objectionable, on account of the abdominal pain it causes in many persons. Kameela. This product of the Rottkra tinctoria is used in doses of 3J-iij. It is an effective remedy, but liable to gripe. 563. R. Extracti filicis maris, . 3is9 Pulveris kamalx, 3 ij Mucilaginis acaciae, Syrupi simplicis, aa f. 3ij Aqu£e cinnamomi, qs. ad f. § iij. M. S. — Half to be taken at bed time, and the other half early in the morning. Mr. J. B. Lawson reports good results from this in the Glasgow Med. Jour., January, 1884. Kousso (Brayera anthelmintica). The reputation first enjoyed by this taeni- fuge has somewhat diminished of late. It is disagreeable to take, and produces much intestinal distress. The dose is about §ss. Accord- ing to Dr. Alois Monti, of Vienna, the compressed pastilles of koosso flowers, from Erlangen, are unsurpassed in usefulness. He has found no difficulty in their employment ; and ten grammes he thinks infal- lible. The alkaloid, koossine, if quite pure, is more convenient, be- cause the dose required is smaller ; two grammes to five grammes, according to the age of the child, are sufficient. With these two, there is no need for any preparatory treatment ; and if the head of the taenia does not come away the first time, they may be repeated the INTESTINAL WORMS. 32 1 next day. Children take them as if they were sugar-plums ; and they do not cause nausea or vomiting, nor are they followed by persistent diarrhoea. Dr. Laboulbene, of Paris, attributes failure to the smallness of the dose. (1884.) Mussanin. Thiel has applied this name to a new anthelmintic, the bark of an Abyssinian tree, Acacia anthelmintica. It is more powerful than kousso, and its taste is more agreeable. The dose is one or two ounces of the powdered bark, or it may be given in an infusion. Naphthalin is recommended among the recent taeniafiiges. Nux Vomica and its alkaloid. Strychnia, has been reported upon favorably, both in Europe and America. Dr. A. R. Kilpatrick, of Texas, uses the following : 564. R. Strychniae sulphatis, Arsenici, Hydrarg. chlor. corrosiv., . ia gr. ^j. M. For one piU. One three times a day. Dr. Masse publishes in the Montpelier Medical, 1877, some obser- vations on a case in which he procured the expulsion of three tape- worms by the administration of the tincture of nux vomica. Pelktierine is highly recommended. Peponis Semina, pumpkin-seeds, are unquestionably both a powerful and a pleasant remedy in tape worm. From 2 to 4 ounces of seeds should be pounded in a mortar, then mixed with milk or water, strained, and the fluid taken on an empty stomach. If the bowels do not act in a few hours, castor oil should be given. The dose should be repeated daily until the worm is expelled. Pepsina. Full doses of pepsin have been found, by M. Bouchut, eminently successful in dislodging and destroying tape-worms in children. ( Medical Examiner, 1878.) Potassii Picronitras. This has been recommended by some German physic- ians. 565. R. Potassii picronitratis, gr. xxviij Pulv. jalapae, 3 nc Ej^tr. glycyrrhizae^ q. s. Make 30 pills. One three times a day. It is efficient, but apt to be followed by general malaise. Saoria, the ripe fruit of the moesa picta, an Abyssinian tree, has long enjoyed a good reputation as a tanicide. The dose is g ss-j, as : 566. R. Saoria, §j Zingiberis, Sij Cassis, gr. xv Aquse, Oj. M. 21 322 DISEASES OF THE DIGESTIVE SYSTEM. Strychnia. See Nux Vomica. TerebinthincB Oleum. Recommended by Dr. Watson in large doses. Others prefer gss, twice a day, continued for some time. Sometimes it is combined with castor oil. 567. R. Olei terebinth, Olei ricini, aa f. §ss Mucilag. acaciae, q. s. M. Make an emulsion. For one dose, fasting. ASCARIS LUMBRICOIDES—LUMBRICI— ROUND WORMS. DRS. MEIGS AND PEPPER, PHILADELPHIA. These writers consider that as the diagnosis of lumbrici is nearly always doubtful, it is best never to risk the irritating vermifuges un- less worms have actually been passed. In slight and doubtful cases they prefer small quantities of worm-seed oil to anything else. It may be given in doses of gtt. iv, to children of two years, three times a day for three days, followed on the fourth day by some castor oil or syrup of rhubarb. The following is a good formula to disguise its taste: 568. R. Olei chenopodii, gtt. Ix-f. 5] Mucilag. acaciae, 3ij Syrupi simplicis, f. § j Aquze cinnamomi, f. § ij. M. Give a dessertspoonful three times a day for three days, and repeat after several days. In giving the pink root, it is best to combine it with some cathar- tic substances, as in the following formula of Dr. G. B. WOOD : 569. R. Spigeliae, Sennre, aa |ss Magnesii sulph., 5i) Foeniculi, 5 j Aquae ferventis, . Qj. M. Macerate for two hours in a covered vessel. Dose, a tablespoonful, to a child two years old, once or twice a day, or every other day, so as to procure two or three evacuations in the twenty-four hours. The fluid extract of spigelia and senna is also a very acceptable combination. PROF. J. LEWIS SMITH, M. D., NEW YORK. The long-popular American remedy for worms is the pink root, spigelia marilandica: S7°- R. Extract! spigeliae fluidi, f.gj Extract! sennie fluidi, f. § s». M. One teaspoonful to a child of three to five years. INTESTINAL WORMS. 323 Or: 571. R. Extract! spigeliae et sennae fluidi, f. §j Santonin], gr. viij. M. One teaspoonful to a child of five years. " This is probably the best anthelmintic that can be employed for the destruction of the round worm in uncomplicated cases, and it is also very useful in treating the vermicularis." In some cases of protracted intestinal disease, attended by an in- creased and vitiated secretion, there is nothing so good as turpentine. The following is Dr. CONDIE'S formula: 572. R. Mucilaginis acaciae, f-lij Sacchari albi, § j Olei terebinthinse, Spiritfls setheris nitrosi, aa f. 3 iij Magnesiae, 3j AquEe menthae, f. § .j M. A teaspoonful to a child of five years. DR. EUGENE BOUCHUT, PARIS. 573- R- Hydrargyri chlondi mitis, gr. ij Santonini, gr. jss Sacchari lactis, gr. xv. M. To be given in one dose, as a vermifuge, in a teaspoonful of honey, to an infant two years old. DR. GIORDANO, FLORENCE. 574- R- Sulphuris loti, 3ss Magnesiae, 3j- M. Divide into four powders. One to be given morning and evening to children who have passed worms, in order to prevent their reproduction. DR. G. CALDERWOOD, ENGLAND. Of all remedies for lumbrici, undoubtedly the best is santonin. In regard to its administration, this writer remarks (British Medical Jourual, February, 1875,) that it should always be given for three or four days continuously before a purgative is prescribed. To give it with, or only once before, a cathartic, does not accomplish the work completely. It acts toxically, and must have time to do its work. The worms are passed like other faecal matter, when dead ; and so long as they are alive, no amouut of purging will bring them all away. DR. F. T. ROBERTS, ENGLAND. This author prescribes an aperient, limits the diet to liquids for a day, and then employs santonin in doses of from one to three grains 324 DISEASES OF THE DIGESTIVE SYSTEM. every morning for two or three days, in sugar or syrup, or made up into lozenges, or with gingerbread. It is more efficacious when mixed with castor oil ; and Kiichenmeister advises that from two to four grains be dissolved in Sj of the oil, and 3j taken every hour until it acts. Troches of santonin, each containing half a grain of the principle, can now be obtained from all druggists. DR. SCHILDOWSKY, OF RUSSIA, Has used iodoform successfully. He gives, to an adult, one grain with ten grains of bicarbonate of soda three times a day, and a quarter of a grain to a child. ASCARIS VERMICUI^RIS—OXYURIS— THREAD WORMS- SEAT WORMS. DR. ROBERTS BARTHOLOW. This author says that the infusion of quassia is one of the most effective injections for the destruction of the ascarides vermicu- laris, which infest the rectum. The stomach administration of sim- ple bitters undoubtedly hinders the development of intestinal worms, probably by correcting a morbid state of the mucous membrane. In the treatment of intestinal parasites, therefore, much good is de- rived from the use of bitters, administered with the view of restoring normal digestion. Eucalyptus may be" used by injection. Carbolic acid is an efficient, but unsafe parasiticide, when injected into the rectum. A solution of the tincture of iron is one of the numerous remedies used to destroy this form of parasite. As their develop- ment is favored by the anaemic state, it is good practice to conjoin with any local treatment the internal use of iron, notably the syrup of the iodide. He uses santonin as follows : A laxative in the morning, fasting through the day, a dose of santonin and calomel at bedtime, a senna draught on the following morning. He sometimes uses troches of santonin : S7S- R- Santonin, |ss Sugar, Tragacanth, Orange flower water, aa q. s. M. To make four hundred and eighty troches. Each troche contains half a grain of santonin. The enema of aloes is very efficient. INTESTINAL WORMS. 325 576- R- Aloes, 9ij Potass, carbonat., gr. xv Mucil. amyli' vel decoct, hordei, f. § x. M. Large medicinal doses of hydrocyanic acid are very fatal to round worms. Salicylic acid has been used successfully in the removal of ascarides, by local application and by internal administration. An enemaof water should precede the salicylic acid solution, which may be composed of borax and salicylic acid with some glycerin : 577- R- Acid, salicylic, 3ss Sodii biborat., 3 ss Aquse, Oj. M. S. — Warm, and administer the whole amount at one time. For a young child, this quantity should be reduced one-half or more. Myrol, a new antiseptic, has been used successfully. DR. T. SPENCER COBBOLD, LONDON. This helminthologist calls attention to the true residence of the seat worm. (British Medical Journal, February, 1784.) He main- tains that the entire length of the colon is the territory inhabited'by the threadworm, the caecum itself constituting the parasite's true headquarters. Knowing this, therefore, to be the case, and likewise understanding, as we'now do, how these entozoa originally gain- ac- cess to their human bearers, it is clear that we are in a position to treat the threadworm helminthiasis on thoroughly rational principles. Injections cannot be conveniently employed to wash out the con- tents of the arch of the colon and caecum, and therefore we must, in the main, rely upon the operation of medicines taken by the mouth. He therefore employs injections only for the purpose of dislodging such oxyurides as have been driven down to the lower bowel. When it comes to the question of the choice of drugs, a great variety of medicinal agents may be used with good effect. Some seem to answer better in particular cases than others. Speaking generally, he gives a preference to active saline cathartics repeated for several days in succession, followed by the use of cold water eneraata. Small doses of chloric ether and sulphate of iron are emi- nently serviceable additions, and the same may be said of aloes, with or without assafcetida. In cases where these drugs are objected to, he has employed various active mineral waters with good results. Bitters of all kinds are useful, and patients who object to salines will 326 DISEASES OF THE DIGESTIVE SYSTEM. swallow any reasonable amount of the infusion of gentian and other pure vegetable tonics. As a rule, oxyurifuges should be adminis- tered in the form of copious draughts ; and the oftener they are re- peated, for a short interval, the more effective will they prove in the end. The rapid passage of the drugs through the bowel will, if several times repeated, carry most of the parasites sufficiently low down to be within the reach of the clysters ; and the prevention of the return of the parasites to the upper part of the colon, is one of the practical points worth looking to. The employment, therefore, of enemata, after the exhibition of remedies by the mouth, cannot fail to prove beneficial. DR. SIDNEY MARTIN. (Gaz. hebd. des. Sc. Med. de Montpelier, 1 89 1.) In treatment of patients, usually children, for seat-worms. Dr. MARTIN has seen good results from the employment of small doses of rhubarb. He advises the following : 578. R. Tincture of rhubarb, gtt. xx Carbonate of magnesium, gr. iij Tincture of ginger, gtt. j Water, f.Siij. This is to be given three or four times daily, according to the effects produced upon the intestines. From the Medical News (1891), the following formulae have been taken for injections for seat-worms a% prescribed by Barthez and West: S79- R Lime-water, f.gMJ Perchlorlde of iron, gtt. x. M. Also 580. Jl. Lime-water, f. 5 iv Decoction of marshmallow, f. 5 j. M. Also the following suppositories formulated by TROUSSEAU : 581. R. Tannic acid, gr. xv Cocoa butter, 5ji M. Ft. suppositorium. Other physicians have employed injections of assafcetida, and some have prescribed such as follows : 582. g. Alcoholic extract of senna leaves, gr. xxx Boiling water, f.giv. INTESTINAL WORMS. MR. WILLIAM DATE, LONDON. 327 583. R. Infusi quassise, Oj Sodii chloridi, § ij. M. Use as an injection, once a day. When this fails to dislodge them completely, give : 584. ]J. Ferri sulphatis, Quiniae sulphatis, Pil. aloes cum myrrhs, Pil. galbani compos., aa gr. j. One such pill thrice daily. This treatment, in a fortnight, will completely destroy the para- sites. PROF. W. H. VAN BUREN, M. D., NEW YORK. 585. R. Acidi carbolici, gtt. x-xx Glycerini, • f- § j Potassii chloratis, ad saturandum Aquae, f. § viij. M. Use as an enema, in thread-worms, {oxyuris vermicular is.') It is sometimes necessary to increase the amount of carbolic acid. DR. F. WEBB, MICHIGAN. This practitioner has stated (Michigan Medical Journal, Novem- ber, 1 87 1,) that in cases of ascarides, the hyposulphite of soda, in doses large enough to produce slight catharsis, given three times a day, has availed to expel ascarides when other vermifuges and var- ious enemata have failed. Along with whatever other treatment is used for thread-worms, it is important to anoint, with mercurial or other parasiticide ointment, the anus and adjacent parts, from time to time, in order to destroy the ova of the worm, which are frequently deposited externally to the rectum. DR. GUICHON, PARIS. 586. Q. Santonini pulveris, 3j Resinos jalapae, gr. ij Chocolate, § j. M. Divide into thirty lozenges. Give one in the morning, on an empty stomach, to an infant two years old; two or three to older children. 587. R. Aloes barbadensis, 3ss Potassii carbonatis, gr. xv Decocti amyli, f^ S x. M. To be given as an injection, in ascarides of the rectum. 328 DISEASES OF THE DIGESTIVE SYSTEM. DR. AITKEN. 588. R. Pulv. scammon. comp., gr. iv Pulv. aromatici, gr. v. M. For one dose at night. The day after taking this purgative, the patient ought to be kept on low diet, with solid food. On the day succeeding the purgative, from 5 to 10 grains of the ethereal extract of santonin, or from 3 to 4 grains of santonin itself, may be given. Injections of infusion of quassia, or of steel and quassia and aloes, or a solution of common salt in gruel, or a similar quantity of lime water, are useful in the expulsion of the ascaris vermicularis. Half an ounce of the com- pound decoction of aloes, taken in the morning, fasting, once or twice a week, and 3 ounces of infusion of quassia may be taken every morning that the aloes are not taken. NOTES ON REMEDIES. Adeps. Anointing the anus and sphincter with lard destroys the ova, and is a useful adjuvant, as it is believed that the ova are only set free in the rectum near the anus. Asarum Canadense. As an internal remedy, the Canada snake-root has been found valuable by Dr. S. S. Bond, of Philadelphia, (Medical Times, September, 1874,) and others. It may be given in infusion, or syrup, or children may chew it as they would liquorice-root. Aqua Calcis, in injections, has been commended. Argenti Nitras, gr. j-iij to aquae gj, as an enema. Ferri Chloridi Tinctura, |ss to aquae Oj, is said to be a very efficient enema. Fuligo Ligni. An infusion of soot has been strongly recommended in ascar- ides, by Dr. Hewson, of Philadelphia. It is made by adding a cupful of soot to a pint of boiling water, and straining. Half or a fourth of this quantity should be thrown up the rectum daily, for one or two weeks. Hydrargyri Chloridum Corrosivum, gr. j to aquae Oj, has been used in ob- stinate cases by Dr. Niemeyer. Hydrargyri Chloridum Mite. M. Valleix was accustomed to anoint the anus and lower bowel with : 589. R. Hydrarg. chlor. mitis, 9iv Axungiae, 3tj. M. Dr. E. F. Walker (New York Medical Journal, 1878,) says that a large dose of calomel (gr. x-xxx) gives better results than any of the ordinary drugs in dislodging seat-worms. INTESTINAL WORMS. 329 Iiydrargyri Unguentum. Anointing the anus and sphincter with mercurial ointment is very useful in destroying the worms there located and their ova. It may also be introduced on a bougie. Potassium Sulphuretum, in the proportion of Qss-j to aquae Oj, is an efficient injection. Quassia and other of the bitter astringents have been used with success in enemata. Rheum has been used as a valuable aid in the expulsion of pin-worms. The following formula is taken from the Medical News, 1890 : 590. R. Tincturx rhei, Hlxxx Magnesii carbonatis, gr. iij Tincturse zingiberis, Itlj Aquse, f-Siss M. Three or four such doses should be given in 24 hours. Sulphur. A dose of sulphur taken every morning aids in expelling the para- sites. Terebinthince Oleum, §ss to milk Oj, may be used as an enema. TRICHINAE, TRICHINOSIS. The general treatment of trichinosis is symptomatic, as up to the present we have discovered no specific vermicide for the trichina spiralis. The suggestion of ergot has been made by Dr. Rhode, of Berlin. He had a case of trichinosis in which severe bleeding of the nose occurred, and in which he prescribed extract of secale cornutum as a styptic. The hemorrhage was immediately arrested, and with this, rapid improvement of the general symptoms also occurred. This result led him to prescribe ergot in other cases of the disease, and in all instances distinct improvement followed. He believes therefore that we have, perhaps, in ergotin, a means of treatment which, without having any marked effect on the human economy, may prove fatal to trichinae and their offspring. Picric and carbolic acid, as well as benzine, which have all, at times, been recommended, have proved entirely useless in pigs, and probably would be equally so in the human subject. Probably the best treatment in the early stage, to cleanse the intestines from the parasite, would be purgative doses of calomel, 3i— ij, on the plan re- commended above for seat-worms by Dr. E. F. WALKER. Dr. Ferrer (Gazz. de les Hopital Valencia) has cured a case of trichinosis with alcohol. He commenced with six and increased to nine ounces daily, in sugared water, in the intervals of feeding. The cure was effected in eighteen days. 330 DISEASES OF THE DIGESTIVE SYSTEM. JAUNDICE. CATARRHAL JAUNDICE. krull's method. This method was introduced some years ago, and seems to be gaining favor rapidly. It consists in free rectal injections of cold water. The patient should lie on the left side, and the first day water at 59° F. should be injected into the bowel, one or two quarts. On the following days the temperature may be gradually raised to 72° F. The injections cause some colicky pain, but not severe enough to be of any moment, and are easily borne for five or ten minutes. Improvement begins as a rule at once. While one or two injections often suffice, they may have to be continued for some time, depending on the antecedent course of the case. PROFESSOR HUGO ENGEL, OF PHILADELPHIA. If a case has an acute and violent beginning, and the diagnosis can be early made, he administers to the patient a fever-mixture, as, for instance : 591. R. Spirittts Mindereri, f.Sj Spiritds aetheris nitrosi, f. § j Tinctur. radicis aconiti, TIlxMV. M. Of this, he lets the patient take a tablespoonful every three hours in half a tumblerful of sweetened orange-water, lemonade. Seltzer or Apollinaris water, until the fever has ceased. Occasionally the dose of the aconite has to be diminished. If the patient is very plethoric, if the fever is high, the pulse full and somewhat hard, and the face looks flushed, he bleeds him at the arm, taking from twelve to six- teen ounces of blood. If there is much nausea, or even if there is little, but the tongue heavily coated, or if there is occasional vomit- ing, he administers a tablespoonful of mustard in a bowl of tepid water, or a hypodermic injection of apomorphia. He cautions against tartar-emetic, to be used for the purpose. If the fever is in- termittent (very, very rare), or remittent (frequently), and above 101°, he prescribes quinine, a few large doses (twenty grains) once every twenty-four hours. If the case has an insidious beginning, he puts the patient at once upon the same treatment that he employs in the acuter cases after the fever has ceased. But no matter how the case is ushered in, as soon as he is posi- JAUNDICE. 331 tive as regards the diagnosis, he orders the local application of from six to twelve European (or twenty-four to forty-eight American) leeches. If there is no special point douloureux or local tenderness (if there is, they are applied as near as possible to it), he has the leeches applied in the hypogastric region, just above the umbilicus and slightly more to the right side of it. The diet consists of milk, beef tea (bouillon), oatmeal gruel (strained), bread soup, and the like, given at regular intervals. With the bowels or the excretion of the kidneys (save as by the medicine above referred to), he interferes only when necessity de- mands such a procedure. Either oleum ricini or Glauber salt answers in such a case the first, and acetate of potash the second purpose. When the acute symptoms have ceased, or have never been pre- sent, his treatment is as follows : After the leech-bites have healed, hie knows of no better way to assist the system to remove the obnox- ious bile than by acting on skin and kidneys, and by applying, a large fly-blister 7x8 inches over the seat of the lesion. Often he applies a second, and sometimes a third blister, always waiting for the skin first to heal ; but more frequently, after the second or third blister, he has half a drachm of mercurial ointment rubbed into the abdominal wall every day or every second day, certainly taking care not to cause salivation. But it is amazing, the quantity of such an inunction that the skin will gradually absorb in these cases, as well as in others, where absorption is our aim, without bringing about salivation. He is convinced that many a patient has derived incal- culable benefit from this treatment. Then he prescribes two remedies : acetate of potash, one drachm four times daily in a large quantity of water, his usual prescription being: 592. R. Potassii acetatis, f. S"i Tinctur. nucis vomic, IUxlviij Glycerini, Syrup rubi idari, aa q. s. ad f. 5 vj. M. Two teaspoonfuls of this medicine, to which the glycerin and the raspberry syrup are added only to improve the taste of it, and the nux vomica to allay any irritability of the stomach, contain exactly one drachm of the acetate of potash ; this dose is administered in a large tumberful of water (if possible, Apollinaris) four times daily. Further, he orders two teaspoonfals of Carlsbad salt to be taken every morning on an empty stomach. But to insure the real effect 332 DISEASES OF THE DIGESTIVE SYSTEM. of this almost specific remedy, certain conditions have to be fulfilled. First, for this purpose he never uses the effervescing salt ; he em- ploys either the imported, genuine, or, with still greater preference, the artificial Carlsbad salt. As it is difficult to dissolve, as it should be taken luke-warm, in a large quantity of water and in a certain manner, he advises his patients as follows : They are to take a goblet of the size of a large beer-glass ; into this they put the two heaped teaspoonfuls of artificial salt, leaving the metal spoon in the glass to prevent it from cracking ; then the glass is slowly filled with boiling water, and the solution continually stirred. If these last two precautions are not observed, a part of the mixed salt will recrystal- lize, and not dissolve in the quantity of water prescribed. Then the glass is covered with a saucer, and kept over night in the bedroom of the patient, who in the morning on awakening, say, for sake of illustration, seven o'clock, once more stirs his Carlsbad water, and then drinks the sixth part of it. Ten minutes later he takes the second sixth, and, if he is now able to leave his bed, as most are, he rises, and while washing and dressing himself, he sips the third sixth. Then he goes into his yard, or in inclement weather into the largest and best-aired room in the house, and walking up and down he drinks every ten minutes another sixth, so that within about half an hour the Carlsbad water has been swallowed. The patient must then wait half an hour for his breakfast. To assist nature still more, he has the patient take a steam-bath every night on going to bed. The room in which the patient is to take the bath is brought to a temperature of 74° F., as determined by the thermometer — to prevent chilling. When the pain has ceased and the faeces have had a green color for a week, without interrup- tion, he gives the patient every fifth or sixth day, in the evening, from five to ten grains of blue mass, followed in the morning by the usual dose of Carlsbad salt. ROBERTS BARTHOLOW, M. D., PHILADELPHIA. 593- B- Eel bovini purificati, 5j Manganesii sulphatis exsiccatse, 9ij Resinas podophylli, gr. v. M. For twenty pills. One three times a day, in catarrhal jaundice. In similar cases he also finds the following of great use : 594- B- Quiniae sulphatis, Qij Ferri sulphatis exsiccatse, 9j Acidi arseniosi, gr. j_ M. To make twenty pills. One thrice daily, in malarial jaundice. JAUNDICE. 333 PROF. WILLIAM PEPPER, M. D., PHILADELPHIA. In simple jaundice — acute congestion of the liver — the indications are to check vomiting, to relieve the congestion, and to start the bile. To accomplish the first, give hydragogue cathartics, elaterium, bitartrate of potash, etc. ; or, if the stomach is too irritable, admin- ister an enema of croton oil, gtt. ij, in emulsion. The congestion of the stomach and liver can be relieved by counter-irritation, as by a large blister over the epigastrium. This is very effective to arrest the vomiting. By the mouth give the following : 595- R- Hydrargyri chloridi mitis, gr. iij Pulveris opii, gr. ij Bismuthi subnitratis, yijss. M. Make six powders. One to be given every three hours. This combination powerfully aids the mercurial in relieving the hepatic congestion, and stimulating the gastro-intestinal glands. The diet in such cases should be restricted to milk. (Medical and Surgical Reporter, 1875.) DR. GEORGE HARLEY, LONDON. In pycemic or septiccBtnic jaundice, great caution must be used not to fatally depress the already broken-down system. If a mercurial is indicated, it should be given in the form of grey powder, and when the alimentary canal has been unloaded it is advisable to give tonic germicides, such as quinine and its congeners. If the patient is sufficiently strong, salicylic, benzoic and carbolic acids may be substituted. In congenital jaundice, the mercurial had better be given to the mother or wet-nurse than to the baby. In contagious jaundice, after clearing out the stomach and bowels by an active emetic followed by a rapidly-acting purgative, germicides and qui- nine should be given. Iron should be avoided. For the head symptoms use chloride of ammonium, bromide of ammonium, acetate of ammonia and the carbonate, of ammonia, either given separately or combined in pairs dissolved in camphor mixture. For »/fl/«r2fl/ jaundice he uses mercurials freely, in combination with quinine, salicine or ipecacuanha. But under the most favorable in- fluences, many of the cases that have long been subjected to some of the worst forms of malarial influences, succumb, from the consti- tution having become, as it were, thoroughly and irretrievably un- dermined by the poison. In catarrhal jaundice the free administra- 334 DISEASES OF THE DIGESTIVE SYSTEM. tion of emetics is recommended. In jaundice from permanent ob- struction, pig's bile will supply an important element to the system, and tend to ward off the fatal end. Fresh bile, taken directly from the gall bladder of the freshly-killed pig, is filtered through very porous filter-paper to free it from mucus. It is then as rapidly as possible evaporated to dryness at a temperature not exceeding i6o° Fah. As soon as dry it is ready for use. Five grains are equal to about one hundred grains of liquid bile, and ten grains is the dose, to be given at the end of stomachal digestion. PROF. CARREAU. (La Sent. Med., 1891.) Carreau uses oil of turpentine in large doses in severe jaundice. In grave cases as many as sixty capsules, containing two or three drops, are given in thirty-six hours, the dose being given as often as every half hour. Where vomiting prevents their action he administers oil of turpentine hypodermically : 596. R. Ozonized oil of turpentine, f. 5iiss Liquid vaseline, f. § iij. PROF. A. GUBLER, FACULTY DE MEDECINE, PARIS. 597- R- Aloes socotrinae, Gambogiae, Hydrargyri chloridi mitis, 5£ gr. xv Syrupi, q. s. M. Divide into ten pills. Order one or two a week, to keep the bowels soluble, in icteric disease of the liver. f MIDDLESEX HOSPITAL, LONDON. 598. R. Piluke hydrargyri, gr. xxx Digitalis pulveris, Scilbe pulveris, aa gr. v. M. Divide into ten pills. One morning and evening, in icterus, to eliminate the coloring matter of the bile from the blood. NOTES ON REMEDIES. Acidum Benzoicum has recently attracted attention as a remedy in jaundice due to suppression of the biliary secretion. Acidum Nitro-MuriaHcum Dilutum is useful both internally and externally, in the form of a bath. It is contra-indicated if there be inflammatory action present. Aloes has been used with benefit in jaundice. Ammonii Chloridum, in doses of gr. xx every five hours, has, in the hands of Dr. Anstie, restored the biliary secretion, in a few doses, when it has been suppressed by a powerful nervous shock or mental perturbation. JAUNDICE. 335 In his opinion, it is one of the most powerful of all biliary functional restoratives. Colchicum, in small doses, combined with mild mercurials, or soap, or alka- lies, or with magnesia or the neutral salts, according to circumstances, has been prescribed by Dr. Copland with benefit. It must be contin- ued for a considerable time, and carefully watched. If there be much debility, or if it produce depression, it should be combined with cam- phor. Copaiba. Dr. B. J. Massiah (British Medical yournal, April, 1879,) says that the cholagogue action of this drug is not sufficiently recognized. In hepatic torpidity, cirrhosis and jaundice, it is a valuable aid. The dose may be 3j thrice daily. Ether, from its power of dissolving cholesterine and its anti-spasmodic prop- erties, has been recommended as an internal remedy in jaundice de- pending on the presence of gall-stones. Euonymin, in chronic hepatic affections, has many supporters. In 1 884 it was highly spoken of at the Paris Society of Therapeutists. Hydrargyri Chloridum Mite. Jaundice sometimes )aelds rapidly to a calomel purgative (gr. v), followed by a saline, which, however, prove useless when the affection is connected with obstruction by gall-stones, or or- ganic diseases of the liver. Magnesii Sulphas. The following formula is sometimes useful in severe forms of jaundice : 599. R. Magnesii sulphatis, 5^^! Magnesii carbonatis, gr. xv SpiritQs ammonii aromatici, lUxxx AqusE, f. 3x. M. Make a drink. Take thrice daily. Podophyllin is often a very reliable remedy in jaundice. Potassii Chloras, combined with carbonate of soda, is useful in chronic or asthenic jaundice, accompanied by a torpid state of the liver. Potassii Sulphas is recommended by Dr. A. T. Thompson, as more useful than other saline purgatives in jaundice. Rheum. Rhubarb is recommended, as in the following formula, from the Medical News, 1891 : 600. R. Pulveris rbei, gr. vij Aquae destillate, f. S vj. Ft. infusum ; filtra et adde Sodii bicarbonatis, Siiss Syrupi men thse piperita, f. 3v. M. Sig : A dessertspoonful every two hours. Sanguinaria, in the form of the powder (gr. ij-v) or the infiision, has been employed with advantage in jaundice and torpor of the liver. 336 DISEASES OF THE DIGESTIVE SYSTEM. Sodii Benzoas. In contagious jaundice (the violent form) Dr. Harley recommends this drug, combined with salicylate of quinine, or quinine itself, when the temperature is high. Taraxacum, combined with small doses of colchicum, has been found ser- viceable in jaundice depending upon hepatic disease. Cathartics. Dr. Gross states that in jaundice depending upon hepatic de- rangement, after bilious evacuations have been produced, an active aperient, every second or third day, for the space of ten days or a fort- night, should never be omitted, so as to carry off the remains of the disease, arid prevent a relapse. This is a simple but successful prac- tice which should not be neglected. Enemata. Dr. Krull, of Mecklenburg, extols enemata of cold water, 60° Fah., as an excellent remedy in catarrhal jaundice (Berliner Klin. Wochenschrift, No. 12, 1877.) He uses one to two litres once a day, to be retained as long as possible. TORPIDITY AND FUNCTIONAL DERANGEMENT OF THE LIVER. CHARLES MURCHISON, M. D., LL. D., F. R. S., LONDON. In the " Croonian Lectures " of 1 874, this eminent authority dis- cussed the functional derangements of the liver and their treatment. Commencing with diet, he recommends one chiefly of stale bread, plainly cooked mutton, white-fish, poultry, game, eggs, a moderate amount of vegetables, and weak tea, cocoa, or coffee. In severe cases, potatoes, rice, sago and fruits have to be given up ; milk suits some, not all. The principal meal should be in the morning, and the quantity not beyond the needs of the system. All alcoholic drinks should be prohibited. Cholagogues: Great advantage is de- rived from aperient medicines ; salines are the best, as sulphate of magnesia, sulphate of soda, tartrate of potash and soda, Friederichs- hall, Pullna, or other saline water ; as to the benefit of mercury, our author says that the skepticism of the most doubting physician would be removed should he unfortunately find it necessary to test its efficacy in his own person. Calomel is the form he prefers. Podophyllin he regards as less certain in its action and more liable to cause griping. Colchicum is a useful adjunct to other aperients. Taraxacum, he thinks, has no specific action, but is useful as a mild TORPIDITY AND FUNCTIONAL DERANGEMENT OF THE LIVER. 337 aperient, and may be advantageously combined either with alkaHes or mineral acids. Alkalies: These are next in importance. One grain of carbonate of lithium, or of carbonate of ammonium, nearly equals a grain and a half of carbonate of sodium, or two grains of car- bonate of potash. It is well to suspend their use occasionally, as, when long continued, they derange gastric digestion. Chloride of ammonium has a great and well-deserved reputation in hepatic con- gestion and other functional derangements of the liver : 601. ^. Ammonii chloridi purificati, § ss Aquae menthae piperitse, f. § iij. M. A dessertspoonful three times a day. It may be combined with either alkalies or mineral acids. The last-mentioned remedies our author considers of minor value, in these complaints. Tonics are apt to disagree in many cases of func- tional hepatic derangement. Neither iron nor quinine acts well. Gentian, chiretta, cascarilla, serpentaria and nux vomica, are prefer- able to preparations of iron and cinchona. Arsenic suits some patients. Opium is contra-indicated, except in those functional hepatic troubles which arise in diabetes. NOTES ON REMEDIES. Ammonii Chloridum is worthy of trial when there is want of biliary action. Euonymin, from the Euonymus atropurpureus, and Iridin, from the Iris versi- color, have been reported upon by Prof. Rutherford, of Edinburgh He gives of the former, gr. j-ij ; of iridin, gr. iv, in pill form. There is little difference in their action, both being feeble intestinal stimu- lants, increasing the functional activity of the liver, and acting mildly and without depression. (Brit. Med. Jour., June, 1879.) For or- dinary and simple cases, the following is a convenient form : 602. R. Ex. euonymi fluid., f- S iij Syr. aurantii, f-Sj- M. S. — One teaspoonful before breakfast. If the debility and torpor are somewhat extreme, a dose may be taken before each meal in which case, half a teaspoonful is almost always amply sufBcient. Hydrargyri PilulcB. Abernexhy's practice, in bilious derangements, of giving, almost indiscriminately, 5 grains of blue pill at night and a senna draught in the morning, is still continued by many practitioners. Ipecacuanha, in small and long-continued doses, is frequently productive of great benefit in functional derangement of the liver. 22 338 DISEASES OF THE DIGESTIVE SYSTEM. Iridin is a cholagogue aperient, gentler in its action than podophyllin. It is very useful in a sluggish state of the bowels, arising from torpidity of the liver, or when the stools are pale, particularly in the interval of overt attacks in gouty persons. Leptandrin is useful in torpidity of the liver, in which case it is said to be a valuable adjunct to podophyllin and iridin. Nux Vomica and Strychnia are valuable hepatic stimulants : 603. R. Extract! nucis vomicae, gr. viij Extracti colocynthidis comp., gr. xlviij. M. For twenty-four pills. One three times a day, in chronic hepatic congestion. Oleum Olivce. Dr. E. P. Townsend (Country Practitioner, Octohei, 1879,) states that, for many years, he has used olive oil, gj, two or three times daily, in cases of chronic hepatis and torpidity of the liver, with or without jaundice, with undoubted good effect. Podophyllin is now much employed in torpor of the liver. Sanguinaria has been used with advantage in torpidity of the liver, the powder (gr. ij-v,) or infusion, being preferred to the tincture. Senna, infusion (f. §j-iij), either alone or combined with sulphate of mag- nesia (3ij-iv), or tartrate of potash (3ij-3ij)> is an efficient purgative in bilious derangements. Taraxacum is a valuable remedy in torpor of the liver. Turkish Baths are sometimes of great advantage as excitants of the liver. PYROSIS. Pyrosis, or water-brash, is not unfrequently connected with or- ganic disease of the stomach; but its most typical form is as a functional disorder, often due to the use of certain ingesta, among which oatmeal, cheese and tobacco, may be mentioned. One of the most useful medicines is bismuth, which may be combined with compound kino powder. The following are some of the prescriptions of PROF. PIORRY, OF FRANCE. 604. R. Sodii bicarbonatis, 5iss Aquse destillatse, Syrapi aurantii florum, aa l.%\ Olei anisi, oxx. j. M. For one dose, in pyrosis. PYROSIS. 339 .6°5- R- Quiniffi sulphatis, gr. xxij Pepsinse, §vss Extracti absinthii, q. s. M. Divide into forty pills. Two before each meal, in functional derangement of the stomach, particularly pyrosis, flatulence and gastralgia, after eating. 606. R. Sodii bicarbonatis, gr. xiv Tincturre columbae, f. 3j Aquse destillatse, f. § jij Syrupi gentianse, f. 3j. M. To be taken during the day, in the same manner as the above formula. 607. R. Magnesife, gr. iss Bismuthi subnitratis, gr. iv-vij Opii jDulveris, gr. ss. M. For one dose; to be taken before eating, in acid dyspepsia and with pyrosis. NOTES ON REMEDIES. Acidum Carbolicum has been employed with success by Dr. Podmore Jones (Practitioner, November, 1868) in the following formula: 608. R. Acidi carbolici, gr. j Alcoholis, f. 3 j. M. Twenty-five droj. s in a wineglassful of water, an hour before each meal. Acidum Gallicum is of benefit in cases accompanied by organic disease of the stomach, or by disease of the liver. Acidum Sulphurosum, in the hands of Dr. Lawson ( Practioner, September, 1868), has produced the best effects, in doses of f.5ss-j, thrice daily, shortly before meals, in plain distilled water. Alum, in doses of 3j thrice daily, in the form of an electuary, has been strongly recommended. Argenti Nitras is an excellent remedy. Argenti Oxidum has been employed with marked benefit. It must not, in these cases, be combined with creasote, as the combination causes violent decomposition and the development of great heat, and even flame. Benzoin. A fluid drachm of the tincture, with mucilage, is said to be effica- cious in many cases. Bismulhi Subniiras, combined with opium, seldom fails to afford relief. Kino Pulvis Composiius is said by Sir T. Watson to be an admirable remedy in this affection, in doses of gr. x, thrice daily. Liquor Ferri Niiratis, in doses of gtt. x-xv, thrice daily, is useful in those cases where tonics and astringents are indicated. Lupuli Extractum has been found serviceable. Magnesia Carbonas is occasionally an effectual remedy. Nux Vomica is very useful in many cases. 340 DISEASES OF THE DIGESTIVE SYSTEM. PERITONITIS. LAWSON TAIT, M. D. (London Lancet, 1887.) Dr. Tait advocates the free purgation of the patient with salines if the case be an early one. In this he is followed by a large number of advocates, who look upon this method as an abortive one in peritonitis, at least that which follows surgical operations upon the abdomen. When the peritonitis is established, one of the main objects is the prevention of much intestinal motion. Efforts at and actual vomiting must be controlled by sedatives, and counter-irritants and depletives over the abdomen are of much value. Where the peritonitis is of a suppurative character, from perfora- tion of the intestine, from rupture of a pus tube in a female, opera- tive measures must be actively carried out and the abdominal cavity freely flushed. Tubercular peritonitis has also been materially bene- fitted by surgical interference. Where the peritonitis is due to faecal impaction it is recommended by SUCKLING to give the following : 609. R. Magnesii sulphatis, Sodii sulphatis, aa 5ss Tlncturae belladonnae, TIlx Aquae, q. s. ad solutionem. M. On the other hand there are those who urgently disparage such treatment under the same circumstances. PROF, J. H. MUSSER, OF PHILADELPHIA. This excellent authority publishes (Univ. Med. Mag., 1889.) the report of a number of cases of acute peritonitis treated medically with every success. His treatment comprises these points: local blood letting, from 3 to 1 5 leeches ; and in more advanced cases blisters over the area of the peritonitis, this to be followed by a hot fomentation. The diet is to be absolutely liquid ; stimulants given when necessary. For thirst he allows cracked ice, lime water, and small amounts of champagne. Medicinally, calomel in small doses, combined with opium, is pushed until ptyalism presents; and if the calomel does not act he gives one warm enema of sweet oil and water. To control the pulse-rate he cautiously gives aconite to chil- dren and veratrum viride to adults. To control pain he uses mor- phine controlled by atropine, hypodermatically. Stimulants, as whisky, digitalis and nitrate of amyl, are used in case of collapse. TYPHLITIS, PERITYPHLITIS AND APPENDICITIS. 341 The cases which he would submit to operative procedures are those in which the symptoms assume a fulminating type ; where collapse is imminent in spite of treatment ; where there is pus or new growth in the abdominal cavity; Ccises arising from intestinal perforation, etc., and those from intestinal obstruction. TYPHLITIS. PERITYPHLITIS AND APPENDICITIS. (For Surgical Treatment see Vol. II.) DR. BOUCHARD. (Gaz. Hebdom., 1889.) The principles of treatment of inflamma- tion in the caecum are laid down as follows: (i) To relieve the pain; (2) to insure complete intestinal rest and to reduce as far as possible all intestinal fermentation; (3) to insure perfect asepsis of the large intestine. (i) The pain may be relieved by the use of poultices, mercurial belladonna ointments and hypodermatic injections of morphine. (2) To prevent possible obstruction of the bowels, mild laxatives, such as magnesia or a dessertspoonful of castor oil, should be given. The use of strong purgatives should be avoided. The diet should consist of milk with lime water, or with the yolk of an egg ; solid food, or easily fermenting food, should not be given. (3) Complete asepsis of the lower bowel can be insured by the use of antiseptic injections, as the following : 610. R. Water, 1000 parts Borate of sodium. Tincture of benzoin. Camphorated alcohol, aa 5 parts. This solution should he used at a temperature of 100° F., two pints of the solution being used at each irrigation. DR. W. T. DODGE. (Mvd. News, 1891.) The important question that confronts the practitioner, when he sees one of these cases of typhlitis, peri- typhlitis or allied affection, is as to whether pus has formed or whether the symptoms are entirely due to the presence of hardened fsecal masses in the large intestine, which condition Dr. DODGE be- lieves to be usually the first stage of caecal abscess. 342 DISEASES OF THE DIGESTIVE SYSTEM. In all cases where the indications for immediate operative inter- ference are not imperative, an attempt should be made to open the bowels at once ; and he recommends for this purpose full doses of sulphate of magnesium. He is in the habit of placing such cases upon tablespoonful doses of this salt given every three hours until faecal evacuations are obtained, unless the exhibition should be fol- lowed by increased pain. It is also a good plan to give large enemata of warm water. Excessive pain should be relieved by the administration of opiates and poultices to the abdomen ; and diet should be restricted to liquids. VOMITING. In the treatment of this distressing symptom, it is of the utmost importance to distinguish between vomiting from cerebral, from uterine, and from gastric irritation, as the management of the three is essentially different. That from uterine sympathy is not consid- ered here. The principal anti-emetics will be found in the notes on remedies : DR. S. G. WEBBER, OF MASSACHUSETTS. Sometimes only a large amount of food taken at one time excites vomiting: then it is sufficient to resort to frequent feeding, giving a very small quantity each time, a mouthful or a spoonful every fifteen or thirty minutes ; thus the stomach never contains a large mass of food requiring considerable muscular exertion to roll it about, and by its weight or bulk exciting the reflex irritability of the nerve centres. Many times, however, this is not enough; the stomach requires more complete rest, and the best treatment is to withhold all food and medicine ; sometimes a few hours' rest is enough, again it requires two or three days; then it will be necessary to use nutrient enemata. Where there has been much vomiting, thirst may be very annoying to the patient ; small lumps of ice held* in the mouth will relieve this, and generally do not cause vomiting. After the stomach has had sufficient rest, it is best to commence feeding by the mouth, with caution, giving a little frequently. Milk and lime water, equal parts, a teaspoonful every half hour, should be first tried ; if well borne, the amount can be increased gradually. It is a mistake to increase the quantity too rapidly. VOMITING. 343 DR. KAATZER. (Dent. Med. Woch., 1891.) This physician has obtained quick relief from hyperemesis in a pregnant, consumptive woman, with permanent result, from the use of the following : 611. ]J. Creasote, TTlxxx Tincture of gentian, f. 3iiss Extract of coffee (German Pharm.), f.Siiss Brandy, f. 5 j Distilled water, f 5 iiiss M. Sig. — Shake well and take a tablespoonful in milk, two or three times a day. NOTES ON REMEDIES. Acidum Arseniosum, in the form of Fowler's solution, is advised by Dr. Ringer, in the morning vomiting of drunkards. Acid Carbolic has remarkable sedative effects, and will arrest the vomiting of acute stomachal and intestinal disorders ; it may be advantageously combined with bismuth, in an emulsion. Bartholow recommends the following formula : 612. R. Acidi carbolici, gr. iv Bismuthi subnitrat., 3 ij Mucil. acacise, f- § j Aq. menth. pip, f. g iij. M. S. — A tablespoonful every two, three or four hours. Acid Carbonic, in the form of an effervescing draught, is often an effective remedy. Acid Sulphurous, in doses of m,xxx, thrice daily, has been employed by Dr. Drysdale, with success (Lancet, July 24, 1869,) in constant vomiting and eructation. Acidum Hydrocyanicum, given in an effervescing draught, is a very efficient remedy in vomiting arising from any morbid conditions. Acidum Tariaricum, in effervescing draughts, sometimes succeeds in allaying vomiting. Ammonii Citras has been recommended in the vomiting attendant on ulcer of the stomach, but Dr. W. Brinton considers that the salts of am- monia do more harm than good in these cases. Ammonii Chloridum is said to relieve the vomiting attendant on scirrhus of the stomach more promptly and uniformly than any other remedy. Bismuthi Subnitras, especially when combined with hydrocyanic acid, often speedily allays vomiting in connection with stomach diseases. Bromides are serviceable in cerebral vomiting, and in cholera infantum in children, and in some cases of reflex vomiting. Calcis Aqua sometimes succeeds when hydrocyanic acid and other remedies 344 DISEASES OF THE DIGESTIVE SYSTEM. fail. It has less influence on sympathetic vomiting than on that con- nected with functional derangement of the stomach. Calomel, in very minute doses, will stop vomiting in cholera infantum and in other intestinal disorders in children. Chloral is highly useful in vomiting of sea-sickness, cholera and reflex vomit- ing. Chloroform, in doses of a few drops, is often very useful in obstinate vomit- ing. Cinnamomum, in aqueous infusion, is often of benefit in continued nausea and vomiting. Cocculus Indicus, according to Phillips, is the great rival of nux vomica in nervous vomitings, when attended with a dull and heavy pain in the head, and intolerance of light and sound. Creasotum is considered by many as an overrated remedy in vomiting. Dr. Ringer considers the principal cause of its failure is due to its being given in to large doses. He obtains the best effects by adding just sufficient creasote to water to make it taste distinctly but not strongly of the medicine, and administering of this a dessertspoonful frequently. He finds it effectual, given in this manner, in allaying nausea and retching, though some consider it to have less power over actual vomiting. Ipecacuanha is considered by Dr. Ringer to have few equals in checking some forms of vomiting. In numerous instances he has found drop doses of the wine, administered every hour or thrice daily, according to the urgency of the case, check vomiting of pregnancy, the morning vomiting of drunkards, the vomiting which accompanies general weak- ness after acute diseases, and that of acute catarrh of the stomach in children. That form of vomiting after meals in which there is no nausea or pain, or even discomfort, is quickly stopped by these small doses of ipecacuanha. Even in vomiting from cancer of the stomach, he has sometimes succeeded with it after the failure of other remedies. Dr. C. D. Phillips states (Praciitioner, November, 1869) that its beneficial operation is clearly discernible in most cases of continued and obstinate retching or vomiting where the stomach is not primarily affected, but disturbed by sympathy with some other organ or part of the body, whether the primary affection be acute or chronic. Iodine. Dr. T. I. Gaunt (Am. Jour. Med. Set., April, 1883) has for a num- ber of years been employing the compound tincture of iodine in drop doses in nearly all forms of emesis, and he reports thirteen cases of the most varied character, in all of which vomiting was promptly arrested by its use. Koumiss, wineglassful doses every half hour, has been found effectual in ob- stinate cases. VOMITING. 345 Nitrite of Amyl z.i\A. Nitro -glycerine are said to be very effective in the vomit- ing of sea-sickness. Nux Juglandis. Dr. Edward Mackey has found (Practitioner, December, 1878) a tincture of walnuts very efiRcacious in hysterical vomiting, that from dyspepsia, pregnancy and anomalous cases. His formula is : 613. R. Fresh walnuts, ixxx Alcohol, f. § xij Water, q. s. M. Distill f. § xvj. Dose, f. 5 j every four hours. Sodii Carbonas is beneficial in vomiting arising from acidity of the stomach. Nux Vomica, in the form of the tincture, is recommended in the vomiting of pregnancy. Dr. Douglas Powel (Practitioner, November, 1868) says that the tincture, in doses of t^^x, will often arrest the vomiting of phthisis. Dr. Barlow recommends, in vomiting connected with malignant disease of the stomach, the following formula : 614. R. Extract! nucis vomicae, gr. j Extracti conii, gr. xij. M. Make six pills. Take one three times a day. Blisters. A small blister over the epigastric region frequently effectually checks vomiting arising from functional or nervous disorder of the stomach, and also that consequent on fevers. Ice in lumps, or minute quantities of iced brandy and water, or champagne, given every hour, is useful in severe vomiting attendant on pregnancy or uterine disease. Leeches. Dr. Tilt states that in vomiting connected with uterine affections, after the failure of ordinary measures, he has, on several occasions, seen it suddenly checked by the application of six leeches to the pit of the stomach, although there was no sign of inflammation there, and the patient's debihty was such as not to justify loss of blood. The same procedure sometimes succeeds in idiopathic vomiting. PART IV. DISEASES OF THE URINARY SYSTEM. Albuminuria — Brighfs Disease (Acute and Chronic) — Diabetes In- sipidus — Diabetes Mellitus — Dropsy (Ascites, Anasarca) — Func- tional Urinary Disorders (Incontinence) — HcBtnaturia — Nephralgia — Urcemia — Uric Acid Diathesis. ALBUMINURIA. Recent researches have demonstrated very conclusively that albu- minuria may and very frequently does exist when there is no disease of the kidney. In fact, some authorities go so far as to say that there is a " physiological albuminuria," noted in perfectly healthy persons. DR. CALVIN ELLIS enumerates among the various causes capable of producing albu- minuria — I. The irritant poisons. 2. Disorders of the circulatory system, as affections of the heart, various fevers, as intermittent or yellow fever, peritonitis, pneumonia or pleurisy. 3. Blood poison- ing with or without fever, as ischaemia, acute rheumatism, typhoid or scarlet fever, diphtheria, variola, measles. 4. Affections or dis- eases of the nervous system or brain, as convulsions, mania, affec- tion of the spine or spinal cord. 5. Changes in the blood, as in suppuration, syphilis, scurvy, cholera. 6. Lead poisoning, tumors or cancerous affections, goitre, interference with the functions of the skin by cold, burns, from varnishing the skin with gum arable. DR. CHATEAUBOURG, OF PARIS, concludes that, 1st. Albumen is found in the urine of the majority of healthy persons, more or less abundantly, and transient in its character. 2. Rest in bed has a clearly-marked influence in dimin- ishing the amount of albumen excreted. 3. Bodily fatigue greatly influences the production of physiological and transient albuminuria. 4. Intellectual labor augments with most people the quantity of (346) ALBUMINURIA. 347 albumen in the urine. 5. Cold bathing exerts considerable influence in increasing physiological albuminuria. 6. Sexual excitement and menstruation nianifestly affect albuminuria in the healthy. 7. Albu- minuria is as frequent in children as in adults, but the quantity of albumen excreted is less. 8. Digestion, if accompanied by rest, does not exert much influence upon physiological albuminuria. DR. F. DE HAVILLAND HALL, LONDON. In the treatment of acute albuminuria, such as is a frequent sequel of scarlet fever, this author condemns the usual procedure (in England) of "hard purging and sweating" (Practitioner, August, 1876). He has achieved much better results from the following plan: Directly any albumen was detected in the urine, the patient was ordered the per chloride of iron, and was allowed no solid food except a little bread and milk, and as much water as he liked to drink ; this treatment, together with keeping the skin gently acting, sufficed in the majority of cases, but in a certain number the urine was almost suppressed, and in some there were ursemic symptoms. Whenever either of these contingencies occurred, he forbade all food for twelve hours, the child to have nothing but water and a drink made as follows : 615. R. Acid tartrate of potash, §) Lemon syiup, f- § j Water, Qj. M. If, at the end of this time, the kidneys were beginning to act, he allowed a little milk, but not more than a pint in the twenty-four hours ; if, however, the uraemia continued with little or no urinary secretion, he persevered with the water and bitartrate of potash ; and in severe cases, nothing else has been given for thirty-six hours. Dry cupping, mustard poultices over the loins, and a purgative, were the only additional remedies employed. The explanation of the good effects of abstention from solid food, and especially meat, during the course of acute desquamative nephritis, is, that if a patient is entirely deprived of nitrogenous food, the work of the kidneys is lessened and the urine is rendered less irritating, and the mild diuretic action of the bitartrate of potash seems to be useful. He sums up the treatment of acute Brighfs disease in the follow- ing words : 348 DISEASES OF THE URINARY SYSTEM. I. Milk and water with arrowroot, no solid food. 2. Mild diuret- ics, such as the citrate or bitartrate of potash, with a free supply of water. 3. The skin kept just moist. 4. A daily evacuation of the bowels. On the question of diet in diseases of the kidneys, in as far as the albuminuria is' concerned, SAS5]KT)Yi-E(Wratsck.-Centralbl.f. Therap., 1 891) states that, while a vegetable diet does cause a diminution in the degree of albuminuria, it is not well borne for a long period, and causes the patient to become apathetic and lowers the blood pres- sure. Animal diet increases the albuminuria according to this author, but improves the general condition and raises blood pres- sure. He looks upon the mixed animal and vegetable diet as best suited. This, it may be said, however, is not the view of the major- ity of authorities, the absolute milk diet being deservedly very favor- ably regarded. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. Some important additions to the therapeutics of albuminuria were suggested by this writer in a paper before the Phila. Co. Med. Soc, in 1883. He would use nitro-glycerine, in doses of one minim of a centes- imal solution (one minim of the pure drug to lOO minims of alcohol), every three or four hours, in acute cases immediately after the subsidence of the acute symptoms, and in chronic cases at all periods. Chloride of gold and sodium is indicated in the sub-acute and chronic cases, especially the latter. The earlier it is given the better, if structural changes are to be prevented or arrested. The good effects to be expected from it will depend necessarily on the extent of the damage already inflicted on the kidneys. The usual dose is one-twentieth grain twice a day, but this may be much increased, if necessary. At the outset, one-tenth grain may be given ; in a week the dose should be lowered to one-fifteenth grain, and after a month the regular dose of one-twentieth grain should be steadily pursued, with occasional intermissiofls. Indiges- tion, gastralgia and colic pains, nausea or diarrhoea, are occasionally caused by it ; and, if so, the quantity administered must be reduced. It is usually, borne without any discomfort. ALBUMINURIA. 349 DR. T. LAUDER BRUNTON, LONDON. This practitioner states that where true albuminuria is present, the indications are : 1. To remove the venous congestion of the kidneys. When this depends on cardiac disease, digitalis is called for; on pregnancy, etc., the prone position lessens it. 2. To diminish the flow of blood to the kidneys. To fulfill this, warm clothing, warm baths, diuretics and purgatives are required. 3. The anaemia consequent on the drain of albumen must be re- moved by iron, and light, digestible food. DR. C. PAUL, OF PARIS. This physician follows in general the following practice. The patient .is restricted in diet to one of milk, and in many instances absolute rest is prescribed. Internally, 616. R. Acidi gallici, gr. viij-xxx Ergoti, gr. x Tr. ferri perchloridi, Tr. iodi, ia gtt. iij Aquse, q. s. M. Sig. — Such a dose thrice daily. Germain See restricts the case entirely to milk diet, and at the same time administers iodide of potassium and tannin. (Form, de la Faculte de Med. de Paris.) DR. BOUCHUT, PARIS. Dr. BouCHUT in cases of albuminuria due to nephritis is disposed to use fuchsin as a remedial agent. He prescribes as follows, con- currently with milk diet : M. 617. R. Fuchsine, gr-J.. Essence of mint, gtt. ij Julep, <\- 5- Sig. — One such dose daily. WILLIAM AITKEN, M. D., LONDON. 618. R. Acidi gallici, 3u Acidi sulphxirici diluti, i. 3s9 Tincturse lupuli, '•?'. ,. Infusi lupuli, f-Svj. M. A tablespoonful three times a day. Said by the author to check the waste of albumen, especially in the more acute and recent forms of albuminuria. 350 DISEASES OF THE URINARY SYSTEM. In the Medical Press and Circular (1889) the following prescrip- tions are given as favorably influencing the symptom, albuminuria: 619. R. Sodii phosphatis, Sodii chloridi, Sodii iodidi, aa Sfiss Sodii bromidi, ^1 . Aquse, f-Sxvij. M. Sig. — Four tablespoonfuls in a day in milk. Also 620. R. Tannin, gr- jj Fuschine, gf- ) Extract of cinchona, q- s. M. For one pill. Sig. — One night and morning. NOTES ON REMEDIES. Acidum Bemoicum, Laboulbene (From Med. Faculte de Paris — Roux) em- ploys this substance with considerable effect as follows : 621. R. Acidi benzoici, gr. xv-xxx Sacchari, 3 "j- AqiKE destillatae, Oij. M. Sig. — As a beverage. Acidum Gallicum in doses of gr. x, thrice daily, has been successfully em- ployed. Acidum Tannicum, in from gr. xxx-lx per day, has been advised in the ana- sarca accompanying albuminuria. Antimonii et Potassii Tartras is recommended by Dr. Barlow in the acute forms of albuminuria. He considers it indicated by the nature of the affection, and calculated to equalize the circulation, subdue the inflam- matory action, and restore the functions of the skin. But he does not employ it to the exclusion of other remedies, as moderate venesection, hydragogue cathartics, the warm bath; and the application of large linseed-meal poultices to the loins. Aqua. Dr. W. N. Dickinson, of London, recommends drinking large quan- tities of pure water, as the safest and best diuretic in this disease. (^Medical Times and Gazette, June, 1876.) Arsenicum. In some cases of albuminuria, seemingly dependent on imper- fect digestion. Dr. T. L. Brunton has derived excellent results from Fowler's solution, gtt. iij, with meals. {^Practitioner, June, 1877). Belladonna will, in the opinion of Dr. Harley, prove very serviceable in chronic albuminuria, provided that the kidney has not passed into the degenerative state bordering on fatty degeneration. ALBUMINURIA. 351 Cantharis, internally, has, it is said, been employed with benefit in purely chronic cases, but must be used with great caution. Chloral. Dr. Thos. Wilson says in the Brit. Med. Jour., 1882 : "The atten- tion of the profession does not yet seem to have been generally drawn to the effect of chloral in removing albumen from the urine, and also the existing oedema." He adds some striking cases. Digitalis is indicated where there is cardiac complication, but must be used cautiously. Ergot is prescribed in cases of so-called functional albuminuria, where vascu- lar relaxation is probably the source of the error. Eucalyptus Globulus. In albuminuria and post scarlatinal nephritis. Dr. Wil- liam Anderson, of Brooklyn, has used with good results the elixir and fluid extract of eucalyptus (Proceedings of Kings Co. Medical Society, August, 1879). He expresses himself very decidedly as to the benefit he has witnessed from it. He gives gtt. x of the fluid ex- tract, in water, every four or six hours. Ferri Jodidum is often beneficial, particularly in old, broken-down constitu- tions. Ferri Chloridi Tinctura is one of the most generally useful preparations of iron in albuminuria, possessing diuretic as well as chalybeate proper- ties. Fuchsin, or Rosanilin Hydrochloride, has been found to check the secretion of albumen promptly by M. Bouchut, of Paris (Gaz.des Hop., 1879). He gives gr. j, thrice daily, in aromatic water ; in one case gr. iss daily for five days was followed by complete recovery. Oxygen, in inhalation, has attracted considerable attention, but the results have been unsatisfactory. Potassii Biiartras in acute and chronic cases is an efficient diuretic, gj to aquae Oj. Potassii Sulphas, gr. x-xx, two or three times a day, is said by Dr. Dickinson to be sometimes invaluable as a habitual laxative. Potassii Sulphuretum has been recommended in the following formula, to es- tablish free diaphoresis : 622. R. Potassii sulphureti, gT- v Tincturae guaiaci ammoniatae, f- 3 ss Liquoris ammoniae acetatis, f. § ss Aquae, f-Sj- M. For one dose, to be taken at bedtime, followed by a pint of hot whey. Scoparius. In scarlatinal albuminuria, according to Dr. S. D. Bell (Trans- actions Pennsylvania State Medical Society, 1876), scoparius has in his hands yielded " invariably the most flattering results." He uses it 352 DISEASES OF THE URINARY SYSTEM. in the form of decoction, made by boiling half an ounce of the tops in a pint and a half of water down to one pint. Of this a tablespoonful to a wineglassful was given every four or six hours, according to the age and severity of the symptoms. Sodii Carbonas has been recommended in albuminuria, on the ground that alkalescence is a necessary condition of the blood ; that the free alkali is soda ; that when this constituent is deficient, the result is coagula- tion of blood in the capillary vessels and ensuing inflammation, and the potash or soda (uncombined or as carbonates) taken into the stomach, have the power of rendering the urine alkaline and dissolving fibrine. The following fonnula may be employed : 623. R. Sodii carbonatis, 3''.. Liquoris potassae, f- 3 ij Decocti chondri crispi, f. § viij. M. A tablespoonful every two hours, in milk. Tartrate of iron may be added when ansemia is very marked. BRIGHT'S DISEASE. ACUTE. DR. AUFRECHT, OF MAGDEBURG, who has paid much attention to the pathology of nephritis, advocates most forcibly the adoption of an expectant line of treatment, in which dietetics play an important role. He absolutely discountenances the prescription of diuretic and diaphoretic drugs, and regards it as not good practice to encourage diaphoresis by hot baths or heated air. His plan consists in the administration of neutral salines, as bicar- bonate of soda, which may be replaced by iron in the later stages, when the ansemia evoked by the albuminuria appears. The diet at first must, he says, be wholly vegetable, in the form of vegetable soups, and starch and saccharine foods ; even milk is to be avoided till after the first or the second week of the acute attack. This rigid regimen is necessary to diminish the special function of the kidney — elimination of nitrogenous matters. He quotes LiCHTHEIM and Senator in support of this doctrine, which recognizes in the defective elimination of the kidney a much graver incident than the outpouring of albumen, and which, therefore, emphasizes the neces- sity of reducing to a minimum the ingestion of proteids, AUFRECHT details one case (of scarlatinal nephritis) where suppression of urine BRIGHT S DISEASE — ACUTE. 353 lasted for eighty hours, and where this expectant treatment was fol- lowed by recovery. He mentions another, where -the anuria lasted for fourteen hours; and he asserts that under the diuretic and diaphoretic plan of treatment cases such as these would almost cer- tainly have succumbed. To avoid misconception, we should add that he prescribes a warm bath occasionally in such cases, but never to the extent of inducing profuse diaphoresis, and that he makes no mention of free purgation. PROF. ATKINSON, OF BALTIMORE. (Md. Med. Jour., 1889.) Professor Atkinson in a clinical lec- ture upon Acute Bright's Disease outlined the following plan of treatment as one promising cure in these cases : First a hot vapor bath causing much sweat, and in extreme cases croton oil and elaterium ; but usually the compound jalap powder, consisting of one part of jalap to two of bitartrate of potash, may be used to get rid of the dropsy. Then a remedy may be prescribed which will increase the action of the kidneys without increasing hyperaemia, and this we find in cream of tartar. A pleasant way of administering this is to add two drachms of cream of tartar to a quart of boiling water, and while hot, slice a lemon with skin into the mixture and sweeten to taste. Under such treatment we may hope for a cure of the disease. DR. F. H. WOODS, URALLA, N. S. W. (Australian Med. Gaz., 1891.) Dr. WOODS publishes the records of a case of acute Bright's disease of a rather intense character in which creolin has been used with marked success. He recommends the following method of combination : 624. R. Creolin, 3^ Glycerini, 3vj Aq. aurant. flor., ad f.gvj Mucil. tragacanth, Svj. M. Sig: f. 3j three or four times a day. ALFRED L. LOOMIS, M. D., NEW YORK. This author is convinced that the diaphoretic and cathartic plan of treatment is wrong, and its apparently good results deceptive, and prefers the following : In the acute stage of parenchymatous nephritis, whatever may have been the exciting cause, the patient must be kept in bed, m a 23 354 DISEASES OF THE URINARY SYSTEM. large, well-ventilated apartment, with a temperature of 75° Fah. ; milk should be his only article of diet. Dry cups should be applied over the kidneys, followed by poultices of digitalis leaves ; and the infusion of digitalis leaves should be administered at the rate of half an ounce every two hours, for twenty-four hours, after which it may be continued at longer intervals, so long as uraemic symptoms are urgent. When the flow of urine commences, the digitalis should be discontinued, and diluent drinks freely administered to keep up the diuresis. If renal secretion is not restored within twenty-four hours after the commencement of this treatment, warm baths, or hot-air baths, should be used in addition ; and if the symptoms remain urgent, hydragogue cathartics may be given. DR. HENRY B. MILI.ARD, NEW YORK. This author strongly recommends rest, and the avoidance of highly nitrogenized food. Light animal broths can be given, while oysters and milk may be partaken of freely. Fruits, vegetables and cereals are suitable, while light acid wines are not objectionable. Diaphoresis he considers indispensable, and this he procures by hot air baths. After the bath, he directs affusion with moderately cold water, followed by rubbing with equal parts of alcohol and water, which removes the cutaneous sensitiveness left by the bath. The hot-air bath should be employed daily or on alternate days, until per- manent relief is established or so long as it seems to be of use. He uses the mild chloride and the corrosive chloride of mercury. He gives the former by combining or triturating one part of the drug with ninety-nine parts of sugar of milk, the adult dose being five to ten grains every two or three hours, taking care not to give it in such doses as to affect the gums or relax the bowels. Of corrosive sublimate he usesonepartof the drugto 10,000 parts of sugar of milk; giving eight to ten grains of the triturate at a dose. An important general distinc- tion in the selection of remedies in acute and chronic nephritis, is that whereas a certain class of irritant and stimulating diuretics, as squills, iron, cantharides, turpentine, etc., are sometimes not only useless but dangerous in acute inflammation and recent congestion of the kidneys, in proportion as these conditions recede from an acute or recent character they will be found appropriate and service- able. Cases of chronic interstitial nephritis are cured or recover, but in attempting to accomplish a cure, the practitioner will err if he rely solely upon the wise and appropriate selection of drugs. It will bright' S DISEASE — ACUTE. 355 be fortunate if his patient be so situated that he can have the ad- vantage of rest both mentally and bodily. The influence of the lat- ter has been shown to be of the greatest value in diminishing albu- minous exudation from the kidneys. Much benefit will often be derived by keeping the patient in bed for a few days until the albu- men disappears under appropriate treatment. Silk or all wool un- dergarments should be worn next to the skin the entire year. The milk diet is highly recommended. The best alcoholic beverages are light Rhine wines and light claret. In nephritis accompanying or caused by syphilis, iodide of potassium has proved useful. It is also useful in the nephritis produced by lead poisoning, and in the gouty kidney or the nephritis of rheumatic gout it has served a good pur- pose. Arsenic has sometimes proved beneficial in diminishing al- buminuria and in relieving headaches and nausea. Turpentine might be found of use where there is a feeble state of renal circulation ; it should be given in drop doses, to an adult, two or three times daily. Various saline mineral waters are recommended. An essential fea- ture of chronic interstitial nephritis is that not only are anasarca and oedema usually absent, but the flow of urine is, on an average, in excess of that of a healthy kidney ; consequently the occasions for the use of diuretics are rare. In enfeebled conditions of the system, however, and of the heart, they are sometimes needed; broom, juni- per and simple water increase the amount of urea, and they become endowed with increased value in proportion as there is a diminution of urea in the urine. The carbonate, bitartrate and acetate of potash and urea should be of use as diuretics, when the secretion of urea falls below the normal. DR. JOHN H. MUSSER, OF PHILADELPHIA. (North Carolina Med. Jour., 1891.) This noted practitioner in- sists as the first element of treatment upon rest with protection of the body. He orders extra clothing to be worn, flannel next to the skin, and in addition a flannel bandage about the abdomen and over the kidneys. In children inunction of the skin may be used to pre- vent catching cold. The second element is the securing of the full- est renal function with the least irritation of the renal structure. In acute nephritis the diuretics should be used whose character is the blandest and of the least irritation ; these in general are those act- ing not upon the epithelium, but upon the vascular side of the kidney, for example water. Increasing the volume of blood by the injec- 356 DISEASES OF THE URINARY SYSTEM. tion of large amounts of water, we compel an increased flow of urine, and hence relieve the kidneys. In addition to water, feebly alkaline drinks may be employed. If vomiting is a marked symp- tom, carbonic acid water may be used for its local effect on the stomach. Water, to which a small amount of bitartrate of potas- sium has been added, answers a useful purpose. In the earlier stages the only medicinal diuretics, besides the alkalies, which are of service, are those which act on the blood vessels alone. Promi- nent among these is digatilis, which may be given in several ways. Five drops of the tincture may be given every three or four hours, but a better way is to administer the infusion in tablespoonful doses four or five times daily. If, however, such complications that pre- vent the administration by the mouth, as coma, be present, digitalis poultices (the digitalis leaves mixed with ordinary flaxseed in the form of a poultice) should be applied over the renal region, each poultice six or seven inches square, and changed every four hours. In later stages the relief of constant high arterial tension enters as an indication. Nitroglycerine is an effective drug in this relation, administered one drop of a one per cent, solution. When the urine is scanty and micturition frequent, the use of dry or wet cups is often of service over the renal region ; and dia- phoretics and cathartics may be of great service in relieving over- worked kidneys. Of the cathartics, the severer ones are used only in ursemic symptoms ; ordinarily calomel in small doses frequently repeated {yi to y^ grain every half hour or hour) will cause catharsis, and it also has a diuretic influence, the latter particularly where minute doses are used, as A grain frequently repeated. Diaphoresis is induced by various ways, by such drugs as neutral mixture or spirit of mindererus where it is not of necessity of prompt occurrence, or by jaborandi, where promptness is demanded. Jaborandi may be administered in form of a poultice of the leaves, or in the form of an infusion, if it do not nauseate too much. Much care must be exercised in the use of jaborandi, as it is a very powerful depressant ; digitalis and stimulants should accompany the jaborandi. Half a drachm of the fluid extract of jaborandi with ten drops of the tincture of digitalis may be given together; or the digitalis may be substituted by a half ounce or an ounce of whiskey. Pilocarpin, the alkaloid of jaborandi, is a useful preparation, and may be given hypodermatically, in doses of yi to ^ grain. Finally diaphoresis may be induced by the use of the hot air bath. The BRIGHT'S disease — ACUTE. 357 patient may sit upon a chair and be covered with a blanket, forming a sort of tent ; and then have an alcohol lamp burning under the chair. This will in a short time produce free diaphoresis. If the patient be in bed the clothing may be raised and the hot air be con- ducted by a tube from a lamp. NOTES ON REMEDIES. Acidum Nitricum, alone or in conjunction with the proto or bi-chloride of mercury, has been sometimes found of great service. 625. R. Acidi nitrici puri, f.5s3 Aq. destill., f. §86. M. Three to six diops three times daily. Acidum Phosphoricum, dilute, has also proved of value, especially after the subsidence of the most acute symptoms. Belladonna is recommended by Dr. Harley in acute nephritis. Colchicum, conjoined with magnesia, is useful in the nephritis of gouty sub- jects. Convallaria Majalis. (Lily of the Valley.) Dr. Millard says that conval- laria is likely to be of great use in nephritis with insufficient power of the left ventricle of the heart. Digitalis is highly recommended by Dr. Henry B. Millard. 626. B. Tinct. digitalis, f-Sss Vini scillae, f. S iss Spts. aeth. nit, f-SiJ- M. S. — A teaspoonful every three or four hours. Or: 627. R. Tunip. contus., 3* Pulv. digitalis, Sjj Pulv. scillae, 3) Vin Xerici, 0). Macerate for four days and add : Potass, acetatis, 3iij- Express and filter. S. — A tablespoonful three times a day for an adult. Ergot has been recommended. Euonymus Atropurpureus. Dr. Wm. H. Holcombe, of New Orleans, de- scribes several cases in which he used with perfect success euonymine, the alkaloid of euonymus ("Wahoo"). Enemaia of three or four quarts of water, at blood heat, will, it is said, some- times cut short an attack of nephritis. The first injection usually brings away with it much faecal matter; the second, to be given im- 358 DISEASES OF THE URINARY SYSTEM. mediately after the return of the first, is usually retained without diffi- culty. Helonias Dioica (unicorn plant) has been accorded curative properties. Iron. Dr. Millard says that the chloride of iron has been of invaluable ser- vice to him in aiding to diminish the excretion of albumen, either alone or in combination with digitahs, where there has been feebleness of the heart's action. Jaborandi. Jaborandi or its alkaloid pilocarpine are remedies from which, in nephritis, particularly if dropsy or oedema be present, we should expect to derive benefit. Of jaborandi, the fluid extract is the most reUable preparation ; the average dose to an adult is 30 drops every two hours. Pilocarpine can be given hypodermically in doses of is to nV of a grain, or even, very guardedly, to an adult i of a grain. Nitro- Glycerine is recommended by Drs. Mayo Robson and Roberts Barth- OLOW. The dose is one minim of a one per cent, solution (alcoholic) every half hour. Opium is a remedy of great value, when assisted by diluents, the hip-bath, and large flaxseed poultices over the lumbar region. Scoparius in infusion is of some value as a hydragogue diuretic. Sodium Tannate, in doses of 10 to 20 grains three or four times daily, well diluted with water, has been used to advantage. EXTERNAL REMEDIES. Baths. The hot bath, or the hot hip-bath, is a useful soothing remedy. Counter-irritants over the region of the kidneys have been considered of value. Dry Cupping has been considered beneficial. Local Abstraction 0/ Blood has been thought useful by several writers. Poultices. Large light flaxseed poultices not only afford present reUef, but arrest the progress of the disease. Tiglii Oleum is one of the best hydragogue cathartics which can be given in albuminuria, as it produces copious evacuations with less sickness and discomfort than elaterium. bright' S DISEASE — CHRONIC. 359 BRIGHT'S DISEASE. CHRONIC. ALFRED L. LOOMIS, M. D., NEW YORK. In the latter stages, those commonly known as chronic Bright's disease, the plan of treatment is essentially tonic. Iron and cod- liver oil are the two great remedial agents, and should be daily ad- ministered, if they do not disturb the stomach. Milk should be the principal article of diet, and the patient should seek a warm and equable climate. The milk may be taken cold or hot, from a half pint to a pint at a time. Wine, in moderation, may be taken with the food. No depletory remedies should be employed in this stage, except in times of an emergency, when, from some sudden renal congestion, the remaining healthy portion of the kidney is impaired, and active uraemic symptoms present themselves. At such times, a hot-air bath, hydragogue cathartics, or stimulating diuretics are to be employed, but with great caution. The Revue de Clin, et Therap. (quoted by Univ. Med. Mag., 1 89 1,) publishes the following methods of treatment of Bright's disease : (i) Classic Method. — The climacteric prescription consisted in the avoidance of dampness and sudden changes of temperature. As to diet, rich or irritant articles of food were avoided, as were also eggs. A pure or mixed milk regime was followed, and such articles as wine, whiskey, beer, etc., were entirely prohibited. (2) Senator's Method. — All white meats and pork are allowed, and the use of vegetables and starchy articles of food, fruits, fats and milk advised. SENATOR also recommends the employment of wine mixed with water. (3) Semmola's Method. — ^The author observes the preceding treat- ment, and besides advises the employment of the following solution to be given in the course of the twenty-four hours : 628. R. Potassii iodidi, gr- "^ Sodii phosphatis, 3ss Sodii chloridi, gf- Ixxv-xc Aquae, f-B^x- M. (4) Bamberger's Method. — Besides a milk diet, tonic and ferru- ginous remedies are employed. The author highly recommends the following preparations : 360 DISEASES OF THE URINARY SYSTEM. (I) Pills of perchloride of iron. Of these pills three to six are given per day. 629. R. Ferri perchloridi, gr. J^ Pulveris menyanthe (buckbean), gr. Jj Extracti gentianae, q. s. M. (II) Pills of the sulphate of iron, after Wiethe : 630. B- Ferri sulphatis, Sodii bicarbonatls, aa gr. Ixxv Extracti taraxaci, q. s. M. To be divided into sixty pills, of which three are to be given in the morning and three in the evening. (III) Decoction of cinchona bark. Five drachms of the bark are placed in six and a half ounces of boiling water for a period of half an hour. The decoction is then sweetened with five drachms of the syrup of bitter orange peel. Of this preparation, according to Wiethe, a dessertspoonful can be administered every two hours. J. M. DA COSTA, M. D., PHILADELPHIA. For the treatment of an acute case, following scarlatina : 631. g. Pulveris ipecacuanhae compositi, gr. iij Potassii nitratis, gr. v. M. For one powder. To be taken at night. And, 632. R. Liquoris ammoniae acetatis, f. 3'ij Spiritds setheris nitrosi, TIlxx Synipi tolutani, TUxxxvij Tincturae digitalis, Tl\.ii). M. For one dose, thrice daily. The skin should be made to act freely by means of hot baths and a few drachms of Rochelle salts, administered on alternate days. The diet should be mild and unirritating, all stimulants being avoided. ^33- B- Tincturae ferri chloridi, f. §ss Acidi acetici, f_ 5 35 Mix and add, Liquoris ammoniae acetatis, f § v Teaspoonful thrice daily. This recipe, a modification of Basham's mixture, is useful in chronic Bright's disease, and in all those cases in which the union of a tonic and diuretic effect is desired. BRIGHT' S DISEASE — CHRONIC. 361 DR. N. M. BASKELL, OF MISSOURI. According to this author (Medical and Surgical Reporter, March 29, 1884), mercurials are very useful in acute Bright's disease. He always uses them, and has never yet salivated a patient. His usual plan, if there is much oedema, with impeded heart-action, is to give the following recipe : 634- R- Hydrarg. chlor. mit., gr. ss Sodii bicarb., gr. ijss. M. Ft. chart No. 3. S. — One powder twice a day. In conjunction with this he gives night and morning : 635- B- Potass, bitart., 3i. veljss Jalapse pulv., gr. viij Gambogise pulv., gr. j. M. Ft. chart. No. j. Should this not cause an elimination of the watery elements rapid enough, and there is danger of uremic coma or apoplexy from re- tardation of the blood, he adds : 636. B- Pilocarpi!! muriat., gr. j Sacchari lactis, grs. x. M. Ft. chart. No. x. S. — One three times per day. For the action of the heart and system, he uses the following tonic, varying the ingredients to suit the exigencies of the case : 637. B- Potass, iodid., Tinct. digitalis, Syr. squills, Liq. ammon. acetat, Fl. ext. phytolac. dec, Syr. sarsap. comp. These ingredients, given according to the age and condition of the patient and the effect desired. Under this treatment his acute cases have always improved rap- idly. He does not continue the mercurials long after the dropsy is subdued. But he has frequently found it necessary to return to them when the symptoms manifested themselves, and always with benefit. In the chronic condition, the most that can be done is to keep the bowels regular and build up the system with tonics. For this pur- pose, he finds nothing better than the comp. jalap powder, the al- terative mixture mentioned above, and a teaspoonful of the ferri 362 DISEASES OF THE URINARY SYSTEM. nitrogeniz. comp. This to be taken three times per day, after meals. Occasionally he gives the powders of pilocarpine three or four days in succession. DR. AUSTIN FLINT, OF NEW YORK. (N. Y. Med. Jour., 1889.) This physician has used with benefit the following complicated formula in chronic Bright's disease where there was evident hsemic alteration from the pallpr of the patient. It is offered with a view, of affording the various salines of the blood which are possibly deficient in cases of this disease. It was sug- gested by the valuable effects obtained by Memminger from the use of chloride of sodium in these cases : 638. R. Sodii chloridi (C. P.), 5iij Potassii chloridi (C. P.), gr. ix Potassii sulphatis (C. P.), gr. vj Potassii carbonatis (Squibb), gr. iij Sodii carbonatis (C. P.), gr. xxxvj Magnesii carbonatis, gr. iij Calcii phosphatis precipitati, 3 ss Calcii carbonatis, gr. iij Fern redact! (Merck), gr. xxvij Ferii carbonatis, gr. iij. M. In capsules, No. Ix. Sig. — Two capsules twice daily after eating. DR. FELIX VON NIEMEYER, PROF. UNIVERSITY OF TUBINGEN. The loss of albumen from the blood being the immediate cause of most symptoms of the disease, the most important task of the phy- sician is to cover the loss of albumen by a diet rich in protein sub- stances and by appropriate medication. Soft-boiled eggs, milk, strong meat broths and roast beef, in as large quantity as the patient is able to digest, are probably the best preventives of the dropsy. Besides this, a moderate quantity of beer or good wine should be prescribed, as by the use of these the waste of tissue is retarded and nutrition promoted. Quinine and iron are the most suitable medi- cines. Our author has obtained most brilliant results, where all other treatment has failed, by putting the patient upon an exclusive diet of milk. They took no medicine whatever, but drank five or six pints of cow's milk daily. After the " cure " had been continued in this manner for about five weeks, some of the patients, who, prior to the treatment, had been in the most wretched condition, had got rid of their dropsy, recovered an appearance of health, and regained so much strength as even to be able to perform hard labor. BRIGHT'S disease — CHRONIC. 363 If the above measures fail in averting or allaying the dropsy, active diaphoresis is strongly to be recommended. Patients in an advanced state of dropsy often rid themselves of it completely in a few weeks by the daily use of a hot bath, of a temperature of 80° to 100° F., followed by sweating for two hours in woolen blankets. Debilitated patients sometimes, however, suffer so much from this treatment as to compel its discontinuance. Whatever the theoretical objections to the employment of diuretics may be, yet, in desperate cases, recourse should always be had to them. Squills and other stimulating diuretics must not be employed without the utmost caution. But there are certain salts, particularly cream 0/ tarfar, which are decidedly beneficial in their effects. The free use of buttermilk, conjoined with the employment of cream of tartar and small doses of Dover's powders, will prove serviceable. The drastic cathartics should only be resorted to in cases of ex- treme need, since the patient is liable to be affected by them, and since, by their persistent use, the digestion becomes impaired. Those most frequently employed are colocynth and 639. R- Elaterii, gr. ^-ss. For one dose, as occasion requires. FRANCIS SIBSON, M. D., D. C. L., ETC., LONDON. In a review of the therapeutics of Bright's disease (British Medical Journal, February, 1877), this eminent practitioner lays down the following principles : The employment of narcotics in any form, in cases of Bright's dis- ease, directly adds poison to poison, of the like kind, and narcotics are, therefore, to be strenuously forbidden in every case of Bright's disease. This -axiom does not rest upon physiological considera- tions only, which, if rightly interpreted, never can lead us wrong, and are, therefore, the true peculiar guide in the treatment of dis- ease ; for we have, also, direct evidence of the deadly effect of nar- cotics in Bright's disease. Death has occurred again and again, from the subcutaneous injection of moderate doses of morphia m those affected with Bright's disease. Neither opium, chloral, chlor- oform, hyoscyamus, belladonna, nor stramonium, should ever be exhibited. For the extreme restlessness, we must give the dromides of ammo- nium and potassium, and Hofmann's anodyne ether; and a few 364 DISEASES OF THE URINARY SYSTEM. drops of ether may safely be inhaled, as well as in the cases with excessive distress of breathing. The bromide may be pushed to large and extreme doses, and their effect ought to be carefully watched, so that if drowsiness be induced by it, in addition to the poison of the disease, iodide of potassium, coffee, and rousing and anti-narcotic means, may be freely resorted to. The danger to combat is from the narcotic poison in the blood, which is not eliminated by the kidneys. To meet this indication, the patient should be encouraged to take exercise in the open air, and to keep his faculties active ; they should be roused by strong coffee and tea, by the society of friends, and by the business of every-day life. When the respiration is greatly distressed and suspended by turns, the proper treatment is steadily to eliminate the poison, and, at the same time, to rouse the powers, either by a small quantity of tea, strong coffee or whiskey; by stimulants externally; and by maintaining the power by means of iron and food. These cases are very formidable, and generally die; but not unfrequently, the patients recover from the emergency, and even live for years. When coma and sopor are present, the hot-air bath and external stimulants, the strongest coffee, and a treatment analogous to that of deep opium poisoning, but differing according to the necessities of the case, must be pursued ; and this sometimes succeeds. DR. BEVERLY ROBINSON. (Medical Record, 1889.) Dr. ROBINSON divides chronic Bright's disease into the three well-recognized forms : i . Chronic parenchy- matous nephritis ; 2. Lardaceous disease of the kidney ; 3. Intersti- tial nephritis. I. The first form may begin insidiously as a chronic disease, or may follow an acute affection. In either case the same rules of diet may be applied. As food an exclusive milk diet is generally con- sidered to be the best, and the author would favor its employment, because it is easily assimilated, gives sufficient nourishment, pro- duces less urea, and flushes the kidneys with a large amount of fluid. When milk cannot in any way be taken, we are obliged to resort to broths and light farinaceous foods. As a beverage the author pre- fers pure spring water, of which several pints a day should be drunk. Pure or mildly alkaline water in large quantities is an excellent un- irritating diuretic. When milk is not well borne alone, it may some- BRIGHT'S disease — CHRONIC. 365 times be taken mixed with lime water, carbonic water, Vichy, etc., or as koumiss or peptonized milk. When milk is used pure, it had better be unskimmed, unless it produces digestive troubles, in which case it is best to skim it. From two and a half to four quarts are sufficient to prevent bodily loss. As a result of clinical experiments instituted by him, and which he details, and from the experience of others, the author believes that a milk diet notably diminishes the amount of albumen excreted by the kidneys. After a time, an exclusive fluid diet may be pro- ductive of harm, by causing an over-dilution of the gastric juice, and too great an excretion of urine, or the symptoms of anaemia and exhaustion. In such cases, especially if the amount of albumen be small, the exclusive milk diet may be supplemented by a certain amount of farinaceous or vegetable food. If even this diet becomes objectionable, a small amount of broiled or roasted meat must be allowed daily, taken at an early dinner. Alcoholic stimulants throw more work on the kidneys, and increase the amount of albumen ex- creted. They are, therefore, to be avoided, except when called for by certain symptoms, as exhaustion, or the profound cerebral anaemia which so often accompanies uraemic symptoms. 2. The dietetic treatment of lardaceous disease of the kidney de- pends somewhat on its cause. If it be phthisis, the diet is that ap- propriate for this malady, without special reference to the renal dis- order. When the disease which caused the renal changes has dis- appeared, the diet should be that advised for chronic parenchyma- tous nephritis. 3. In the dietetic treatment of this form of nephritis, we must en- deavor to prevent the accumulation of urea in the blood, and to make up for the loss of albumin. It is not possible to prohibit all nitrogenous food, but the amount allowed should be very small. Milk and cream should be given in abundance, and the other articles of the diet supplied from the vegetable kingdom. In ad- vanced cases, an exclusive milk diet must be employed, and the milk may be diluted with Vichy, if necessary, to render it more palatable. Alcoholic stimulants should be avoided as far as possible, except sometimes in the treatment of uraemia, as stated above. PROF. DUJARDIN-BEAUMETZ. (Weekly Med. Rev., 1890.) In a clinical lecture by DUJARDIN- Beaumetz, he says that in renal insufficiency it is of the greatest 366 DISEASES OF THE URINARY SYSTEM. importance to know the amount of solid ingredients contained in the urine. The quantity of urine secreted is a matter of secondary- consideration. If the solid ingredients, and especially the nitro- genous substances, are found in diminished quantity for any length of time, we have renal insufficiency. For all practical purposes it is sufficient to make an approximate calculation of the amount of solid substances. The amount of albumen contained in the urine is not of very great importance ; in the worst cases a hardly appreciable quantity of it may be found, while a considerable quantity, seventy- five grains and even more, is sometimes found in the urine of pa- tients in a satisfactory state of health. Our whole attention should be given to the quantity of solid substances, and to the presence of toxic materials. When there is a deficiency of solid ingredients in the urine, we must, in the first place, endeavor to hasten the elimination of toxic principles accumulated in the system ; and secondly, to reduce to a minimum the amount of toxic material introduced with the food, or the result of assimilation, or of mal-assimilation. To meet the first indication, purgatives, diuretics and sudorifics may be employed. The belief was formerly entertained that in chronic nephritis the use of diuretics might increase the congestion by throwing more work upon the kidney, and in that way even aggra- vate the disease ; but it is now generally conceded that it is rational to employ diuretics in this condition. The special class of diuretics, which induce diuresis by increasing arterial tension must be used. Amongst these, preparations of digitalis are the best. Strophanthus has the great advantage of producing an immediate action. It may be given in all cases where the pathological changes in the kidneys are not too far advanced, for in order to enable this class of diuretics to act, there must be a certain amount of healthy tissue remaining in the kidneys ; they will not produce any eflfects if the heart pre- sents a condition of complete sclerosis, or if the kidneys have under- gone radical changes. Sparteine, adonis and convallaria are of minor importance. Cafi"eine has the great advantage that it can be given hypodermically. A syringeful of the following solution may be used, repeated two or three times a day, as needed : 640. R. Caffeine, Benzoate of soda, ai 5ss Boiled water, f_ 2 js^^ BRIGHT'S DISEASE — CHRONIC. 367 Theobromine is similar in its action to caffeine. Kola also pos- sesses decided diuretic virtues, no doubt on account of the caffeine and theobromine which it contains. An infusion of roasted kola nut may be used ; it is prepared like coffee. The diuretic action of lactose and glucose has been demonstrated beyond a doubt. Ger- main See used milk sugar in twenty-five cases of renal insufficiency, administering about three ounces per day, dissolved in one-half gal- lon of water ; the effects were remarkable. The author used glu- cose instead of milk sugar with equally good results. If there is vomiting or a repugnance to sugar, a solution of either milk sugar or glucose may be injected into the rectum, as these solutions are readily absorbed by the large intestine. The use of purgatives is also of much importance; all patients with urinary insufficiency ought to have at least two or three liquid stools every day. To get this result all the different laxatives may be made use of, even dras- tic purgatives may be given, when there are symptoms of uraemic poisoning. At last the cutaneous surface ought to be made to thor- oughly perform its functions. Daily sponge-baths of lukewarm water with the addition of cologne or other aromatic alcoholic liquid may be given, followed by energetic frictions. But often, in spite of all efforts and the use of the most active eliminating agents, we are powerless to rid the system of toxines in sufficient quantity to prevent symptoms of poisoning. Even then we need not despair: inhalations of oxygen may be used; they act by heightening the vitality of the red-blood corpuscles, by causing increased combustion, and thereby permitting the destruction or transformation of some of the toxic principles. Or blood-letting, either local or general, preferably the latter, may be resorted to ; a certain quantity of poisonous materials accumulated in the blood may be eliminated in this way. As to the amount of blood ab- stracted, we must be guided by the resisting power of the patient; when there is great weakness, transfusion must be thought of. All symptoms of a serious nature supervening in the course of urinary insufficiency, are the result of the accumulation of toxic materials in the system. These have three different sources. Some originate in the physiological processes taking place in the organ- ism ; others are the result of faulty digestion. Still others are in- troduced with the food, meat containing a number of cadaveric al- kaloids. The therapeutic measures adopted must correspond to these different sources. Fatigue and severe physical as well as m- 368 DISEASES OF THE URINARY SYSTEM. tellectual exertions must be avoided, the digestive functions must be regulated, abnormal fermentation combated by intestinal antisepsis, for instance : 641. R. Salicylate of bismuth, English magnesia, Bicarbonate of soda, of each, 5^iss. M. Divide into thirty wafers. A chiefly vegetable diet must be adopted, consisting of milk, which may be taken in any shape or form, cream and custards, also cheese, not in a state of decomposition ; eggs, farinaceous foods, beans, lentils, chocolate ; green vegetables and fruits must be well cooked. Bread should be well baked or toasted. If meat is al- lowed, it must be well done, as cooking destroys the elements of putrefaction and fermentation. Game, oysters, fish, old cheese, must be absolutely forbidden, because they all contain ptomaines. Beer or malt extract may be taken, but no liquors or wine. This diet is applicable only in the less serious cases ; when symptoms of poisoning threaten, an exclusive milk diet must be adhered to. BELLEVUE HOSPITAL, NEW YORK. The following is a summary of a plan of treatment recommended at Bellevue Hospital, New York : Diet. This class of patients should abstain, as much as possible, from meat. The opinion has been expressed that the excessive animal diet accounts for the great prevalence of the disease in America. Milk should be substituted for meat, and should be asso- ciated with lime. Butter may be used ; eggs, if they agree, and fresh fish in the morning. Fried fats should be carefully excluded, but cream may be taken without stint. Vegetables and fruits are always good, but those should be selected which contain the least amount of woody fibre. Rice and potatoes, therefore, may be used ; but asparagus, turnips, cabbage, and notably beans, which contain woody fibre in large quantities, should be assiduously avoided. Onions may be eaten with impunity, and are rather beneficial. For the An M; Ter in die, ex aq. Diuretics may sometimes be employed, with good results, by the en- dermic method. Skimmed Milk. From six to eight pints should be used daily, and the diet restricted to it. The good effect should be seen inside of a week. EXTERNAL MEASURES. Camphorated Vapor Baths. At the Queen's Hospital, Birmin^am (England), these baths are used with good effects for the relief of Bright's disease. They are also said to produce very free perspiration, and axe given every evening, in the following manner : The patient is seated upon a cane-bottomed chair, with a large blanket pinned around his neck ; half an ounce of camphor is placed upon a tin plate, under the chair, and above the flame of a small spirit-lamp, by the heat of which the camphor is slowly vaporized. This plan of treatment is also employed in some cases of convalescence from acute or sub-acute rheumatism, when the action of the skin is defective, and when some pain and stiff- ness of the joints remain. DIABETES INSIPIDUS, POLYURIA, POLYDIPSIA. 373 Scarifications and other counter-irritation over the region of the kidneys, as capsicum plasters, or even a flannel bandage constantly worn to pre- serve an area of warmth over these organs, often prove of marked serv- ice in renal affections, chronic as well as acute. DIABETES INSIPIDUS. POLYURIA. POLYDIPSIA. PROF. A. BOUCHARDAT. The Hygienic Treatment. This is always essential to success. The excretions should be regular and complete ; the bladder thoroughly emptied every six hours at least. Exercise should be taken regu- larly, and to a considerable amount ; chilliness, after it, being care- fully avoided. A sponge-bath should be taken every morning, fol- lowed by long and quick flesh rubbing. The following may be added to the bath, to increase the action of the skin : 644. R. Potassii carbonatis, Sij's Essentiae lavendulse. gtt. xxx Tincturae benzoin., f. 5 j- M. The diet is of the utmost importance. Food should be taken sparingly, well cut, and thoroughly masti- cated. Tomatoes should be forbidden, and also asparagus and beans, if their use cause renal pain or slight deposit in the urine. Meats of all kinds may be allowed, but only moderately ; still more sparingly must we allow eggs, fish, lobsters, shrimps, shell-fish and old cheese ; milk is often useful. Almost all seasonable vegetables are good, particularly spinach, endive, lettuce, artichokes, celery, carrots, parsnips and potatoes. The last-named are useful, and should take the place of some of the bread with the meal. Radishes may be advantageously used daily. The daily use of cresses or salad is indicated. All fruits, if the stomach bear them well, may be served daily. Olives, almonds, walnuts, hazel-nuts, and pistachio nuts, must be served moderately. Good chocolate is allowable. If coffee provokes urinary secretion, it may not be advised. Brandy and liquors should be avoided ; very little beer allowed ; and for alcoholic drink, a light white or red wine, diluted freely with water. White, sparkling wines are contra-indicated, as well as gaseous 374 DISEASES OF THE URINARY SYSTEM. drinks, as soda-water. On waking, going to bed, and with meals, sufficient watery drink should be taken to give about three pints of urine. This watery drink should consist of pure water; or better still, a litre of water in which is dissolved one or two teaspoonfuls of powdered Seignette salt (tartrate of potash and soda). DR. C. P. B. CLUBBE Recommends the use of electricity. He reports the case of a woman who passed from eighteen to twenty pints of urine per diem. It was light colored, very low specific gravity, and contained no sugar. All the drugs recommended for diabetes were tried, without result. She was then ordered electricity (faradism), to be applied over the region of the kidneys every day for about twenty minutes at a time. Under this treatment she improved very much, and the improve- ment continued. DR. J. M. DA COSTA, OF PHILADJiLPHIA. One of the very few cases of complete cure from this generally fatal disorder, is reported by this author in the Transactions of the College of Physicians of Philadelphia, 1875. The treatment was by ergot, f.5j of the fluid extract being given at the outset thrice daily, increased, in a few days, to f..5ij, three times a day. The cure was accomplished in about two months, and was permanent. Dr. Da Qo%tk (Med. Register, 1889) more recently has expressed himself upon this point in much the same manner. He stated in a lecture before his class that in true diabetes insipidus he has usually obtained his best results from the use of ergot. In the volume of the Transactions for the following year, Dr. James Tyson reported a case in which he administered ergot with temporary benefit, but not with actual success. He then prescribed gallic acid (gr. xv) four times a day, with rapid and he believed permanent improvement. DR. OPITZ, DRESDEN. (Therap. Gaz., 1889.) Among the late drugs which have been employed in the treatment of polyuria, antipyrin has apparently accomplished more remarkable results than any other. Opitz, of Dresden, has made a careful study of its value in three cases of long standing (one of twenty years' duration). The results were imme- diate, and all traces of the condition disappeared— in one case per- DIABETES INSIPIDUS, POLYURIA, POLYDIPSIA. 375 manently, in another for a long time after the withdrawal of the remedy. In the third case the amount of urine promptly rose again to its former amount upon the withdrawal of the antipyrin, to fall again upon the renewal of the drug. The author recommends that in the beginning of the treatment about thirty grains should be given, increasing this by fifteen grains daily until about a drachm and a half be given daily in divided doses, or the amount of urine fall. After about eight days the treatment should be relaxed, and then omitted to see if the result be permanent. PROF. A. TROUSSEAU, PARIS. In some instances. Professor TROUSSEAU derived advantage from valerian; it should be administered in full doses, extracti Valerianae; gr. XV, thrice daily. Dr. Bouchard considers that the action of valerian is to spare waste of tissue ; and in support of this view, he mentions that cer- tain Indians of Lower California and Mexico are accustomed to go through a course of it for a month before they enter upon a severe expedition, so that they may be better able to bear fatigue. He gives it in frequent small doses, and gradually increases the amount taken, until he has, in some cases, reached a dose of thirty grammes in twenty-four hours. (Medical Times and Gazette, May 23d, 1874.) DR. HENRY KENNEDY, LONDON. This gentleman (Practitioner, February, 1878,) relates five cases all substantially cured by dilute nitric acid. He commences with f5j to a quart of water, this amount to be taken in divided doses daily ; and if necessary increases the acid to the daily amount of of.vj. He has had no failures with it. • PROF. WESTPHAL. (Berlin Klin. Woch., 1889.) A case of polyuria is reported in the journal referred to, from ErUs Clinic, in which a young woman was the subject, passing enormous quantities of urine and constantly thirsting for water. Noting the fact of the existence of perspiration with the polyuria, the fact that upon enforced abstinence from water the polyuria disappeared, the fact that micturition apparendy was dependent in time upon drinking water, and the fact that the total quantity of urine did not represent the total quantity of water m- 3/6 DISEASES OF THE URINARY SYSTEM. gested, the diagnosis of a nervous polydipsia was readily made. In this case relief was promptly obtained, and may be expected in sim- ilar cases from the use of bromides and valerian to calm the sensory fault of excessive thirst. NOTES ON REMEDIES. Antipyrin in large doses (p. 374) has apparently a decided effect over dia- betes insipidus. Atropia has been tried, but though it diminishes the urine, the thirst contin- ues. (Dr. Renduer, France.) Auri Chloridum is considered by Baktholow to be a promising remedy. The dose is from is to -h grain. Belladonna. Dr. John M. Scudder, of Cincinnati (Eclectic), claims that belladonna merits the name of a specific in this disease. In some cases, however, the remedy, to produce any effect, must be administered in such doses as to be dangerous. Creasotum has been employed with some advantage. Ergota has been highly praised by Dr. Da Costa (above). Gallicum Acidum, combined with opium, is spoken of by Dr. H. C. Wood, as the most generally successful remedy in this disease. Jaborandi. This drug was used in this disease by Professor T. Laycock, of Edinburgh, in 1875. Its efficacy is doubtful. Muscarine has been used with apparent success. Nitricum Acidum. Almost a specific (see above). Opium, with tannic or gallic acid, is valuable. Oxygen is indicated, and has been successfully employed. The internal ad- ministration of chalybeate medicines, or mineral waters, should ac- company the inhalations of oxygen. Pure oxygen is not necessary ; an admixture with three parts of air will suflSce, and the inhalation should be made morning and evening. Rhus Aromatica has been introduced by Messrs. Parke, Davis & Co., De- troit, on the recommendation of a number of practitioners of its effects in checking polyuria. The dose is f gss-j of the fluid extract in sweetened water, several times a day. It is stated to act prompdy in arresting the excessive secretion of urine. Valeriana was introduced by Trousseau. Its effects are valuable. (P. 375). The doses must be large and increasing to 3J-ij of the powder thrice daily. Failures are attributed to its too timid use. DIABETES MELLITUS. DIABETES MELLITUS. 377 DR. AUSTIN FLINT, JR., OF NEW YORK. This author gives his treatment in a paper before the meeting of the American Medical Association in 1884. He places almost sole reliance on the use of a diet from which starches and sugar have been excluded. This should be carried out absolutely. Sys- tematic daily muscular exercise should be enforced, but fatigue should be scrupulously avoided. All alcoholic excesses and the use of sweet fruits must be avoided. In cases where the sugar persists, he uses a solution of the bromide of arsenic, in doses of three drops three times a day. This may be continued for weeks or months without unpleasant effects. He continues the rigid diet for at least two months, even in the mildest cases. The return to ordinary diet must be gradual, and the urine during this time should be examined for sugar every five or six days. PROF. DUJARDIN-BEAUMETZ. (La. Med. Mod., 1890). Before the last Medical Congress, that at Berlin, this noted physician outlined the following plan for the cure of the diabetic. He recognizes three forms of diabetes : a mild variety yielding readily to anti-diabetic diet; an intermediate form in which the sugar in the urine is decidedly diminished by medicinal treatment, but never entirely disappears ; and a severe form, in which little or no influence is manifest from the use of medicines. He looks upon the dietetic treatment as the most important. He does not insist upon the absolute fatty and meat diet so widely employed ; but permits a small amount of bread, preferably crust. He forbids all fruits and milk because of the sugar in these substances. Alco- holic liquors and strong wines are prohibited, as well as malt bever- ages. Only wine diluted with water may be allowed. He recom- mends the use of tea and coffee and the use of saccharin as a means of sweetening. He does not regard it proper to continue a strict anti-diabetic diet for a great length of time, but believes that after the first few months the rigidity of the treatment should be relaxed. Alkaline waters, as those of Vals or Vichy, are often of service; and light gymnastic exercise and walking should be ordered. The skin is to be kept clean by frequent bathing, and out-of- door life is to be urged upon the patient. Inhalations of compressed 378 DISEASES OF THE URINARY SYSTEM. air or oxygen, warm baths and massage afterwards, are measures to be considered in this or that case. Where there is a decided neu- rotic element in the case, the bromide of potassium may be em- ployed with benefit very frequently ; and in many cases alkalies, as the carbonate of lithium and arsenic, are of good service: Martineau, who follows much the same plan, prescribes 'in the following manner: In a glass of Vichy (Hauterive) a packet of the carbonate of lithium containing about eight grains is dissolved, and then about three drops of Fowler's solution added. Such a dose is to be taken twice daily. DR. W. MiJLLER, The assistant of Prof. ECKSTEIN in the clinic at Kiel, has pub- lished some important observations on the use of salicylate of soda in the treatment of diabetes. It appears that full doses of the salt cause the sugar to disappear entirely, but this is not a permanent result, for, after a while, the sugar returns. A very great tolerance of the remedy exists in this disease, and large doses may be taken with impunity. BoucHARDAT, in commenting on these observations, states that he has not had good results from this treatment. Bar- THOLOW concludes, however, that since the remedy is well tolerated, and during its exhibition in considerable doses the sugar disappears, it may be used with advantage at critical times to stop the waste. PROF. A. BOUCHARDAT, PARIS. The Dietetic Treatment. This is indispensable to success. Some writers are exceedingly stringent, but M. BouCHARDAT has proved, by the comparison of the articles of food which a diabetic may take without prejudice, that it is quite possible to keep up a sufficient degree of variety in the character of the meals. The list of articles which it permits is about as follows : All sorts of meat, roasted, stewed, and even dressed with spices, but not with flour ; fresh-water fish and marine fish, in eating which the want of bread is less felt than in eating meat ; oysters, mussels, crabs, lobsters, etc. ; eggs in all forms known to the culinary art ; rich, good cream, but no milk ; of vegetables, spinach, artichokes, asparagus, green beans, the dif- ferent varieties of cabbage; of the salads, water cresses, endives, lettuce ; of fruits, strawberries and peaches. Although the loss of sugar is augmented by a very free supply of liquid, and decreased DIABETES MELLITUS. 379 by a prevention of it, yet it is not advisable to forbid the patient to quench his thirst. J. M. DA COSTA, M. D., PHILADELPHIA. 645. R. Pulveris opii, gr. ss. R)r one pill, thrice daily. The Opium treatment. Dr. Da Costa has found to be productive of the most good in his hands. He cannot explain the rationale, but he does know that it has the most influence in lessening the thirst, the excretion of sugar, and the general waste of flesh. The only objection to its use is the risk which is run of accustoming the patient to taking this powerful drug. 646. R. Ammoniae carbonatis, Sij-iv Aquae cinnamomi, f. §vj. M. A tablespoonful three or four times a day. This, in addition to a moderately re- stricted diet, forms a very good treatment. 647- R- Tincturae Jerri chloridi, gtt. xx-lx. For one dose, in water, thrice daily. This will often do good when nothing else proves of service. The pepsin and rennet treatments amount to nothing. Dr. Da Costa has tried them faithfully, and merely lost time. Diet. Although substances containing a great deal of sugar, and still more those containing a great deal of starch — ^which is readily converted into sugar — are poisonous to diabetic patients, yet it is not advisable to put them on a strictly animal diet. Such a regimen is irksome in the extreme, and will not be followed out. After all, it is not the saccharine substances which go into the body that cause diabetes ; they merely add to it. It is simply impossible to ai'oid giving food capable of being converted into sugar. Bran bread is perfectly unobjectionable ; but a small quantity of ordinary bread should be permitted. Cakes made from almond-flour are favorites with English physicians. Fruits should be interdicted, and potatoes sparingly used. Bran-baths (two or three handfuls of bran in the bath) are very serviceable in relieving the dryness of the skin, which is so trouble- some. 648. R. Infusi cascanllse, Oj. A wineglassful two or three times a day. 38o DISEASES OF THE URINARY SYSTEM. The use of this light bitter lessens the thirst. Of course, water must be allowed beside ; but the infusion will take the place of a good deal of water. PROF. S. D. GROSS, M. D., PHILADELPHIA. A very successful treatment suggested by this eminent surgeon is recorded in the Medical and Surgical Reporter, August S, 1 871, and March 16, 1872. The drugs used are opium, tannic acid, and ergot internally, and the application of ointment of veratria to the spine. The following prescriptions may serve as illustrations of the manner in which they may be used : 649- R- Acidi tannici, gr- ^ Opii pulveris, gr. ss. M. To be taken three times a day, between meals, and tincture ergotEe, f. 5 j. in water before each meal. 650. ]J. Veratrise, 3j Unguenti cetacei, S j. M. For an ointment. A piece the size of a cherry, to be well rubbed along the spine morning and evening. The patient should be directed to abstain as much as possible from animal food, to confine himself to a simple vegetable diet, and to procure lager beer or ale to drink instead of water. If either of these becomes nauseous, he can use weak tea or whiskey and water. The tannic acid should be increased gradually until twenty or thirty .grains, three or four times a day, are administered. The quan- tity of opium and ergot need not, however, be increased in like pro- portion. The combination may be : ^5'- R- Acidi tannici, 9j • Opii pulveris, gr. j Tincturse ergotae, f.3iij- M. This quantity three or four times a day. Under the judicious use of this treatment, even severe cases of this very grave disease have recovered in three or four months, and have remained free from relapses. DR. J. HOAG, INDIANA. This writer claims, in the Journal of Materia Medica, September, 1874, to have achieved uniform success with the following treat- ment : The patient is forbidden all fruits and vegetables save bread of unbolted wheat flour, and this in the most limited quantities. DIABETES MELLITUS. ,81 Tea, coffee, liquors, and all drinks except pure water and milk di- luted with lime-water at meals, are also forbidden. The diet should be fresh meats, cream, cheese, butter, soft eggs, fish, oysters and small quantities of bran bread. The entire body is sponged daily with an alkaline bath, and the following ordered : 652. R. Antimonii sulphureti, a: Pulveris ipecacuanbae et opii, a;; Ammonise carbonatis, g: Pulveris opii, gr ^ jj_ Make twenty powders. One to be taken morning and night Also: 6S3- H. TinctUHE cinchonse, f.|j Tincturse ferri chloridi, f. 5iv Tincturse digitalis, f'g; Spiritds lavandulae compositi, f. §j. jj. A teaspoonful daily, at noon. THE MILK DIET TREATMENT. This is either absolute gr modified. Dr. A. S. DONKIN, of Dub- lin, (Dublin Journal of Medical Science, November, 1875,) prefers the former as the only one of real value. He uses skim-milk, and his rule is that the skm-mWV. regimen must be exclusive ; that the quantity of skim-milk — properly prepared by the care/ul removal of the cream — beginning with four, five, or six pints on the first day, must be increased more or less gradually, according to circumstan- ces, to eight, nine, ten, eleven, or twelve pints in the twenty-four hours, according to the age, sex, size, and condition of the patient. No rule as to quantity can be laid down to suit individual cases ; it must be regulated to suit the requirements of each, but in no instance should it exceed twelve pints. Not more than seven or eight pints should be taken in the natural fluid condition. When a larger quantity is necessary, the surplus should be made into curd by the essence of rennet, and taken at separate meals. The skim-milk may be taken cold, or warmed to a temperature of 100° or so, but it must not be boiled, because a temperature of 212° alters the physi- cal properties of caseine. and greatly impairs its therapeutic prop- erties. The specific gravity of the skim-milk used should never be below 1035 ; that of the best quality is 1040. The daily allowance must be divided into regular meals. The constipation which this diet generally produces must be carefully remedied by the frequent administration of castor-oil, or of some mild saline aperient. The 382 DISEASES OF THE URINARY SYSTEM; author does not parade this method of treatment as a panacea ; his experience of it has led him to the conclusion that if there is no progressive reduction of the specific gravity of the urine and of the sugar it contains after the expiration of a week (all rules having been observed), it may as well be discontinued. On the other hand. Dr. GEORGE W. Balfour gives pure milk. From two to three months is the period usually stated as sufficient to cause the complete disappearance of sugar from the urine ; and then the diet may, if desired, be rendered more solid by the de- traction of some of the milk, and the addition of butchers' meat and green vegetables. It is doubtful, however, whether diabetic pa- tients, even though apparently cured, can ever return to ordinary diet. Present experience of such cases is too limited to afford any data at all in regard to this. When the milk diet is employed in the cure of other forms of ill-health, it is often conjoined, after the first few days, with a small amount of solid food ; and what such patients relish most is plain bread with salt, or a salt herring, the mawkish sweet taste of milk inclining them this way. In diabetes, the thirst present usually makes it better to give the patient his full allowance of milk, and let him divide it over the day as he pleases. NEW REMEDIES. Jambul, a recent addition to the physician's armamentarium, has been employed in a large number of cases, and has very frequently been followed very promptly by a diminution and often complete disappearance of sugar from the urine (vid. Centralbl. f. Klin. Med., 1889; Bull. Gen. de Therap., 1890, etc.). The best results are ob- tained in the form of medium intensity ; and the best method of administration is the exhibition of the fluid extract, or of the pow- dered seeds (gr. v-x). It is supposed in some way to prevent sac- charification of the starchy foods in the economy, and is also said to have the same action on the vasomotor centres as the bromides have. Strychnia is highly commended by the practitioners of the dosi- metric school, preferably in the form of the arseniate of strychnia, in doses of gr. i^-i^. Iodoform and lodol are said to have shown excellent results in diabetes by Cerna (Med. News, 1890). Suiphonal is mentioned by Casarelli (Jour, de Med. de Paris, 1890) as favorably influencing diabetes, diminishing the glycosuria DIABETES MELLITUS. 383 as well as the polyuria and the thirst. The author recommends that it be given at first in doses to the amount of six or eight grains a day, increasing it to forty or fifty grains. The favorable influence of the medicine is seen equally with a mixed or absolute meat diet. Antipyrine in the hands of this writer does not prove so valuable. Pancreatin has been suggested by 'LE.¥WE(LyonMcdicale, 1890), following the line of research instituted by Minkowski and Mehr- INGin the production ofdiabetes by the removal of the pancreas. The suggestion has not, however, been sufficiently followed to permit of a decision. Pilocarpine has also been used for the purpose of stim- ulating the pancreas, under the idea that a pancreatic lesion inter- fering with the pancreatic function underlies at least one form of diabetes — the wasting variety. NOTES ON REMEDIES. Alkalies and Alkaline Waters have, according to Professor Seegen, proved themselves the best remedies in diabetes — the natural waters, such as Carlsbad, in Europe ; in the United States, Bedford Springs, Perry Springs, Congress Springs, Bethesda or Waukesha, etc. Ammonii Carbonas is regarded by Dr. Barlow ( Guy's Hospital Reports, vol. x), in doses of gr. v-viij, with a few drops of tincture of opium, in a light, bitter infusion, every six hours, as a most efficient remedy. Ani- mal food, together with cruciferous vegetables, as greens, brocoli, tur- nip tops, etc., should, at the same time, be freely taken. Ammonii Citras, conjoined with the use of Dover's powder or ipecacuanha, is considered by Dr. W. Prout as one of the best of diaphoretics in diabetes. Ammonii Phosphas is recommended by Dr. Basham {British Medical Jour- nal, April 10, 1869), combined as follows : 654- R- Ammonii phosphatis, Ammonii carbonatis, aa gr. x Spiritus ammonite aromatici, n^xxx Aquse, f-SJ- M. Add this to the juice of a fresh lemon, and order to be taken thrice daily. Its use must be persevered in. Antipyrin is one of the few drugs which seem to have a decisive action in diabetes. Its field of employment lies especially among the milder cases. It is administered either alone or in combination with bicar- bonate of sodium, in doses of gr. xv-xx, thrice or four times daily. Arsenicum renders good service when the patient is thin, and assimilation defective, but in fat subjects it should not be exhibited. (Bartho- LOW.) It may be combined with the phosphates, thus : 384 DISEASES OF THE URINARY SYSTEM. 655. ]J. Syr. calcii lacto-phos., t S jv Liq. potass, arsenit., f-Sj. M. S. — ^A dessertspoonful ter die. Arsenite of Bromine is highly recommended by Dr. R. H. Gilliford (Medi- cal and Surgical Reporter, ^vx^q 9, 1883). Belladonna, in full doses, in connection with sulphur baths, has been recom- mended by Prof. GuENEAU de Mussy. Cakii Sulphidum has been recommended in diabetes by Dr. Ringer, gr. \ thrice daily. It has also been very favorably reported on by other . physicians, and deserves a careful trial. Dr. C. M. Cauldwell (iV. Y. Medical Journal, April 5, 1884), has used calcium sulphide in three cases ; in one it produced no effect whatever, in the others improve- ment began and recovery took place during the administration of the remedy. The dose is i to \ grain three to five times daily. Dr. C. concludes that although calcium sulphide is certainly not a specific in diabetes, yet it seems worthy of a trial in persistent cases of this dis- tressing disease. Carbolicuvi Acidum has been used successfully in Germany. 656. IJ. Acidi carbolici, gr. xv Aquae menthas piper., f. § x. M. One-third of this quantity in divided doses, each day, increased gradually to one-half the quantity daily. Codeia is preferred by Dr. F. W. Pavy (Guy's Hospital Reports, 1870), to opium and morphia, as being equally effectual in controlling the dis- ease without exerting the same narcotic effect. The proper commenc- ing dose is gr. J^, thrice daily, which may be gradually increased to gr. ij-iij. Creasote has been recommended by Sir T. Watson and Dr. T. H. Tanner. It will, in some instances, remove the extreme thirst, especially when the quantity of sugar is small. Cuprum. Finely pulverized copper, gr. ^-yi, twice daily, with meals, has been found by Dr. Grazzini to diminish the saccharine excretion. (London Medical Record, December, 1878). Ferrum. Preparations of iron are nearly always useful : 657- E- Tincturae ferri chloridi, f. 5vj Acidi nitro-muriatici, gtt. Ixxx. M. Twenty drops three times a day. Glycerinum. has been administered in Germany. 658. B. dyceiini puri, f.3yj-vin Acidi citrici, jjaj M«s=. Oij. M. To be drunk at intervals through the day. DIABETES MELLITUS. 385 Hydrogen Peroxide has been tried successfully by Dr. John Day. (Lancet, January, 1868). 659- B- Tinct. hydrogen, perox. ether., f 5ss Aquae, f.jj. j^ This amount three times a day. Iodoform is highly recommended by Professor Moleschoit, of Rome. He uses the following formula : 660. R. lodoformi, gr. xv Ext. lactuc. sat., gr. xv Cumarin, gr, i... m. Ft. pil. No. XX. Sig. — One pill from twice to eight times a day. « lodol 3iS well as iodoform is mentioned by Cerna as favorably influencing cases of diabetes under his observation. Jaborandi has, of late, been employed with success, in some cases of this disease, and its alkaloid, pilocarpin, has been given with some show of success by Lannois (Lyon Med., 1890). Jumbul is a new drug rapidly growing in favor in the treatment of diabetes mellitus. It is given in doses of gr. v-xx of the powdered seeds. Lactic Acid has been used with varying success in the treatment of diabetes. Dr. Foster reports some cases apparently decidedly benefited, and Dr. Ogle gives an account of two cases in which no good results were attained. Cases have been lately reported in which the patients were improved by the use of lactic acid, but on the whole the utility of this agent in diabetes must be held to be as yet sub judice. Disappoint- ment in the use of lactic acid is frequently experienced from the poor quality of the drug. Milk. Cures by the milk diet have been reported ; in consequence of the larger proportion of lactic acid which it contains, buttermilk is more especially indicated in diabetes. Nux Vomica, gr. j, increased to gr. iv of the extract, has been found success- ful by Dr. E. Zarzana. (Gaz. Med. di Roma, December, 1878). Opium and its preparations are well borne, and very valuable in diabetes. From gr. vj-xij, daily, are required to produce a decided impression. Yet it cannot be said to be curative. Of the various alkaloids. Dr. F. W. Pavy (Guy's Hospital Reports, vol. xv) finds that opium, morphia, and codeine, all possess the power of checking the elimination of sugar in the urine. Of the three, he considers codeine to be the best. Dr. Pavy begins with yi, grain of the last, and gives it, by gradually in- creasing doses, to the extent of 10 grains three times a day. He says it is superior to all other medicinal agents in its controlling influence over the disease, none other giving the same immediate and striking 25 386 DISEASES OF THE URINARY SYSTEM. effects. It should be given in full doses, and persevered in, diabetic patients being very tolerant of its use. It produces its best effects in old cases occurring in the aged. Phosphoric Acid, largely diluted, lessens the inordinate thirst more effectually than any other acidulated drink. Potassii Bromidum, Dr. AusiiN Flint (American Practitioner, January, 1870), relates three cases treated by bromide of potassium, in doses of fifteen to twenty grains three times a day, combined with ordinary diabetic diet. In each, there was a rapid diminution of thirst, a de- crease in the specific gravity of the urine, and an improvement in the general health. In a paper before the Paris Academy, in T883, Dr. DojARDiN Beaumetz Said that bromide of potash is essentially an ad- juvant in the treatment of diabetes ; it has its advantages and disad- vantages. In cases of medium intensity, and sometimes in grave cases, in conjunction with dietetic means and the alkaline treatment, it may cause the sugar to disappear from the urine, but at the expense of a loss of strength on the part of the patient. The general impres- sion of the members of the Academy appeared to be that this medi- cament might be used when the sugar did not disappear under the use of proper dietetic means, but that it was not well to employ it primarily. Potassium lodidum has cured cases of syphilitic origin. Quinice et Morphia Bromidum. This combination has been used in diabetic phthisis, by Dr. Benjamin W. Richardson, of London. He states that, under its influence, the quantity of sugar and of urine notably decreases, the cough is lessened, the appetite and digestion .are im- proved, and the recurrent hectic is held in abeyance more certainly, than by any other remedy with which he is conversant. QuinicB Sulphas will diminish the sugar in most instances. Rheum is praised by Dr. Copland, not only as a useful aperient in diabetes, but as a promoter of the digestive and assimilative processes. Saccharin, an organic synthetic compound discovered by Fahlberg, has been widely used as a substitute for sugar. It has sweetening powers a number of times more pronounced than sugar, and is said to have some slight beneficial effect upon the disease. Sodii Citras. Recent journals have called attention to a recommendation by M. GuYOT Darmecy, of citrate of soda in the treatment of diabetes, given in daily doses of one-half to one drachm. Analysis has shown* that sugar disappears from the urine when this salt is used with the food instead of common salt. In the Detroit Lancet, 1883, Dr. O. C. Knight recommends the soda citrate as "an excellent remedy." Sodii Phosphas is regarded by Dr. W. Prout as one of the few saline purga- tives admissible in this disease. DROPSY. 387 Sodii Salicylas. Dr. Muller Warner, in the Berlin Klinische Woschenschrift, January, 1877, gives the following conclusions: i. Salicylate of soda can completely remove the symptoms of diabetes mellitus, yet its action does not appear to be lasting in many cases. 2. The symptoms of diabetes are made to disappear the quicker by salicylate of soda, the greater the dose in which it is used and the longer it is borne by the patient. 3. The first action of medium daily doses (gij-sijss), on diabetes, appears gradually to abate, while larger doses (giv in a day) act on patients progressively. 4. Salicylate of soda can be borne in chronic diabetes mellitus, in large doses, for a long time, without special disturbance of the general condition. Bethesda Water. The Bethesda water, from Waukesha, Wis., has a wide and well-deserved reputation in this disease. Its use should not be ne- glected. The various alkaline waters, particularly those of Vals and Vichy, are to be commended. DROPSY. It is to be clearly held in mind that dropsy in itself is but a symp- tom of some other condition — that it is not a disease ; and that the indications for its relief vary with the nature of the underlying malady causing it — cardiac, renal', hepatic or what-not. It is to be understood in this connection that the following remarks apply to the renal form alone, whenever they depart from general principles. FREDERICK T. ROBERTS, M. D., M. R. C. P., LONDON. This esteemed authority remarks that far too little heed is usually given to the question of rest and position, in the treatment of dropsy. The part affected should be maintained in an elevated posture, the legs, for instance, if anasarcous, placed higher than the body. Pressure should be applied by bandages or adhesive strips, and is a very valuable adjunct. All external dropsical parts should be kept clean and dry. A decided diminution of drinks and liquid articles of food is adapted to dropsical accumulations in serous cavities. The only diaphoretic he considers of much practical value, is some form of bath which promotes perspiration, such as the warm, vapor, hot-air or Turkish bath. They are most valuable in renal dropsy. The hcst purgatives are extract of elaterium, (gr. yi, gradually in- 388 DISEASES OF THE URINAKY SYSTEM. creased to gr. ss,) jalap (9j to 3j)i and cream of tartar (5j to 5ij). For a diuretic, the following : 65l. R. Extract! elaterii, gr. v Pulveris scillse, Pulveris digitalis, aa gr. xx Extract! hyoscyami, gr. xxx. To make twenty pills. One to be given every other night. DR. WALSHE. Diuretics, uncertain in their effects, are often rendered much more active by preliminary cupping or dry-cupping of the renal regions. Qf the numerous diuretic agents, the infusion of digitalis has ap- peared to Dr. Walshe the most active, and no amount of apparent weakness of the heart is, per se, an absolute contra-indication to its use. Hydragogue purgatives often 'prevent the action of more di- rect diuretics ; and small doses of blue pill occasionally, at bedtime, are very useful adjuvants. Diaphoretic drugs are of very little utility, but the free diaphoresis produced by the vapor or hot-air bath is sometimes strikingly bene- ficial. If there be any tendency to bronchitis, bronchial discharge should be encouraged by the free use of expectorants. Removal of anasarcous fluid by mechanical means becomes necessary, if medicines fail in controlling its increase ; and if inflammatory changes in the skin appear imminent, scarification is dangerous, being not rarely followed by erysipelas, while acupuncture over the insteps, or at the upper and inner parts of the thighs, is not attended with the same danger. C. MURCHISON, M. D., F. R. S., ETC., LONDON. 662. R. Pulveris scillae, gr. jjs Pulveris digitalis, gr. ss Pilulse hydrargyri, gr. ij. M. For one pill, two or three times a day. This is a pill which has enjoyed a long and merited reputation for treatment of dropsy, in the Middlesex Hospital. Diuresis will also sometimes be induced by fomenting the abdomen with an infusion of digitalis of about four times the usual strength, 663. R. Potassii acetatis, gr. xx Spiritlls setheris nitrosi, f. 3 ss Decocti scoparii, f!§iss. M. To be given with each dose of the above pills. DROPSY. 389 At the same time, an ointment composed of equal parts of blue ointment and ointment of belladonna is to be applied over the ab- domen. This treatment is a successful one in cases of ascites due to cirrhosis. ROBERT J. GRAVES, M. D., DUBLIN. 664. g, Potassii nitratis, Potassii carbonatis, aa 5j Tincturee scillse, Tincturae digitalis, aa gr. xxx Mellis despumati, f. § ij. M. For an electuary. To be taken in teaspoonful doses, in the course of three or four days, in order to increase the activity of the kidneys, in various forms of dropsy. 665. ]J. Oxymellis scillae, f.fjiss Potassii bitartratis, 5 ")• M. Dose, a tablespoonful, as a diuretic, in various forms of dropsy. DR. GUIBERT, PARIS. 666. R. Tincturae scillas, Tincturae digitalis, Tincturae colchici, aa f. 5") Linimenti camphorae, f. 3 vj Aquae ammoniae, f- 3 iss. M. To be rubbed well into the abdomen and thighs in dropsy. DR. PORCHER, PARIS. 667. Jt- Sodii sulphatis, Potassii bitartratis, aa § j Spiritds EEtheris nitrosi, , f. 3ijss Syrupi, '• 3 j Aquae, '■ 5 vss. A tablespoonful twice daily, in dropsy accompanied with an active, full circulation. It procures an abundant alvine evacuation, and often, at the same time, a copious secretion of urine. 668. B;. Tincturae cantharidis, ri''-^ SpiritQs aetheris nitrosi, rz^ Syrupi aurantii corticis, 3'... », Aquae fceniculi, ^-S^")- '^■ A tablespoonful two or three times a day, in different forms of dropsy PROF. A. GUBLER, FACULTfe DE MfeDECINE DE PARIS. 669. E- Tincturae digitalis, __ Extracti ergotae fluidi, ^ *-^ ^^ Acidi gallici, ^.'. Potassii bromidi, p ^ .. Aquae lauro-cerasi, f 5'" Sy^P"' ., fliv M. Oxymellis sciUae, '• => • A tablespoonful in water, two or three times a day in various forms of dropsy. 390 DISEASES OF THE URINARY SYSTEM. 670. R. Pulveris scillas, Pulveris digitalis, Scammonii, aa 9iv Syrupi, q- =• ^• Divide into one hundred pills. From one to five a day, in various forms of dropsy. ST. MARY'S HOSPITAL, LONDON. 671. R. Elaterii, gc.iss Extracti hyoscyami, Extracti gentianae, aa gr. be. M. Divide into ten pills. From one to three as a drastic purgative in certain forms of dropsy. HENRY WILLIAM FULLER, M. D., LONDON. 672. ]J. Pulveris scillse, Pulveris digitalis, ai 9j Potassii nitratis, 3 v. M. Divide into fifteen powders. One or two a day, in various forms of dropsy. 673. R. Potassii sulphatis, Potassii bitartratis, Potassii nitratis, aa 3 iss Digitalis pulveris, gr. xv. M. Divide into twenty powders. From one to three a day, in oedema of the lower limbs. Repeated purgatives. DR. W. R. BASHAM, LONDON. 674. R. Liquoris ammonise acetatis, f. § j Acidi acetici diluti, f. 3 'jss Tincturae ferri chloridi, f. 3 ij Aquae, f. § viij. M. Mix the acetate of ammonia and acetic acid first; then add the iron. The resultant should be of a bright sherry-red color. Dose, two tablespoonfuls three or four times daily. This is the original " Basham's mixture," which has stood the test of the fullest experience. DIURETICS AND CATHARTICS. Diuretics are of much service in dropsical affections. In passive dropsies they may be combined with tonics and mild stimulants. Their operation is greatly aided by previous depletion, if the patient be not much debiliated. Dr. J. HoPE finds diuretics of the highest service in dropsy connected with disease of the heart, especially when accompanied by a scanty secretion of high-colored urine. He re- commends particularly in these cases, digitalis, squills, and acid tar- trate of potash. The dyspnoea, palpitation and cough decrease as the quantity of the urine increases. In inflammatory dropsy attendant on granular disease of the kidneys, the use of diuretics, particularly those of a stimulating character, is generally condemned. The ad- ministration of diuretics by the endermic method is sometimes effect- DROPSY. ,gj ual in removing dropsies. The diuretics usually employed in the treatment of dropsies are digitalis and digitalin, sweet spirits of nitre, juniper, acetate of potash, nitrate of potash, cream of tartar, squills] broom tops. The following formulae have been recommended: 675. R. Digitalin, g^ 3 Pulveris scillse, Pulveris scammon., £| g^ jjo^ Mucilaginis, q_\ jyi Make one hundred pills. Of these, two, then four, and lastly six, are to be given daily, according to the effect produced. 676. R. Potassii nitratis, 3;;; Baccar. juniper., Jxv Vini albi, Oiss. Dose, f. § iij daily. 677. R. Potassii bitartratis, Juniper baccar. contus., aa § ss Aqu3e ferv., Oj. M. This infusion is considered by Prof. StilLe to have few superiors in the idiopathic forms of general dropsy. 678. R. Scoparii (seeds), § ij Alcoholis, f. I viij. M. Macerate for ten days. Dose, f. 5 j-ij thrice daily. If it cause diarrhoea, five or six drops of laudanum may be added ; if the patient is much debilitated, iron or quinine may be added. This formula is of service in all forms of dropsy excepting ovarian. Cathartics, particularly elaterium, gamboge, and cream of tartar, are of great service in dropsical affections, but they are to be used with great caution when the patient is nearly debilitated, and, as a rule, to be avoided in dropsy connected with heart disease. Dr. Christison recommends gamboge, in doses of gr. v-vij, every other day, finely powdered and combined with cream of tartar, as a certain and easily-managed cathartic in reducing dropsy. Colocynth may be employed in dropsical affections connected with disease of the liver, but is inferior to elaterium. Croton oil is sometimes useful when given with great caution, in small and only gradually-increased doses, but is inadmissible if the patient is old or debilitated. Elaterium is a very efficient cathartic in dropsy, anasarca, and oedema, arising in connection with disease of the heart. Dr. J. Hope gives it in the form of a pill, in the doses of gr. yk-]i, com- bined with capsicum, to prevent griping, and with a grain of calo- mel, to prevent its emetic effects. One of these pills should pro- 392 DISEASES OF THE URINARY SYSTEM. duce six or eight watery evacuations, and may be repeated two or three mornings in succession, or every second or third morning, ac- cording to the patient's strength. The dose of elaterium may be carried, with caution, to two grains. The effects of this remedy, ac- cording to Dr. Hope, are sometimes truly astonishing, removing an extreme universal anasarca in three or four days ; but, as it is apt to be violent in its operations, it should be given to strong subjects only. The following formulae are also valuable : 679. R. Elaterii, gr. ij Extract! gentiani, gr. xx. M. Divide into four pills; order one every hour, till it causes free evacuations. Repeat every two or three days, for a fortnight, and then suspend for a short time. 680. R. Elaterii, gr.j Extracti colocynthidis compositi, gr. xl Extracti hyoscyami, gr. xij. M. Divide into twelve pills. Take one every night. 681. R. Pulveris jalapae compositi, gr. xx-xxx Potassii bitartratis, gr. v-x-xv Olei carui, gtt. ij Aquas, f. § iss. For one dose; to be repeated, so as to keep up an unremitting discharge from the bowels. This formula is recommended by Dr. CHAPMAN. NOTES ON REMEDIES. Ammonice Murias and Benzoas are useful in dropsy dependent upon hepatic disease, and also in ovarian dropsy. Dr. Copland recommends these combmations vi^ith warm, diuretic effusions. Arlentin. This alkaloid of uva ursi is a potent diuretic, and has been com- mended by Dr. Mensche (Land. Med. Record, 1883) and others. Asclepias Syriaca. This plant, vulgd milk-weed, has a specific power in dis- pelling dropsical effusions. It was first brought forward by Dr. Jew- ETT, in an article in the New York Medical Society's Transactions for 1869, and later, Dr. Hutchins reported to the Kings County Society very remarkable results from its use. For instance, in forty-eight hours, a man described as frightfully distended was reduced to a skeleton, and any disposition to re-accumulation of water was rapidly relieved by an infusion of this drug. If not carefully given, it may produce vomiting or diarrhoea, both of which are to be avoided. Dr. Jewett's mode is to put y^ ounce in a pint of gin, add an infusion of 2 ounces of juniper berries in a pint of water, and give from i to 4 teaspoonfuls, as the stomach will tolerate it, every four hours, until the effect is obtained. He expresses unbounded confidence in it, after an DROPSY. 393 experience of thirty years ; but he warns us that, although the root is officinal in the United States Dispensatory, it is only the bark of the root which is active. A fluid extract is prepared, the dose of which is lo drops. It has been erroneously referred to, in various articles, as Apocynum Cannabinum. ArmoracicB Radix. Horse-radish was much employed as a diuretic, by Sydenham and the older physicians, in dropsical affections. Blatta Orientalis. A derivative obtained from the cockroach, has been in- troduced from Russia. In doses of gr. ij-iv, its diuretic action is well marked, and it has secured the testimony of a number of ob- servers. Caffein. The citrate of caffein, gr. iv-viij, has been used by Prof. Gubler with good results, in cardiac dropsies. Cannabis Indica has been used (n^xx of the tincture every four hours) as a diuretic in dropsy. Chimaphila Umbellata (Pipsissewa) is recommended in large doses of the extract as a valuable diuretic. Copaiba. Dr. S. Wilks (Lancet, March 21st, 1873), speaks with the greatest confidence of the resin of copaiba as a diuretic. It is particularly use- ful in cases of dropsy from cardiac or hepatic disease. Fifteen or twenty grains in mucilage and flavored water should be given, three or four times a day. Digitalis is much employed in dropsical affections, alone or combined with squills, mercury, carbonate of ammonia, or tincture of the chloride of iron. Sir H. Holland recommends a combination of digitalis and tincture of the chloride of iron in the dropsy following scarlet fever- The same combination is useful in many other forms of dropsy attended with anaemia. Diuresis is sometimes induced by the external applica- tion of digitalis to the abdomen, either by fomentation with an infusion of about four times the usual strength, or by frictions with an embro- cation of equal parts of tincture of digitalis and soap liniment, or by poulticing with a warm linseed poultice, to which a fluid ounce of the tincture has been added. Ferri et Potassii Tartras has been found useful as a tonic and diuretic in cases of anasarca connected with disturbed action of the heart, in which it would be dangerous to give any stimulating tonic. yaborandi is very valuable in renal dropsy, when the secretion of urine is much decreased or suppressed. Pilocarpin, its active agent, is administered as a diaphoretic in renal insuffic- iency in doses of y^-Yt grains hypodermically. It is a curious fact that this drug is not well borne by negro patients. Magnesii Sulphas is commended by Dr. Hay in the removal of dropsical 394 DISEASES OF THE URINARY SYSTEM. effusions, administered in large doses in the least possible quantity of water, early in the morning, the patient having not as yet drunk any water and abstaining from drinking until the action of the salts. In this way large watery passages are induced, and water being withheld temporarily there is less liability of the replacement of the effusion. Phosphoricum Acidum Dilutum, diluted with oil and acid, as an embrocation over the abdomen, has been employed with benefit in some cases of dropsy. Rheum, in small doses, or in infusion as a vehicle for the saline diuretics, squills, juniper or colchicum, is regarded by Dr. Copland as a useful medicine in dropsies. Solidago Virga Aurea (Golden Rod) is commended as a valuable diuretic. Sinapis is spmetimes beneficial, because of- its diuretic and stimulant quali- ties. It is best given in the form of whey, made as follows : 682. R. Bruised mustard seeds, S ss Boil in Oj of milk, and strain. The whole to be taken daily in divided doses. Terebinthina Oleum, in doses sufficient to act freely on the bowels and kid- neys, is occasionally useful in ascites, unconnected with renal disease or with great gastric irritability or inflammatory action. Urtica Dioica. An infusion of the root of the stinging nettle is considered by Dr. Maris, of Philadelphia, the very best diuretic he is acquainted with. EXTERNAL MEASURES. Acupuncture is the introduction of needles into the body to relieve or cure disease, and is often needful in dropsical affections. It is performed by running five or six fine steel needles, two or three inches long, right into the dropsical part. The needles are furnished at the blunt end with a knob of sealing-wax or ivory. They should be introduced by a slight pressure combined with a semi-rotary motion between the thumb and forefinger, and withdrawn with the same motion. Ordi- narily, no fluid escapes on the withdrawal of the needles, but occa- sionally a drop of blood follows. Gentle pressure will suffice to re- strain any hemorrhage, which exceptionally may occur. The pain is quite trifling, and often scarcely noticed. The needles may be intro- duced into muscular, aponeurotic and tedinous parts, but not into serous cavities. They should be inserted to the depth of one-fourth of an inch to two or three inches, according to the thickness of the muscles. Abdominal Compression. When there is any tendency to absorption in ascites, it will be greatly accelerated by tightly bandaging the abdomen with a flannel bandage. FUNCTIONAL URINARY DISORDERS. 395 FUNCTIONAL URINARY DISORDERS. INCONTINENCE OF URINE. This affection is most frequent in children, although adults are not free from it. One of the most popular remedies is belladonna, or its alkaloid, atropia, administered in sufficient doses to exert the physiological effect of the drug. PROF. S. D. GROSS, PHILADELPHIA. In the nocturnal incontinence of children, there should be a bland and unirritant diet, late suppers should be avoided, no drink taken after supper, and the bladder emptied on retiring. The position in bed should be upon the side or belly, to prevent the urine from irri- tating the neck of the bladder. The internal remedies of most use are as follows : 683. E- Strychniae, gr.j Pulveris cantharidis, gr. ij Moqjhise sulpbatis, gr. iss Ferri pulveris, 9j- M. Make forty pills. Give one three times a day to a child ten years old. The cold shower-bath once or twice a day is a valuable auxiliary. DR. C. P. LEE, PLEASANTON, KANS. {Kansas City Med. Rec, 1888.) Dr. Lee states that as a rule the treatment of these cases consists in the adoption of means for the improvement of the general health. Tonics, cold sponging, cold sitz-baths are indicated if they can be borne. Faradization is often of value, applied directly to the urethra and neck of the bladder. It is m'ost common among children, but also occurs in adults ; it is more frequent in girls than boys. Where causes for local irrita- tion, as from long prepuce, worms in the rectum, marked acridity of the urine, or careless habits, etc., have been excluded, the condi- tion may be regarded as one of local debility. It is usually aggra- vated by anything that disturbs the general health, especially un- wholesome diet; and also where the patients are permitted to drink excessively in the latter part of the day, and are not kept suffici- ently warm at night. Where there is a suspicion of a local cause, this should be at once 396 DISEASES OF THE URINARY SYSTEM. removed. The diet should be easily digested, but generous ; the quantity of fluid taken should be regulated, especially in the latter part of the day. The bed-clothes should be warm, but not in ex- cess. If possible, the patient should be aroused several times dur- ing the night to pass the urine — and day and night regular hours kept for the performance of the function. Medically Dr. Lee has had the best results from the use of bella- donna. He would give nightly doses of powdered belladonna leaves, from }i to j^ grain, with a like amount of the extract ; if small doses do not succeed, the quantity of the drug should be increased until the physiological effects are produced. Tepid and cold baths, either local or general, are useful aux- iliaries. DR. ROBERT FARQUHARSON, LONDON. This writer, in a study of the action of drugs on incontinence, (Practitioner, July, 1879,) divides cases of incontinence into three classes. In the first class, debility and anaemia are the exciting causes. The patients are pale and weak. In such, small doses of iron will act better than anything else, and will effect a cure in the lighter cases. The second class includes those in which the debility is generally congenital and dependent on an excessive irritability of the bladder. The drugs most potent in these cases are ergot and belladonna. Of these. Dr. F. prefers the latter. It must, however, be vigorously pushed, up to the full development of its physiological effects, which, when this drug is given to young persons, need never excite any ap- prehension. He has given the tincture in doses of f.sij, to a boy of nine, f.sijss, to a girl of thirteen, etc. The third class may be called a sort of choreic condition of the bladder, sometimes associated with skin diseases, often more or less intermittent. In such, sulphate of zinc, arsenic, strychnia and iron may be used, singly or in combination, with possible good results, but on the whole the treatment is far from satisfactory. Galvanism and blisters to the spine occasionally are efficacious. The dietetic plan, recommended by some, of withholding all meat, is rejected as useless by our author. Santonin, praised by RiNGER, he has tried without effect. In children who sleep heavily, Professor FONNSAGRIVES has oc- FUNCTIONAL URINARY DISORDERS. 397 casionally observed that a cup of strong coffee in the evening pre- vented them from wetting the bed ; he believes that this, and also belladonna, act simply by causing them to sleep less profoundly, and then they do not lose control of the sphincter muscles of the bladder. DR. SAMUEL S. ADAMS, OF GEORGETOWN, D. C. According to this author (American Journal of Obstetrics, June, 1884), belladonna is the remedy /a?- excellence in the treatment of those cases believed to be associated with a tonic spasm of the bladder. In order to derive benefit from the drug, it should be given in large doses at bed-time, which should be increased drop by drop, daily, until improvement results or its physiological effects are obtained. If there is relaxation of the sphincter vesicae, or paresis of the muscles of the bladder, strychnia is indicated. If- the pa- tients are puny or in ill-health, the general health must be improved while we are giving the above remedies. He does not advocate circumcision as the certainly indicated remedy in all cases, nor does he believe that every boy who has in- continence, with an elongated prepuce, should be compelled to un- dergo the operation. If the prepuce cannot be retracted, he would advise operating; and while sometimes the opening in the prepuce is large enough, yet it cannot be retracted owing to adhesions. In such cases, if these adhesions are broken up, favorable results will follow. He performs the operation of circumcision in the following man- ner: The prepuce is drawn forward and Henry's clamp tightly applied; the end of the prepuce is then cut off with scissors and the clamp left on the stump for several minutes to check bleeding ; a director is then pushed along the upper surface of the glans, and the mucous membrane divided beyond the corona. The membrane is then turned back to meet the retracted skin, and made fast by five silk sutures. In about ten days the patient is well. He re- moves only that part of the mucous membrane that is cut off with the end of the prepuce ; for by leaving a long membrane it can be turned back and thereby hide the cicatrix, which is a source of mor- tification to many parents. PROF. ATKINSON, OF BALTIMORE. (Med. Times, 1888.) Prof. Atkinson prescribes for a child aged about 5 years : 398 DISEASES OF THE URINARY SYSTEM, 684. R. Extract! ergote fluidi, f. 3i Tincturse nucis vomicae, gtt. xvj Syrupi, f. S iss. M. Sig. — ^Teaspoonful thrice daily; the dose to be doubled after a few days if necessary. DR. GRISOLLE. (Les Nouv. Retnedes, 1888.) 685. R. Extract! nucis vomicae, gr. iij Fern oxidi, gr. xlv Quassiae pulveris, gr. tIv Syrupi, q. s. M. Ft. pilulae. No. xx. Sig. — One to three pills daily. DR. S. W. ARMITAGE, CEDAR BLUFF, ARK. For children about ten years of age. Dr. ArmitagE suggests the following formula : 686. R. Extracti jaborandi fluidi, Extracti belladonnae fluidi, aa f. 3 j Extracti tritici repentis fluidi, f. § ss Extracti ergotae fluidi, Extracti rhois aromatici, aa f. § j Aquae, f. | ss. M. Sig. — ^Teaspoonful thrice daily. Or, 687. R. Syrupi ferri iodidi, f.Siy Extracti belladonnse fluidi, f. 3 j Extracti ergotae fluidi, f. § j Syrupi, q. g. ad f. | iij. M. Sig. — ^Teaspoonful thrice daily in water. Or, where the bladder is very irritable, 688. R. Strychniae sulphatis, gr. j Pulveris cantharidum, gr. ij Morphinae sulphatis, gr. iss Pulveris ferri su'phatis, gr. xx. M, Ft. pilulae, No. xl. Sig. — One thrice daily. DYSURIA. PROF. J. B. FONNSAGRIVES, PARIS. The forms of dysuria of functional origin are derived from neu- ralgia, paralysis or torpor of the muscles of the bladder and its neck. Hysterical subjects are quite liable to them. In nervous affections of the neck, the plan adopted by CIVIALE is the best; this includes FUNCTIONAL URINARY DISORDERS. 399 catheterism of the urethra, vesical injections at first of warm water, then of cold, douches on the hypogastrium of warm and cold water, followed by revulsives to the same spot, and light purges. Where the dysuria is owing to nervous atony or partial paralysis, Prof. F. believes the best results are to be had from electricity and strychnia. The former may be employed in either of the three methods recommended by DUCHENNE, (described in most works on medical electricity.) When these means fail, he would resort to in- jections of very weak solutions of tincture of cantharides, gtt. j-iij, in half a tumbler of warm water, a method successfully employed by LiSFRANC. NOTES ON REMEDIES. Arlentin. This new alkaloid of uva ursi has been extolled by German phy- sicians in dysuria. Benzoaies. The benzoates of lithium or potassium have come into favor as agents to increase the quantity of the urinary secretion, and also to cause the disappearance of uric acid from the urine. They are well spoken of for this purpose by Dr. A. B. Garrod, of London (Lumleian Lectures, 1883). Cantharides. In cases of temporary scanty or suppressed urine, as in hard drinkers, single-drop doses hourly of the tincture of cantharides will often re-establish the secretion. Circumcision. Dr. Wm. Muir xt.-^oxX.s ( Glasgow Medical Journal, 1884), the case of a boy suffering from incontinence in whom the foreskin was unusually long and a little inflamed. Circumcision was performed, and in two months the boy was quite cured. Rhus Aromatica. The introduchon of rhus aromatica has supplied the phy- sician with an efficient remedy against that very annoying condition of the bladder which gives rise to incontinence of urine. The mode of its action seems to be through its specific tonic influence on the bladder, and particulariy on the sphincters of that viscus. The dose is gtt. X or XX of the fluid extract every three hours, or on going to bed. The following combination (Medical World, 1888), is an accepta- ble one : 689. R. Acidi benzoic!, Sodii boratis, aa 5 v Extract! rhois aromaticse fid., f-3J Extract! biichu fluidi, r I '^ Glycerinse, , rl'^ • M Sig.— One tablespoonful four times daily: after elTects are established gradually de- crease the dose to one teaspoonful four times daily. 400 DISEASES OF THE URINARY SYSTEM. Stigmata Maidis. The stigmata of maize exert an action on the urinary organs both anaesthetic and diuretic, and promise to have a wide applicability in their functional disorders. About a scruple of the extract is a dose. HEMATURIA. DR. JAMES TYSON, OF PHILADELPHIA, Read a paper on "Malarial Hcematuria" before the Pennsylvania State Medical Society in 1883, in which he said that if the diagnosis is accurately made, the results of treatment are often brilliant. It is that for malaria. Quinine, in doses of three to five grains every three hours when the hemorrhage is continuous, until it ceases. Or, if intermittent, sixteen to twenty grains, sufficiently anticipating the paroxysm, should be given. Mercurials may be combined with quinine. Iron, arsenic, and astringents, have not been found of much service. The natural waters containing iron and alum may be expected to be of service, such as the Orchard Acid Springs of New York, and Bath Alum and other springs in Virginia, and some have a reputation in haematuria. The "malignant" form of malarial haematuria, of which many more cases have occurred in the Southern United States during the past fifteen years than previously, is much more serious and more fatal than the form spoken of by Prof. TVSON. The haematuria is here sometimes ushered in with a chill or two, or the bloody urine may appear at once. Large quantities of bloody urine are passed, it is said one or two gallons in twenty-four hours. The urine is porter-like, and the sediment sometimes almost tarry in consistence. There is obstinate nausea, and vomiting of bilious and dark matter resembling black vomit. Intense jaundice rapidly supervenes; sometimes in an hour the whole body is stained yellow. The jaun- dice is haematogenetic. There may be fever, hot skin, and temper- ature of 1040 to 106°, but the strength rapidly declines, and the patient often dies in from twenty-four to sixty hours, and if he re- covers, convalescence is prolonged. The negro seems to be ex- empt. Autopsies show the same intense coloration of the internal organs, and sometimes the spleen is enlarged. H^-MATURIA. 401 The only curative treatment is by quinine aided by mercurials. Morphia and carbolic acid have controlled the vomiting. Stimulants are necessary. The treatment of this virulent form of malarial haematuria, or haemaglobinuria, as it is more correctly regarded, is under consider- able dispute in relation to the value of quinine. The following gen- tleman is quoted as setting forth the views of large numbers of Southern physicians : Dr. R. M. Brown, of Texas, (Texas Courier-Record of Med., 1888,) says that it is his plan in mild cases with fair strength to begin with an emetic, preferably ipecacuanha. Then if the patient is consti- pated he would give a full dose of calomel, from ten to twenty grains, with twenty grains of bicarbonate of sodium, to be followed in four or six hours with four tablespoonful doses of Epsom salts every hour until bilious dejections were brought down. If diarrhoea already exists he gives small doses of calomel, from one to two grains, with five grains of subnitrate of bismuth, and a quarter of a grain of powdered opium. For vomiting he has always found that a few drops of laudanum are all that is needed to quiet this distressing symptom. As soon as the bowels are well opened the stomach quiet and pyrexia begins to subside, he resorts to full "and free use of quinine, giving to an adult at least forty grains as fast as it can be borne, and endeavoring to continue in such doses and intervals as would steadily maintain the impression for two days. In event of this failing he would increase the amount. In connection with the quinine diluent diuretics should be freely administered, uva ursi, pipsissewa, sweet spirits of nitre and digitalis, being the most efficient. In severe cases friction with mustard or capsicum, hot applications to the extremities and along the spine, are appropriate. Warm alkaline baths promote the action of the skin, assist in allay- ing thirst and diluting the urine. As much fluid as the stomach will bear, either warm or cold, should be given. On the other hand there are those physicians who regard quinine as only increasing the evil of malarial haematuria, and who look on the drug as positively contraindicated in all these cases. SAMUEL FENWICK, M. D., LONDON. Haematuria occasionally appears without obvious cause, or follows a slight chill or other exposure. When the urine is decidedly tinged, an ice-bag may be applied to the loins. The patient must 26 > 402 DISEASES OF THE URINARY SYSTEM. be kept at rest, and if severe he is better in bed. Sound port wine is one of the most useful astringents. Ergotin may be injected sub- cutaneously. The acetate of lead is of but slight efficacy in these cases. Internally, gallic acid may be prescribed, or one of the fol- lowing combinations : 690. R. Extract! ergotae fluidi, TUxiv Acidi gallici, gr. x Aquae cassise, f- § j- M. For one dose. 691. R. Aluminis, 3iss Syrupi simplicis, 3vj Infusum rosse acidi, ad § viij. M. One to two tablespoonfuls as required. The discharge of bloody urine is a symptom of so many diseases, as well as local injuries, that it can only be referred to here in gen- eral terms. Internally, one of the most efficient remedies is ergot. DR. CHARLES HORION, PARIS. 692. R. Ergotae pulveris, gr. xv Acidi tannici, gr. iij Digitalini, gr. \. M. Divide into ten pills. Give five a day, in hiematuria. Prolonged cold injections into the bladder, cold compresses to the perineum and pubes. DR. W. LANGE, ERLANGEN. 693- R- Extracti ergotae fluidi, IUxxv Acidi tannici, gr. xxx Aquae destillatae, f-Syj Syripi, f. § j. M. The whole to be given in tablespoonful doses, in the course of the twenty-four hours in haematuria. Cold compresses to the bypogastrium, ice by the mouth, cold enemata. PROF. S. D. GROSS, M. D., D. C. L., PHILA. 694. R. Olci terebinthinae, Acidi sulphucici diluti, ia f. 5 j Acidi gaUici, gr. xxx Mucilaginis acaciae, f. § ss Mu«. f!§j. M. A dessertspoonful every three hours. In all cases, ice to the hypogastrium and in the rectum or vagina is serviceable ; rest in the recumbent posture, the pelvis elevated, and the room cool, are important accessories. Dr. W. Atlee gives the fluid extract of ergot in doses f..lss-j, and continues it daily at bedtime for a considerable period. H.EMATURIA. 403 PAROXYSMAL HEMOGLOBINURIA. DR. STEPHEN MACKENZIE, OF LONDON. According to this author (Lancet, January 26, 1884), syphilis has be6n shown to be an antecedent in several cases, and the disease has been cured in some such by anti-syphilitic treatment. In others, malaria is the cause. Syphilis should be inquired for ; and when present, treated. In the majority of cases quinine is the remedy of greatest service, even in cases not evidently malarial. Probably some patients who get well when taking quinine would have done so without it. Most patients find by experience that the only way to prevent attacks is to avoid exposure to cold by clothing and habits. But it was possible, as suggested by Dr. Barlow, that gradual accus- toming to cold might be at once the most philosophical and success- ful mode of treatment, and this is decidedly worthy of trial. NOTES ON REMEDIES. Alumen injected into the bladder, in a solution of the strength of gr. xx to aquae Oj, sometimes arrests the discharge in hsematuria, after the fail- ure of ordinary remedies. As an internal remedy in haematuria, alum is less effectual than gallic acid. Atnmomi Chloridum, in five-grain doses, four times daily, has been success- fully used by Dr. W. Jone Morris, of England. Argenti Nitras in very weak solution, injected into the bladder, in haematuria arising in connection with vesical tumor, is recommended by Sir H. Thompson. Benzoin Odoriferum. Dr. R. M. Nicholls, of Louisiana, says, in the Medi- cal and Surgical Reporter, February 3, 1 883, that quinine, with the infusion of spice-wood, benzoin odoriferum, as a drink in the place of water, will cure haematuria. Chian Turpentine with three drops of arsenical solution, three times daily, and a four-grain dose of quinine every day at noon, has proved beneficial in the hands of Dr. Ralfe (Lancet, November 17, 1883). Digitalis, according to Bartholow, has an undoubted power to arrest hemor- rhage ; it may be combined with other remedies that are synergistic, thus : 695. R. Infus. digitalis, f- 3 ij Tinct. krameriae, - r « vr Ext. ergotse fl., aa f.gj. M. S. — ^A tablespoonful pro re nata. 404 DISEASES OF THE URINARY SYSTEM. Ferri Chloridi Tinctura, in doses of Tti,x-xx, several times a day, is a valu- able remedy in hemorrhage from the bladder. Gallicum Acidum, alone or combined with sulphuric acid, opium or digitalis, is an excellent astringent in haematuria. Dr. W. Brtnton recommends the following formula : 696. ft. Acidi gallici, gr. x Acidi sulpburici diluti, IHx Aquae, f. §j. M. For one dose. Guaiaci Tinctura, gj, twice daily, has been used with success by Dr. John N. Upshur, of Va. (Half-Yearly Cotnpend.,'^v\y, 1879.) Ipecacuanha is a valuable remedy in hsematuria. It should be given in the manner recommended for haemoptysis. Krameria, in scruple doses of the extract, is highly commended by Sir T. Watson, alter all ordinary remedies have failed. Matico, in infusion, doses §ij, every two or three hours, is regarded by Sir H. Thompson as equal to gallic acid or lead in haematuria. Plumbi Acetas, in doses of gr. ij-iv, combined with gr. ss-j of opium, is a well- known and effectual remedy. Quinine is highly effective in the intermittent trouble. Tannicum Acidum, in the form of a pill, is an effectual astringent in hemor- rhage from the bladder. Terebinthinos Oleum is employed with benefit where there is debility, relaxa- tion and anaemia. Prof. Bartholow commends the following formula : 697. R. Olei terebinthinae, f. Siij Extracti digitalis fluidi, f. 5j Mucilaginis acaciae, f. § ss Aquae menthae piperitse, f. §j. M. A teaspoonful every three hours. NEPHRALGIA (RENAL COLIC). Nephralgia, as a symptom, may be regarded as expressive of a gravelly or lithic acid diathesis; it arises from the irritation of gravelly particles of lithic acid (amorphous), or of crystalline grains of lithic acid or lithates, detained in the renal tubes, till washed out by the urinary stream, giving rise to a distinctive group of symptoms. Bearing this pathological fact in mind, the remedial agency of diluents, of alkaline citrates and tartrates, or any agent which, while RENAL COLIC. 405 it dilutes the urine and increases its quantity, also renders the uric acid more readily excreted, will readily be admitted. Nephralgia, arising from the above causes, is recognized without much difficulty, and its temporary relief easily and promptly obtained. The potash salts, as effervescing citrates, mild mercurial alteratives and saline purgatives, especially the Carlsbad or Friederichshall waters, speedily effect the desired relief. As nephralgia is symptomatic of a gravelly irritation of the urinary passages, so, if the gravelly condition continues unreHeved, nephralgia becomes the sign of a calculous disease of the kidney. The general treatment of Lithiasis is a question which is considered under " Surgical Therapeutics," and under Uric Acid Diathesis. The immediate treatment of nephralgia must be by opium in large doses, preferably either by enema or by the hypodermic injection of morphia. Dr. F. KiNG, of Georgia, has observed that ipecacuanha, gr. XXX, at one dose, will sometimes relieve both the irritability of the stomach and the pain in such cases. (Half-yearly Compend., January, 1878.) Active counter-irritants over the seat of pain also aid in giving relief. See further in " Surgical Therapeutics," under " Lithiasis." DR. CHRISTOPH, OF CONSTANTINOPLE. (Jour. Am. Med. Assoc, 1889.) This practitioner has been very favorably impressed with the value of inhalations of chloroform for a few seconds when the paroxysms of pain manifest themselves. The patient may use the remedy if there be no special contra-indi- cations, inhaling the chloroform for fifteen or twenty seconds, when as a rule the pain will have disappeared. Or the inhalations of chlo- roform may be replaced by 698. R. Butyl chloral, 3) . Water, \-\^Z Alcohol, *:3"1 „ Glycerine, f-3')- **• Sig. — ^Two or three tablespoonfuls during the day. In order to dissolve the stones he uses three teaspoonfuls of mag- nesia bor. nitr. with sugar in water. 406 DISEASES OF THE URINARY SYSTEM. UREMIA. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. Probably the most conspicuous good results from the administra- tion of pilocarpin have been obtained in the eclampsia of albumi- nuria. The powerful action on the sudoriparous glands, and the excretion of the urinary solids by the sweat, are the causes of the extraordinary relief obtained from this remedy in suitable cases. It should be borne in mind that pilocarpine tends to excite uterine action, and hence its administration may, under some circumstances, be improper, but in most cases this effect is desired. There are, however, two important contra-indications ; a weak heart, from thin- ning and atrophy of the walls of the organs, or from fatty degenera- tion, and a tendency to pulmonary congestion and oedema. In some instances, in a few minutes after its hypodermic use, the respiration becomes embarrassed, by congestion and oedema of the lungs and by enormous bronchial secretion. It may be well to mention that atropine, subcutaneously, in one case in which it was administered, removed these symptoms and saved the patient's life. PROF. M. CHARTERIS, M. D., GLASGOW. The objects of treatment are to increase the flow of urine, and awaken the action of the skin. Hence, diuretics and diaphoretics are in order, as : f^^- R- Tinct. scillee, f.3ij Liq. ammon. acetat., f. § ij Decoctum scoparii, ad f. § vj. M.. Two tablespoonfuls thrice daily. And: 700. ]i. Liq. ammon. acetat, f. §j Spts. aetheris nitrosi, f. § ss Tinct. hyoscyami, f. 3 ijj Aquam camphorae, ad. f. § vj. M. A tablespoonful every three hours. During the convulsions, chloroform should be inhaled ; or chloral may be injected hypodermically. In sudden attacks in plethoric persons, as sometimes in pregnancy, free venesection has much to recommend it, and should not be dismissed as absurd simply be- cause it was the panacea of our forefathers URAEMIA. 407 DR. ALFRED L. LOOMIS, NEW YORK. Of diuretics in acute uraemia digitalis stands first ; but it must be given in large doses, f.i^ss of the infusion of the leaves every three hours for twenty-four hours, or until the diuretic effect is produced. During the convulsions, chloroform should be given by inhalation. When they cease, morphia, hypodermically, is demanded. This will control the muscular spasms and aid the processes of elimination. The injections may be given every two hours until these effects are produced, both in puerperal and non-puerpral cases. The dread which has so often been expressed of opium in uraimic conditions is groundless ; as are also the alleged " accumulative " effects of digitalis. DR. LIONEL S. BEALE, ENGLAND, Lays down the rule that in blood-poisoning occurring in the course of renal disease, or when there appears any tendency to this condi- tion, we must never give sedatives. A very little opium may de- stroy life in chronic renal affections. The treatment that must be adopted is free purgation and the administration of sudorifics, and where there is reason to think the kidneys will respond, diuretics, such as certain tartrates, citrates, acetates, carbonates, or nitrates ; but irritating diuretics, such as cantharides, juniper, and the infu- sion of broom, should not be given. The frequent use of the hot-air bath will often keep off renal coma for a long time. This may be given by placing the patient inside of a frame, with his head out, covering the frame with blankets, and heating the interior by means of a spirit lamp, the chimney of which can be covered with an iron tube emerging between the blankets. Headache and nausea are often early symptoms of uraemia, and should at once be treated with sudorifics and purgatives, as elater- ium, gr. ^ ; this drug acts satisfactorily, but must be given with caution for fear of hypercatharsis. The vomiting may be relieved by small doses of creasote, hydrocyanic acid, ice, or carbonate of soda. All patients showing any tendency to uremia require careful watching, and should be visited frequently. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. This teacher remarks (Med. and Surg. Reporter, April, 1879.) that his observation has taught him that in many cases uraemic poisonmg is present in spite of the fact that the secretion of urine is quite free. 4o8 DISEASES OF THE URINARY SYSTEM. In all cases of Bright's disease, where the patient is attacked with persistent vomiting, with a clean tongue, accompanied by headache, dullness, dilated pupils, and diarrhoea, there is probably incipient uraemic poisoning, no matter what the quantity of the secretion may be. In such cases, an excellent agent is benzoic acid; gr. xx may be given every third hour, largely diluted with water. This acid pre- vents the accumulation of the urinary salts in the blood ; it is a diu- retic in the sense that it influences the excretion of solid material. Such cases also require free purgation. Pills containing one drop each of croton oil, may be conveniently used for this purpose. The vapor-bath is also valuable, which may be given in bed by placing hot bricks, wrapped in damp towels, around the patient, under the covers ; or a warm bath may be substituted if the patient is able to take it. Dry cups to the loins should not be neglected, as they aid in stimulating the kidneys. When the benzoic acid begins to disagree with the stomach, as it probably will after three or four days, some other acid may be sub- stituted, as the muriatic, gtt. x, three or four times a day, in an ap- propriate vehicle. NOTES ON REMEDIES. Bleeding. Dr. Hiram Corson has found bleeding from the arm highly bene- ficial. Chloral Hydrate. Dr. Tyson highly recommends it. Chloroform is considered by many an important adjuvant, pushed to its anaes- thetic effects. Morphia. In uraemic convulsions. Prof. A. L. LooMis recommends hypoder- mic injections of half a grain or more of morphia. URIC ACID DIATHESIS. In many cases (Medical World, 1889) of neuralgia, headache, in- flammation of joints and other manifestations of a foreign element in the blood, an investigation will show a dark acid urine, with pos- sibly brick-dust deposit. In such cases excellent results may be obtained from the lithium salts — the bromide if there be much pain, URIC ACID DIATHESIS. 409 insomnia or itching, and the benzoate and salicylate in all cases, combined with aconite and pilocarpin, as follows : 701. R. Litbii bromidi, Lithii behzoatis, Lithii salicylatis, 5£ 5; Tincturse aconiti, mxij Pilocarpinse muriatis, ot. j ^V^' f.ij. M. Sig. — One teaspoonful every hour, gradually increasing interval to three or four hours. When the acute symptoms have subsided, the bromide, aconite and pilo- carpine should be withdrawn, and the other two ingredients continued once or twice daily for an indefinite period. DR. HENRI PICARD. (Jotir. de Med. de Paris, 1889.) As a solvent for uric acid within the system, in the treatment of this diathesis, PiCARD commends the following combination of lithium : 702. R. Lithii carbonatis vel citratis, gr. xv Sacchari pulveris, 3 iss Acidi citrici, 5 ss Sodii bicarbonatis, §ss. M. Fiat pulvis, dividenda in chartulas aa 3 ss. Sig. — A powder containing half a drachm from one to four times daily. He remarks that the English prefer potash to lithium, and sug- gests the following formula : 703. K- Potassi bicarbonatis, §iss Acidi citrici, Sj Aquae, f. % xij. M. One ounce of this last mixture added to three or four of water makes an almost tasteless fluid, and may be given even to children without difficulty. DR. ALEXANDER HAIG. This author has published in various English journals (Lond. Pract., 1888; Brit. Med. Jour., 1889, etc.) numerous articles upon the production of the uric acid diathesis, its relations to health and disease, and its treatment. Dr. Haig looks upon the production of uric acid and of urea as not dependent on each other, but states that in health there is a constant equation (i : 30) between these substances as produced by the economy. There does, however, ex- ist a difference in the proportionate excretion of these matters, and when this occurs it is evidence of disease and a symptom of the gouty diathesis. Dr. Haig states that in an acid condition of the 4IO DISEASES OF THE URINARY SYSTEM. fluids of the body, the uric acid in the blood is not held in solution, but swept into various filtering tissues, as the liver and spleen, or into the tissues of the joints in the distal parts of the body where the circulation is slow. Here it slowly accumulates without produc- ing any especially marked symptoms. However, upon some exces- sive diet of alkaline substances, the fluids of the body become less acid and more alkaline proportionally. This diminished acidity causes an increased solution of the uric acid, which by this alkaline wave is washed out into the current and through the body in in- creased amount. By its irritant properties upon the tissues, espec- ially the walls of the blood vessels, it leads to constriction of the vessels, increased vascular tension, and the headaches and other phenomena of an outburst of gout. Dr. Haig's plan of treatment, then, rests, in the occurrence of the attack, upon quickly throwing out of solution -the uric acid which has been taken up by the alkalinized blood. This he does by ad- ministering some such solution as dilute nitro-muriatic acid. The uric acid being thrown out of solution, no longer circulates, and the symptoms resulting from its irritation and action on the vessels sub- side. During the intervals between gouty paroxysms, he endeavors to gradually dissolve the mass, which he believes when deposited from the blood has settled in the liver and spleen, by such remedies as the salicylates and the alkalies generally. In this manner he cau- tiously rids the system of the excess of uric acid, and thus avoids the occurrence of " uric acid storms " which precipitate the gouty symptoms. PART V DISEASES OF THE NERVOUS SYSTEM. The General Therapeutics of the Nervous System — Apoplexy and Cerebral Hyperemia — Cerebral Ancemia — Chorea — Epilepsy — Headaches — Insanity — Insomnia or Wakefulness — Neuralgia — Neurasthenia — Paralysis — Progressive Locomotor Ataxia (Posterior Spinal Sclerosis) — Spinal Irritation — Spasmodic Diseases — Vertigo. THE GENERAL THERAPEUTICS OF THE NERVOUS SYSTEM. The general resources at the command of the physician in treat- ing diseases, are set forth as follows by DR. E. C. SEGUIN in a lecture in his Opera Minora, 1884: Means which increase the blood supply. The first is posture. By placing the patient on his back, the amount of blood in the spinal cord is increased. In this position, if the limbs and trunk are ele- vated, anaemia of the brain is counteracted. Compression of arteries is another important measure. Tourniquets may be applied to the limbs in extreme cases of cerebral anaemia. Compression of the carotids was used to cut short epileptiform seizures supposed to be due to cerebral hyperaemia. Of stimulants, alcohol is the best; food may also be regarded as a stimulant. Paralyzing the vaso- motor nerves, by producing enlargement of the arteries, is productive of hyperemia in the arterial district to which the nerves are dis- tributed. Of means to produce this result, the most effectual is in- halation of amyl nitrite, gtt. ij-v. In the epileptic aura it is fre- quently efficient in checking the attack. Means which decrease the blood-supply. Of these the most obvious is venesection. This is now out of fashion ; but with symptoms of violent cerebral hyperaemia in a full-blooded subject, it would be proper to use it. Leeches and wet-cups relieve hyperemia, not by abstracting blood, but by irritating nerves, and thus acting on the (411) 412 DISEASES OF THE NERVOUS SYSTEM. vaso-motor filaments. Position, as by raising the part, decreases its blood-supply. In congestion or .other affections of the spine, place the patient upon his face. In some cases of insomnia, the patient can sleep in the sitting posture. Cold, applied continuously, dimin- ishes the amount of blood in a part. The best method of employ- ing it is to apply ice in block immediately to the skin ; or pounded ice in a bladder ; or the ether spray. It is indicated in meningitis and in intra-spinal congestion and in inflammation. Galvanism stimulates the vaso-motor nerves and produces local anaemia; so also will ergot, and in a less degree belladonna. These two remedies are therefore largely used in congestions and inflammations of the nerve-centres. Mental and physical rest are important aids to diminish the blood-supply to the nerve-centres. Cerebral excitants. Alcohol stands first, then cannabis indica, and in some constitutions belladonna and opium in small doses. Emotional excitement is especially indicated where the mind is occu- pied in contemplating delusions. Spinal excitants. Of these the most prominent are nux vomica, and its alkaloids, strychnia and brucia. The indication for their use is simple exhaustion of the nerve-centres, not due to inflammation. They are also valuable in some few cases of chorea, epilepsy and spinal irritation. The dose should be small at first, but pushed rapidly to the point of obtaining the physiological effects of the drug. Quinia is also entitled to a place in this class of remedies. Cantharides seems to act more particularly upon the lower portion of the spinal cord. It is useful in bladder paresis, impotency, and simple genital inertia. (Phosphorus may be used in the same class of cases as the latter drug, in instances of genital weakness, etc.) Cerebral Depressants. Cold may be employed for this purpose, as above stated. Bromide of potassium is a true hypnotic, and valu- able in insomnia, delirium, mental anxiety, etc. Hydrate of chloral is the best medicine for producing sleep. It does not intoxicate nor much disturb the digestive system. It is invaluable with insane patients. A safe dose is gr. x-xv ; but under special necessity this may be doubled or even tripled. The conjoint use of the bromide and chloral is very satisfactory. The usual method is to administer gr. x-xx. of the bromide in the afternoon, following it at bedtime with an equal quantity of chloral ; some writers, however, commend the use of much larger doses. Opium has frequently, especially on females, very unpleasant after-effects. A very small amount of THE GENERAL THERAPEUTICS OF THE NERVOUS SYSl-EM. 413 atropia, added to a solution of morphia, will palliate the nauseating and constipating effects of the latter. Spinal Depressants. The typical medicine of this class is conium. It is the antagonist of strychnia, and can be used with benefit in spasmodic affections. This remedy should be given only once a day. The fluid extract in doses of gtt. v-x, combined with bromide of potassium, is an efficient remedy in chorea and epilepsy. Bromide of potassium is also a spinal depressant, and diminishes reflex excita- bility. It is indicated in morbid excitement of the lumbar part of the spinal cord, as in nymphomania and satyriases. The vomiting of pregnancy, that after the inhalation of ether, and the spasmodic state of various sphincters, are cured by it. In epilepsy it is our chief reliance. Within the past few years a number of the hydro- carbon derivatives have been employed in cases of epilepsy, having probably an action depressant to the cord — notably antipyrin,^ which in doses of gr. v— viij. has been used beneficially, particularly in case of the status epilepticus. Tonics and Restoratives. Two remedies of this class are especially applicable to the nervous system — phosphorus and fats. The vari- ous phosphates, if they do good, do so very slowly, and are of little service in serious disease. Phosphorus itself may be administered in Thompson's formula (see Index), or as phosphide of zinc. Some organizations are very susceptible to this remedy. In cere- bral mal-nutrition, in neuralgia, in spinal irritation, in hysteria, and in varieties of paralysis, this drug is of the highest value. Fatty food, as cod liver oil, etc., is demanded in these same conditions. Of other tonics may be named strychnia, arsenic, zinc, iron, quinia, and cold. Cold may be applied by sea-bathing, the shower-bath, etc. Strychnia as a tonic must be given in small doses for a long period. Arsenic is often marvelous in chorea. In the nervous state produced by alcohol, oxide of zinc is almost as satisfactory as arsenic in chorea. It is best when combined with nux vomica. Quima appears to exert a direct restorative effect on the nerve^centers. Iron does not especially affect the nervous system. Two specific modes of medication may be mentioned here, which relieve many cases of nervous disease by acting on the pathological conditions which cause them. One is the treatment of constitu- tional syphilis by iodide of potassium ; the other the specific medi- cation in malaria. Malarial neuralgia is a frequent affection. A rapid removal of this disease is secured by using quinia in the shape of hypodermic injection over the affected nerve. 414 DISEASES OF THE NERVOUS ■ SYSTEM. Counter-Irritants. The alternate application of cold and heat does much to improve the nutrition of paralyzed parts. The actual cautery is a means of the utmost value in the treatment of nervous affections. A deep burn is not needed, surface irritation being all that is necessary. The cautery, heated to a white heat, should be rapidly drawn over the part selected, four or more strokes, of from one to six inches in length, being made. If properly performed, the pain is not great, sores never result, and even blisters but sel- dom. Setons have gone out of fashion, and properly, as there are grave objections to their use. Blisters are an invaluable means. They should not produce suppuration. Repeat the blisters and heal the blebs as soon as possible. Dry cupping is beneficial in many spinal affections ; their number should be large — from ten to twenty. It is not necessary to apply them immediately over the seat of disease. Wet cups are still used in some inflammatory affeq- tions, but it is doubtful if they act better than the dry, and the irri- tation is greater. Sulphur baths act as a counter-irritant by their ef- fect on the skin. The sulphuret of potassium may be dissolved in water for a bath ; or sulphur may be vaporized while the patient is covered, except his head, by a rubber cloth. Ten or twenty min- utes of this exposure produces a great deal of cutaneous irritation. In locomotor ataxia a series of such baths have done great good, They are also useful in lead-poisoning. Electricity. All three forms of electricity may be used — frank- linic, galvanic and faradic. Within certain limits, all of these have useful applications in nervous disease. Hygienic Means. The principal measures are supporting diet, the relief of constipation, moderate exercise short of exhaustion, etc. Pneumonic affections and bed-sores must be guarded against. With regard to coffee, alcoholic drinks and tobacco, in dealing with those accustomed to their use we should require moderation rather than abstinence, as the nervousness consequent upon giving up an estab- lished habit is worse than the effects of moderate indulgence. APOPLEXY AND CEREBRAL HYPEREMIA. 415 APOPLEXY AND CEREBRAL HYPEREMIA. In cerebral hyperaemia the one great indication is cerebral haematic depletion, and the treatment demanded should be mainly directed to this end. The attack having passed, to strengthen the vessels weak from dilatation is to be accomplished — best as part of a measure generally directed. In apoplexy, the diagnosis made, the treatment varies. In ex- tradural hemorrhages or cortical hemorrhages operative measures come early to mind. In intra-cerebral apoplexies such means of advance are not at hand, and the efforts are to be directed to the removal of the escaped blood by absorption or other like methods, to preserve the patient's condition during this period of removal, and the effort to strengthen the vascular walls. DR. KELLOGG. (Neiv York Med. Jour., 1887.) Cerebral Hypercemia. — In discuss- ing the subject of baths, this author speaks of the very commend- able practice of using tepid baths associated with cool applications to the head and the nape of the neck in cases of simple cerebral hyperaemia. Such measures are very applicable in cases of threat- ened or incipient insanity, where sleeplessness is associated, often having marvellous effects. The bath should be between 80-95 de- grees F., and may be somewhat elevated after the patient is im- mersed. The duration of the bath should not be above 10 or 15 minutes. After the patient has been removed, and rubbed dry, and is in bed, ice bags or other cool applications are to be placed over the head and cervical and upper dorsal spine. Sleep and improve- ment usually come on promptly. DR. EDWARD C. MANN. Cerebral Hyperemia ; Congestion of the Brain. — This diseased condition is a common one of American life. Its treatment, as laid down by Dr. Mann (Psychological Medicine, 1884), is to warn the patient against great elevations and alternations of temperature, ex- posure to the sun, alcohol, and sleeping with the head too low. Dry cups to the back of the neck, hot mustard water to the feet, ice to the head and the nape of the neck, purgatives, fluid extract of ergot Sss to §j, thrice daily, combined with sodium bromide, and the use of cerebral electrization, are all to be used as circumstances de- mand. 41 6 DISEASES OF THE NERVOUS SYSTEM. Where there are a feeble pulse and pale surfaces, stimulants should be used in moderate quantities. Tonics are also demanded, and there is none better in the case of overworked professional and business men than "Warburg's tincture" (see Index) in 5j doses be- fore breakfast daily. It is disagreeable, but should be taken clear on an empty stomach, in capsules, if too unpleasant. Static elec- tricity is excellent in these cases. Change of climate is desirable, and the prompt cessation of prolonged study and overstrain are de- manded. When there is any mechanical impediment to the proper return of blood from the brain, we must do all in our power to keep the heart and lungs working normally. Rest for body and mind is imperative. The application of pressure directly over the carotid arteries, thus reducing in some measure the blood supply, has been proposed, and may be employed in special cases ; the measure has not, however, become of general use. PROF. HUGO ENGEL, M. D., OF PHILADELPHIA. Apoplexy. To be able successfully to treat a case of apoplexy, the following points have to be kept in view : There are four vari- eties — a the congestive, b the hemorrhagic, c the embolic, and d the serous variety. In the congestive variety and in the hemorrhagic variety, when in the latter the same symptoms show themselves, as flushed face, in- jected eyes, throbbing carotids, stertorous breathing, total uncon- sciousness, slow, full pulse, decrease of temperature and hemiplegia, the most successful treatment is : Application of 12 to 16 leeches to anus, (or one or two to the nasal mucous membrane, or withdrawal of a quantity of blood by venesection.) Three or four drops of croton-oil, diluted with same quantity of olive-oil, rubbed into the back of the tongue. Loosening of tight clothing, perfect rest, position of head higher than the body. This is the only treatment which has any effect on these two vari- eties. As soon as the patient revives, means are employed to diminish the arterial flow of blood to the brain, to limit the inflam- mation ensuing, and to cause absorption in case of clot. These ob- jects are best achieved — By perfect rest in the recumbent position (the head higher), in a large, well-ventilated room, which is kept dimly lighted. No visitors APOPLEXY AND CEREBRAL HYPERyEMIA. 417 are allowed ; the patient is not permitted to talk on business affairs ; all excitement is kept from him, as well as all and every exciting or depressing influence, and he is regularly fed on a low fluid, and con- centrated, but bland diet. The action of the skin is slightly stimulated by daily sponging with tepid water. A bladder with ice is applied to the head, until all acute symptoms have vanished. The bowels are kept open by salines, of which Glauber-salt, administered on the empty stomach in the morning, one hour before breakfast, and in a dose sufficient to insure three motions, is the best. Fifteen to twenty grains of bromide (sodium or lithium) are ad- ministered three times daily, two hours after meals, largely diluted with water. In case of throbbing pulse and over-acting heart, two drops of the tincture of the root of aconite are given every three hours, until active symptoms have ceased ; but in case of weak, rapid and irregu- lar pulse, one drachm of infusion of digitalis every four hours is substituted for aconite, and continued until the pulse becomes normal. As soon as the active symptoms have all ceased — never before — the above treatment is gradually abolished, and the following adopted : Gradually increasing doses of corrosive sublimate are continued for about three to four weeks. The following prescription is to be recommended, a teaspoonful representing one-sixteenth of a grain : 704. K- Hydrarg. bichlor. corros., gr- j Sodii chlorid., gf- J™. Aquse destiUat., f-fvij Glycerini, f-§J- M. S.— First, a dessertspoonful in water three times daily, immediately after meals; then three teaspoonfuls (second week), and lastly, one tablespoonful (third week). If then there are still left any residual symptoms (disturbances of special senses, sensation or motion), the hair is shaved off on top of the head, and a large fly- blister (five by six inches) applied to the head, while internally iodide of potassium is administered in gradually-increasing doses, beginning with three grains three times daily in water two hours after meals, and continuing up to fifteen, twenty or more grains. At the same time electricity and manipulation may now be applied to the paretic limbs. Until all sequelae have vanished, the treatment w"h ""°: sive sublimate and iodide of potassium is alternately employed, but the general attention to the secretions is kept up. If the symptons are such as denote the existence of minute aneur- isms, or if the hemorrhage is of an oozing character, fluid extract of ergot hypodermically employed is beneficial. Most cases of the embolic variety evince almost no loss of con- 27 41 8 DISEASES OF THE NERVOUS SYSTEM. sciousness ; but the patient, a victim of chronic valvular lesion, is generally at once seized with paralysis. It is a real paralytic stroke. Here the face usually is pale, the pulse irregular, the heart excited. It is natural that in such a case the treatment greatly varies from the foregoing. Such a patient is kept at perfect rest, the same as in the varieties just described. Attention is paid to the secretions, which should not be specially stimulated, but neither be allowed to be locked up. The physician should first try to prevent a repetition of the acci- dent. The procedure will depend but upon one fact : whether there still is compensatory action in the heart or not. If there is, the pa- tient should be put under the influence of aconite until the excite- ment is past. In most cases, however, compensation has ceased or very nearly so, and infusion of digitalis, f..3j, four times daily, is the treatment indicated. The next object to be achieved is the absorption of the embolus. This is done in the same manner as in the case of a clot frojn the hemorrhagic variety. The treatment of the paralysis also is the same as of that following the first two kinds of apoplexy. The picture of the serous variety is very similar to that presented in cases of large hemorrhagic effusions at the base. They mostly are cases of chronic Morbus Brightii, or of dilated heart, or of gen- eral fatty degeneration. The patient looks pale, the pupils are widely dilated, the pulse is rapid, feeble and irregular, and the patient is utterly insensible to all external impressions, and there is total want of motion. (These cases are to be treated after the manner usually employed in case of Usaemia {quod vide), under which category they properly belong. Convulsions, if happening in apoplexy, can be stopped with hypo- dermic injections of morphia. Often the most important question regarding treatment of apo- plexy, is: Bleeding or not bleeding? If a patient dies, and we have not bled him, people say he ought to have been bled ; if he dies and has been bled, they say he ought not to have been bled. The following rules experience has proven to be the safest : Bleed, if the pulse is regular and below 80. Bleed, if the face is flushed and the eyes are injected. Bleed, if there is hypertrophy or over-action of the heart. Bleed, if it is a case of congestion in a high liver. Never bleed if the pulse is irregular and rapid. APOPLEXY AND CEREBRAL HYPEREMIA. 419 Never bleed if the face is pale. Never bleed if there is valvular lesion of the heart or dilatation of it. Persons with a tendency to apoplexy, or such having had one at- tack, should observe the following : Never take a cold or hot bath (tepid baths or sponge-baths they may take) ; never allow the bowels to be constipated longer than twenty-four hours ; never strain at stool ; keep the circulation quiet. There is one other form of apoplexy demanding special notice. If a person below the age of thirty-five or forty, with no organic lesion of the heart, not the victim of Morbus Brightii, and not sub- ject to epilepsy or to petit-mal, is suddenly seized with unconscious- ness, accompanied by convulsions or not, and sirnulating apoplexy, the attack is caused by syphilis. Mercurial inunction (daily one drachm) or internal administration of calomel until salivation sets in, followed by a course of iodide of potassium in gradually-increasing doses (beginning with ten and increasing up to eighty grains three times daily), until the patient for one year has had no similar attack, and later every spring and every fall the administration of fifteen to twenty gr. doses of the iodide for about three weeks, will prevent further seizures. If the attack was accompanied by convulsions, bromide of sodium in twenty gr. doses three times daily has to be administered, until the specific treatment has made a sufficient im- pression. (The attack itself is to be treated as any other case of apoplexy. DR. WILLIAM A. HAMMOND. Apoplexy. In his treatise on Diseases of the Nervous System, Dr. Hammond observes that the general treatment of apoplexy should be directed, first, to the prodromic stage of cerebral congestion ; secondly, to the apoplectic seizure ; thirdly, to its consequences. I. Inactive cerebral congestion, local bleeding, as cups to the nape of the neck, or leeches to the temples or just inside the nostrils, often affords marked relief. Cold is another very useful agent, ap- plied as ice or cold water to the cranium and nape of the neck. During sleep the head should be elevated. The clothing should be loose about the neck. Sinapisms to the feet, and mustard to the epigastrium, are often of service. Internally, the bromides of potas- sium, sodium, calcium or lithium, are indicated. 420 DISEASES OF THE NERVOUS SYSTEM. 7°S' R- Potassii bromidi, Sj Aquae, f. S iv. M. A teaspoonful three times a day, in a little water. This, continued for about ten days, is usually sufficient to relieve the head symptoms. The bromide of lithium often acts more promptly than either of the others. Dose, gr. xxx. Ergot contracts the cerebral vessels, and is of great value in the treatment of active cerebral congestion, in all its forms, especially in the first or hyper- aemic stage. An excellent formula is : 706. K- Sodii bromidi, §j Ergotae extract! fluidi, f. § iv. M. A teaspoonfvd three times a day. Or the ergotin of Bonjean may be given in pill form, gr. iij-x, ter die. When the pain in the head is a prominent feature, prompt re- lief is often given by 707. R. Extr. fl. paulliniae, f. 3 ss.-j, p. r. n. In conjunction with these remedies, the oxide of zinc, gr. ij thrice daily, is a powerful agent in relieving congestion and giving tone to the nervous system. It should be taken after meals to avoid nausea. After the symptoms of congestion have disappeared under this treatment, it becomes expedient to give tonics and restoratives. Among these, strychnia, phosphorus and cod-liver oil stand first. The following extemporaneous mixture is preferable to any of the manufactured syrups or elixirs, with like ingredients : 708. R. Strychniae sulphatis, gr. i Ferri pyrophosphatis, Quiniae sulphatis, £5 5; Acidi phosphor, diluti, Syrupi zingiberis, i5 f.gjj. M. A teaspoonful three times a day in a little water. Or the following : 709. R. Strychniae sulphatis, gr. j Quinite sulphatis, 2j Ferri bromidi, 5 S3 Acid, hydrobrom. (Fothergill's.) f § iv Teaspoonful in water after each meal. Phosphorus almost always acts well in such cases. It may be given in the form of phosphorated oil, or the phosphorated resin ; or in one of the following formulae : APOPLEXY AND CEREBRAL IIYPERyEMIA. 421 710. R. Olei phosphorati, f. 1 55 Mucil. acaciae, f. § j Olei bergamii, gtt.xj. M. Make an emulsion. Dose, Bfteen drops thrice daily. 711. R. Zinci phospbidi, gr- iij Rosar. conserv., q. 3. m. Make thirty pills. Dose, one three times a day. Arsenious acid, in doses of one-fiftieth of a grain, three times daily, after eating, has a favorable action, especially in those forms of cerebral congestion which have been the result of mental exertion or anxiety. The bowels should be kept in a soluble condition, severe muscu- lar exertion avoided, the stomach should not be overloaded, alco- holic stimulants should be shunned, and the mind maintained tran- quil. When the Ccise demands abstraction of blood, leeches should be applied inside the nostrils. " In no other way can the blood be so advantageously drawn from the brain." 2. During an attack, when there are coma and the ordinary symptoms of the apoplectic condition, there is nothing to be done in the way of medication which can afford the slightest prospect of relief Blood-letting, purgation and the iodide of potassium, do no good at all, and the first two probably harm. The patient should be kept perfectly quiet, with the head well elevated, and in a room with the temperature about 60°, and well ventilated. The bowels, if not moved naturally every day, may be emptied by an enema of warm water ; the urine should be drawn off with a catheter, if re- quired ; the strength, if feeble, as indicated by the pulse, should be kept up by a cautious use of stimulants ; and if the patient is rest- less and does not sleep well, some one of the bromides should be administered. The food should be of the most nutritious character and taken frequently. If symptoms of inflammation make their ap- pearance, cold to the scalp and blisters to the neck are called for. 3. In about two weeks after the stroke it will be proper to take action to restore the power of motion. The means are passive mo- tion, strychnia, phosphorus and electricity. The muscles of the affected limb should be kneaded and the joints flexed and extended, and the surface rubbed every day for five or ten minutes at a time. Strychnia should be administered, preferably by hypodermic injec- tion, in doses of i^ of a grain once a day. In many old cases of 422 DISEASES OF THE NERVOUS SYSTEM. hemiplegia this has an excellent affect. Phosphorus may be em- ployed as follows : 712. R. Zinci phosphidi, gr- "j Extract! nucis vomicae, gr. x. M. Make thirty pills. One three times a"day. No agent is so valuable, however, as electricity. The induced current is usually sufficient for recent cases ; but old cases may re- quire the primary current. The poles, terminated by wet sponges, should be applied to the skin covering the paralyzed muscles, or to the nerves. The interrupted current should be applied. The same agent is valuable to restore sensibility to the parts. J. HUGHLINGS JACKSON, M. D., LONDON. Apoplexy. — Pending the seizure, the chief thing is to keep the patient quiet. Two drops of croton oil should be put on the tongue and the urine drawn off, if it does not pass freely without help. The application of blisters to the back of the neck, or of mustard plasters to the calves of the legs, is a common practice, with no evidence to show that these applications are of service. Still, in certain cases of chronic cerebral disease, blisters relieve the patient of severe pain in the head ; and it is not possible to deny that they may be of service when the circulation of the brain is quickly disturbed after a clot. Were our author to use blisters, which he never does, he, would only employ them where there is secondary disturbance of the circula- tion. It is hard to believe that mustard plasters to the calves of the legs can be of any service or disservice. Dr. Jackson never pre- scribes any medicine, except croton oil, by the mouth. If the patient is found in, or has passed into, a condition in which the face is flushed, the temperature above 100, the veins prominent, and the respiration and circulation largely disturbed, treatment, be- yond, perhaps, purgatives, is of little use. If, however, the pulse be not very rapid, little more than 100, and if it and the respiration be regular, it is not unreasortable to think that the system may be relieved — though the ultimate size of the clot may not be influenced — by bleeding. The practice of bleeding in cerebral hemorrhage, deprecated by TROUSSEAU and ToDD, must be exceeding rare in England, as in the whole course of Dr. Jackson'S life he has seen but one person bled for cerebral hemorrhage. If the pulse be very high, 120, 130 or 150, or if it be weak, venesection must not be thought of APOPLEXY AND CEREBRAL HYPEREMIA. 423 This is about all of the little that can be done for patients who are in the apoplectic condition. When this condition is passed, we are practically unable to help in the immediate difficulty of infusion of blood in nervous tissue. We have still, as in many other diseases, to improve the general health. The proper care of a patient who has a clot of blood in his brain, and who is liable to have more effused, consists in attending to his diet, excretions, sleep and exer- cise. Yet there is nothing in this peculiar to the treatment of cere- bral hemorrhage. For the immediate lesion, blood in nervous tissue, our author knows of no direct treatment. DR. ALLEN M. HAMILTON, OF NEW YORK, In his work on Nervous Diseases, speaks very highly of hydrohromic acid in cerebral hyperaemia. He gives the following formula : 713. U. Sol. acidi hydrobromici, Elixiris simplicis, aa f. § ij. M. A teaspoonful before each meal. As a prophylactic measure, he has patients apply cold (ice-bag, etc.,) to the back of the neck for fifteen minutes, night and morning, " and finds it succeed admirably. It is of great importance to im- prove the cutaneous circulation by the flesh-brush, cold, the Turk- ish bath, etc. His treatment of the attack and sequelae agrees substantially with that given by HAMMOND. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. To allay cerebral irritation and excitement, prussic acid has been employed with benefit. We should use from two to five minims of Scheele's dilute acid, giving it at first at short intervals (every quarter of an hour) and, when efiects are produced, every hour or two. It is also employed subcutaneously, in five-minim doses. NOTES ON REMEDIES. Acidum Arseniosum is of benefit in strong plethoric subjects with a tendency to apoplectic congestion, but it is not applicable to old, weakly per- sons. It is supposed to act by reducing the excess of the red globules of the blood. Hamilton esteems it most when the circulation is slug- gish, and suggests : 714. R. Sol. potass, arsenit., • r^ Quinise sulph., 3 ^^ Acidi sulph. aromat., ^v'*. ^ Aquse anisi, ° '^' A tablespoonful every four hours. 424 DISEASES OF THE NERVOUS SYSTEM. Acidum Hydrobroviicum. Fothergill's hydrobromic acid is of great value in cerebral hyperemia. Dr. D. C. Wade, of Detroit, combines it with ergot as follows : 715. R. Ergotse extract! fluidi, Syrupi simplicis, aa f. 3 ss Acidi hydrobromici diluti, f-Sj- M. A teaspoonful in water as required. He says of this that it surpasses any other combination he has ever tried, rapidly reducing symptoms of plethora and the determination of blood to the brain. Aconitum. In simple apoplexy in plethoric persons, with full pulse, hot skin and flushed face. Dr. C. D. F. Phillips thinks aconite " decidedly the best" remedy that can be employed, nij. of the tincture of the root every half hour. It should be avoided when the heart is weak and the face pale. (Materia Medica, 1879.) Bromides. These are recommended by all recent writers for diminishing arterial tension and cerebral blood pressure. They may be combined with ergot (F. 706), with aconite if cardiac action is violent, or with digitaHs if the heart is weak ; as 716. R. Tinct. aconit. radicis, f-3j-ij Sodii bromidi, § iss Aquse menth. piper, ad f. § iv. M. A teaspoonful three times a day. (Hamilton.) Digitaline — granules (one sixtieth of a grain bis die) — will not unfrequently permanently relieve the congestive form of hemicrania, especially where the hemicrania is associated with cardiac weakness. Ergot is a powerful cerebral anaemiant. It may be given in 5-gr. doses of the watery extract thrice daily, alone or combined. Dr. N. S. Foster (Lancet, September, 1878,) uses ergotine, gtt. xij of a solution gr. x to aquae f.3 j, injecting it deeply into the muscles, to avoid suppuration. When the patient was seen early, his success was striking. Dr. Emer- son (Amer. Lancet, 1887,) also commends its use, and has known it to effect marked beneficial results in passive cerebral congestion. Hydrargyri Chloridum Corrosivum. Dr. Headland recommends for the threatenings of apoplexy in old age (e. g., vertigo, confiision of ideas, and general embarrassment of the mental faculties), corrosive subli- mate in doses of gr. ^V in solution, three times a day, for three or four weeks. Hydrargyri Chloridum Mite. Administered as recommended by Dr. J. Cop- land (grs. x-xv, mixed with a few grains of gamboge, lubbed up with butter, and placed at the root of the tongue), calomel, although a speedy and effectual purge, is not unattended with danger. Alarming ptyalism has followed this treatment. APOPLEXY AND CEREBRAL HYPEREMIA. 425 Fotassii lodidum has been recommended in cerebral apoplexy, on account of its eliminative power, after the acute symptoms have subsided. Strychnia. Dr. Marshall Hall has derived great benefit from the use of acetate of strychnia in the threatenings of apoplexy. He advises the following formula : 717. B. Strychniae acetatis, gr. j Acidi acetici, TIlxx Alcoholis, f. 3ij Aquae, f. 3vi. Dose, ten drops, combined with a rigid system of mental discipline, diet, etc. Verairum Viride. Dr. Roberts Bartholow says there can be no doubt that this drug renders valuable service in acute parenchymatous congestion of the brain. Dr. H. C. Wood esteems it of value in all cases where local depletion is indicated, as it acts to the dilatation of the large vessels — and, as it were, " bleeds a man into his own veins." GENERAL REMEDIES. Operative Measures : In meningeal hemorrhages, due usually to rupture of middle meningeal artery, or of one of its branches, from trauma or other cause, the question of relief of the cerebral compres- sion by the clot is to be considered (vide Surgery) by means of trephining. Blood letting is no longer the routine practice in apoplexy. M. Constantin Paul, however, believes that bleeding may be of service in apoplexy, not as affecting the cerebral lesion, but as acting on the apoplectic condition, on the asphyxia and stasis of blood in the veins. He has seen the condition of such patients very markedly improved. It is now generally recognized that there is less danger in not bleeding at all, than in taking blood in doubtful cases, in which there may be some of the indications for bleeding. The co7itra-indications of bleeding in apoplexy are an age over sixty, a feeble, very frequent, intermitting, slow or large pulse, or one inclined to double beat ; a respiration labored and accompanied with cold per- spiration ; great mobility of the nervous system, with weak muscles, whether the body be thin or corpulent ; an attack soon after a full meal, or after great mental or bodily fatigue. The indications for bleeding are a quick, wiry, resisting pulse; flushed countenance ; warm perspirations ; noisy breathing ; a ten- dency to spasmodic muscular contraction ; and an age under sixty. Cathartics. In all cases of cerebral plethora, the bowels should be kept sol- uble. Aloetic preparations are said by some writers to be specially derivative ; others prefer the regular use of Friederichshall, Hunyadi Janos, or other similar mineral water. In an apoplectic attack, purga- 426 DISEASES OF THE NERVOUS SYSTEM. tives are indicated. One to two drops of croton oil on the back of the tongue, will bring on purgation when the patient is unconscious. When conscious, J^ grain of elaterium with % gr. nux vomica makes an efficient pill. Diffusible stimulants may be given with advantage, particularly when the pulse has a double beat, in atonic cases where bleeding is contra-indicated. Aqua ammonia is one of the best of these : rti,xij-xv may be adminis- tered in water, and the vapor also applied to the nostrils. Or f..^ss-j of the aromatic spirits of ammonia may be given in water or camphor mixture. Or grs. v of the carbonate of ammonium may be ordered. Enemata. Terebinthinate and other enemata often afford relief, not only by removing scybala, but by their powerful revulsive action. EXTERNAL REMEDIES. Counter-irritation. Capsicum cataplasms to the feet are powerful and ex- cellent revulsives, which will, however, cause vesication if kept on too long. Sinapisms to which have been added powerful capsicum, or oil of turpentine, may, in most instances, be applied with evident benefit, to the soles of the feet and inner parts of the calves and thighs. Blisters applied to the calves of the legs and sometimes to the nape of the neck, are of benefit in simple or " serous " apoplexy, but of little advantage in sanguineous apoplexy. An open blister at the nape of the neck (or better, a seton or issue there,) is often very useful when there is a tendency to apoplexy. Turpentine stupes to the extremities are frequently productive of benefit. Electricity is considered by Dr. Hammond an invaluable agent for the relief of the sequelas of an apoplectic attack (p. 422). It will generally be found to restore the sensibility of the part before removing the motor paraly- sis. The electric wire brush and the wet sponge are the appliances most frequently demanded. In recent cases this will almost invariably prove effectual. Hypersesthesia, which is sometimes a troublesome legacy of the cerebral extravasation, may be similarly managed. Galvanism. According to Dr. Roberts Bartholow, galvanization of the brain and of the cervical sympathetics is one of the measures to be resorted to in acute active or passive congestion of the brain. Galvanization in cerebral hyperaemia has been found of much efficacy by Dr. C. H. Hughes, of St. Louis. He says that an essential property of the constant descending galvanic current in induced cerebral hyperaemia is that of a tranquilizer of irritable nerve tissue, secondarily contribut- ing to the contraction of over-distended vessels. It acts on the irri- table brain like bromides, hyoscyamin and chloral, vaso-motor results being secondarily induced when there is over vascular distention as well as primarily accomplished. (Alienist and Neurologist, 1884.) CEREBRAL ANEMIA. 427 Ice applied to the head while the feet are immersed in hot water, is sometimes productive of benefit, but must be employed with great caution in debilitated or old subjects. Dr. Bartholow is of opinion that ice is often used without due discrimination. When the face is pale, the surface cool and the circulation depressed, cold applications to the head are harmful. On the other hand. Dr. James M. Goodhart, of Guy's Hospital, London, believes that the indication to restrain the hemorrhage is so imperative, that the application of cold locally is very generally called for, although its employment seems rather contradic- tory to the general course of treatment otherwise required. Leeches. In threatened apoplexy arising from the suppression of an habitual discharge, as from piles, leeches applied to the verge of the anus often afford prompt relief. If the threatened attack arise from suppression of the menses, the leeches should be applied to the inner side of the thighs. Sir Henry Holland states that he knows of no mode in which a given quantity of blood can be removed with equal good effects. Leeches to the verge of the anus give more immediate benefit than three times the number to the temples or elsewhere. CEREBRAL ANEMIA. DR. EDWARD C. MANN. According to this author {Psychological Medicine, 1884), the first essential of treatment in this disease is to obtain rest of both body and mind. Alcohol, preferably in the form of old rye whisky, is useful. The constant galvanic current is a valuable remedy. Strychnia, in doses of gr. tV, is one of the most certain drugs. Cod- liver oil and phosphorus are also indicated. When spinal ancemia is also present, the first great means of cure resides in the judicious employment of counter-irritation to the af- fected portions of the spine. The compound mustard liniment is one of the most suitable agents for this purpose. It should be ap- plied on flannel and the virhole covered with oil silk. A full nourishing diet is necessary, and as soon as the system is somewhat improved, change of scene, traveling, and cheerful so- ciety, are to be recommended. 428 DISEASES OF THE NERVOUS SYSTEM. NOTES ON REMEDIES. Arseniosum Acidum, in the form of Fowler's solution, gtt. ii-iij, thrice daily, combined with the same quantity of laudanum, three times a day, has been exhibited with excellent results in some cases by French phy- sicians. Auri Chloridum is stated by Dr. Bartholow to have a high degree of utility when there is present the condition of cerebral anaemia. Ferrum. As in all cases of anaemia, the preparations of iron are of use. The chalybeate waters offer an excellent method of administering it. Where there are epileptoid seizures, Bartholow recommends the fol- lowing : 718. g. Potassii bromidi, § j Ferri bromidi, gr. iv Aquas, f. g ij Syr. simplicis, f. § vj. A tablespoonful twice daily. Boy-Teissier ( Marseille Medical, February, 1889,) recommends the sesquibromide of iron in cases of chlorosis, associated with nervous symptoms, in doses as in above prescription. Pasquet (Gaz. Med. de Montreal, V. 2, No. 8, 1888,) suggests the following prescription in the same class of cases : 719. R. Tinct. ferri. cMoridi, f.gj Quiniaesulph., 3j Solve et adde Potass, bromidi, § j Aquae fontis, f. § xxiv Liq. potass, arsenitis. f. 3iiss. M. Sig. — Dose for adult, two teaspoonfuls to a tablespoonful in a little water after each meal. Nitro-glycerine has a remarkable power to develop cerebral hypersemia, and is therefore of value in transitory cerebral ansemia. The dose is gtt. riu. (Hammond.) Phosphorus and the Phosphates are applicable in these cases through their stimulating action on the nutrition of the brain substance. CHOREA. In this affection the indications are, the checking of the motor spasms by sedatives, the removal of possible irritative reflex causes, the maintenance of irritation, the establishment of rest; and as a CHOREA. 429 measure of precautionary value, the heart is to be watched closely for the establishment of chronic and deforming endocarditis. DR. A. W. HAMILTON, NEW YORK CITY. This writer gives the results of his observation with various drugs in the New York Medical Journal, February, 1877. He has found strychnia serviceable carried up to the point where stiffness of the sural muscles is arrived at. Next to this comes arsenic. It must be given in large doses. Occasionally, digestive troubles are pro- duced very quickly by this drug, and then strychnia may be sub- stituted. Dr. Wm. a. Hammond closely agrees with the author in the use of these remedial agents ; and has found good results from the use of the following: 720. g. Zinci bromidi, 3j Syr. simplicis, f. Sj M. Sig. — Ten drops ter die, increased as rapidly as the stomach can bear it. Dr. Hammond would rely mostly, however, upon strychnia. 721. R. Strychniee sulph., gr. ij Aquae, f. § j. M. Sig. — Five drops ter die to a child of ten to fifteen years of age. Cold to the spine cannot be overestimated as a plan of treatment ; either the ether-spray, or ice-bags every day, allowing them to stay on about ten minutes. Perroud, who has used the ether-spray, makes applications from four to eight minutes in duration every day. In thirty-five cases treated with the ether-spray, from fifteen to twenty applications produced permanent benefit. The spray should be directed to the upper part of the cord, over the upper cervical vertebrae. Eserine has been recommended, and BOUCHUT has given the results of four hundred and thirty-seven cases, two hundred and five who took it in pilular form, and two hundred and thirty-two hypodermically. The average dose was from two to five milligrammes. He obtained temporary benefit, which seemed to wear off; but when the drug was repeatedly administered, he ac- complished many cures. He reports twenty-three cures by an aver- age of seven injections. It is a dangerous remedy, however, and produces severe gastric symptoms. Conium is occasionally efficaci- ous, but its effects are temporary. Phosphorus, with cod-liver oil, is a most valuable curative agent, and in cases where everything else 430 DISEASES OF THE NERVOUS SYSTEM. failed, it has succeeded. Prof. J. M. Da Costa has had excellent results from the use of ferric bromide, administering it in doses of gr. V, to a child of lO or 12 years, and increasing if the patient bears it until benefit is derived. In some instances, nothing does good. Put them in a dark room, and keep them perfectly quiet. The diet should be regulated with judgment. Plenty of fresh air and sleep come next, and absolute mental rest must be enforced. The school- books and the school-room are to be parted from, and agreeable diversions planned. An excellent auxiliary to medication is the salt- bath. A handful of rock-salt in the water, and the energetic use of the rough towel, will infuse a tone and vigor that will soon be- come apparent. Decided medication is useless in these patients when their personal habits are not looked after. DR. LEGROUX. (Rev. Mens, des Maladies de VEnfance, March, 1888.) This writer recommends highly the use of antipyrine in the treatment of this affection ; he reports six cases treated successfully by himself (the shortest case terminating in six, the longest in twenty-seven days). He would give the drug freely, as much as gr. xv ter die to a child of ten or twelve years. Other writers, as MONCORVO, of Rio Janeiro, VOLNER, NeGRIe and DUMM, BOUSSI, LAURENfIN, Wood, Anderson and Simon agree in commending the drug in this disease. In this connection it should not be forgotten that certain patients show an idiosyncrasy toward this drug, which may manifest itself by conditions of greater or less collapse, or the development of urticaria, or a coryza. Small children are, however, not so liable to such unpleasant effects as older persbns. DR. EDWARD C. MANN. The treatment adopted by this author he reports as having given most satisfactory results {Psychological Medicine, 1884). He en- deavors to give the nervous system rest and nutrition, the former by avoidance of excitement, early hours, and warm baths at bed time ; the latter by using phosphates, cod-liver oil, or the oil in con- nection with the phosphide of zinc, gr. ^v, thrice daily. Gentle gymnastic exercises are valuable and should not be neglected. The specific, however, is arsenic, in the shape of Fowler's solution, used hypodermically. Three minims, mixed with an equal amount CHOREA. 43 1 of water to avoid irritation, are injected subcutaneously for a week every other day, increasing two minims each week, and in a month or six weeks a cure will be obtained, though in old cases sixty or seventy days may elapse before a cure is complete. Marked im- provement is always noticed from the first by this plan of treatment. The gastric disturbances which are noticed when the medicine is given by the mouth are avoided, and the good results are obtained much more rapidly. , Dr. J. K. Chambers, of London, commends the use of arsenic highly, combining cod-liver oil and iron where indicated. He calls attention to the necessity of preventing undue self-attention in these cases, and urges that they be kept constantly interested, that mir- rors be removed from their apartments, and that they should be given the advantages of frequent change of scene. PROF. BOUCHUT, OF PARIS. This eminent writer classifies the forms of chorea and their treat- ment as follows : 1. Verminal chorea, from worms. Santonine, or if taenia be sus- pected, male fern, or kousso. 2. Dental chorea, from irritation of teeth. Remove the offending tooth. 3. Ancsmic chorea, seen in convalescence. Iron, quinine, arseniate of iron and soda, &c. 4. Chorea from moral cause. Isolation, rest, antispasmodics, firm government. 5 . Partial chorea, where the affection is partial, limited to a single limb and monoplegic. Subcutaneous injections of morphia, and sulphate of eserine, tincture of gelseminum, &c. 6. Organic chorea, that is, resulting from the organic nature of the malady. "All remedies which have power to disperse the congestion of the spinal cord, as ether-spray, douches, sulphur baths, vesica- tories, cauterization, &c. M. Bouchut prefers dotted cauterization yjxthfusain, euonymus, europczus, and daily hypodermic injections of morphia, or valerianate of ammonia. The drugs he employs are opium, emetics, arseniate of soda, chloral hydrate. He lays great stress on procuring sleep, and says that he has made children sleep fifteen and eighteen hours a day for eight and ten consecutive days, by administering chloral to them. After breakfast at eight o'clock he gives forty-five grains of chloral. The child is roused for its 432 DISEASES OF THE NERVOUS SYSTEM. dinner, two hours after which a similar dose is given ; it wakes to- wards evening, and on being fed, enjoys a natural sleep. He has never seen any ill effects from this remedy in children. PROF. WILLIAM AITKEN, M. D., EDINBURGH. The indications of cure are : i . To remove, if possible, all morbid states of the body which may tend to aggravate the disease, such as constipation, anaemia, amenorrhoea, worms. In this connection may be mentioned the experience of Dr. GEORGE T. STEVENS, of New York, in the ocular factor in the aetiology of chorea. This writer {Transactions of New York Academy of Medicine, 1876,) regards chorea as frequently dependent upon anomalous refraction, and has found that not rarely stubborn cases have promptly disappeared upon the correction of such faults by suitable glasses. This suggestion of Dr. STEVENS is not in entire accord with Dr. G. E. DE SCHWEINITZ (New York Med. Jour., Jwte 23, 1888J, who finds the co-existence of ocular errors and chorea not especially in- creased above the occurrence of such errors in normal children. Pathological conditions of the nasal and pharyngeal mucous membrane may also be at the bottom of the affection, and such factors should be eliminated. 2. By well-regulated purgative medicines to subdue any cerebral congestion. 3. To sustain the strength and improve the vigor of the nervous system by tonic and stimulant medicines, by food, and by the cold bath. 722. R. Camphorse, 9v Syrupi, q. ». M. Divide into twenty pills. One three times a day. Useful after discbarges have be- come healthy by the action of the purgatives. 723. R. Spiritfls ffitheris nitrosi, f. §j Aquae camphone, f. | iij." M. Tablespoonful three times a day. Many young women, who attribute the attack to fright, get well under this treatment. THOMAS HILLIER, M. D., LONDON. 724. R. Liquoris potassii arsenitis, THij Potassii bicarbonatis, gr. iij Potassii iodidi, gr. jj Aquae camphorse, f. § ss. M. For one dose, thrice daily, to children aged five, for aggravated chorea, attended with severe pains in the limbs, and rheumatic persistent swellings. CHOREA. 433 Arsenic in full doses is a valuable remedy in a fair proportion of cases, but in some instances it entirely fails. Iodide of potassium is useful when the patient is subject to chronic rheumatism. Occasionally purgatives and tonics, especially iron, are attended with much success. Strychnia, so highly recommended by TROUS- SEAU, seems, to our author, to be really injurious in the acuter stages of the disease ; in the more chronic form, and where there is a tendency to paralysis, it is of service. Iron and strychnia may be combined thus : 725. B. Sttychniae, gr. J Vini ferri, f. § iv. M. A teaspoonful, thrice daily, to a child ten years of age. Narcotics, such as opium, belladonna, cannabis indica, or conium, are of little or no use. Antispasmodics, such as valerian and assa- foetida, are also useless. Our author has seen good results from the employment of baths of sulphur et of potassium: 726. Jt. Potassii sulphureti, § iv Aquse (90° F.), O xxx. For a bath; the patient to remain in it for an hour daily. This bath is also recommended by Dr. Felix VON NiEMEYER, when there is anaemia. Gymnastic exercises, shampooing and passive movements, are of service. As many muscles as possible should be exercised, without fatiguing any of them. Shower baths are useful in the latter stages, when the patient is not timid, or too much excited by them. Dr. NiEMEYER quotes Benedikt, who declares that out of more than twenty cases of chorea, treated by him by the constant gal- vanic current, not one has failed to recover. The current which he employs is just strong enough for the patient to feel it distinctly, and he applies it along the spine, the patient standing erect. Pain- ful currents aggravate the symptoms. G. H. BARLOW, M. D., LONDON. In ordinary cases the exhibition of purgatives to keep the bowels freely open, and the sulphate of zinc, in doses gradually increased from gr. j-xij-xv-xx, or even more, will effect a cure ; when, how- ever, the sulphate has been used in these large doses, its sudden discontinuance seems to be felt by the system, and a return of the 28 434 DISEASES OF THE NERVOUS SYSTEM. symptoms ensues. The best rule, therefore, for its exhibition is as follows : The bowels being kept open, the sulphate should be commenced in doses of gr. j, for a child ast. twelve years, and this should be in- creased by the addition of gr. j to each dose daily, until it either causes sickness, or there is an obvious diminution of the choreic movements. In the former case, the dose should be diminished by at least one-half, and so continued for several days, with a view of establishing a tolerance ; but if, on the other hand, there be marked improvement, it should be no further increased, but continued with- out alteration until either the improvement ceases — in which case it should be again gradually increased— or the disease has altogether subsided. When the latter is the case, the dose should be dimin- ished day by day, rather than discontinued suddenly, as by following the former course, we have less reason to dread a relapse. When anasmia is present, iron has more control over the disease than zinc. The sulphate of iron may be combined with the zinc. HSPITAL DES ENFANTS, PARIS.. The means of treating chorea more particularly employed at this hospital, are the tartar emetic plan advocated by GiLLElTE, and still employed by ROGER ; gymnastics, advocated by Blache ; and sul- phurous baths. The tartar emetic plan is this : Three days' treat- ment : during the first day, three to six grains of the remedy, (ac- cording to age;) during the second, five to ten grains; during the third, eight to twelve grains ; then three days' rest ; then three days' treatment; commencing the new series with a dose one grain stronger than in the first series — to end with a third turn, often at- tended by good effects. Gymnastics are highly beneficial in milder cases of chorea, and in the declining stage of the severer forms. As much may be said of sulphurous baths. The other means employed at the hospital are: Opium, chloroform inhalations, salt baths, hydrotherapy, tonics, etc. Strychnia, so warmly advocated by Prof. Trousseau, is scarcely ever employed at the Hopital des Enfants. TREATMENT BY ENFORCED REST. A number of writers have reported favorably of the treatment of chorea major by absolute and prolonged rest in bed. Dr. W. F. Wade, (British Medical Journal, December 28, 1872,) gives the patient a sufficiency of good plain wholesome food ; keeps CHOREA. • 4, - her in bed, in order that the muscular and nervous systems may have the greatest attainable repose, and thus prevent wear and tear. This also secures a uniform warm temperature. He prescribes two tablespoonfuls of compound decoction of aloes twice or thrice a day, if there is constipation. This is all that is necessary in many cases • but if improvement is not going on satisfactorily, he gives sulphate of zinc, in doses of two or three grains, three times a day, in water, and increases the dose until each dose produces slight nausea. In the Chicago Journal of Nervous Diseases, April, 1877, Dr. Ransom Dexter relates a case of chorea major in which many remedies had proved inefficient, and which was much improved by such absolute rest as was obtained by closing all means of external irritation. The patient was kept in bed, the room was darkened, the eyes bound up, and the ears plugged with cotton. The result of this procedure is very satisfactory. Dr. John Van Bibber, of Baltimore, has tried a modified plan of this treatment with success, (Transactions of the Medical and Chi- rurgical Faculty of Maryland, 1878.) He states that mere confine- ment in bed in a hospital ward is not sufficient. The presence of other patients, the passing to and fro of nurses, the bustle of admin- istration, and numerous distractions, would give to a choreic patient much cause for restlessness. Unless the rest is without interruption or irritation, it will be found, if not useless, of little benefit. Hence, it is necessary to provide an apartment for the patient where the blinds can be closed to avoid irritation by the eyes, absence of noise to avoid excitement by the ears, absence of any conversation to render the mind as quiet as possible. Add to these requisites an attendant who can be still and patient, the advantage of good nourishment and necessary medicine, and this is a system which is essentially gc^od and curative. To prevent the patient being injured by too long confinement, he employs massage, once or twice daily. Bastian {^London Lancet, July 6, 1889) treated a case by pro- longed rest, inducing almost continuous sleep by means of chloral and potassium bromide for two weeks. At the end of this period the patient was allowed to remain awake as desired for a week, and then put asleep for three weeks — only permitting short waking hours daily for feeding. This, as well as 8 or 9 other cases men- tioned as thus treated during the two years previous, was successful. Gairdner (London Lancet, August 3, 1889) also reports several cases treated by means of chloral successfully. 436 DISEASES OF THE NERVOUS SYSTEM. NOTES ON REMEDIES. Acidum Arseniosum is highly recommended by numerous authors. Dr. A. Flint says it has stronger testimony than any other drug. Dr. Begbie, who, in an experience of thirty years, states that he has never known it to fail, prescribed gtt. v. of Fowler's solution twice daily, after a meal, and added one drop to the dose every day, until the specific effects appeared, when he suspended it for a time. Dr. Eustace Smith, of London, remarks that the tolerance of children for arsenic is a matter of common observation, and this tolerance is especially marked in the case of non-febrile disease, such as chorea, where there is no increased irritability of the digestive organs. To a child between the ages of five or six and twelve, the subject of this complaint. Fowler's solution may be given in doses of lo minims three times a day, directly after meals. The influence of this treatment upon the disorder is seen almost im- mediately, and it is rare for any of the physiological effects of the drug to be observed. By this means, cases of the disease which had resisted smaller doses of arsenic, may be cured in a few days, and even severe cases seldom last longer than a fortnight or three weeks. Anilin, first employed by Dr. James Turnbuix, is also recommended by Dr. F. E. Anstie. The dose is gr. i-iij. thrice daily, of the anilin sulphate. It is a white powder, easily taken. Antitnonii et Potassii Tartras is recommended by Dr. C. West, in acute cases, given in full doses. Dr. Thomas Hillier, however, condemns its use (which he has found inutile) as a depressing remedy, ill adapted to a disease like chorea, of weakly, badly-fed children. In French practice, it is advocated by Gillette and Roger. (P. 434.) 'Camphora is a remedy in which many physicians have considerable confi- dence. The monobromide is said by Dr. Lamande, of Paris, to cure some cases with great rapidity. Chloral, by its hypnotic effect and the consequent ameliorating influence of the sound sleep it produces, has been found of benefit in many cases. Chloroformum Purificatum. Chloroform inhalations are not approved of by Dr. C. B. Radcliffe, unless alcoholic stimulants are given before the inhalation. Friction along the course of the spine, night and morning, with a liniment composed of equal parts of chloroform and oil of almonds, is beneficial in some cases. Cimicifuga is highly recommended by many physicians. Prof. A. STiLLfe considers it as one of the most valuable remedies in this disease in pure uncomplicated cases, given in doses of sufficient strength to develop its specific effects. Dr. Sydney Ringer, however, finds it only effectual in cases of rheumatic origin, and even in these he prefers arsenic. Prof. H. A. Hare, in his lectures on diseases of children, recommends this drug given in the form of the fluid extract in doses of twenty or CHOREA. 4,- thirty drops, as the most valuable remedy next to arsenic in the treat- ment of chorea in the young. Conii Succus. To insure good effects from this drug, Mr. J. F. W. Siek (Lancet, 1883,) says that it must be given in large doses, and that its action must be sustained by frequent repetitions of the dose at short intervals. The uncertainity of the action of given specimens of succus conii necessitates great care in its administration, and militates against its general adoption. But cases in which neither chloral nor morphia have any effect may arise, and in which, as in the above, succus conii may prove effiacious. Drs. Clifford Allbutt, Eddison, Harley and Churton have obtained good results in the treatment of chorea, with violent movements, by large doses of succus conii. The patients took from 3 ij every hour to 5 ss every four hours during two or three days. It was given sometimes alone, sometimes in combination with morphia or bromide of potassium. It seems that the best results are obtained by large doses at first, until the system is thoroughly under its in- fluence, when smaller doses, frequently repeated, will continue its action. No toxic effects were ever noticed in these cases. Cuprum Ammoniatum once enjoyed a high reputation in the purely nervous form of chorea. Electricity. Prof. H. Nothnagel highly recommends the constant current, combined with tepid bathing or the application of ice-bags to the spine. Dr. Dana (Arch, of Pcediatrics Apr., 1888.) recommends careful daily anodal galvanization of the brain, a current of from one to three milliamperes being employed, the positive electrode upon the head, the negative to the abdomen. Ferri Bromidum is much used by Prof. Da Costa and others. Ferri Carbonas is often a useful remedy. Ferri Oxidum Hydratum in large doses (^ss-j increased to jiii-iv, every six hours) is highly recommended by Drs. Elliotson and Wilks, con- joined with the use of active purgatives. Children readily take yi drachm doses in treacle. Ferri et Quinice Citras has also been found useful. Hamilton says digitalis often increases the benefit of iron preparations. Iiydrobromic Acid in the post-hemiplegic cases is, according to Anders (Med. and Surg. Reporter, 1887), of more value than the salts of this acid. Hyoscyamin in doses of sV gr., at first twice daily, increased in frequency, is praised by Drs. Oulmeot: and Laurent. In post-hemiplegic chorea, Erb {Therap. Monatschrift, 1887,) has 438 DISEASES OF THE NERVOUS SYSTEM. seen good effects from hyoscine, either as the hydrochlorate, hydro- bromate or hydroiodate in doses ol gi-rin-zh-n- MorrhucE Oleum is very favorably spoken of by Drs. F. E. Anstie, C. B. Radcliffe and Thomas Hillier, in cases of chorea in scrofulous children or those of spare habit. Dr. Raixliffe generally gives the oil in conjunction with hypophosphite of soda (gr. v-viij), making the draught containing the hypophosphite the vehicle for the oil. Some- times he adds carbonate of ammonia to the solution of the hypophos- phite ; and sometimes dissolves camphor in the cod-liver oil, thus masking the taste of the oil and making the stomach more tolerant of it. Moschus has been employed with benefit, but generally fails. Nux Vomica was employed by Rougier in minute doses gradually increased. Trousseau preferred strychnise sulphas (which see). Oleum Terebinthinm is sometimes given with the view of obtaining its anthel- mintic, purgative and stimulant effects. Opium is tolerated in very large doses in this disease, but Dr. Radcliffe's experience is not favorable to its use. Phosphorus is favorably reported upon by a number of physicians, as a rem- edy in this disease. Physostigma has been used with success by Drs. Harley and Ogle. The latter gives : 727. R. Pulveris physostigmatis, • 3i Alcoholis, f.Sj. M. Begin with 20 minims, thrice dailj', and increase, by 10 minims a dose, to f.3j. Potassii Bromidum has proved a failure in the hands of Dr. Ramskill, but has been favorably reported upon by a number of French physicians. Auri Bromidum is mentioned favorably by Dr. Goubert (Ann. Therap. Med.-Chir., June, 1889), beginning with o.i grain and increasing daily by A grain until sleep is produced. Potassii lodidum is considered useful by Dr. Hillier in cases of chorea oc- curring in children subject to chronic rheumatism. It is also bene- ficial in patients tainted by syphilis or scrofula. Quinim Sulphas has been employed in some cases with advantage. Santonin proves often valuable, by disclosing the unsuspected cause of the choreic movements, viz., worms. Sodii Arsenias is useful in those cases in which other arsenical preparations are badly borne. Sodii Salicylas has been found of some value by Dr. S. Weir Mitchell ; and it has been well spoken of by Dr. Dresch. (Bull. Gen. de Ther., 1879.) CHOREA. . 439 Stanni Chloridum has been employed in doses of gr. Yt \.o "%, three times a day in pill, or dissolved in hydrochloric ether. If it increases the symptoms at first, this is regarded as a good omen. If it be followed by gastro-intestinal irritation or dryness of the throat, it must be stopped or the dose lessened. StrychnicE Sulphas is recommended by Trousseau. Its effects should be carefully watched, and its administration confined to obstinate chronic cases. Valeriana is recommended by some writers. Vinum. Dr. William Strange (Brit. Med. Jour., 1881,) gives a purge to clear out the primse viae and then administers f.| iij-vj of port wine daily. This simple treatment cures most cases. Zinci Oxidum is generally considered inferior to the sulphate of zinc. Zinci Sulphas is very highly recommended by some physicians, (Barlow, GoLDiNG Bird and West) but in the hands of others (StOne, Hillier, etc.) it has not fulfilled expectations. Some authorities say that it only does good up to a given time, which is shown by the patient's complexion assuming a bright and clear color ; also, that when this point is reached, the zinc not only becomes injurious, but if continued marked anaemia shows itself. Should this state of things happen, iron combined with the zinc sometimes does good ; as a rule, however, iron and quinine act much better. According to Bristow, the lule to be followed in giving sulphate of zinc, is to begin with doses of a grain or two three times a day, ■ which are slowly increased by successive increments until from 20 to 40 grains are given at a time. In the less acute type, valerianate of zinc will be found of especial use, particularly when the attack has with it some of the characteristics of hysteria. Trousseau says: "Zinc does best with florid, and iron with pallid children." external remedies. Baths. Simple cold baths and affusions are always of service. An excellent auxiliary is the salt-bath. In anaemia, sulphur-baths are beneficial. Ether-Spray. The application of atomized ether along the spine has proved of service in relieving the spasms, especially in recent cases and those originating in fright. It is said also to be of benefit in chronic cases and in rheumatic chorea. A spray of methyl chloride has been used instead of the ether, but possesses no specific value. Electricity. Dr. Charles L. Dana contributes an article on this subject to the Med. News, 1883, in which he claims for anodal galvanization that it is a most valuable adjunct in the treatment of chorea ; that given daily for a week or ten days with arsenic, and probably without, it will 440 DISEASES OF THE NERVOUS SYSTEM. materially shorten the duration of the disease in most cases of chorea in children. The method of application is as follows : A large sponge- electrode of flexible brass, four by two inches, is thoroughly moistened with salt water. The hair of the patient is also thoroughly wetted, and the electrode applied over the side of the head, above the ear. In hemi chorea it need only be applied over the side opposite to the one affected. The other electrode is placed in the hand of the affected side. The electrode upon the scalp is made positive, and a stabile current of three to six Stohrer's, four to eight Daniell's cells, is passed for from three to six minutes. Hygienic Measures. Fresh air, change of scene, regulated movements, good food, and friction to the spine, are of the utmost importance in all cases. Gymnastics are especially recommended in the milder forms of chorea, and during convalescence in the severe cases. Drs. E. B. Gray and H. M. Tuckwell have published a large number of cases, (Lancet, November, 1876,) to show that the hygienic plan alone is sufficient to cure chorea, and quite as promptly as by any drug. They trust to judicious nursing and good diet, and merely give a placebo of sugared water. As early as 1871, they showed that the average dura- tion of chorea treated on the expectant plan was, as far as their obser- vations had then gone, from ten to eleven weeks ; and that the average duration of chorea treated with arsenic in gradually increasing doses, according to Begbie's plan, was likewise from ten to eleven weeks ; the difference, if any, being slightly .#n favor of the expectant plan. They also compared these results with the estimate of Dr. Hillier, who, in his work on Diseases of Children, gives the mean duration of thirty cases treated with arsenic, etc., as "about ten weeks ;" and with See's estimate of " sixty-nine days," as the average duration of one hundred and seventeen cases treated with various medicines. An isolated ward ; a good nurse ; a large crib, well padded round, and walled in with pil- lows j plenty of nutritious food, without stimulants — on these they feel inclined to rely in the treatment of severe chorea, till we obtain more conclusive evidence than has yet been adduced that the disease can, in the slightest degree, be favorably influenced by any medicine as yet discovered. Inhalations of chloroform arrest the convulsive movements so long as the pa- tient is under their influence, but the progress of the disease is not checked by their administration, and they can only be regarded as palliatives in severe cases. EPILEPSY. 441 EPILEPSY. In the treatment of epilepsy the main indications are the preven- tion of reflex disturbances which may induce the motor paroxysms, the diminution of sensory impressions, the lessening of the motor explosions, and by hygienic measures to procure the strongest pos- sible condition for the inhibitory centers. REMOVAL OF CAUSES OF REFLEX IRRITATION. Such causes are to be found in wide profusion. Faulty ocular refraction (^Atlanta Med. and Surg. Jour., June, 1887), a diseased testicle {Amer. Jour. Med. Sc, June, 1889), a foreign body in the nose (ibid.), clubfoot {Times and Register, May 25, 1889), scars, etc., may be mentioned, and the removal of the cause by proper measures leads to the permanent restoration of the case. In all recent instances of epilepsy such causes should be sought for, and attention to any genital irritation, as from long or tight prepuce or from excessive self-abuse, may be repaid by success. PROF. C. E. BROWN-SEQUARD, M. D., PARIS. The formula which this distinguished neurologist recommends in idiopathic epilepsy, is : 728. R. Sodii bromidi, Potassii bromidi, Ammonii bromidi, aa 3iij Potassii iodidi, Ammonii iodidi, aa Sjss Ammonii carbonatis, 3i Tincturae columbae, f- 3 'ss Aquae, q- »• ad f. S viij. M. Sig: Teaspoonful before each meal and a teaspoonful at bedtime; in water. When the patient's pulse is weak, substitute for the bicarbonate of potassium in the above formula, the carbonate of ammonium, and for the six ounces of infusion of columbo, an ounce and a half of the tincture of that medicine, with four ounces and a half of distilled water. Of this he says : " This combination of the three bromides I have found has considerably more power in controlling epilepsy than the use of one alohe or of two combined. If you employ the bromide of potassium, you must employ with it the bromide of ammonium and the iodide of potassium or ammonium. A combination of these 442 DISEASES OF THE NERVOUS SYSTEM. three salts acts with far greater power than when either one is used alone. It is essential always to add the bromide of ammonium if the other bromides are employed. In these cases, it is also essential to employ some means of counter-irritation at the base of the brain ; or, in cases of distinct aura, some means of counter-irritation at the place where the aura starts. In those cases in which the aura starts" in the finger, I have succeeded most wonderfully in controlling the attack by the application of a circular blister, in the shape of a liga- ture, to the finger itself." He also adds the following very important rules relative to the treatment of epilepsy by the bromides of potassium and ammonium, em- ployed together or separately. 1. That the occurrence during the day of the sleepiness caused by these remedies can be avoided by giving relatively small doses in the daytime and a much larger dose late in the evening. 2. That the quantity of these medicines to be taken each day must be large enough to produce an evident though not complete anaesthesia of the fauces and upper parts of the pharynx and larynx ; that daily quantity being from forty-five to eighty grains of the bromide of potassium, and from twenty-eight to forty-five grains of the bromide of ammonium, when only one of these salts is employed, and a smaller quantity of each, but Especially of the second, when they are given together. 3. That an acne-like eruption on the face, neck, shoulders, etc., should be produced, and it is most important to increase the dose when there is no eruption, and also when the eruption is disappear- ing, unless the dose already given in the twenty -four hours is so large that any increase of it causes great sleepiness in the daytime, a decided lack of will and of mental activity, dullness of the senses, drooping of the head, considerable weakness of the body, and a somewhat tottering gait. 4. That it is never safe for a patient taking either of the bromides or both, and receiving benefit therefrom, to be even one day without his medicine, so long as he has not been at least fifteen or sixteen months quite free from attacks. 5. That the debilitating effect of the bromides in patients already weak, as are most epileptics, ought to be prevented or lessened by the use of strychnia, arsenic, the oxide of silver, ammonia, or cod- liver oil, cold douches or shower baths, and, of course, wine and a most nourishing diet. In making use of strychnia or arsenic, it EPILEPSY. 443 must be kept in mind that not only the bad influences of the bro- mides, but also their favorable influences against epilepsy, can be diminished by these powerful agents (especially strychnia), and that it is therefore necessary, when these agenb are used, to increase the dose of the bromides. 6. That iron and quinine — ^which are generally injurious to epilep- tics, except in cases in which the nervous affection is caused, or at least aggravated, 'by chlorosis, anaemia, or malarial cachexia — are more particularly injurious in cases in which the bromides are taken. 7. That a gentle purge every five or six weeks usually gives a new impulse to the usefulness of the bromides against epilepsy. DR. E. C. SEGUIN, OF NEW YORK. Dr. SegUIN'S method of prescribing the bromides in the treat- ment of a case of " idiopathic " epilepsy is the following : Two solutions are employed. 729. R. Potassii bromidi, 1 ) Ammonii bromidi, 5 ss Aqu3e fontanse, § vij. M. S. — ^To be given by the teaspoonfal. And, 730. R. Sodii bromidi, 3J Ammonii bromidi, § ss Aquae font., 3 ^'j- S. — ^To be given by the teaspoonful. M. The quantity administered is, as a rule, so divided as to give by far the largest dose in the evening. The bromide is cautiously m- creased, still keeping the nocturnal dose the largest, until slight bromism is produced. It is usually necessary to maintain slight bromism for months, but just as little is to be given as will prevent the attacks. The precise quantity required must be studied in each case. Children tolerate the bromides, as well as the iodides, m relatively large doses. It is regarded as important thoroughly to dilute the bromides in order to facilitate their absorption— the dose to be taken in a wineglassful or half a tumberful of water. Under no circumstances should the bromides be discontinued ; they may be diminished, but not stopped until the word aire can be pro- nounced. They should be continued at least three years after the The adjunct treatment consisted in the use of measures to prevent 444 DISEASES OF THE NERVOUS SYSTEM. the acne to a certain extent, such as the occasional use of arsenic, sulphur-ointment, mercurial plaster, and alkaline lotions ; to correct the general debility or slight paresis, by the use of strychnia, nux vomica, oxide of zinc and quinia ; to relieve the dizziness by the inhalation of nitrite of amyl, by stimulants and by quinia ; • regulat- ing the patient's diet and hygiene, and the use of cream, cod-liver oil, iron, quinine, phosphorus, strychnia, with nitro-muriatic acid, wine, beer, or whisky. In certain cases such medicines as act more directly upon the morbid state of the nervous centres are associated with the bromides, and the favorite among these is belladonna. In the treatment of cases of epilepsy in which a definite causative lesion can be made out, the bromides are used. simply to combat th-e habit. Regarding the method of using the bromine salts in the treatment of epilepsy and other neuroses, he makes the following remarks : 1. The prolonged use of bromides is contra-indicated by con- genital feebleness. 2. The bromides are well borne by persons of fairly full habit and good nervous power. 3. The bromides are indicated in cases of abnormally great irritability of the nervous system in its motor (muscular and vaso- motor) and ideational tracts. 4. The contra- indications above named; are to be much less regarded in the management of that formidable neurosis, epilepsy. 5. Epilepsy is the oilly disease which justifies the deliberate production of a degree of bromism for its cure. From extensive and very elaborately conducted experiments, to determine the precise effects of bromide of potassium in epilepsy and its proper dose. Dr. T. S. Clouston, of Edinburgh, has found that the diminution of the fits, and all the other good effects of the medicine, reach their maximum in adults at thirty-grain doses thrice daily ; while ill effects are manifested when thirty-five grain doses thrice daily are reached. In regard to the other bromides. Dr. Erlenmeyer {Correspon- dens-Blatt, 1877,) has experimented -with bromide of lithium, re^com- mended by Dr. Levi, of Paris, on account of having no action on the heart. From his own experiments, he is disposed to believe that it is inferior to bromide of potassium as a remedy against epi- lepsy. He has also tried bromide of quinine, and found it had a more hypnotic action than bromide of potassium ; he finds it use- EPILEPSY. 445 ful in treating periodic fits of insanity and hypochondria, but is not inclined, on the whole, to give it the preference to the more com- monly used drug in epilepsy. In combination with the bromides, atropia has been favorably mentioned by Dr. L. P. Yandell, jr., of Louisville. 731. K. Potassii bromidi, gr. xv Atropise sulphatis, gr J, Aquae, q. s. M. For one dose, three times a day. It is said to act more promptly than the bromide alone (^Medi- cal and Surgical Reporter, 1878). Atropia has been used succes- sfully alone by Dr. Sevetlin, of Vienna, and later by Dr. Leides- DORF. The latter found it to act beneficially if given to the extent of tV grain of the sulphate daily. The trial was made in conse- quence of the accepted fact that small doses diminsh the action of the reflex nerve-centres, while large doses produce an opposite effect. Cases of motor epilepsy of not long standing recovered rapidly, and some old cases, complicated with mental derangement, also got well while taking the drug. In other cases the attacks were rendered less frequent. The observation was confirmed by experiments on animals. (^Medical Examiner, No. 34, 1877.) A combination of the bromides with chloral hydrate has been used with advantage by Dr. J. C. SHAW, of Brooklyn, and various New York physicians. The usual formula is : 732. R . Potassii bromidi, § j Chloral hydratis, § ss Aquje, f. S vij, M. Four to six teaspoonfuls a day. This seems to bring about the good — i. e., antispasmodic — action of the bromide without so much cutaneous eruption, general physical deterioration, and mental depression, as we too often see during the ordinary treatment of chronic cases of epilepsy. DR. CHAS. S, POTTS, OF PHILADELPHIA. This prominent nervous specialist (University Med. Magazine, October, 1889), after using with but indifferent results various of the newer remedies, as antipyrine, antifebrin and bromide of ammonium in a number of cases of idiopathic epilepsy, employed as an experi- ment the combination of the first and last of these, with results of the most flattering character. In no cases did it fail to cause 446 DISEASES OF THE NERVOUS SYSTEM. marked amelioration, and in some it gave relief after the failure of all the commonly used remedies. Dr. Potts prescribes the following: 733- R- Antipyrine, 3ij-3iv Ammonii bromidi, 3 iv- S i Aqiuc cinnamomi, ad f. § iij M. Sig: f.3j three times daily. DR. WILDERMUTH OF STUTTGART. (Therap. Monatshefte, December, 1889.) This physician reports good results from the use of amylene hydrate, particularly in cases of nocturnal paroxysms. The amount given varies from one to two drachms daily in wine or cider, in two or three doses. The author considers it particularly indicated in cases with frequent convulsions, where there is severe bromism, and in nocturnal epilepsy, best in these latter cases alternated with bromides and combined in recent cases with atropia. The alkaloids of nux vomica appear to have a well-merited repu- tation in this disease. Thus: WALTER TYRRELL, M. D., "LONDON, States that he has watched the effects of strychnia upon various forms of epilepsy, and has no hesitation in affirming that in a large majority of cases, its effects are most beneficial. He found but three cases in which it produced no favorable result, and no cases in which it produced an unfavorable effect. He gives a medium quantity as a dose, for a lengthened period, rather than carrying the dose too high at first. The best results are obtained from gr. A to gr. A, twice a day, in solution, the system appearing to regain its nervous strength under the continued use of the medicine. The following was a favorite prescription with the late MARSHALL HALL, M. D., LONDON: 734- R- Strychnise acetatis, gr. j Acidi aceticl, ITlxx' Alcoholis, f 5 ij Aquoe destillatae, f^Syi. M. Ten drops (gr. jij) to be taken in water thrice daily. Another alkaloid, brucia, has been tried by EPILEPSY. J. SPENCE RAMSKILL, M. D., LONDON. 447 735- R- Bmciae, gr. iv Alcoholis, f. 5ij Aquae destillatse, f. 3vj. M. Ten minims to be taken, diluted with water, twice daily ; every ttird day, an addition of five minims slioxild be made to the dose, until from a third to a half grain is reached, in the treatment of stomachal epilepsy. If any stiffness of the jaws or other toxic symptoms appear, the dose is to be diminished five minims, and continued until any new objectionable symptom is manifested ; then it is again lessened. No benefit will be derived until a full dose is reached ; often the reverse effect. (London Lancet, January i6th, 1869.) As a rule, patients will take twice as much brucia as strychnia, without any necessity for diminishing the dose. After the continuous admin- istration of brucia for a month, it is well to suspend its use for some days, and then again resume it. Great satisfaction will be obtained by giving the bromide of potassium in large doses, at bedtime, and at the same time ordering brucia twice daily, thus insuring the "sedative influence of the bromide and the tonic effect of the brucia on the whole nervous system. DR. ALLEN M'LANE HAMILTON, NEW YORK. In regard to the bromides, this writer prefers the sodic bromide, administered on an empty stomach, to the extent of 5j in the twenty-four hours. He has observed that a heavy dose at night is apt to do more good than if the amount prescribed is equally divided up through the day. In a great many patients the attacks occur at the waking hour, probably owing to the sudden change in the cerebral circulation. A mild diffusive stimulant has overcome this, and in many cases warded off the attack. He directs his patients who have their convulsions at this time to keep a glass of sherry or a small quantity of spts. ammoniae aromaticus near at hand, to be taken before rising. Cold douches to the head are valuable. If the attacks be irregular, it will be found necessary to divide up the dose. Belladonna and its alkaloids are of great value when the seizures occur in the daytime, or are of the variety known z.s petii mal. He has injected the sulphate of atropia, in ^V gr. doses, beneath the skin at the back of the neck, with good effect. It should be admin- istered until dryness of the throat is obtained, and should be given a patient trial. A remedy of his own suggesting is nitro-glycerine. 448 DISEASES OF THE NERVOUS SYSTEM. He says it is as powerful a medicinal agent as it is an explosive, -fs of a drop producing a rapid cerebral hyperaemia. It is safer than amyl nitrite, and produces a more lasting congestion, and acts bet- ter as an abortant of the attack. 736- B- Nitro-glycerinse, gtt. v Alcoholis, f.Sj. M. Ten drops of this contain about tV of a drop of nitro-glycerine, which amount is the proper dose. Mixed with alcohol it is non-ex- plosive. Dr. Hamilton has found a combination of the various anti-epi- leptic remedies to act better than any one singly, and for many years has derived much satisfaction from the following formula : 737- B- Strychnise sulpbatie, gr. j Fl. ext. ergotae, f^ § iss Sol. potass, arsenitis, f. 3 ij Sodii bromidi, § iss Tr. digitalis, f. Siij Aquse mentb. pip., q. s. ad f. § iv. M. S. — A teaspoonful before eating, in a halftumblerfal of water. If the attacks be of the form known as petti mal, he thinks either ergot or belladonna are our best agents. With either form of treat- ment it may be found often necessary to use auxiliary general treatment. The syrup of the combined phosphates, or the syrup of the lacto-pKosphate of lime, is a good adjunct ; and salt baths, cold head douches, regular food, early hours, and the breaking off of bad habits, will often cure the disease, even when it has lasted for many years. As a last resort, should continued medication prove useless, the actual cautery or a deep seton at the back of the neck, will occasion- ally arrest these bad cases. The oxide of zinc is ah old and standard remedy. From recent trials. Dr. Augustus Voisin states that though it acts more slowly than the bromide of potassium, its effects are more certain; and, after having used both these two medicines for more than twenty years, he habitually gives the preference to the oxide of zinc, used after the method of Herpen, of Geneva, that is, commencing with small doses, gr. ij-iij, combined with valerian, thrice daily, and slowly increasing them to the maximum, gr. xv. thrice daily, and continuing for a long period, three to six months. The same high opinion of the zinc is expressed by J. Waring-Curran, M. D., of EPILEPSY 449 Dublin, who combines it in pill form with extractum glycyrrhizae as an excipient, applying occasionally Chapman" s spinal ice-bag. EDWARD C. SPITZKA, OF NEW YORK. This neurologist has found ergot and conium valuable drugs in epilepsy, (Physician and Pharmacist, 1879). INHALATIONS. George Johnson, M. D., King's College Hospital, London, speaks in high terms of chloroform in connection with bromide of potassium in this affection. He thinks that the action of chloroform inhalation in warding off a threatened fit, and in cutting short a violent and prolonged paroxysm, is as uniform and certain as the action of an- aemia in exciting convulsions. The same has been said of the use of inhalations of amyl nitrite. It is considered by Dr. Crichton Browne to be invaluable in many cases, in not only postponing, but in altogether preventing epileptic seizures. A vinaigrette, or small-stoppered bottle, containing a sponge soaked in nitrite of amyl, should be carried in the pocket, and the fumes inhaled on the first symptoms of the aura. Even in the advanced stage of the status epilepticus. Dr. B. believes its inhal- ation very beneficial in most cases. (West Riding Lunatic Asylum Reports, 1873. Believing that the coma of epilepsy is due to lack of oxidation of the brain substance, Cripps (Liverpool Med. Chir. Jour.,]\x\Y, 1887) suggests inhalations of oxygen in the post-epileptic coma. MECHANICAL AND PHYSICAL MEANS. Dr. Brown-SeQUARD has found : 1. That it is not necessary to apply an irritation (by a ligature, pinching, etc.,) on the very limb from which an aura seems to start, as the same means applied elsewhere may succeed ; but the chance of success is much greater by the former than by the latter way. 2. That a constant or a frequent irritation (by a blister, an issue, a seton, the actual cautery, etc.,) on the place from which an aura seems to start, may not only prevent fits, but by some change of nutrition locally (if the aura is really of peripheric origin), and in the nervous centres, may reduce, or even destroy altogether, the tendency to fits, and lead to a complete cure. 3. That as a circular ligature may procure a temporary good effect, 29 450 DISEASES OF THE NERVOUS SYSTEM. SO a narrow circular blister applied all around a ]imb, a toe or a fin- ger, or a circular cauterization with a white-hot iron, may cure epi- lepsy in cases with a distinct aura. 4. That even in cases in which there is no aura, felt or unfelt, ligatures, pinching, and other means of irritation, may prevent the occurring of expected fits. When an attack of epilepsy is followed by a comatose state, or even a sleep with heavy breathing, it is of the greatest importance to place the head of the patient in such a position that the tongue, which is then paralyzed, will not fall on the larynx and cover its aperture. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. 738- R- Zinci valerianatis, gr. iij Extracti belladoniiEe, gr. J Pulveris digitalis, gr. \. M. For one pill. To be taken thrice daily in cases of epilepsy, associated with irregular- ity of the heart. HOSPITAL OF DISEASES OF THE CHEST, LONDON. 739- B- Potassii bromidi, gr. x Tincturae conii, TUxxx Tincturse Valerianae ammoniatse, l^x AquK camphors, f. § j. M. For one dose, thrice daily. HOSPITAL OF UNIVERSITY COLLEGE, LONDON. 740. R. Potassii bromidi, gr. x Spiritfls chloroformi, tllxviii Infusi quassise, f. 3;. M. For one dose thrice daily. PHILADELPHIA HOSPITAL, 741. R. Sodii bromidi, Ammonii bromidi, £5 gr. ijsg Potassii bromidi, „_ y Syrupi aurantii, n^xy ■^q'^' q. s. ad f. 3]. M. Dose : One to four drachms, t. d. NOTES ON REMEDIES. Antipyrine. While of apparently but little value in the ordinaiy run of cases of epilepsy, this drug seems to be of benefit when employed in instan- ces of the disease which are influenced by the menstrual function. In these cases Lemoine (Jour, de Med., de Clin., et de Pharm., Decem- ber 20th, 1888), administers ten grains twice daily, continuing the administration only through the menstrual periods. EPILEPSY. 45 1 The cases of epilepsy associated with periodic attacks of migraine also seem amenable to treatment by this drug. Antifebrin. Dr. Diller (Therapeutic Gazette, June, 1889,) has used this drug with some benefit in lowering the number of seizures of epilepsy, giving about the same dose as above in case of antipyrine. In the average run of cases, however, he regards this drug as inferior to the bromides. The editor has frequently succeeded in checking the status epilepti- cus by the exhibition of these two compounds, the latter apparently having the safer and surer action. A combination of either of the two above drugs, particularly antipy- rin, with ammonium bromide, is commended highly by Dr. Potts. Acidum Hydrobromicum. Hydrobromic Acid is preferred to the bromides by Dr. C. L. Dana (N. Y. Med. Jour., 1883). He has seen the greatest benefit from it. He uses it in preference because it is agreeable to take and does not produce an eruption or bromism. It is argued by Dr. H. C. Wood (Med. News, 1 884) that the failure of this acid is owing to the small doses given. He has tried gij-iij. daily with decidedly ben- eficial results. Each dose was given after meals, with an equal quan- tity of ginger syrup and diluted with a full half pint of water. These doses were well borne and there was little bromism. Dr. W. C. Wade, (^Detroit Medical Journal, December, 1877,) gives the following pre- scription : 74Z. R. .Stramonii extract, fluidi, gtt. 160 Acidj hydrobromici diluti, Syrupi, aa f.gj. M. One-half teaspoonful in water, the dose to be increased until the specific effects of the stramonium are marked, and there to be maintained. He adds : " I will simply say of this combination, that its effects in this disease are remarkable, and I think I have reason to consider it superior to any other plan of medication." Ammonii Bromidum is often prescribed in epilepsy alone, or in combination with bromide of potassium. (F. 729.) Ammonii Carbonas is a valuable palliative, though possessed of no curative in- fluence in this disease. Dr. Anstie and others assert that, if there be time to administer a dose previous to an impending attack, it will often avert it. Pereira recommends it in large doses (gr. x-xx), in the hysterical form of the disease. Ammonia Aqua is recommended by Dr. Hope and others in epileptic con- gestion of the brain, arising from debility. The following formula is the most efficacious : 743. R. Aquae ammonise, m|^ jj Aquae menthse vindis, '• o '"• 452 DISEASES OF THE NERVOUS SYSTEM. For one dose. If taken at the first warning of an attack of this character, it seldom fails to arrest its supervention. The inhalation of ammoniacal vapor immediately after the first warning of an attack, is recommended by Pereira, Pinel and others as often averting its occurrence. Ammonii Valerianas, although very deliquescent, and therefore uncertain in its operation, is favorably reported upon by a number of writers as a remedy in epilepsy. Amyl Nitrite. See Nitrite of Amyl. Amyl Hydrate. Amyl alcohol is recommended by Wiedermuth (Neurol. Centralbl., August i, 1890,) in epilepsy where there are frequent at- tacks ; where there is marked bromism, necessitating the interruption of medication, and in nocturnal cases alternating with the bromides ; and in recent cases combined with atropine. Arsenici Bromidum. Dr. Clemens, of Frankfort-on-the-Main, has employed for a number of years a liquor arsenici bromidi, as follows : 744. R. Pulv. arsenici albi, Fotassse carbonatis, ia 3] Aquae destillatse, Oss. Buil and add, Aquam, ad f. § xij Brominii, f. 3 ij- After cooling and filtration, it shovdd be a colorless liquid. Dose, one or two drops in a glass of water once or twice daily. This dose need not be increased. All his cases have been decidedly improved by this, but he claims only two complete cures in fifteen years. Assafcetida is recommended by Dr. Pollock (Lancet, August 21, 1869,) as capable of giving satisfactory results in the following combination : 745- R- Tincturae assafoetidse, Dlxxx Ammoniae carbonatis, grs, iij. M. For one dose, to be repeated thrice daily. In cases of epileptic seizures, due to the presence of worms in the alimentary canal, assafsetida is a useful agent. Atropia. See above y p. 445 ) . Bismuthi Subnitras has been employed by Dr. Copland (the bowels being kept freely open) alone and in combination with tonics aiid anti- spasmodics, with good results. Borax : This drug in doses of ten or fifteen grains three times daily, has in the hands of Dr. Hill {Med. News, May 1 1 , 1 889) , and Dr. Finlay ( Glas- gow Med. Jour., Sept., 1887), proved of considerable value in lower- ing the frequency and severity of epileptic seizures, without any special reference to the pathology of the individual cases. It may be admin- istered as follows : 746. R. Sodii biboratis, 3 iij Glycerini, f. § j Aquae, q. s. ad f. S iij. M. Solve sodii biboratem in glycerin! fervida, et adde aquam. Sig. — Dessertspoonful thrice daily. EPILEPSY. 453 Camphora seems to be useful in cases associated with hysteria or uterine dis- orders. It should be given in combination with tonics and anti- spasmodics. The mono-bromide is a desirable form, in doses of gr. v-x. Castoreum is a very old remedy in this disease, having been recommended by Celsus. Centaurea Benedicta. Dr. J. G. Westmoreland {Acology and Therapeutics, p. 320,) observes that the "blessed thistle" has proved a usefiil remedy in epilepsy. A decoction of the leaves is used, 3J to water Oj, the dose being giij-iv, daily. Cerii Oxalas is recommended by Prof. Simpson. Chloroformum. Chloroform inhalations are recommended (p. 449,) both during the paroxysm and in the interval. Dr. Brown-Sequard con- siders this method of treatment particularly valuable in cases partaking of a hysterical character. Cinchona is rarely successful in true epilepsy, but of great benefit in the epileptiform paroxysms of intermittent fever. Conium has been found by Dr. Harley to cause rapid and decided improve- ment in epilepsy arising from sexual abuse, or from the irritation of dentition, but in that arising from peripheral disorder of sensation, from menstrual irregularity, or from emotion, it fails to exercise any beneficial influence. Cupri Sulphas Ammoniatus produces positive benefit, according to Augcste VOISIN. Hydrargyri lodidum Rubrum has been recommended by Dr. Fuller (Medi- cal Times, February 14, 1857,) in cases where there is reason to sup- pose thickening of the dura mater. Hyoscyamus in occasional full doses (f.^iv-viij of the succus, or ttlx-xxx of the tincture,) has been found by Dr. Harley very serviceable in epi- lepsy arising from emotional disturbances, but in other varieties of this disease it has proved useless in his hands. Moschus is sometimes useful. Dr. A. T. Thomson says that it diminishes the violence of the paroxysms of idiopathic epilepsy, and greatly lengthens the intervals, when administered as follows : 747- R- Mcschi, 3j' In a bolus for one dose, every eight hours. Mckel Bromide has been found by Dr. J. M. Da Costa (Med. News, 1884,) to be decidedly active, more so than other bromides. The dose is gr. v-x, repeated as necessary. It has a marked effect on epileptic seiz- ures. Lithium and rubidium bromides have also been suggested, and, it is claimed, are somewhat more effective than the bromides of the less positive elements. 454 DISEASES OF THE NERVOUS SYSTEM. Nitrite of Amyl, by inhalation, has been found eminently useful by Dr. S. Weir Mitchell and others. Nux Vomica. In epilepsy following the disappearance of the menstrual dis- charge, Copland recommends nux vomica combined as follows : 748. R. Extracti nucis vomicae, gr. x Pilulse aloes cum myrrha, 3ij. M. For thirty-six pills. From one to two, night and morning. Its employment demands caution. Oxygen Inhalations are recommended by Dr. Ramskill. (Medical Times, July 4, 1863.) On the accession of giddiness, or other uncomfortable symptoms, they should be stopped. Phosphorus is regarded by Dr. Anstie as well worthy of further trial in this disease, as it improves the patient's general health, and relieves the sense of languor and depression. Potassii Bromidum is the remedy par excellence in epilepsy. See opinions already given of Drs. Brown-Sequabd, Clouston, Hammond, etc. It cures in very many cases, and rarely fails to diminish the number of attacks. Quiniee Sulphas is sometimes prescribed. Prof. Ludwig Meyer, of the Berlin Chants Hospital, has long recommended a full dose of quinine, gr. xx-xxiv, at the first symptoms of the aura. In some instances he has succeeded in obtaining a permanent cure by continuing this treatment. Dr. Nothnagel has witnessed the same favorable result from a large dose of common salt (Allgemeine Medicinische Central Zeitung, No- vember 19, 1876). Santonin is of service when the epilepsy iS due to the presence of worms in the alimentary canal. Sinapis is a useful emetic in epilepsy from over-distention of the stomach. Sodii Chloridum. See under Quiniee Sulphas. Stanni Chloridum has been employed in doses of gr. }i to }{ thrice daily, in pill, or dissolved in hydrochloric ether. Strychnia is strongly recommended by Walter Tyrrell, and in the threat- enings of epilepsy, by Marshall Hall. Tabacum is supposed to have a curative influence in epilepsy produced by onanism, as the use of tobacco allays sexual lust. Terebinthinee Oleum, though little used in epilepsy, is strongly recommended by Sir Thomas Watson, who states that if he were called upon to name any single drug from which, in ordinary cases, he should hope for re- lief, he should mention turpentine ; and by Dr. Headland, who pre- scribes it as follows : 749. R. Olei terebinthinie, f.5ss. Thrice daily in capsule ot emulsion. EPILEPSY. . r . 455 750. R. Olei terebinthinse, Oleiricini. 55 ^.5;;^ j^ ror one dose at occasional intervals. Valeriana is highly praised as a remedy for epilepsy by Brisbane, Fother- GiLL, Haller, Willis, and others, but regarded as of little' value by CuLLEN, Heberden, and Home. It may be prescribed in the form of valerianate of zinc, in doses of gr. i, gradually increasing as the stom- ach bears. Dr. J. M. Da Costa sometimes prescribes it with bella- donna and digitalis. (F. 738.) Veratrum Viride has been found by Dr. E. F. Mortx)UGH, of New York, to diminish the severity and frequency of the convulsions. His prescrip- tion is : 751. R. Morph. sulph., gr. iss. Tinct. verat. virid., Aqu^'. ii f.Sss. M. Twenty minims hjrpodermically during or before a convulsion. (New York Medical Record, September, 1878.) Zinci Oxidum is regarded by Dr. Russell Reynolds as superior to the sul- phate of zinc in epilepsy. He gives it in doses of grs. iii-v, thrice daily. Dr. Waring Curran strongly urges it as an adjunct to bromide of potassium. Dr. Herpin (Bull. Gen de Therap., November, 1876,) prefers lactate of zinc as superior in taste and tolerance, and of equal value. It is given in doses of gr. ij, ter in die, gradually increasing. Zinci Sulphas is a long-used remedy in epilepsy, of occasional value. Emetics, given when an attack is imminent, will often, according to Dr. Mar- SEiALL Hall, ward it off. Stimulants. A draught of wine or of some diffusible stimulant may put off an attack. external remedies. Cold Shower Baths are useful in epilepsy when the patient is not too timid nor too much excited by them. Methodical hydropathic treatment often benefits, but, according to Nothnagel, is never sufficient alone to effect a cure. Turkish Baths are sometimes employed, but great caution is required in the use of so powerful an agent. Blisters. A narrow circular blister applied above or at the starting point of the aura will sometimes prevent or modify a paroxysm. Dry Cupping sometimes, according to Dr. Graves, averts a paroxysm of epi- lepsy, where previous headaches or other premonitory symptoms ad- vertise its approach. Electricity has given unsatisfactory results in epilepsy. Dr. Copland says 45 6 DISEASES OF THE NERVOUS SYSTEM. that " the safest method of employing electricity is to place the patient on the insulating stool and subject him to the electric bath, and to draw sparks from different parts, when thus insulated and placed in connection with the prime conductor." Shoemaker (Med. Times and Register, August 31, 1889,) regards galvanism, applying descending currents from the vertex to the epigastrium, as of some value. The current should be applied so as'to anticipate the seizure. The current from two or three cells is sufficient. Niermeijer (Deui. Med. Woch., October 4, 1888,) has had excellent results from combining cerebral galvanism with the usual bromide treatment. Anode over the motor gyri, cathode in one hand ; application daily ; length of treatment seven weeks to ten months. Forcible Extension of the muscles where the aura is seated, or the application of pressure between the starting point of the aura and the trunk, may avert an attack. Brown-Sequard has stated that forcible extension of the great toe will arrest an attack, as he has verified in many cases. The Actual Cautery. This is a most valuable resource in epilepsy. Brown- Sequard's rules are as follows : i. The instrument has to be heated to whiteness. 2. It must be shaped like an olive (blunt end). 3. It must not be allowed to bum the skin, but is passed rapidly along the space to be acted upon, so that after the operation is over nothing is seen but a white line, very much resembling a scratch with a finger nail. So applied, it is never painful. It can be repeated every other day, as there are no scars or irritation left. Under such circumstances it is unnecessary to anesthetize the area to be cauterized. The cau- terizations are generally applied over the motor areas (Fere, Brit. Med. Jour., October 12, 1889), and are especially applicable in cases of post-hemiplegic or traumatic origin. The Seton. Dr. Thomas J. Griffiths has strongly urged the employment of the seton in epilepsy. (Report of the Supervising Surgeon, U. S. Marine Hospital Service, 1876.) He introduces a large seton, fifteen or twenty strands of silk or flax thread, and allows it to remain for months, if necessary, removing only when the patient seems to be per- manently improved or has recovered, unless too great irritation be produced by its presence, when it is removed temporarily, to allow the irritation to subside. The place of election for its introduction is the back of the neck. Of five cases of epilepsy, four were cured or greatly benefitted. No other treatment was used except tonics. The dis- turbance of the mental faculties, which is the common attendant in such cases, rapidly improves after the insertion of the seton. Trephining. In cases of focal (Jacksonian) epilepsy, it has become a rather common practice for surgeons to remove the irritated focus by opera- tion. While the results of this procedure are as yet open to some con- HEADACHES. 457 jecture, the number of those cases in which at a more or less late date the symptoms have recurred is rather large for the success of the measure as a general practice. In cases of irritation of the cortex by depressions after fractures, where the history of the case points directly to the traumatism as the starting point of the disease, trephining is imperatively demanded. HEADACHES. Headache as a symptom is found associated with many varying conditions, as periostitis of the cranium, disease of the teeth, ear and eye, astigmatism, cerebral affections, neuralgia and rheumatism of the scalp, quininism, uraemia, alcoholic poisoning, etc. It is not infrequently the result of reflex causes operating from distant organs, as from the stomach or uterus. A diagram of diagnostic value has been published by Dr. Dana {Med. News, March i6, 1889), illustrating the location of the various aetiological headache spots. a— Anaemia, endometritis, bladder; *— Constipation, caries of incisor; e—'Enoi of eye-refraction; rf— Gastric dyspepsia; <— Eye; /—Decayed teeth; ^^Pharyngitis, otitis media; A— Utenis; i- — Spinal irritation. In all cases in which such etiologocal factors may be determined, the treatment of the cephalalgia is, of course, the treatment or re- moval of the cause. LOCAL MEASURES. While in these headaches the proper and only scientific treatment demands the eradication of the irritative focus causing the reflex pain, much may be done temporarily to relieve the pain by local measures or nervous sedatives. Among the local applications, a cloth wrung out of a 20 per cent, solution of menthol and wrapped about the head or laid over the painful area, is to be highly recom- 458 DISEASES OF THE NERVOUS SYSTEM. mended. Or a spray or lotion of aconitia may be profitably em- ployed. Such a lotion as the following is soothing : 71:2. R. Extracti aconiti fol. fiuidi, '•§^* Aqu», q.s.adf.Sj. M. Or a combination of camphor and chloral is not infrequently used. 753. R. Camphora, __ Chloral hydratis, aa M. Ft. lotio, The eau seditif of Raspail is a similar preparation : 754- B- Sodii chloridi, 3 1 Spiritvls camphorse, f- S j Aquae ammoniae, f- S iss Aquae, Qj. M. Ft. lotio. Solutions of the cyanide of potash are commended by TROUS- SEAU. The simple application of cold cloths or of cloths wrung out in any quickly evaporating solutions are often of value. Hot applications with the use of cups or blisters are indicated where the pain is evidently of a neuralgic character, and the offend- ing nerve can be recognized by the practitioner. BILIOUS OR DYSPEPTIC HEADACHE. This ftame is associated with a form of cephalalgia, usually frontal, occurring as a reflex of fault in the digestive function, often accom- panied by feelings of fulness, weight and discomfort in the epi- gastrium and in tolerably fixed relation to the taking of meals. There is often a very slight icterus present as well, showing in the selerotics of the eyes. . In such case if the headache come on early after a meal, and can be traced to indigestible articles consumed, and the patient toler- ably strong, Dr. Henry G. Wright states that an emetic may be properly administered, as : 755*. R. Pulveris ipecacuanhae, gr. xxv Ammonii carbonatis, gr. v Aquae menthse viridis, i. 3 iss. M. Take at one dose, and follow by some warm water. It is in this variety that, in the milder cases at least, so much may be accomplished by means of pepsin, especially if combined with some cholagogue. The editor in such instances is partial to the following plan : HEADACHES. 459 7S6. R. Hydrargyri chloridi mitis, gr. ij Sacchari albi, q_ 5_ j^_ Ft. pulvis, dividenda in chartulas, No. x. Sig. — One every half hour until six are taken — this followed, if necessary, in two hours by a glass of Hunyadi water, oil, or some other mild cathartic. Meantime after each meal the following may be given : 757- R- Pulveris pepsini, gr. xx Pulveris carbonis ligni, Pulveris aromalici, aa gr. x. M. Ft. pulvis, dividenda in chartulas No. x. Sig. — One after each meal. The purpose of such administration is easily recognized, and the clinical results confirm the idea. Such a headache may be often warded off by : 758. R. Pilulse hydrargyri. Pilule rhei compositi, aa gr. iv Extract! hyoscyami, gr. ij Divide into two pills. To be taken at night. CONGESTIVE HEADACHES. In the treatment of congestive headaches, the aperients so fre- quently required should be cordial and saline, such as 759- B- Infusi sennse compositse, Infusi rhei, aa f. 3v Tincturse cardamomi comp., f. §j Syrupi, f- 3 ss. To be given as a draught in the morning. Or, 760. R. Resini podophylhi, gf- "J ■Pulveris capsici, gr- ^j Extracti belladonnae, gr- 'J Massae, q- s. M. Ft. massa ex. qua. ft. pilulse, No. xviij. Sig. — One at night time. 761. R. Extiacti sennse fluidi, z?'^^ Magnesii sulphatis, 3 Jl .. Acidi sulphurici aromatici, fz '' Syrupi aurantii corticis, f- 3 ] Infusi rhei. Dose, a tablespoonful in the morning. f.|ijss. M. Good results may be expected in these cases from the combina- tion of a bitter with an alkali, as : 46o DISEASES OF THE NERVOUS SYSTEM. 762. R. Sodii carbonatis, yV _ Extract! gen tianae fid. comp., ,:3]f? Aquje, q. s. ad f.iiij. M. Sig. — Dessertspoonful before meals. It is well to combine a mild calomel purgative dose with the above, preceding it. Or some such prescription as the following may be of use as pre- scribed by Dr. SEYMOUR : 763. R. Pilulse hydrargyri, S'- ™^ Ferri sulpbatis exsiccati, gr- ^j Pulveris opii, S'- 1^*. Extract! gentianse, S^- xxiv. Misce et fiant pilulae, No. xxiv. S. — One or two before bedtime. Or the following, prescribed by Dr. PEPPER : 764. R. Resini podophylli, gr. ij Extract! colocynth. comp., gr. xij Extracti nucis vomicae, gr. iij Ferri sulphatis exsic, gr. xij M. Ft. pilulae, No. xii. Sig. — One at bedtime. For continuous treatment of dyspeptic symptoms associated and probably distinctly related to headaches, the following prescription is often of distinct value : 765. R. Tincturae gentianae compositae, Extracti Valerianae fluidi, aa f. § ij Tincturae nucis vomicae, f. 3j Sodii bicarbonatis, 3ii] Acidi carbolici, gtt. x. M. Sig. — One teaspoonful after each meal. Where the headache comes on because of irregularity of the meal or from want of food, a warm draught with the following may be of service : 766. R. Pulveris rhei, gr. 1 Magnesii carbonatis, gr. xl Spiritfls ammoniae aromatici, f. 5 ij Syrupi zingiberis, f. § ss Aquae menthae piperitae, q. s. ad f. § ij. M. Sig. — ^Tablespoonful in water. Where the stomach is very irritable, with much flatulence, the fol- lowing is excellent : HEADACHES. 461 767. R. Bismuthi subnitratis, Sodii carbonatis, £5 ot 1 Pulveris capsici, gr' yyj, jj| Ft. pilulx et divide in chartulas No. viij. Sig.— One twice daily— especially where there is acidity, loss of appetite and lack of tone. There are no medicines so invariably useful in cases of congestive headache, attended with debility, as the preparations of iron. If the patient be of stout phlegmatic habit, the tonic may be combined with a cordial and saline, according to the following formula : 768. R. Ferri sulphatis, gr. xxxij Magnesii sulphatis, 3x Acidi sulphurici diluti, f. 5 ij Tincturse cardamomi composite, f. § jj Syrupi, Aquje pimento, aa f. § j. M. A dessertspoonful in water twice a day. 769. R. Tincturse ferri chloridi, f. 5ij Acidi muriatici diluti, f. 3 ss Tincturse cinnamomi, f. § iss Syrupi, Aquae cinnamomi, aa f. 5vj. M. A dessertspoonful in water, twice a day, about half an hour after food. In the congestive headache of females past the middle period of life, especially when these headaches accompany alterations of the whole system at the great climacteric period, Prof. J. M. Da Costa finds the use of saline cathartics is of service. Also, a mustard foot bath every night. The application of a hot salt-bag to the back of the neck often affords relief. This form of headache is frequently associated with cardiac enlargement. MIGRAINE, HEMICRANIA, PERIODICAL OR SICK HEADACHE. The conditions underlying the headaches embodied in this head- ing are due to the faults of digestion, of vision, caries of teeth, to a localized neuralgia caused by malaria, gout, or some similar affection, to hysteria, etc. ; and the proper treatment must depend always upon the nature of the cause. As a general treatment available in most cases, of whatever origin, the use of cannabis indica is recommended by Dr. GREENE (Prac- titioner, 1872,) and since by Dr. E. C. Seguin (Opera Minora, 1884). The latter gives the details of his plan as follows : First. — ^The treatment of the patient consists in removing all re- lievable exciting causes, and more especially in correcting acidity. For this purpose he gives nitro-muriatic acid and alkalies, greatly 462 DISEASES OF THE NERVOUS SYSTEM. reducing the saccharine and amylaceous foods of the patient. In cases attended by debility, anaemia, and imperfect nutrition, it may be necessary to resort to tonics, including cod-liver oil. Second. — Treatment of the attack. The first thing to be done is to place the patient under circumstances which secure quiet and semi-darkness. The attempt to "fight out" a sick-headache is nearly always vain, and may be injurious. It is better not to allow the patient any food, not even liquids, until toward the close of the attack, or even not till next day; by this nothing is lost, and much wretchedness is avoided. Ice, or ice washed in brandy, is grateful. If the patient have a warning (aura of migraine) before nausea or pain, much can be done to cut short the attack or diminish its severity by the use of guarana, caffeine or croton chloral hydrate, (grs. viii or x every hour.) In his hands, guarana or the powder of the seeds ol paullinia sorbilis, has proved very efficacious. Third. — Treatment of the disease. The principle of the treatment is to keep the nervous system steadily under a slight influence of cannabis for a long period of time. He gives to adult females ^ of a grain of the alcoholic extract of cannabis indica before each meal, increasing the dose after a few Weeks to y^ grain. Males can generally begin with ^ grain, and it is well to give them ^ grain in two or three weeks. These doses must be taken with the greatest regularity, just as faithfully and regularly as bromides in epilepsy. Indeed, when beginning such treatment, he usually obtains a promise from the patient that he will regularly take the pills for a period of three months. As a rule, no appreciable immediate effect is produced by the above doses, though lightness of the head and slight confusion of mind may result from an initial dose of ^ grain three times a day. Under this apparently and essentially simple plan of treatment, results are obtained ; that is, the majority are greatly relieved, some entirely cured. DR. A. SEURE, OF PARIS, Strongly recommends (Bull, de Ther., 1879,) the administration of chloral in an enema, on the occurrence of the paroxysm of migraine, having found it almost infallible, and exempt from the disadvantages attendant on other modes of giving this substance, and far prefer- able to the employment of morphia, quinine, etc., for the same pur- pose. He gives, according to the sex or robustness of the patient, HEADACHES. 463 from one and one-half to three grammes, in a glass of tepid water, the effect of the chloral being rendered still more prompt by the addition of a tablespoonful of brandy. If a sense of burning in the rectum is excited, this may be prevented by adding the yolk of an egg, or substituting tepid milk for the water. When, as in some persons, there is difficulty in retaining the enema, the quantity of liquid may be diminished, and a drop or two of laudanum added. PROF. HARVEY L. BYRD, M. D., BALTIMORE. In the treatment of sick headache, Prof. Harvey L. Byrd, M. D., of Baltimore, recommends the use of an emetic of ipecacuanha, and after its action, the use of the following : 770. R. Chloralis, 3j AquEe, f. I ij. M. A tablespoonful every hour until sleep is induced. DR. JOHN MUSSER. This physician (Medical Waif, February, 1889), recommends in the treatment of this form of sick headache, the administration of one drop of tincture of mix vomica every ten minutes, until amelio- ration has distinctly set in. GEORGE KENYON, M. D., HARROWGATE, ENGLAND. In cases of hemicrania due to visual fault or to the irritation of the dental branch of the fifth nerve, the following is often of value : 771. R. Carbonis bisulphidi, f-SU- As a local application in periodical and hysterical headache, and even in many cases of dyspeptic cephalalgia. About two drachms of the bisulphide of carbon is poured upon cotton wool, with which a small glass-stoppered bottle is half filled. The mouth of the bottle is applied closely as near as possible to the seat of the pain, and so held from three to five or six minutes. In a minute or two, a sensation as of several leeches biting the part is felt, and in three or four minutes more, the smarting and pain be- come rather severe, but subside almost immediately after the re- moval of the bottle. (Medical Times and Gazette, July, 1868.) It is very seldom any redness of the skin is produced. The effect of the application is generally immediate ; it may be repeated, if neces- sary, three or four times a day. The application of a leech to the nasal mucous membrane is re- 464 DISEASES OF THE NERVOUS SYSTEM. commended by JOAL i^Rev. Mens, de Laryng., d'Oiol. et de Rhinol., July, 1888) in cases due to visual strains. MALARIAL HEMICRANIA. This form of headache is more common than at first thought would be credited, and having eliminated the possibility of a gastric factor in the aetiology of the case, one might profitably try the use of quinine in most cases of periodic headaches. It may be administered in pill form, timing the administrations to the expected occurrence of the headache. A mild mercurial or saline purgation preceding the administration of the quinine is val- uable in that it ensures a fuller and more rapid action of the drug. Quinine is sometimes used in these cases hypodermically, in doses of a grain or more, the administration being applied directly over the seat of pain. The drug may be dissolved in pure water in suffi- cient quantity for such medication. Arsenic in this form is also often of distinct service : 772. ]J. Acidi arseniosi, gr. ^'j- Cinchonse sulphatis, gr. ij Ferri et potassii tartratis, gr. j. M. Ft. pilula, No. j. Sig : One pill t. d. after meals. In this connection it may be proper to call attention to the head- aches due to syphilis, sometimes occurring very early after the prim- ary lesion (six to ten weeks) but usually later, and quite amenable to anti-syphilitic remedies. True neuralgic headache is recognized by its complete intermit- tence, by its plainly superficial character, and by its following the course of recognizable nerve branches, which often present one or more painful spots in their course. The stimulant narcotics are the most efficient drugs to combat it, especially the preparations of opium. Dr. Wright gives : 773- R- Morphias muriatis, gr. j Pulveris camphorse, gr. xxiv Mucilaginis acacias, q. s. M. Divide into six pills. One pill to be taken when the headache is very intense. Five hours are to be allovped to elapse before repeating the dose. Dr. Spender speaks well, of the local application of chloroform applied as is carbon disulphide by Dr. Kenyon (vide supra). Or a bit of blotting paper steeped in liquor atropines (gr. j. to f. §j water) may be applied to the painful area. HEADACHES. 46s Heat and cold are also valuable aids in the relief of the pain as clothes wrung out in hot water, or a bladder filled with ice. NERVOUS HEADACHE. In this connection may be mentioned the hysterical headaches of young female patients. In this form, PROF. R. J. GRAVES, M. D., DUBLIN. 774- R- Olei terebintbina:, f. 3j-ij. For one dose, to be given in cold water. Our author places much reliance on this medicine in the hysteri- cal and nervous headaches of young women. Some will bear and derive benefit from two or three of these doses in the day, experi- encing from its use a diminution of headache, the removal of flatulence, together with a moderate action of the bowels and kid- neys. The turpentine may also be given in the form of an enema. Occasionally it causes dysuria, and cannot be persevered in. Dr. Thomas Tanner recommends for these hysterical head- aches, the following: 775- R- Zinci valerianatis, gr. xij-xxiv Extract! belladonnse, gr. iij-v Extracti gentianae, gr. xxiv. M. Divide into I2 pills. One three times daily. Dry Clipping at the nape of the neck, between the shoulders, and below the clavicles, is often of great service in hysterical headaches. Six cups should be applied and allowed to remain on for ten or fifteen minutes. PROF. WILLIAM A. HAMMOND, M. D., NEW YORK. 776. R. Zinci oxidi, 9iJ-» Confectionis rosae, ^.• *• "*• Divide into twenty i^ills. One to be taken three times a day, after meals. This formula is. of great value. The minimum dose (gr. ij) should be commenced with, gradually increasing to the maximum (gr. v.), if necessary. 777. R. Bismufhi subcarbonatis, 9'i Confectionis rosse, '\- '• Divide into twenty pills. One after each meal. These pills will often take the place of those of oxide of zinc. They are particularly useful when there is gastric disturbance. 30 466 DISEASES OF THE NERVOUS SYSTEM. Bromide of potassium is serviceable when the nervous system has been irritated ; when exhausted, it does harm. Bromide of ammonium is similar to the bromide of potassium in its action, but the dose need not be so large. Our author often uses both combined. Opium and its preparations are rarely of value in this disorder. If used, the hypodermic method is the best. Phosphorus is beneficial in all the forms of nervous headache. It is, however, difficult of administration, and leaves an unpleasant odor about the person. The best results are obtained from the following method of administration: 778. R. Acidi phosphorici diluti, '•S^ Syrupi phosjihati compositi, f. § iij. A dessertspoonful, in water, three times a day. Arsenic, as a nerve tonic, stands next in value to zinc. Granules of arsenious acid (gr. jtj) are preferable to FowLER'S solution. Galvanism is highly praised by some, and severely condemned by others, in this affection. The brain cannot be acted upon to any considerable extent by the induced current or by the reflex action. Our author advises, always, the constant current ; being careful to avoid too great intensity, lest amaurosis be produced. (Half-yearly Compendium of Medical Science, July 1868.) Dr. Wright states that in nervous headache, the combinations of hyoscyamus with camphor, with chloroform, or with a diffusible stimulant, generally afford great relief. The following formulae may be used : 779. R. Extract! hyoscyami, Fulveris.camphorse, aa 9ijss. M. Divide into twenty pilk. Two to be taken when the pain is severe. 780. R. Chloroformi, f.Siss Tincturae hyoscyami, Tincturce cardamomi composite, oS f. 3 ss Olei limonum, Hlxvj Sacchari, Pulveris acaciae, aa 3 ss Aquae camphorae, f, § ijj. J], Dose, a tablespoonful. 781. R. Tincturae hyoscyami, Spirittts ammonix aromatic!, aa f. S ss Syrup! aurantii corticis, f.gj Aquse menthae piperitae, f. § ij. M, Dose, a tablespoonful. HEADACHES. 467 782. R. Pulveris campborse, 1 Quinize sulphatis, aa gr. x Extract! aloes, pj-_ xij Extracti hyoscyami, 2ss Mucilaginis acacix, q. g, f^^ Divide into eighteen pills. Two to be taken twice a day, in case of nervous head- ache when there is great debility and sluggishness of the system. WILLIAM HENRY DAY, M. D., LONDON. This author, in his work on Headaches, their Nature, Causes and Origin, states that the subjects of neuralgic and ordinary nervous headache are usually anaemic, and require nutritious diet and rest. Frequently taints of gout, syphilis or mercury are present in very obstinate cases, and must receive proper treatment before a cure can be effected. Locally, we may use a chloroform and aconite liniment, or ointment of belladonna or veratria. The following is useful : 783. R. Sodii bypophosphitis, 3ss Infusum columbse, ad f. § vj M. Two tablespoonfuls thrice daily. Arsenic is a remedy of the greatest value ; it must not be aban- doned as soon as constitutional symptoms appear, but only sus- pended for a day or two and recommenced. 784. R. Tinct. cinchonse, IHxx Liq. potass, arsenitis, Hlv Mist, camphorse, f-3i- M. This amount thrice daily. In many cases of headache the element of brain tire is to be dis- tinctly recognized and treated. DR. DANA. This physician in a valuable paper upon cephalalgia (Med. News, March 16, 1889), states that, as a rule, headaches among brain workers require a different class of remedies from those employed among muscle workers. Nervines like antipyrin (gr. iij-gr. xxx), caffeine (gr. j-gr. v), and the bromides act well, and attention to diet, exercise, and the eyes is especially required. In these cases the various effervescent preparations of the bromides with soda, caf- feine, etc., may be of service, although they are to be used unstint- ingly because of the usually small amount of bromine present. Among the laboring classes, among the females especially, the 468. DISEASES OF THE NERVOUS SYSTEM. causes, anaemia, syphilis, malaria, and rheumatism, must be particu- larly sought for, and be removed as far as possible. In the headache of neurasthenia, menthol (gr. v) in hot water gives relief; or a combination of menthol (gr. v). and antifebrin (gr. v-x). This author states that in the use of antipyrin the results often depend upon the manner of dosage. Often the best results are obtained by small doses frequently repeated. RHEUMATIC HEADACHE. Rheumatic headaches occasionally manifest themselves as rheu- matism of the scalp, causing the latter to be quite tender and pain- ful. In such headaches the use of local measures is often of consid- erable value, as recommended below: DR. HENRY G. WRIGHT, LONDON. 785. R. Lirimenti chloroformi, Linimenti belladonnse, aa f. § iss Tincturtc opii, f-§j. M. For external application, in rheumatic headaches. Mustard plasters applied to the neck are also exceedingly useful as a means of counter-irritation. In such cases (rheumatic head- ache) the following aperient is of advantage, viz : 786. R. Pilulse colccj'nthidis compositoe, gr. xv . Extract! colcbici acetici, gr. iij Olei carui, inj. M. Divide into four pills. Two to be talteti at bedtime, and one on consecutive nights. These pills should be followed, in persons of a costive habit, by a morning purga- tive, as follows : ■787. B. Magnesiae, Qiy l.iquons potassae, THxlv Extract! sennce fluidi, f.Sij Syrupi zingibeiis, TinctuKE aurantii, 55 f. § ss Aq"!S. f!§j. M. Dose, a tablespoonful. The administration of an alkaline medicine containing potash, if continued with regularity, will generally be followed by rapid ameli- oration of the pain and tenderness. The following may be used : 788. R. Potassii bicarbonatis, ^iv Potassii chloratis, 5 is3 Tincturse cinnamomi, Tincturse aurantii, 55 f. 3yj Syrupi aurantii corticis, f. § jsj. jj. A dessertspoonful to be taken twice or three times a day. HEADACHES. 465 If imprudent exposure to cold has produced an aggravation of the headache, and particularly if the patient be subject to catarrh, it is advisable to. administer a sudorific at bedtime, such as 789. R. Pulveris ipecacuanhse compositi, gr. xij Pulvens camphorae, Pulveris guaiaci, 53. gr. iv. M. For one powder. To be taken about bedtime. GOUTY OR LITHyEMIC HEADACHE. DR. A. HAIG, LONDON, ENG. This gentleman in a series of articles appearing in the London Practitioner and British Medical Journal for the past two years, (of which a resume appeared in Wood's series of medical and surgical monographs for the present year) views the production of this form of headache as produced in some such manner as follows, and bases his treatment upon his views of the mode of origin. Uric acid how- ever formed occurs in definite proportion in the economy with urea, both metabolites of nitrogenous material ; and normally is excreted in the urine in a constant proportion (i uric acid; 35 urea). In acid conditions of the body-fluids the uric acid is relatively insol- uble, and instead of being carried to the kidneys for excretion, is deposited in the organs and tissues, notably the liver and the spleen: If, now, the fluids be suddenly rendered alkaline by the ingestion of alkali in medicine or food, this excess is dissolved from the tissues and swept into the circulation, acting upon the coats of the vessel^ and making them tense, and possibly having a direct action on the nerves, producing, at any rate, a congestive headache. As soon as the abnormal amount is removed from the circulation by the kid- neys or by redeposition in the tissues, the symptoms abate. The plan of treatment then depends upon keeping the uric acid from the circulation in abnormal amounts. If the patient be met in an attack, immediate relief (within half to one hour) may be ac- complished by the administration of an acid, so as to precipitate the substance from the blood, as by 790. R. Acidi nitro-muriatici dil., TIlv-xv Infusi columbse, C'l^^ »» Aquie, q.s.adf.§3- "• Sig. — One dose. In the interval every effort is to be made to keep the excessive amount of the deleterious material from the blood, and to promote 470 DISEASES OF THE NERVOUS SYSTEM. its excretion as much as possible. The former object is accom- plished mainly by the removal from the diet of butcher's meats and other highly nitrogenized foods, which may be replaced by flesh of fish, occasionally by fowl and game and by milk. The excretion of the offending substance is best accomplished by means of the sali- cylates and by the use of the phosphate of soda alone or combined — 791. R. Sodii salicylatis, 3ii Syrupi limonis, f. B j Aqiue, q. s. ad f. § iij. M. Sig. — ^Teaspoonful after meals. Or 792. R. Sodii phosphatis, 5ii Extract! colchici fluidi, f. 3 iss Aquae, q. s. ad f, § iij. M. Sig. — Dessertspoonful after meals. Water should be taken freely in these cases, particularly the alkaline waters, as the lithia waters of Londonderry spring in New Hampshire, or of the Buffalo springs of Virginia. ANAEMIC HEADACHES. These are apt to occur mostly in women, particulary in those suffering from chronic depletive uterine complaints ; and are to be remedied in that case by the treatment of the primary affection, with the administration of iron and the exhibition of gastric stimu- lants to promote nutrition. In many cases the anaemia is due to some disturbance of other functions, and is to be treated as a simple anaemia. In all these cases iron is of prime importance. An excellent formula prescribed as a general tonic by Dr. GooDELL, may be used in this connection : 793- R- Hydrargj'ri chloridi corrosivi, gr. j-ij Liqnoris arsenici chloridi, Tinct. ferri chloridi, aa f. 3 j Acidi hydrochlorici diluti, f. 3 iv Syupi, f.|iij Aquae, q. s. ad f. | vj. M. Sig. — Dessertspoonful in a wineglass of water after each meal. NOTES ON REMEDIES. BILIOUS AND DYSPEPTIC HEADACHES. Ammonii Acetaiis Liquor is recommended by Prof. Siille, who considers few remedies so successful in sick headaches as a teaspoonful or two of this solution. HEADACHES. 47 1 Ammonii Carbonas will sometimes offer almost instantaneous relief. Ammonii Chloridum is useful in bilious, as well as hysterical headaches. According to Dr. Anstie, gr. x-xx, if given early enough, seldom fails to cut short and greatly mitigate the attack. It is given with great benefit when the pain is most intense, in any form of headache. Argenti Nitras is recommended by Dr. J. Johnson (in combination with minute doses of compound colocynth pills), in the habitual stomach headache to which delicate and literary men are so subject. Hydrargyri Chloridum Mite, or other mercurial, is of service in headaches arising from biliary derangement, or a torpid state of the bowels. It should be followed, at a short interval, by a saline or other purgative. Magnesia, in cases accompanied with constipation, affords great relief. Magnesii Citratis Liquor. A dose of the effervescing citrate is often very effectual in dyspeptic headache. Pepsin is of the greatest value in the prolonged treatment of the underlying gastric inefficiency. Podophyllum is prescribed with benefit in many forms of bilious headache. Potassii Bromidum has been recommended for the prompt relief of the paroxysm. CONGESTIVE OR PLETHORIC HEADACHE. Aloetic purgatives are beneficial in congestive headaches. Leeches may be applied with advantage to the inner nostril, temples, to the crown of the head, or to the verge of the anus. Saline aperients are recommended by Drs. Da Costa and Wright. Sinapisms, to which have been added powdered capsicum or oil of turpen- tine, are often applied with benefit to the soles of the feet and the inner parts of the calves and thighs. Water, locally applied, hot, is often more effectual than the cold lotions usually employed. Diligently steeping the temples, forehead, occiput, and nape of the neck with water, as hot as can be borne, in many cases will be found a useful remedy. The hot foot-bath is of ten of signal service. GOUTY headache. Colchicum may be employed with greater freedom in gouty headache than in ordinary gout, according to Dr. Wright. Sodii Salicylas is of great value as a means of breaking up the lithaemic state upon which these headaches are dependent, by promoting the excre- tion of uric acid (gr.*x-xx). Sodii Phosphas is also recommended by Dr. A. Haig {loc. cit.) for the same purpose. 472 DISEASES OF THE NERVOUS SYSTEM. Acids, as dilute nitromuriatic, aromatic sulphuric, etc., are of use in cutting short the attacks of gouty cephalalgia. HYSTERICAL AND NERVOUS HEADACHES. Ammonii Chloridum is advised by Dr. Anstie, to be administered in the same manner as for bilious headache (which see above). Ammonii Bromidum is recommended by Prof. Hammond, alone or combined with the bromide of potassium. Antipyrin, Antifebrin, Phenacelin and others of the hydrocarbon derivatives, are often of great service in the headaches of nervous tire, admin- istered best in small doses (gr. iij.) often repeated. Argenti Nitras is highly prized by Dr. Graves, administered in considerable doses, /. e., gr. J^ five or even six times daily, for five or six days at a time, when the paroxysm has abated. If thore be constipation, the nitrate should be combined with minute doses of compound colocynth pill. Cajuputi Oleum is used both externally and internally, in nervous, rheumatic, and neuralgic headaches. Camphora is useful, combined with hyoscyamus. Chloroformi Spirit its, in the dose rri,xv-xxx, often affords prompt relief in- nervous and hysterical headaches. Cimicifuga is useful in the headaches attendant on uterine derangement. Guarana is particularly efficacious in the relief of sick headache, in doses of half a drachm to a drachm. Hyoscyamus is strongly recommended by Dr. Wright, in nervous headache. It may be combined with camphor, with chloroform, or with a diffusi- ble stimulant. Lavandula. The compound tincture, administered according to the follow- ing formula, makes an agreeable stimulant : 794. K- Tincturse lavandulze compositse, SpiritQs chloroformi, SpiritQs xtheris compositi, aa f. 3) Aquse camphors, f. § iij. M. Dose, two tablespoonfuls in water. Opium may be added if indicated. This is a very effectual recipe for the headache of hysteria. Menthol (gr. v) or with antifebrin (gr. iij-x) is recommended as internal treatment in the headaches of neurasthenia by Dana (loc. cit.). Nitro-viuriaticum Acidum is recommended by Dr. Tanner. 795. R. Acidi nitro-muriatici dil., f. 3ij Stn chniae. * gr. ^J SpiritQs chloroformi, f. 3vj Tincturse zingeberis, f. 3 iij Aquse, q. s. ad f. § iij. M. Sig. — Teaspoonful in water three times a day, in nervous headache. HEADACHES. 473 Tinctura Nucis Vomiccs is commended by Dr. Musser {loc. cif.) in drop doses repeated e-zery ten minutes. Oleum Eucalypti is commended by Dr. Morris Lewis {Med. News, Tuly 20, 1889) in doses of m, v. every four hours. Phosphorus is recommended by Prof. Hammond in all forms of nervous head- ache. QuinicB Sulphas is beneficial in hysterical headaches associated with anaemia. Terebinthice Oleum is recommended by Dr. Graves in hysterical headache. Valeriana is of especial benefit in hysterical headache. Dr. Ashwell recom- mends the following formula : 796. R. Tinctune valeriante, SpiritCls retheris compositi, Spintfls lavandulre co:upositi, aa lUxxx Tincturje hyoscyami, TIlxx Aqiue camphorae, f. 3 x. M. For one dose. Dr. Connolly recommends the following : 757- R- Tincturse valeriarie ammoniatx, Spiritfls aetberis compositi, aa ll^xxx Aquxe camphorae, f. 3jss. M. Or: 798. R. Tincturse Valerianae aramoniatae, f. 3j Acidi sulphurici diluti, IHxv Aquae camphorae, f. § iss. Make a draught to be given twice or thrice a day. Zinci Oxidum is regarded as of great value in nervous headache by Prof. Hammond. Zinci Phosphas is recommended by Dr. Tanner in hysterical headache, asso- ciated with debility. Zinci Valerianas is also recommended by Dr. Tanker, combined with bella- donna. external remedies. ^iher to the forehead, on a very thin compress, to avoid irritation of the skin, by thus favoring its free evaporation, is an excellent application. Camphora, locally applied, is a valuable remedy in nervous headaches. The following formula may be employed : 799. R. Camphone, 3J Another excellent local application is what is known in France as " L'Eau Sedative de Raspail." (F. 754-) 474 DISEASES OF THE NERVOUS SYSTEM. Dry Cuppivg is recommended by Dr. Graves. Oleum Cajuputi. A few drops rubbed upon the painful part are often effec- tual. Oleum Menthce applied to the forehead and base of the occiput often gives immediate relief. It is best dissolved in alcohol. Shower Baths are often of great advantage in hysterical headache. NEURALGIC HEADACHE. Ammonii Chloridum, given when the pain is most intense, in the dose of gr. x-xx, sometimes affords prompt relief. Camphora, in the form of "Raspail's sedative water" (F. 754), is sometimes very useful. Caffein. The citrate has been recommended in doses of gr. j, every hour, for some time before the expected attack. Coffee is much used by Belgian physicians. The juice of a lemon makes a valuable addition to a cup of strong coffee in these cases.. Caffein may also be em- ployed hypcdermically. PERIODIC HEADACHE. Arsenici lodidum has been found by Dr. Walshe to give relief in the most violent cases of periodic headache. It should be given in doses of gr. Ts-rV, twice a day, two hours after eating, and continued for a month or two. Ammonii Carbonas and a saline purgative, at the commencement of an at- tack, are recommended by Prof. Flint. Belladonna is sometimes of service as a prophylactic. Caffea is a popular and efficient remedy. Potassii Bromidum often rapidly relieves headache of a paroxysmal character, with heat of the head and flushing of the face. QuinicB Sulphas, in small doses, is recommended, by way of prophylaxis, by Prof. Flint, and in cases of malarial periodic headache it is of cura- tive value. Zincum. The various preparations of this metal, more especially the valeri- anate, may be employed with advantage in the intervals of the attacks. INSANITY. In fact of the growth in popular estimation of asylum treatment for mental alienation, and the legal necessity in a number of our states for such care in cases where private treatment of the same INSANIl'Y. 475 general tone cannot be obtained, renders anything but a brief re- view inappropriate to the object of the work. Insanity, briefly, should be regarded as a disease manifesting it- self by mental exaltation (mania), by mental depression (melan- cholia) and by mental destruction (dementia). These are all for practical purposes one and the same disease in various manifesta- tions ; and the line of treatment only varies with the varying stages or manifestations of the disease. HYPOCHONDRIASIS. The milder forms of melancholia, or Hypochondriasis, are to be regarded as belonging in this connexion. A. O. KELLOGG, M. D. In the treatment of the early stages of this form of mental alien- ation, this writer (Amer. Jour, of Med. Sciences, January, 1878,) says that the digestion and sleep, especially the latter, are to be im- proved. For this purpose, he has found the following drugs to be most useful, in the order given : Hydrate of chloral, gr. x— Ix ; tinc- ture of hyoscyatnus, f..5j— iij ; liq. morphice sulphatis, f..5j-f..'5iij ; or two or more may be combined, especially the two first mentioned. Opium often aggravates the insomnia. Traveling, so often recom- mended, is worse than useless. In the majority of cases, overwork or exhaustion from innutrition, lactation, etc., has led to the condi- tion, and rest is imperatively demanded. The patient must be carefully nourished and sustained by a full, generous diet. From fear of biliousness or indigestion, he has probably fasted, abstained from food at least, and perhaps from drink ; but as to the last, it is not improbable that he may have indulged excessively in stimulat- ing beverages. These, in moderation, however, are not without their use; for in all such cases, there is generally deficiency of nerve and brain force, which, next to good, nutritious food, is sup- plied by wine, eggs, milk, malt liquors, iron, quinine, strychnine, arsenic, etc., as, in the judgment of the physician, may seem in- dicated. PROF. FELIX VON NIEMEYER, M. D., TUBINGEN. The only way to cure a hypochondriac, is to rid him of his mor- bid sensations ; but it is useless to dispute with him and try to con- vince him of the error of his ideas. In the first place, any existing 476 DISEASES OF THE NERVOUS SYSTEM. derangement of the system which v/ould cause a feeling of illness in a sane person, should be corrected. The benefit derived from var- ious natural mineral springs is no doubt due to their happy effect upon the gastric disorders which so frequently give rise to this dis- ease. Preparations of iron, sea-batking, and cold foot-baths, are fre- quently appropriate. Drastic cathartics must be used with caution, though they cannot be altogether dispensed with, and generally afford temporary relief. Patients should be warned against over- dosing. This also applies to the use of carminatives, for which they nearly always beg. The psychical treatment should have in view the diversion of the attention from the sensory to the motor and intellectual spheres; This object will not be attained in educated patients by ordering long walks, wood-sawing, gymnastics, and mechanical pursuits, be- cause the attention is not diverted by such action out of the sphere of sensation. A hypochondriac merchant sawing wood is always busy with the thought that he is doing so because he is sick. Gen- eral rules are of little value, as the directions must always be in ac- cordance with the capacity, education and means of the patient. In the gravest forms of insanity the treatment may be followed out upon the, lines indicated as follows : ACUTE INSANITY. Bell and Lemoine {Annal. Med. Psychologiqiies, Paris, January- March, 1889) summarize their methods in the treatment of mel- ancholia as follows : 1. Rest in bed for a prolonged treatment. In this way cerebral anaemia is best prevented and the patient removed from the dis- turbing influence which often forms the basis of delusions. 2. Every morning the patient is given a glass of Hunyadi water, preventing in this way the disturbing effects of constipation. 3. Tincture of nux vomica is given in small doses twice daily before the two principal meals of the day. 4. Laudanum is used in progressive doses, commencing with 5 drops and increasing by 5 drops every day until distinct improve- ment in the patient's condition is produced. They have never had occasion to exceed 200 drops daily, however, but would not hesitate to do so if necessary. Acute insanity, whether mania or melancholia, presents as one of its most common features, and one demanding active treatment, insom}tia. INSANITY. 477 DR. T. M. LLOYD, LATK OF MORRIS PLAINS ASYLUM. In an article by this gentleman upon the "Use of Hypnotics in the Insane" {Therap. Gaz., February, 1888), he gives as his own experience and that of several asylum physicians to whom he had addressed inquiry, the statement that chloral hydrate continues to be a favorite hypnotic, and that the bromides of sodium or potas- sium, opium in some of its forms, hyoscine, hyoscyamine, various preparations of hyoscyamus, paraldehyde and urethan are used in the order mentioned. The use of chloral as a hypnotic in cases of acute as well as of chronic insanity, is commendable in connection with the bromides, as the following prescription, a favorite in the insane wards of Phila- delphia Hospital : 8co. R. Chloral hydratis, Potassii bromidi, ai 5 v Sj rupi et aqua; cinnamomi, aa ad f. § iv. M. Sig. — ^Teaspoonful every hour until sleep is prodticed or until four doses have been administered. Dr. Clouston in his classical work upon insanity recommends that extractum cannabis indices Jlttidum be added in appropriate dose (gtt. iij— viij) to such combination, where the remedy is to be used for considerable periods, the addition of the hemp tending to diminish the untoward mental effects of profound bromism. Opium is usually used in a similar combination for the purpose of causing sleep in the insane ; but many physicians are opposed to its employment. It apparently is of little value alone in mania; and has seemed to give its best effects in cases of simple melan- cholia, and hallucinatory cases, where brain exhaustion has appeared to be a factor in the aetiology of the case. (Ziehen, Therap. Monat., February and March, 1 889. Of the later hypnotics the preparations of hyoscyamus, hyoscine and hyoscyamine, are probably the best known. These are admin- istered hypodermically, in doses of gr. tsc-iJo ; or may be given by the mouth in pill form in slightly larger doses. Of the two, hyoscine is probably the more efficient. Sitlpkonal, according to Wetherill (Am. your, of Insanity, July, 1889), Obersteiner, of Vienna, and others, is one of the most cer- tain hypnotics in its results. The latter finds that generally less than a single gramme (15 grains) is usually effective ; that the sleep 478 DISEASES OF THE NERVOUS SYSTEM. is quiet and refreshing, and where pain is a factor morphia may be safely combined. DR. T. S. CLOUSTON, EDINBURGH. (Am. your, of Med. Set., April, 1889.) Dr. CLOUSTON, speaking of the use of hypnotics, sedatives, and motor depressants in con- nection with insanity, presents the following views : Make up your mind from the symptoms of the case whether there is demanded a simple hypnotic, a general nervous sedative, or a simple motor de- pressant ; and in administering any drug, closely watch its effects, both upon the higher nervous functions and upon the organs and the general organism. Stop the use of drugs as early as possible, always be on guard lest any of the highest functions of mental inhi- bition are being damaged by prolonged medication. Constantly watch over the general health, and keep up measures for the pre- servation of the health, nutrition, and the higher functions while such remedies are being employed. Paraldehyde is the purest and least harmful hypnotic yet introduced when the insomnia is marked and intractable. Urethan and sulphonal cannot compare with it, and opium and chloral are specialized in their advantages and dis- advantages. (Paraldehyde may be administered in doses of gr. xv— — Ix; it is frequently administered by enema held in egg albumen.) Hyoscine is the best pure ipotor depressant, but must be guarded. Over-medication is, however, of the greatest danger ; it is usually far better to treat the patient by improving the general nervous tone and nutrition of the body than to merely produce quiet and sleep by drugs. It is commonly safer to permit an outlet for the excessive motor energy than merely to depress it by drugs. DR. A. SIMONS ECCLES. {London Practitioner, March, 1888.) Persistent sleeplessness combatted constantly by means of drugs, becomes finally, of the gravest import, the prolonged medication almost invariably produc- ing deleterious effects on the organism. In many cases hot baths are productive of refreshing sleep and are to be commended. Dr. EcCLES prescribes that the temperature of the bath-room should be not less than 65° F. The patient is then directed to stand at the edge of the tub, and the head and face is rapidly douched with water at ioo° F. ; the cooling of the nude body from exposure to the air and the determination of the blood to the brain from the hot INSANITY. 475 sponging cause a general dilatation of the cerebral vessels. The entire body is then immersed, except the head, in a bath at 98° F., which is rapidly raised to 105° and 110° F., according to the con- dition of the patient. After eight to fifteen minutes the patient is wrapped in warm blankets, and slowly, without exertion, conducted to his room, night-clothes donned, and the patient put to bed with a hot-water bottle to his feet. In a few minutes, the room being darkened, the patient usually sleeps. Dr. ECCLES prescribes in those cases in whom, because of cardiac or other disease, the above measures are inapplicable, massage and friction of the back and limbs, with gentle kneading of the abdomen, to which is applied a hot moist compress and friction of the feet. The compress is made of twilled calico eight yards long and half a yard wide, previously heated in a closed earthen vessel, and when used partly unraveled and moistened, the moist part applied to the abdomen and the hot part wound around the abdomen and hips, thus applying a most soothing heat and moisture. Cool applications to the head, the drinking of hot milk, etc., are valuable adjuncts to such measures. The nurse should only be engaged under the directions and be subject only to the instructions of the physician in charge. Care is to be taken in employment of a competent nurse ; strength for an emergency, firmness for control, cheerfulness for companionship, high principles and pleasing manners for respect — all must enter into the judgment when a choice is to be made, as well as intelli- gence for the proper attention to the methods of the physician and the necessities of the patient, and the dangers of homicide or suicide. DR. THOMPSON, BRISTOL ASYLUM. Dr. Thompson, in reporting his experience with hydrobromate of hyoscine (London Lancet, February 4, 1888,) concludes as follows: We find then, that in mania in any form the hydrobromate of hyos- cine is the best calmative which has yet come to our notice. In some cases of general paresis attended by busy restlessness, with dry skin and some suppression of the urine, a small dose puts the patient in a much more comfortable state. Dr. THOMPSON uses as his ordinary dose ^j^ of a grain, hypodermically. Conrad (CentralbL f. Nervenheilkunde, Psych, und gericht. Psy- chopath., November 18, 1888,) speaking of the hydrochlorate of the 48o DISEASES OF THE NERVOUS SYSTEM. same alkalod, commends it in the same class of cases in doses of tJ«~iV grain ; but urges tliat its use be not long continued, as it is apt to produce unpleasant effects, and is especially to be restricted in cases complicated with cardiac diseases. (For other measures, see Insomnia, especially physical means.) A second grave symptom in acute insanities is the motor excita- bility, leading often to deeds of violence and destruction. The purely medical treatment of this condition depends upon the administration of motor depressants, as conium or hyoscine, of general nervous sedatives, as the bromides, valerian, etc., and in the employment of physical restraint. PHYSICAL RESTRAINT. The question of the propriety or impropriety of such restraint has in this country undergone considerable discussion within the past five or ten years, and many asylum physicians claim to eschew the use of such measures entirely. That there is a marked ad- vantage in the removal of such practice from the asylum role to a large degree is undoubted ; but that it should be entirely abolished is just as improper. The average asylum patient never demands either restraint or confinement beyond those of the walls of the institution ; but occasionally the practice of restraint or close con- finement for a limited period is judicious. Away from asylums, both restraint and constant confinement are frequently absolutely essential ; and as these measures are attended by difficulties and inconveniences of marvellous proportions both to patient and keepers, the practice of home treatment saving in the most exceptional cases is to be discouraged. Restraint in bed is best accomplished by means of a heavy can- vas sheet, a hole cut in it for the head and two for the arms, a con- siderable portion falling down over the back when placed over the patient in the erect position. The patient is placed supinely in the bed, and the sheet laced by cords to the edge of the bed-frame and about the foot to prevent his slipping down too far and thus ex- tricating his head and arms. The advantages of this means over the ordinary wristlets and anklets is that there is no tendency to excoriation. Confinement in close quarters should be constantly supervised by the physician to prevent any tendency toward carelessness and lack INSANITY. 481 of cleanliness. Ventilation should be insisted upon, and in winter a sufficiency of warm and pure air. Where the motor excitability is very marked or the patient a violent epileptic, the walls and floor may be padded with advantage, but the room must under no cir- cumstances be permitted to become in the least unclean. Where the patient is less violent but cannot be permitted to be at large, the apartments must be made as cheerful and home-like as possible, and frequent airings in charge of a competent attendant, and attendance upon cheerful attractions, are to be insisted upon. Pilocarpine (gr. }i-}4, hypodermically) is highly valued in delir- ious excitement by Dr. WiLLOUGHBY (London Lancet, May 25, 1889.) A third common condition in the acute psychoses is the failure of nutrition, and emaciation. The means at hand to combat this symptom of failing vitality depend as much upon hygiene as upon medication. Close confinement, except where absolutely necessary, is unpardonable, and then every effort at occasional walks in the fresh air under close guard is to be made, and the most marked attention to ventilation and general and personal cleanliness to be had. Wherever any employment is possible, it is necessary. As stimulating to the nutritive functions, the bowels should be carefully attended to, constipation being rather common, and some bitter tonic may be advantageously given, as : 801. R. Strychnias sulphatis, gr. ss Tincturse cinchonae compositae, q. ». ad f. § iij. M. Sig. — ^Teaspoonful thrice daily. Under no circumstances, however, is polymedication to be prac- ticed upon the patient — an evil much more to be condemned than neglect of medicine. Ocz2&\on2\\y forcible feeding is necessary, because of some delu- sional abstinence from all nutriment on the part of the patient. This should not be postponed until late, lest all benefit be lost, and the patient die. It is best accomplished by taking a long, smooth rubber tube of small calibre, the end well rounded by rubbing with a rag dipped in chloroform, and affixing it to an ordinary glass fun- nel. The tube is well oiled, and the free end thrust into the nostril and carried back along the posterior wall of the pharynx and well down into the oesophagus. The tube introduced, it is well to make sure that it has not gone into the larynx, an error which can be 31 482 DISEASES OF THE NERVOUS SYSTEM. easily made out by watching whether any air is forced by respira- tion through the funnel, and by noticing whether respiration is easy. This error being eliminated, liquid food of any sort may be poured into the stomach, as the case may require. As a basis for these foods milk is almost universal, either as a milk punch, egg-nog, milk with the various beef preparations or what not. The food, it should be remembered, is best assimilated if warmed. CHRONIC INSANITY — GENERAL PARALYSIS OF THE INSANE, ETC. In the chronic insanities, chronic mania, melancholia, dementia, and the various specialized forms, as well as in most cases of Gen- eral Paresis of the Insane, the same general rules as to hygiene are to be carried out. Exercise, care in diet, care in cleanliness, cheerful surroundings, all are especially demanded, as much if not < more than in the acute forms (except the convalescents from acute insanity). Sleep must occasionally here also be produced artific- ially, and in these cases the bromides, especially combined with Can- nabis Indica, as commended by Clouston (loc. cit.), are to be em- ployed. But in these cases, too, the use of other than medical means for producing sleep is to be praised. Attention to the condition of the boweb must be constant, regu- lating any tendency to constipation with a well-ordered laxative: 802. Jl. Extracti casrarse sagradae fld., f. §j Syrupi yerboe santce, f. § j Aquse, q. g. ad f. § iij. M. Sig. — ^Teaspoonful in morning in water; or the elixir of cascara may be substituted for elegance. In cases of general paralysis of the insane, except where the case is in the earliest stage and of specific origin, there is no special treatment. DR. EDWARD C. SEGUIN. In the treatment of insane and melancholic patients at home, this writer (^Opera Minora, 1884), states that the first requisite is to se- cure a good nurse, and create a cheerful moral atmosphere. Many such patients will need building up with tonics and nutritious food. Phosphorus, in the shape of "Thompson's solution" (F. 807), iron, arsenic, strychnia, and alcohol, are demanded. To produce sleep, chloral or opium are preferable to the bromides. Cannabis CHRONIC INSANITY. 483 indica is also useful. Galvanization of the spinal cord has been used in the treatment of melancholia with apparent success. The hygiene of the patient must be carefully watched, the bowels regulated, cold sponging advised, and the patient occupied and amused. Where there is a decidedly suicidal impulse, or where food is per- sistently refused, it is better to place the invalid in an asylum. NOTES ON REMEDIES. Auri et sodii chloridum has produced excellent results in various forms of mental disorder. It is especially indicated where there is ansetnia, but is not suitable for plethoric subjects. The dose is gr. A-2V, in pill or dissolved in mint water. Cannabis Indica is commended by Clouston as a valuable adjuvant to the bromides, in prolonged administration. Conium, either as the succus (gtt. iij) or extractum fluidum (gtt. iij-x), is used in great motor excitement. Hyascine and Hyoscyamine (gr. uk-ss) and their salts are commended as hypnotics and motor sedatives. Hypnotism, with persistent suggestion, is claimed by Charcot and others to be of considerable service in dispelling delusional and hallucinatory insanities. Paraldehyde is used extensively as the purest hypnotic remedy. It is given preferably by the rectum, because of its unpleasant odor, in doses of gr. xv-lx or more. Pilocarpine is of value in mental excitement, delirium, etc., of the acute in- sanities. It may be given hypodermically (gr. J). Potassii Bromidum and the other bromides, particularly that of sodium, are of considerable service as general nervous sedatives. Potassii lodidum may prove of service in many cases of insanity, because they aiise from syphihtic poison. In twenty-one cases of. dementia para- lytica, Dr. Snell found signs of spyhilitic infection in eleven. (Schmidfs Jahrbucher, 1883.) Sulpkonalis being used extensively as a pure hypnotic (gr. x-xxx). Urelhan, according to Adam, of Paris {Ititernat. Klin. Rundschau, October 28, 1888), is a valuable hypnotic (gr. xv-lxiv), but its use is not gen- eral, and is by some regarded as uncertain. 484 DISEASES OF THE NERVOUS SYSTEM. INSOMNIA OR SLEEPLESSNESS. DR. G. EICKHOLT. In a study of this symptom (Deutsche Med. Woch., November, 1883), this writer divides it into three forms: 1 . Insomnia from mental or physical over-exertion, including that from the excessive use of tea, coffee or opium. 2. Insomnia from disease, as neurasthenia, chronic gout, neural- gia, etc. 3. Insomnia from functional or organic disease of the brain. The treatment begins with establishing careful hygienic regula- tions of the habits and diet. Tea and coffee must not be taken in the evening. Warm baths, a half hour in duration, before retiring, are beneficial. Hyperaemia of the brain may be reduced by wrap- ping the head in cloths wrung out of cold water. When anaemia of the brain is present, a glass of beer or hot punch acts as a hypnotic. Of medicines, bromide of potash or soda stands first in neurasthenic and irritative cases. A full dose, about eighty grains, should be taken, well diluted, say in a tumbler of weak mint tea, about an hour before retiring. Opium may answer in anaemic, but is contra-indi- cated in urasmic individuals. Chloral is generally useful, but should be avoided where the heart is weak, where there is arterial disease, and in old age. Cannabis indica and tannate of cannabine are use- ful in neurasthenia and melancholia, but are to be avoided in cases of cerebral excitement. Paraldehyd should not be exhibited, on ac- count of its unpleasant taste and smell ; and the same is still more true oi acetal. DR. A. SIMONS ECCLES. (London Practitioner, March, 1888.) The production of sleep by baths, etc., is treated at length by this author, an abstract of whose article may be found on p. 478, in the therapeutics of Insanity. PROF. WILLIAM A. HAMMOND, M. D., NEW YORK. The principles which should prevail in the treatment of wakeful- ness may be arranged into two classes : 1st. Those which, by their tendency to soothe the nervous system, or to distract the attention, diminish the action of the heart and blood vessels, or correct irregularities in their function, and thus lessen the amount of blood in the brain. INSOMNIA OR SLEEPLESSNESS. 4^5 2d. Those which directly, either mechanically or through a spe- cific effect upon the circulatory organs, produce a similar effect. In slight cases, the measures belonging to the first class often prove effectual. Among them are music, monotonous sounds, gen- tle frictions of the surface of the body, soft undulatory movements, the repetition by the insomnolent of a series of words till the atten- tion is diverted from the existing emotion which engages it, and many others of similar character. In persistent insomnia, however, these are nugatory. Chief among the means embraced under the second head are those which tend to improve the general health of the patient. In regard to food, while it is an error to suppose, as is generally done, that a moderately full meal, eaten shortly before bedtime, is necessarily productive of wakefulness, there is no doubt that this condition is ^induced by an excessive quantity of irritating or indi- gestible food. A hearty supper of plainly cooked and nutritious food rather predisposes to sleep. This is due to the fact that the process of digestion requires an increased amount of blood in the organs which perform it, and consequently the brain receives a less quantity. This hypnotic effect is neutralized, however, when the food is immoderate in amount or irritative in quality, as it then, either by the pressure upon the abdominal vessels or through a re- flek action on the heart, augments instead of diminishes the quan- tity of blood circulating in the brain. Attention should, therefore, be paid to the diet of the insomnolent. As a rule, people are under- fed. This is especially true of women. The tone of the system is thus lowered, and local congestions of different parts of the body are produced. If the brain be one of these, wakefulness results. Most of the cases of insomnia in women are of the passive variety, and require not only nutritious food, but stimulants. Whiskey is generally to be preferred to brandy and many kinds of wine. Noth- ing can be better, as a good stimulant, and at the same time tonic, than Tarragona wine, drunk at dinner, to the extent of a glass or two. Next must be ranked good lager beer. There are cases in which coffee induces sleep. Our author men- tions several in which passive wakefulness was entirely and speedily cured by a cup of strong coffee, taken for three or four nights in succession, at bedtime. In females of languid circulation and a consequent tendency to internal congestions, it is particularly useful. The employment of stimulants is only of service in the asthenic 486 DISEASES OF THE NERVOUS SYSTEM. or passive form of insomnia; in the sthenic or active form they would, of course, increase the difficulty. Physical exercise in the open air, extended to the point of induc- ing a slight feeling of fatigue, is productive of good effects. The warm bath calms nervous irritability and determines blood from the head. Putting the feet in water of the temperature of 1 00° F. will often induce sleep, particularly in children, after other means have failed. Cold water (32° F.) applied directly to the scalp, has a good in- fluence in those cases in which the individual is strong, the heart beating with force and frequency, and the mental excitement great. It is not admissible in the asthenic form of wakefulness. In insomnia dependent upon severe and long-continued mental exertion, all means will fail if the individual will not consent to use his brain in a rational manner. Proper intervals of relaxation must be insisted upon, and in some cases mental rest. Travel is always of the greatest advantage in such cases. Among the purely medicinal agents, bromide of potassium holds the first rank. It diminishes the amount of blood in the brain, and allays any excitement which may be present in the sthenic form of insomnia. The flushed face, the throbbing of the carotids and temporals, the suffusion of the eyes, the feeling of fulness in the head, all disappear as if by magic under its use. Of the older hypnotics, morphia finds its place where the insomnia is due to or associated with pain ; chloral where the lack of sleep is due to brain tire ; and the bromides where it is due to general nervous excitement. NEW HYPNOTICS. Hyoscine. TiRARD {London Practitiotier, 1887,) recommends this drug as the hydroiodate in cases of Bright's disease where asthma prevents sleep. Erb {Therap. Monats., 1887) has seen it of value in paralysis agitans, and other writers commend it in motor excitement, preventing the oncome of sleep. It may be used as the hydroio- date, hydrobromate or hydrochlorate, all of about equal value (dose, hypodermically, gr. ^j^). It is apt, however, if used to excess to produce unpleasant effects, as vertigo, and dryness of mouth and throat, and is not commended in cases of weak circulation or organic cardiac disease. Its best action is seen in the insane, in delirium tremens, etc. INSOMNIA OR SLEEPLESSNESS. 487 Hyoscyamine. Also a derivative of hyoscyamus, is used in prac- tically the same subjects in which the above finds use. It is admin- istered in slightly larger doses (gr. ,;,-,;„) ; and it is claimed for it that It has not so much tendency to produce the unpleasant effects that hyoscine has. Amyl Hydrate. This hypnotic according to AVELLis (Deut. Medi- cin. Wochensck., November i, 1889,) GuRTLER (Berlin. Klin. Woch- etisch., February 16, 1889) and others, is a valuable addition to our pharmacopoeia. It would appear to stand with chloral, but has no untoward effect upon the heart. It may be administered in the sleep- lessness of phthisis, where the coughing is allayed by it, in pertus- sis, in cardiac diseases, and in fevers. Unlike chloral it has no effect on the mucous membranes and may be administered by mouth or rectum. The usual dose for an adult is from 30 to 45 grains ; but it should be carefully graded, as in excess it is apt to produce un- pleasant alcoholic-like effects. Dr. Fischer recommends that it be sometimes combined with morphia: (L'Abeille Med., February 20, 1888.) 803. R. Amylene hydrate, gr. xc Morphia hy<1rochlorate, gr. \ Extract of glycyrrhiza, 5 iiss Distilled water, f. 3xxv. M. Sig. — Half on retiring. Or 804. JJ. Amyl hydrate, gr. Ix Morphia hydrochlorate, gr. <■ M ucilage of acacia, f. 3 v j Water, f. Sxiiss. M. Sig. — Enema. GiJRTLER (loc. cit.) suggests the addition of some other corrigant, as oil of peppermint, along with the extract of liquorice used to conceal the taste. It is well given in capsules containing ten to twenty grains. Sulphonal is a hypnotic of considerable value in the treatment of the insomnia of mental disease. In ordinary cases, however, it does not seem to meet as much favor as among the alienists. The drug appears to be slower in its action in the beginning than amyl hydrate, and very apt to persist in its drowsy effects during the following day if the dose be large; while with small doses the hypnotic effect is often lost. It is not without untoward effects, in 488 DISEASES OF THE NERVOUS SYSTEM. some cases producing headache, dizziness, ringing in the ears, and depression the following day. The usual dose is 30 or 40 grains; and habituation to its employment is rare. Methylal: This drug has been used hypodermically (gr. iss.) by Kraft-Ebing ( Therap. Monats., February, 1 888), with success in the insomnia of delirium tremens ; and is recommended by Hadjes and BOUBILA (^L Encephale , November 3, 1888), in the chronic forms of insanity in doses of one to two drachms. In six days the power of the drug administered as in latter instance, is gone ; but returns in three days. Paraldehyde: This drug is a favorite in many asylums, but has not, on account of its disagreeable properties, found much favor generally. It is, however, a powerful hypnotic, and is found ser- viceable not only in simple insomnia but also where there are asso- ciated convulsive symptoms, in cough, asthma, etc. Dr. A. B. Cook (^Progress, January, 1888,) recommends it in the form of an elixir, as not irritating to the stomach in that form. Dr. A. A. Rawson {Med. and Surg. Rep., June 2, 1888,) recommends the fol- lowing method of administration : 805. R. Paraldehyde, f.5ij Glycerine, f.Siv Syrup. f.ii Sweet spirits of nitre, f. 3x Oil of anise or of orange, gtt. xx. M. Sig. — ^Tablespoonful every half hour until sleep, or until six have been taken. It is often given per rectum to avoid its effects upon the stomach, and its taste and the odor on the breath ; combining it with mucil- age of acacia or with egg albumen. Chloramid: This hypnotic, introduced by VON Mehring, is a derivative of chloral and somewhat like it in' its action. It does not, however, have the untoward effects upon the circulation that chloral has, and hence seems safer. It is especially useful in senility, neurasthenia and the insomnias unassociated with pain. It is given in doses of fifteen to thirty or more grains. Urethan is also recommended as a hypnotic, but J. P. Crozier Griffith {Med. News, 1888,) characterizes it as uncertain in its effects after doses of gr. xv. It is administered in doses of gr. xv- Ix., and seems to have few if any unpleasant effects. INSOMNIA OR SLEEPLESSNESS. 489 NOTES ON REMEDIES. Aconitum. Dr. Anstie says, " I have often seen insomnia accompanied by a harsh, dry skin, yield to the administration of aconite in repeated small doses." One drop of the tincture in a teaspoonful of water every fifteen minutes. Alcohol. Dr. James Sawyer observes (Lancet, June, 1878), " To many peo- ple a ' nightcap ' of toddy is a superfluous and hurtful luxury. But it can give, perhaps, better than anything else, rest and sleep to the ex- sanguine and worried brain." Alyl hydrobromaie, hypodermically or by the mouth, is said to be a hypnotic of unusual value (La Med. Hypodertn., March i, 1889). Its dose is 5 drops. Atropia. This alkaloid is combined by Dr. Roberts Bartholow with mor- phia to procure sleep, care being taken that there is no excess of atropia, or an amount of atropia sufficient to antagonize the cerebral effects of the morphia. They should be used in the proportions of gr. Tij-^V of atropia to J4^->^ of morphia. As the susceptibility to atropia varies immensely, the precise quantity to' be employed in any case must be regulated accordingly. Cannabis Indica is often prescribed in sleeplessness, alone or combined with hyoscyamus. Dr. Fuller gives it in chronic rheumatism, to induce sleep, and Dr. Oxley, (Liverpool Medical and Surgical Reporter, 1868,) in chorea, in doses of »n,x of the tincture, for a child of seven, and so on. Dr. Tilt gives one-grain doses. Chloral is a valuable remedy for sleeplessness in exhaustion of the brain through severe mental application or excitement of feeling, in con- valescence from acute febrile diseases, and in insanity. It should only be used as a temporary' remedy, when it is necessary that we should at once secure a fair amount of sleep. The patient ought never to be allowed to swallow this dangerous but valuable drug whenever he feels disposed ; he ought only to take it upon the special prescription of his doctor. Hyoscyamus is very variously esteemed by different writers. It is an uncer- tain drug, most useful where the insomnia is purely psychic. It acts better combined with quinia. (Tilt.) IgnaHa, in small doses, is highly praised by H. G. Piffard, in insomnia from nervous erethism. In such doses, he says it is "par excellence, the controller of functional phenomena of the cerebro-spinal axis." (Note to Phillips' Mat. Med., 1879.) Lupulin is often convenient in the insomnia of the aged. Moschus has proved eminently successful in the hands of Dr. Graves, in per- sons of irritable and nervous disposition. He administers it m one- 490 DISEASES OF THE NERVOUS SYSTEM. grain doses every two hours during the day, either alone or with assafoetida, in order to procure sleep at night. Opium and its alkaloids must be used cautiously in simple wakefulness. Morphia is the most hypnotic. Next, narceia and codeia. Potassii Bromidum is a powerful hypnotic, especially in cases of overtaxed mental energy or emotion, and in the sleeplessness of convalescence ■ frora fever, at the termination of acute diseases, or after surgical ope- rations. In the well-nourished, it is, says Dr. James Sawyer, by far the best hypnotic. It soothes the irritated and irritable cerebral cells ; it is a direct and absolutely safe brain sedative, and it is marvelously powerful in producing nervous calm. But it must be given in full doses, thirty to sixty grains at bedtime. It is well to conjoin with it some drug which will favor the contraction of weakened cerebral ves- sels ; for this purpose we may give tincture of ergot or tincture of digitalis, one or both. In many cases of chronic wakefulness, arising from mental strain, the patient is distinctly anaemic. Unless the anosmia be remedied, the insomnia cannot be cured. {^Lancet, June, 1878.) Somnal. Radlauer (Lond. Lancet, November 16, 1889), regards this drug as chloral urethan (ethylated). In half-drachm doses it acts as a hypnotic, and seems to be without unpleasant effects. Under the name of Uralium, a combination of urethan and chloral is praised by Poppi (Gaz. deg. OspitaL, Milan, February 6, 1889,) in the insomnias of hysterical or cardiac origin. EXTERNAL REMEDIES. Cold and Warm Baths, etc. Sleep may often be induced by the temporary application of cold to the general surface of the body. A person who has been lying awake will often fall asleep at once after getting out of bed and sousing his head, neck, and hands in cold water, or after standing at the bedside until he feels chilly, and turning over, shaking up, and cooling his pillows and the bed-clothes. So also warm spong- ing and warm foot-baths, before retiring, will often induce sleep. Dr. Anstie makes the important observation that the action of all narcotics is greatly aided by heat to the extremities, and a hot mustard foot- bath, on going to bed, will enable the patient to sleep with one-third of his ordinary hypnotic dose. Electricity. When sleeplessness results from an overworked brain and conse- quent paresis of the vaso-motor nerves, the stimulus of electricity has been resorted to. Althaus recommends this treatment. Two large pads are used with a Weiss' constant battery of from ten to fifteen cells. One pad is placed over the nape of the neck, the other, which can be conveniently made of an old reflector, and covered with cham- ois leather, is placed over the stomach. The anode is applied to the back, the cathode to the stomach, for about half an hour at a time. NEURALGIA. 49 1 NEURALGIA. DR. SAMUEL FENWICK. Handbook of Prognosis and Treatment, p. 43, 1884). This physician lays down the following general rules for treatment of neuralgia during the attack. " Of late years it has been the custom to look upon neuralgia as an idiopathic disease of the nerves. That such is the case occasionally there is no doubt, but in the majority of instances the pain in the nerve is the result of some irritation near to, or at a distance from, the seat of suffering. It is a useful rule always to trace back the affected nerve to its roots, and if in this way you can meet with no apparent cause for the pain, you should carefully examine all the other organs supplied by branches of the same nerve. Nothing is more damaging to the reputation of a practitioner than the discovery that what has been treated as neuralgia of the head is due to irritation of the gums or teeth, or that a node on the rib is the source of a supposed affection of the intercostal nerve ; that an aortic aneurysm or disease of the spine has been overlooked, whilst attention had been exclusively devoted to the nerves irritated by these diseases." Where the suffering is severe, and accompained with spasm, inhalations of ether or chloroform are indicated. Where there is tendency to general convulsions, general sedatives as bromide of potash or chloral are best employed ; and the use of the warm bath is often valuable if the patient's health permit. The most import- ant method of treatment is the hypodermatic use of sedatives, the best of which is morphia. Local sedatives are also of value, lini- ments, fomentations, the use of morphia over a blistered surface. Galvanism is sometimes efficacious, where medicaments have failed. In all cases, rest is imperative ; the patient should be placed in such position that the painful part can act most fully and easily. DR. E. C. SEGUIN. In the treatment of trigeminal neuralgia Dr. Seguin employs aconitia in the following formula : 806. B- Aconitice (Duquesnel's), ■°°^ Glycerini, Spts. vini rect,, ^.a 4. Aq. menth. pip., ad 62. M. A teaspoonful two or three times a day on an empty stomach. 492 DISEASES OF THE NERVOUS SYSTEM. In some cases he has used .008 or even .01 aconitia in the same formula. The susceptibility of patients to aconitia varies greatly. (Opera Minora, 1884.) He has obtained "remarkable results" with this formula, giving relief in some most severe cases of epileptiform trigeminal neuralgia. It must be remembered however, that in the treatment of chronic neuralgia, and many neuroses, it is necessary to obtain the physiol- ogical effect of the drug employed in order to do good. The drugs most esteemed by Dr. S., in this disease, are aconitia, iodide of po- tassium, gelsemium, belladonna, quinia, morphia, and phosphorus. The last mentioned is particularly efficacious in THOMPSON'S SOLUTION: 807. R. Phosphori, Alcoholis, .06 20. Dissolve with heat. Glycerini, Alcoholis, 48. 8. Essentiae menth. piper.. 1.2 Mix the two solutions. Dose, one teaspoonful — about gr. -^ of phosphorus. Full doses should be given, about one teaspoonful every three or four hours. Dr. Seguin has cured a severe chronic facial neuralgia in twenty-four hours with this preparation. Where there is nervous prostration, cerebral anaemia or melan- cholia, he combines it as follows : 808. ]J. Sol. phosphori (Thompson), I part Olei morrhuje, 4_6 parts. A teaspoonful after each meal. FRANCIS E. ANSTIE, M. D., LONDON. This skillful practitioner, in his classic work. Neuralgia and its Counterfeits, emphasizes strongly the importance of an abundant and nutritive diet, defective nutrition being nearly always present. His general plan of treatment is as follows : I. CONSTITUTIONAL TREATMENT.— (^a^ Nutritive remedies: fat, cod-liver oil, butter, etc. (b) Preparations of iron are useful (the carbonate, especially,) only where there is actual anemia, (c) The nerve tonics (quinine, arsenic, and zinc,) are beneficial in some cases, and not so in others. Sulphate of quinine is useful in malarial neu- ralgia, and also, in small doses, in some cases of non-malarial neu- ralgia, especially in ophthalmic branches of the fifth pair. Arsenic NEURALGIA. 493 is useful, and more widely so than quinine, in both the above classes of neuralgia. Valerianate of zinc has also been employed with ben- efit, (d) Constitutional remedies directed against a real or presumed depravation of the blood by some special poison ; as, iodide of po- tassium and corrosive sublimate against syphilitic neuralgia; col- chicum against gouty neuralgia ; and iodide of potassium against rheumatic neuralgia. 2. Narcotic Stirculant Remedies for Neuralgia. — At the head stands opium, represented by morphia. Next, belladonna, or more exactly, atropia. The subcutaneous injections of these sub- stances are of considerable benefit. Best medium, hypodermic dose of morphia gr. }i ; of atropia (gr. ^\,r^^)- Belladonna (gr. j^-^ of the extract) given by the mouth, has a special influence on painful affections of the pelvic organs. Indian hemp, internally, (in pills or gr. J{— ^, one every night) is very effective in certain forms of neuralgia, especially migraine and clavus. Chloride of ammonium (doses of gr. 10—20) is useful in migraine, clavus, inter- costal and hepatic neuralgias. Sulphuric ether is supremely useful in certain visceral neuralgias, as gastralgia, uterine or ovarian neu- ralgia. Turpentine pearls are beneficial in sciatica. Aconitia is, ordinarily, too depressing. Alcohol is most useful taken at meals, or especially for the relief of pain. 3. External Remedies. — Flying blisters, of extreme and general use ; mustard plasters, liniments, and ointments, (best is chloroform, diluted with seven parts of oil liniment ; ) and electricity (continuous low tension current from BUNSEN'S or Daniell'S battery), are re- commended. DR. ROBERT^ BARTHOLOW, PHILADELPHIA. The deep injection of chloroform for the relief of neuralgia has been practiced by this physician and others with success. He gives the following directions regarding it : I. The Method. The injection consists of five to fifteen minims of chloroform, thrown into the part by a hypodermatic syringe. This amount is sufficient to produce the best results. The needle is passed into the part deeply enough to reach the neighborhood of the aff"ected nerve. The chloroform is then injected slowly, so that it may diffuse into the tissues immediately adjacent to the sheath of the nerve. The action is local, and not systemic. He has heard with amazement of the subcutaneous use of chloroform, as morphia 494 DISEASES OF THE NERVOUS SYSTEM. is employed. Thrown into the subcutaneous connective tissues, not only is the pain great, but there is danger of producing abscess and sloughing. 2. The Site of the Injection. This method is applicable only to superficial neuralgia. It is essential to success that the chloroform reach the tissues about the trunk of the nerve. In the case of tic douloureux, the chloroform must be deposited near the foramina at which the various divisions of the aerve emerge ; in the case of sciatica, about the ischiatic notch. The same rule obtains in regard to other forms of neuralgia. The same writer extols a combination of anodyne and hypnotic remedies, as follows : 8og. ]J. Chloral hydratis, Camphorae pulv., aa 3j _ MorphiiE sulphatis, gr. ij Chloroformi, "Ixl. M. The morphia will dissolve more readily if aided by gentle heat. Atropia may be added to this solution, if desired. The proportion of atropia, as also of morphia, is determined by the use to which the remedy is to be devoted. To the i6o minims of the above solution, ^ij of a grain of atropia may be added. Twenty mimims of this solu- tion will contain 7^ (seven and a half) grains of chloral, the same quantity of camphor, J^ of a grain of morphia, and ,>j (one ninety- sixth) of a grain of atropia. This combination. Dr. B. extols as of wide application in all forms of neuralgic suffering. Locally, it may be painted on the surface, in superficial neuralgia, in coccydynia, in acute rheumatism, cancer, ulcers, etc. Internally, it should be administered in Capsules, or on a lump of sugar, not mixed with water. As an anodyne, the dose is gtt. x- XXX. Whenever pain or convulsive nervous action is to be allayed, Dr. B. believes no combination of remedies will be found equal to this one in general usefulness. PROF. J. M. DA COSTA, Hi. D., PHILADELPHIA. 810. R. Aconitiae, gr. iv Veratriae, gr. xv Glycerini, f.3ij Cerati, 5vj. M. To be rubbed over the painrul parts, care -to be taken to see that there is no abrasion of the skin. NEURALGIA. 495 (Prof. Gross sometimes employs veratria ointment in cases of neuralgia, of the strength of 5j to 5j.) 8il. R. Potassii bromidi, § ss iivLCci coiiii, f . 3 x Aquam cinnamomi, ad. f. § iij. M. A dessertspoonful to be taken three times a day. Useful in epileptiform neuralgia. 812. R. Strychnise sulphatis, gr. ss Quinize sulphatis, gr. xv Cinchona sulphatis, 3j Pulveris rhei, 3 ss Extrajti gettiance, q. s. M. Divide into thirty pills; one to be taken four times a day, in intercostal neuralgia of malarial origin, associated with constipation. DR. NATHAN S. DAVIS, OF CHICAGO, States in his Clinical Lectures on Important Diseases, 1874, that in many severe and obstinate cases of neuralgia, sciatica, tic-douleureux, etc., careful examination will reveal traces of inherited or acquired syphilis. In such, the only hope of recovery must be founded on an effort to change the diathesis. The means best calculated to efifect this are : 1. Regular and judicious exercise in the open air. 2. A plain nutritious diet, chiefly of milk, farinaceous articles and fruits, with absolute exclusion of all alcoholic drinks, tobacco, and strong tea and coffee. 3. The use of alteratives which will not depress the system. To effect the last mentioned, small doses of the iodides and mercury are well to begin with, as S13. R. Sodii iodidi, Siij Hydrarg. chloridi corrosivi, gr. j Extracti conii fluidi, f-Sj Syrupi simplicis, Aquas menthse, aa f.SJ. M. A teaspconful before each meal and at bedtime. As soon as this preparation has had a visible effect on the gums or the Schneiderian membrane (if the latter has been involved), it should be discontinued, and the following given in its place : 814. R. Potassii iodidi, 3"j Fotassii bromidi, Ojj Extracti conii fluidi, c\-v M Aquae menthsE, f-S'y- ™' A teaspoonful three or four timti a day. 496 DISEASES OF THE NERVOUS SYSTEM. If, under this treatment, which must be continued six or eight weeks, the patient becomes debilitated, some direct tonic must be given. The best Dr. DAVIS has used in such cases is the syrupus ferri pyrophosphatis, f.oj half an hour before each meal ; or, a pill as follows : 815. R. Ferri citratis, gr. ij Strychnise, gr. A- M. For one pill. One thrice daily before meals. In many cases of uncomplicated neuralgia. Dr. DAVIS has derived great advantage from belladonna, in such combinations as the follow- ing: 816. R. ^theris nitrici, ■ f-iij Tincturse belladonnae, f.Sij- M. A teaspoonful in sweetened water every three or four hours. 817. R. Chloroformi, Tincturae belladonnae, aa f. 3 iij Syrupi aurantii corticis, f. § iij. M. A teaspoonful every two hours until the pupil becomes slightly dilated, when the interval between the doses should be doubled. 818. R. Tincturx belladonnae, Tincturse gelsemii, aa f. § ss. M. Twenty drops every two or three hours. DR. McLAURY. (St. Louis Polyclinic, June, 1889.) This physician has had very good results from the use of menthol in hemicrania, infra-orbital neuralgia, sciatica, etc., and suggests the following prescription : 819. R. Menthol, 5ij Alcohol, Glycerini, Syrupi, aa f.§j. M. Sig. — One teaspoonful in warm water as required. Or it may be administered as follows : 820. R. Menthol, 3j SpiritQs vini rectificati, ad f. 3 iv. M. Sig. — 20 to 80 minims in hot water as required. DR. CORNING. (Internal. Jour, of Surg, and Antisep., January, 1888). This gentleman recommends the following rather formidable procedure in cases of obstinate neuralgia, which he calls the "endermic use of NEURALGIA. 4^7 cocaine." It consists in the vesication of the epidermis by canthari- deal collodion, and the removal of the skin; over the denuded surface an India-rubber membrane is applied, the edges tightly- glued to the surrounding skin. The rubber membrane is provided with a metal shield through which 50 minims of a 2 per cent, solu- tion of cocaine are introduced beneath the membrane. The method may be of benefit ; it at least is original. DR. METCALF. (Bost. Med. and Surg. Reporter, 1887). Dr. Metcalf recom- mends highly as an internal remedy for neuralgia the following : 821. g. Tincturae aconiti radicis, Tincturse colchici seminis, Tincturae belladonnae, Tincturae acteae racemosae, aa M. Sig. — Six drops every six hours until relief is felt. PROF. WILLIAM A. HAMMOND, M. D., NEW YORK. 822. H. Extracti belladonnae, gr. v. Divide into twenty pills. One thrice daily, the dose to be increased as necessary. The use of belladonna is chiefly to change the habits of the sys- tem. This drug, although at one time much overlauded, is very efficient in the treatment of neuralgia. Our author has not used atropia often, as the dose is difficult to graduate. Hypodermic injections of morphia may be used during the parox- ysms of pain. In their use, avoid the face ; a good point is the in- side of the arm. 823. K. Tincturae aconiti, f. S ss. Rub vfith a rag upon the painful part, until a sense of pricking is felt. This is next in value to the subcutaneous use of morphia. The action is often very powerful. Dr. H. once caused temporary par- alysis of the arm, in a lady, by the too free application of the tincture. Chloroform may be used externally, internally, or by inhalation, not carried to insensibility. Repetitions of the inhalation may break up the paroxysm. Hypophosphites are useful ; may be given in doses of from ten to twenty grains. They act by setting free phosphorus in the stomach. Galvanism. — The direct galvanic current may be successfully used both for the relief of the paroxysm and for breaking up the habit of the disease. For the first, apply the poles so that the position is 32 498 DISEASES OF THE NERVOUS SYSTEM. near the seat of the greatest pain, and pass the current continuously for several minutes. To change the habit of the system, apply one pole to the nape of the neck, and the other over the course of each sympathetic nerve, moving it along the neck. DUCHENNE says that neuralgia can generally be relieved by faradization. Dr. H. has not been so uniformly successful, but often effects a cure by the appli- cation mentioned. The use of tea generally aggravates neuralgia, while coffee, on the contrary, does not, but if strong, is often of service. In neuralgia of the fifth nerve, various authorities have recently reported favorably of croton-chloral. Dr. E. P. Hurd; of Massachu- setts, has employed it in various cases of intractable neuralgia, in the following formula : 824. R. CrotoJi-chloralls, 3j Glycerini, Syrupi aurantii, aa f. S j. M. A teaspoonful as required. Intercostal neuralgia or pleurodynia, a complaint which is often a painful and annoying one, may generally be relieved completely by applying two or three strips of plaster firmly round the side over the seat of pain. The emp. roborans is a good form of plaster for these cases. It is desirable that the practitioner should himself see that the application is properly made, and that it is not left to the pa- tient, as the result entirely depends on its being accomplished in an effectual manner. Anal neuralgia. 825. R. Extract! belladonnse, 3ss Chloroformi, ml Glycerini, f. 1 53. m. Anoint with liniment, several times a day, the afifected parte in neuralgia of the anus, when there exists neither fistula nor any lesion of the rectum. TIC DOULOUREUX (FACIAL NEURALGIA). FRANCIS E. ANSTIE, M. D., LONDON. In the treatment of this terrible kind of neuralgia, to which Trou.ssEAU gave the name of epileptiform, Dr. A. recommends (Half-Yearly Compendium of Medical Science, July, 1869,) the fol- lowing plan in the earlier stages of the malady : I. Counter-irritation, applied, not to the branches of the fifth, but to those of the occipital nerve,, at the nape of the neck. A blister NEURALGIA. 499 in the former situation is often as useful ; in the latter, it is some- times strikingly effective in gaining a short respite. 2. Nutritive Tonics. The assiduous use of cod-liver oil, or of some fatty substitute for it, should be insisted on from the first, and is of the highest consequence. 3. Subcutaneous Injection of morphia, or of atropia, according to circumstances. Commence with the use of )^ of a grain of mor- phia twice daily, increasing this, if necessary, to )^ and ^ of a grain, and in rare cases to one grain. If this produces, along with the other measures, a notable remission of the pain, it should be cautiously and steadily decreased, as circumstances may admit. In cases where morphia fails, atropia may be tried in doses commenc- ing at jS of a grain. The injection of a less quantity than this would probably be useless in severe tic. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. 826. R. Liquoris potassii arsenilis, gtt. v Syrupi rhei aromatici, f. 3j. M. For one dose, thrice daily, after meals. At night apply a hot salt-bag to the back of the neck and order the following pill : 827. R. Extracti belladonnse, gr- \ Extract! hyoscyami, Extracti colocynthidis compositi, Pulveris zingiberis, aa gr. j. M. W. MUNRO, M. D., ENGLAND, Believing that, in tic douloureux, the blood-vessels of the part affected are in a state of constriction, our author has used Calabar bean, in several cases, (Medical and Surgical Reporter, December 5th, 1874,) with exceedingly satisfactory results. He drops into the eye two or three drops of a solution of extract of Calabar bean (one to forty), or applies one of Streatfield's ophthalmic squares to the eye. PROF. FELIX NON NIEMEYER, M. D., TUBINGEN. 828. R. Extracti hyoscyami, ._ ^ Zincioxidi, ^ »')• *'• Divide into forty pills. Begin with one pill, morning and evenmg, and increase to ^enty or thir'^y of them daily. Thesefknown as Meglin's piUs, have a good repu- tation in Germany. PROF. KUSSBAUM, OF MUNICH. In the ^rtzl. Int. Blatt., 1883, this great surgeon recommends a 500 DISEASES OF THK NERVOUS SYSTEM. trial with salicylic acid before proceeding to stretching or to resec- tion of the nerve. In all the recently-sent cases he first tried this remedy, and he found it in every one a radical cure ; not only a pal- liative effect, but really an utter disappearance of the painful disease was the result in every case. Especially in cases of rheumatic nature, N. is positive of having discovered in salicylic acid a specific for tic douloureux. He administered the drug in the following manner : 829. R. Acidi salicylici, 0.2, gr- SJ Sodii salicylatis, 2.0, gr- 32- M. Ft. pulv. Within twenty-four hours the patient takes from four to six of such pow- ders. EDWARD WAAKES, M. D,, LONDON. 830. R. Potassii bicarbonatis, 5iss Extracti ergotse fluidi, f-5j_ Infusi ergotae, f-Svj. M. Two tablespoonfuls every four hours. B. M. WALKER, M. D., PLYMOUTH, NORTH CAROLINA. Our author reports (American Journal of the Medical Sciences, April, 1874,) a case of tic douloureux treated by ice. The patient, a lady aged sixty, had been treated in various ways during five years, no remedy securing a longer period of relief than a few weeks. She was directed to use ice upon the part, which was over the fifth pair of nerves, and to continue the application as long as she could bear it, at the same time holding brandy in the mouth. The pain, for a while, was more intolerable than ever before ; then it began to subside, and perfect quiet was obtained. The pain did not return the next day, as was customary, nor was there any subsequent re- turn nor necessity for treatment. SCIATICA. DR. McNUTT. (Med. News,]w\Y .7, 1888.; The use of sulphur externally in cases of sciatica is lauded by this physician. In conjunction with the external application he administers it internally in the following form: 831. R. Sulphur praecipitati, Ferri carbonatis, aa 3iv Glycerini, f.3iv Aquae gaultherise, adf.fiv. M. Sig. — ^Teaspoonful every two hours. NEURALGIA. 501 The external treatment consists in enveloping the leg in flowers of sulphur during the night. Permanent cures are said to result from such procedure. Other physicians, as DuCHESNE (Jour, de Med. de Paris, January 15, 1888,) and COWDEN (Jour, of Amer. Med. Assoc, July 7, 1888,) also testify as to the value of this mode of treatment of sciatic neu- ralgia. Dr. BOUVARD also testifies in favor of this method (Rev. de Tkerap. Med.-Chir., K-pril 15, 1889.) DR. HENRY LAWSON, ENGLAND. Out of some eighty cases of sciatica, lumbago, and brachialgia treated by this physician, some of them excessively bad cases, in not more than three did the subcutaneous injection of morphia fail to give relief, in most cases complete. By means of this relief, the pa- tient was enabled to eat and drink with comfort, and by help of per- chloride of iron, and in some cases by cod-liver oil, he was enabled to put on flesh rapidly, and to repair the waste of tissue under which he had been laboring. The salt he uses is the muriate. Five grains are dissolved, by the aid of heat, in one drachm of distilled water ; it must be injected warm, as the solution solidifies on cooling. The place of injection should be chosen as near as possible to the seat of pain, and the point of the needle should not be more than half an inch long. Dr. Dawson does not object to the puncture of a min- ute vein, as thereby the medicine is more rapidly absorbed, while the alarming symptoms which ensue are generally very transitory. The patient should have eaten a hearty meal about half an hour previous to the injection ; this prevents, to some degree, the sopo- rific effect of the drug, while it heightens its effect in allaying pain. (Medical Times and Gazette, January, 1877.) C. G. COMEGYS, M. D., CINCINNATI. Following Malgaigne, this physician has frequently succeeded in promptly curing refactory sciaticas by touching, with a red-hot wire, a certain spot on the ear, on the same side as the one affected, to wit, the anterior part of the helix, just at its entrance into the concha. Another very eflScient remedy is to inject fifteen to twenty drops of common ether (in the ordinary superficial manner) behind the great trochanter. The pain is sharp, but not lasting, and the relief often astonishingly prompt. It should be repeated daily, if required. (Cincinnati Lancet and Clinic, August, 1878.) 502 DISEASES OF THE NKRVOUS SYSTEM. PROF. J. M. DA COSTA, M. D., PHILADELPHIA. 832. R. Emplastri epispastici, l|in.x5in. To be applied over the affected part. Let it draw for five or six hours, poultice it, and then remove the cuticle and dress with : 833. R. Morphise sulphatis, gr. i Pulveris marantse, gr. ij. M. For one powder. Also, ten grains of Dover's powder, to be taken at night. DR. LABORDE, FRANCE. 834. R. Olei terebinthins, f- i viij Chloroformi, Tincture opii, aa f. Sij- M. A useful liniment in sciatica. To be rubbed on by means of a piece of flannel, several times a day. 835- B- Aquae ammoniae, f. 3v Olei terebinthinae, Olei amygdalae dulcis, aa f. § j. M. Rub on three times a day, in obstinate sciatica. PROF. FELIX VON NIEMEYER. M. D., TUBINGEN. 836. R. Olei terebinthinae, f. 3 j Mellis, f.gj. M. For an electuary. A tablespoonful twice daily. VOGT'S method of SUBCUTANEOUS NEUROTENSION. In the Centralzeitung, 1883, Dr. VOGT describes a method of nerve-stretching without a cutting operation. This is by forcible and extreme flexion of the limb. In sciatica the leg is extended at the knee, and forcibly flexed at the hip-joint upon the body, while the healthy leg, the pelvis and the body, are retained in a fixed posi- tion. By manoeuvres of this kind, properly adjusted and repeated, the nerve of the suffering part is firmly extended, and a similar re- sult obtained as when it is lifted from its sheath and stretched. Very favorable results are reported. EDWARD WAAKES, M. D., LONDON. 837. R. Extracti ergotae fluidi, f. 3ij Aquas cinnamomi, f. § iij. M. A dessertspoonful in water every four hours. Tinctura ferri chloridi may be added if indicated. When ergot is likely to be useful, its good effects commence immediately. PROF. M. ROSENTHAL, M. D., OF VIENNA. This author advises wet cups or leeches in very painful, acute NEURALGIA. 503 cases, followed by flying blisters to the painful points, an^ the in- unction of opiated ointments. When turpentine can be given inter- nally, without causing digestive troubles, it should be administered thus, but otherwise only by frictions. Electricity is of little value in sciatica of central origin, but when from peripheral irrritation, the secondary current should be applied to the painful points for five to ten minutes, by means of dry electrodes, using weak currents at first and gradually increasing their intensity. A hydrotherapeutic plan, applicable to all cases, and often successful, is the use of moist packs, followed by cool affusions, or half baths at about 65° Fah., with friction to the limbs. Hot vapor baths, ice-bags, cold douches and sweats, advocated in many hydrotherapeutic establishments, should be confined to robust individuals, and to the peripheral forms of sciatica, in which their success is often gratifying. guy's hospital, LONDON. 838. R. Liquoris plumbi subacetatis, Tinctuixe opii, Mellis, aa f.Sij Confectionis rosae, §j. M. Make a liniment. This is known in the pharmacopcEia of the hospital as linimentum plumbi opiatum, and is much used. VARIOUS SPECIAL CAUSES. Under this heading must stand first the various infectious and toxic neuralgias, as due to malaria, syphilis, or the chronic mineral toxae- mias from lead, etc. In case of malarial neuralgia, the malady not infrequently mani- fests itself as a hemicrania, or as a facial pain. In those cases where malarial infection is likely, the use of quinia is strongly suggested, combined with or followed by arsenic in some form. (Vid. FUSSELL, Med. and Surg. Reporter, 12,^7.) Syphilitic neuralgias are rather apt to manifest themselves in dis- tinctly localized pain, as in tic douloureux, in small areas over the vertex, etc. Where the relation is evident, anti-syphilitics are of course demanded. Chronic lead poisoning is not rarely followed by neuralgias due to local inflammatory causes. The use of iodide of potash and the various salts rendering the lead soluble and capable of elimmation are to be employed, as well as ordinary measures for the relief of the acute attack. 504 DISEASES OF THE NERVOUS SYSTEM. Neuralgias are not infrequently found associated with the anae- mias due to the above conditions, and various idiopathic anaemias, in relation of effect. The cause of the anaemia removed, the use of iron, as in form of Blaud's pills, is often of great service ; so, too, in the neuralgias of chlorosis, etc., iron and arsenic are of value. In the neuralgias due to nerve injury, local and general sedatives are to be used gradually, lest a habit be created. Galvanism, and every effort to bring about regeneration of the nerve, are to be prac- ticed ; where the neuralgia is evidently due to pressure on the nerve from a cicatrix or tumor, the relief by the knife is the quickest and most complete. Dr. Sturgis commends in the recurrent headaches of children, ergot, prescribing ten drops of the solution, thrice daily, with or without iron, as demanded. NOTES ON REMEDIES. Acidum Arseniosum is a remedy of a deservedly high reputation in neuralgia, having a wider range of application than quinine. In malarial cases it should be given in larger doses (in,x-xxx, thrice daily, of Fowler's solution) than in non-malarial. In the latter, n|,v of Fowler, or gr. tV of the arseniaie of sodium, in pill, with extract of lupulin, will prove effectual in the cases amenable to this remedy. It may also be given hypodermically and endermically. It is used by Dr. Da Costa in Tic Doloureux. Prof. GuBLER obtained some brilliant successes with this substance. He said, indeed, he had never met a neuralgia of the fifth pair which resisted it. He used the nitrate of aconitine, in doses of gr. t«, in solution, or Hottot's aconitine, dose, gr. nij, pushing it up slowly to gr. Vi, if the disease did not yield. He disapproved of pills, as they may not be dissolved. He employs the following : 839. E. AconitiEe (crystal,) gr. \ Alcoholis, q_ s_ Aquae, q. s. adf.'sij. M. One teaspoonful every eight hours. He says he has never known a case to resist this, heroic remedy. AconiticB Oleas. This preparation has been found by Dr. H. A. Kelly, of Baltimore {Med. News, 1883), very effective in severe trigeminal neuralgia. Three drops of the two per cent, solution is gently rubbed into the skin over the painful part. Complete relief is afforded in . from three to five minutes. • Aconiium is a remedy of great value in chronic cases of neuralgia, when the secretions are in order, and the general health not much impaired. Its NEURALGIA. SOS use should, therefore, be often preceded by purgatives and tonics. In acute cases it is not indicated before all signs of active disease have been subdued by other means. Its external use should usually pre- cede its internal administration, which need only be resorted to in case of failure of the former. The combination of quinine with aco- nite seems to increase its efficacy, and add permanency to the relief afforded by it. This combination is especially indicated in anaemic or debilitated patients, where there is no apparent nerve lesion or ex- citing cause. ^ther. In simple neuralgia, particularly of the nerves of the head, Prof. Stille recommends combining the anodyne effect of ether with its re- vulsive effects, by applying it on small compresses covered with some solid substance, immediately over the points where the painfiil nerve emerges from its bony canal, or where it in any other way becomes superficial. Alcohol. Dr. Anstie has several times observed, in acute neuralgia, that after large doses of various narcotics had been tried in vain, the first real and substantial relief was obtained by the use of a moderate dose of alcohol ; the consequence of overdosing the remedy is, however, nearly always disastrous. Ammonii Chloridum is often of signal benefit, in doses of twenty or thirty grains. Anthemis. Chamomile, in substance, in doses of gr. Ix, or in a very concen- trated infusion, is administered with success in France, in neuralgia of the fifth nerve. Antifebrin and Antipyrin are both of value as analgesics, the latter being probably the better of the two ; they are administered in dose of five to ten grains, or even double that amount where well borne. The worth of these drugs is considerably diminished by the fact that they are not always without serious ill effects. In their action they closely resemble each other, although their derivations vary considerably. Apiol is said to be of service in intermittent neuralgia. Atropia instillations are often of service in supraorbital neuralgia, where there coexists ocular disease— relieving by removing the intraocular strain. Beberia Sulphas has proved successful in some cases, after the failure of quinine. In doses of gr. x, night and morning, it is more effective than in smaller doses. It is commended by Simpson in tic. Belladonna, whether used externally or internally, ranks among the first of the sedatives and anodynes of service in neuralgia. (P. 493-) I* occasionally fails of effect, however. Brown-S^quard combines it with six other narcotics, for the relief of neuralgic pains. Atropta 5o6 DISEASES OF THE NERVOUS SYSTEM. is preferred by some to the preparations of belladonna, but the dose is more difficult to graduate. The sulphate is the most soluble. Caffea is much employed by Belgian physicians. Prof. Hammond finds that it is often of service, but that tea generally aggravates neuralgia. Cannabis Indica is ranked as a neuralgic remedy next in value to opium and belladonna and their alkaloids. Carbolicum Acidum, by hypodermic injection, gtt. ss., has been shown to be efficacious by Dr. Schrumpf, of Strasbourg (Gaz. Med. de Strasbourg, 1883). He has never found any ill results, and usually four or five injections will cure any idiopathic case of sciatica, lumbago, pleuro- dynia, etc. Chloroformum always acts as a palliative in, but rarely cures, neuralgia. Mennier (Bull. Gen. de Therap., 1887) recommends the hypodermic use of a I in 4 solution of chloroform in liquid vaseline, to be used in neuralgia, the injection being without pain. Cimicifuga racemosa, given best in the form of the tincture (f.gss-f.gj), is used occasionally, apparently with good results, in case of nervous- troubles of a neuralgic nature. Cocaine, in any of its salts, preferably the hydrochlorate, is of exceeding value in the treatment of painful affections generally, as it has the effect of paralyzing the terminal filaments of the sensory nerves. It is usually applied on tampons, in solutions varying from i per cent, to 20 per cent., or is injected hypodermically over the painful area (an average hypodermic dose being nj,. xx, of a 4 per cent, solution). The drug has an exceedingly wide application ; and exerts a marked analgesic effect over a brief period. Coniiitn is inferior to opium and belladonna. It is "of some value, however, as an ointment, with wool-fat or lard, in cases of neuralgia. In the pains of pregnancy it may be of service thus applied to the perineum ; so too the pain of uterine cancer and of vesical irritation. (Madigan, Med. Standard, 1887). Creasotum has been employed internally by Dr. Elliotson in cases of sciatic neuralgia, with apparent benefit. Croton Chloral Hydrate, in doses of gr. ij every hour, has been found promptly to mitigate paroxysms of neuralgic pain. Cupri Sulphas Ammoniatum. The value of ammoniacal sulphate of copper in the treatment of this affection has been asserted by M. Fereol, in a communication in April, 1879, to the Acad^mie de M6decine. He states that in cases in which every treatment has failed, even the administration of gelsemium and of aconitia, a cure or remarkable re- lief may be obtained to the most severe symptoms by this drug. The dose is gr. j three times daily, and may safely be increased to gr. v. NEURALGIA. 507 Ergota is, according to Phill ■^, (Mat. Med., 1879.) most useful in visceral neuralgias, especially gu stralgia. Waakes (Brit. Med. Jour., August 8, 1868) has found it useful in cases of tic. Exalgine, a new analgesic, a mtthyl compound of acetanilide, is stated to be of considerable value, given in doses of four or five grains. Bardet i^Les Nouv. Remedes, March 24, 1889) recommends the following combination, giving from one to three tablespoonfuls in twenty-four hours : 840. R. Exalgine, 3i Cherry cordial, f. 5x Syrup, f.|j Water, 'f. § v. Dissolve the exalgine in the ccrdial, and then add the syrup and water. I Ferrum is useful in cases associated with anaemia ; in others it fails. Galbanum has been found of%ervice in neuralgia dependent upon uterine derangement, given as .o)lows : 841. R. Pilulae galbani cqiipositae, gr. iij-vij Pilulse hydrargyri, gr. iij- M. One pill to be taken every other night. Gehemium is an important addition to the therapeutics of neuralgia, espe- cially in non-congestive forms. According to Dr. E. Heroguelle, of Paris, (Medical Examiner, December, 1877,) it acts favorably in cases of dental neuralgia of the fifth pair, of the frontal, temporal, supra, and infra-orbital nerves, the brachial plexus, the intercostal and ilio-lumbar nerves. Sciatic neuralgia appears to resist, rather more than other neuralgias, the calming effects of the drug. Two to five drops of the fluid extract is the dose. According to Prof. Massini, the cases in which gelsemium produces most benefit are those of sim- ple rheumatic neuralgia of the alveolar branches of the trigeminus ; in those it rarely fails. It also sometimes relieves the pain remaining after the stopping of a carious tooth. Where there is any inflamma- tory affection of the bone or periosteum, no good can be expected from the remedy. J. Chiron uses the following formula : 842. R. Tinct. gelsemii, Jl^ Syrup, simplic, '•3'^ ^,_ ... ^ Aqui destillat.. q. s. ad f. § vuj. M. S.— From three to five tablespoonfuls daily, either half an hour before or three hours after the mid-day meal. Guaiacum is of service in forms of neuralgia of a rheumatic character. From n^xx to Tn,xl of the ammoniated tincture may be given every five hours, until relief is obtained. 5o8 DISEASES OF THE NERVOIS SYSTEM. Hyoscyatnus is considered by Dr. Harley as n ore efficacious than belladonna in neuralgic affections of the internal v fscera. Hyperosmic Acid. Prof. Billroth, of Viennr, has had success in some obsti- nate cases of sciatica, by the hypodermic injection of a one per cent, solution of hyperosmic acid. Within a day or two the pain was greatly relieved, and finally disappeared. (Med. Compend., 1884.) Ipecacuanha. Dover's powder at night o''c;in affords much comfort. An eighth or a quarter of a grain of rncrphia may be added when indi- cated. Menthol is of value, either applied externally or internally, in dose of about four or five drops well diluted. Morphia, hypodermically injected, affords sf '^edy and often permanent re- lief. Dr. Anstie has cured cases by t ^ee or four injections of gr. J/g, which would have been very tedious mder the old plan of treatment. Many cases yield in a week or ten ^^ays to hypodermic injections twice daily. • Oleum Cajuputi may be employed with advr jitage, either externally or in- ternally, in cases unconnected with inflammatory action. Oleum Terebinthince is not unfrequently of benefit. It is equally appropriate to the inflammatory and non-inflammatory states of neuralgia, and it is said relapses are less frequent after it than after most other remedies. Oleum Tiglii has been used with success in some cases, in which it has seemed to exercise a special influence apart from its purgative action. Opium, both internally and externally used, is of great service in certain cases ; but ordinarily, far inferior to morphia injected subcutaneously. Parthenicine, the alkaloid of Parthenium Hysteriophorus, is stated to be of value in assuaging the pain of neuralgia (Ulrici, Med. Chron., March 1889). Phenacetin has been used to a considerable extent during the last year or more as an analgesic, and seems to have a general application. Its dose is gr. x-vx for an adult. Dr. Avers (Med. Rec, August, 1889,) has rarely had to give a second dose to relieve any painful affection. Physostigma has exerted local anodyne effects in several cases of neuralgia re- ported. Ptscidta Erythrina. The Jamaica dogwood has been proved to be an excel- lent agent in many forms of neuralgia. It is a calmative and hypnotic, well suited for those who cannot tolerate opium. The dose is gss-j. of the fluid extract. An efficient combination is : 843- B- Potassii bromidi, g ss Fid. extr. piscidia, f. | ij Syrupi simplicis, q. s. ad. f. | iv. M. A teaspoonful hourly till relieved. NEURALGIA. ^09 Plumbi Acetas is said to be a safe and effective remedy in many cases of superficial neuralgia, and even in neuralgia of the abdominal viscera. Potassii Bromidum, in full doses, often effectually relieves some forms of neu- ralgia. Potassii Chloras, in doses of gr. xxx a day, has, in three weeks' time, it is re- ported, produced wonderful effects in facial neuralgia. Potassii lodidum is of service in neuralgic affections dependent upon an in- flammatory state of the nerve coverings, and is to be used in neural- gias dependent upon syphilitic taint. Dr. Graves advises it in doses of 3J during the day, dissolved in a decoction of sarsaparilla, in cases of sub-acute or chronic sciatic neuralgia, and where the patient must follow out-door avocations. QuinicE sulphas is of great value in all neuralgias of malarial origin, and in a certain number of non-malarial cases. In the former, it should be given in full doses (gr. v-xx), shortly before the expected attack; in the latter, doses of gr. ij-iij thrice daily are as large as are likely to benefit. Dr. Anstie says that he knows of no circumstances which in- dicate beforehand that quinine will be useful in non-malarial cases, ex- cepting that in neuralgia of the ophthalmic branches of the fifth, it is more effective than in other non-malarial neuralgias. Prof. Gross fre- quently combines quinine with morphia, strychnia, arsenic, and aconite, in the treatment of neuralgia. Dr. Takner combines it with bella- donna and camphor, and with the chloride of arsenic. 844. R. Quiniae sulphatis, 9j Liquoris arsenici chloridi, f. 3 iij-iv Acidi siilphurici aromatici, f. 3 ij Syrupi zingiberis, q. s. ad f. § iij. M. One teaspoonful in two tablespoonfuls of water, directly after breakfast, dinner and tea, in severe neuralgia. Sodii Arsenias is of service in neuralgia where other arsenical preparations are badly borne. Sodii Carbonas often, in full doses, speedily arrests neuralgia connected with acidity of the stomach. Sodii Hypophosphis, in drachm doses, given in beef tea, thrice daily, has proved successful. Sodii Salicylas is often necessary in cases of rheumatic neuralgias, rather fre- quently manifesting themselves in the form of sciatica. It may be given in doses of gr. xv-xx, and may be excellently combined with antipyrin (gr. v-x) or phenacetin. Salicin has also its use in this con- nection. Stramonium is only found of benefit by Dr. Fin^LER where the symptoms shift from limb to limb, but never when the disease is stationary. 510 DISEASES OF THE NERVOUS SYSTEM. Strychnia is of use in epileptiform neuralgia and locally. Terebinthinm Oleum is considered by Dr. ANEniE as a remedy worthy at least a trial, in doses of »n,x thrice daily, in the more obstinate cases of sci- atica. It is, however, usually very disagreeable to the patient. Df. NiEMEYER also rcGommends it in electuary, and Dr. Romberg speaks of it almost as a specific. Dr. W. A. Jamieson (Edinburgh Med. Jour., March, 1877,) gives the following formula: 845. R. Olei terebinth., f.Sij Olei ricini. f. Si* / Tinct. cardam. comp., f. 3 j Mucilaginis, Aquae, aa q. s. ad f. § ij. Take at one dose. He adds, the patients who derive most benefit from oil of turpen- tine in sciatica present the following appearances : Usually middle- aged, they look older than they ought, and have hair, as Anstie so well phrases it, prematurely and permanently gray. The complexion may be pale or fresh, but it nearly always exhibits a peculiar ashy gray or stone colored aspect. Valeriana exerts a favorable influence in neuralgia associated with hysteria. The ammoniated tincture may then be given, combined with guaiacum. Zinci Valerians is a serviceable remedy in those cases in which the disease is purely nervous, and in those which accompany uterine derangement. Zinci Phosphas. Dr. Camille Troubert (Gazette des Hopitaux and Courier Medicale, 1878,) mentions a number of cases in which this treatment, first proposed by Ashburton Thomson, was successful when other means failed. Two or three granules, of four milligrammes each, were given daily. It is important that the granules shall be used, as other preparations are uncertain. Stimulants. Dr. Anstie has found in some cases of acute neuralgia (particu- larly of the fifth nerve), that after the failure of various narcotics, a moderate dose of alcohol has at once given relief. He also states that, in certain chronic neuralgias of the aged, where the power of digesting ordinary food is almost suspended by reflex irritation, an almost ex- clusively alcoholic diet, continued for some time, occasionally works wonders. external remedies. Aconitum and Aconitia, locally applied over the seat of pain, is a most pow- erful palliative in neuralgic affections. Dr. Fuller, having observed that it fails so long as signs of active disease exist, restricts its use to purely chronic cases. Dr. Da Costa sometimes prescribes it with veratria, in ointment. (F. 810.) NEURALGIA. 1 1 j Acupuncture is of use, after inflammation has subsided, in those cases in which there is effusion within the sheath of the nerve. It then promises speedy and effectual relief, but is useless, and may be prejudicial, in all other cases. It is more especially of use in cases of lumbago, which often respond promptly to such measure. .'Ether. The local application of atomized ether is now often resorted to. In facial neuralgia. Dr. A. M. Cartledge ( Med. Herald, May, 1883,) pro- tects the eye with a piece of oil silk, and directs a spray of ether upon the part affected until its temperature is down to the freezing point of water — say for eight minutes — which will generally suffice. To gen- erate the spray he uses Richardson's atomizer, which is a simple ad- dition to the ordinary perfume atomizer. Agua Ammonice. The following method of applying strong water of ammonia in neuralgia, is recommended by Prof. Stille : Take small disks of cloth, about a half or three-quarters of an inch in diameter, and apply them, moistened with the ammonia, over such points in the course of the affected nerve as are tender upon pressure, or are the seat of spon- taneous pain. Cover the pieces of cloth with coins, buttons, or other convenient bodies, to prevent evaporation. Cotton contained in a thimble and saturated with the caustic Uquid, forms a still more con- venient arrangement. As soon as slight vesication occurs, the pain is relieved, yet not so thoroughly as when the same effect has been ob- tained by means of cantharides. The addition of morphia to the ves- icating liquid renders its effects more prompt and certain. Argenti Nitras, administered hypodermically, five or six drops of a strong so- lution (one to four) has been used with prompt results by M. Luton. (La France Medical, June, 1877.) Intense pain is caused at first. Belladonna is much used externally. Trousseau highly recommends the ex- ternal application of belladonna when the neuralgia is superficial. In such cases may also be employed a compress saturated with a solution of atropia. Dr. Flint uses atropia in preference to belladonna, in liniments and ointments. These applications, however, are all inferior to the hypodermic injection of atropia. Dr. K. Waller, of Geneva, recommends that this and similar extracts and alkaloids should be dis- solved in chloroform for external use, as they are more easily absorbed. Cantharis. Blisters should be tried in cases of any severity ; if the hypo- dermic injection of morphia and atropia has failed, flying blisters should be employed. Dr. Anstie states that, in numerous early cases, one or two flying blisters, appHed successively over the different points in the course of the painful nerve, have at once and permanently arrested the disease. Chlorqformum may be applied pure (especially serviceable when the pain is localized in a small space) or in liniments. "Gelatinized chloroform," 512 DISEASES OF THE NERVOUS SYSTEM. made by incorporating one part of chloroform and two parts of white of egg, is a useful form for application. Counter-irritation in cases of idiopathic neuralgia is of the greatest service, applied along the course of the painful nerve. If there be spots ten- der to the touch, the counter-irritant should be appHed directly to such locality. Among the many counter-irritants, many specifically mentioned, attention must be called to the actual cautery, the electric wire brush, etc. In case of tic Dr. Anstie commends counter-irritation to the nape of the neck. Dr. Da Costa sometimes orders a hot salt bag to the nape of the neck. Electricity seems to be of service only in cases unconnected with irritation in distant parts of the body; then the continuous galvanic current is often of essential service. If employed before the pain has subsided, the interrupted current very generally aggravates the patient's suffer- ings. (See Hammond's remarks, p. 497.) Franklinization. Dr. V. J. Drosderff (Med. Record, 1883,) has employed franklinic electricity in neuralgia or rheumatism. Immediately after a sitting, pain and tenderness disappear, and, during the remaining part of the day, the patients feel much better than before a sitting. Each successive franklinization brings a further decrease of intensity of neuralgia. In cases of short standing, three or four sittings suffice to completely remove the agonizing pains. Ten to fifteen sittings cured even cases of neuralgia of twelve years' standing, which had ob- stinately resisted galvanization, faradization, and all possible thera- peutic means. In each of the author's cases, either complete cure or very considerable improvement followed. There is no necessity to undress a franklinized patient, as the therapeutic effects of this excel- lent agent remain unchanged — a circumstance of practical importance in female cases. Frigus. Ice applied to the spine, by means of his spinal bag, is recom- mended by Dr. Chapman ; or by the spraying of freezing solutions cold may be easily applied in the absence of an ice-bag or bladder. Hydrargyri lodidum Viride. The following ointment has been strongly re- commended : 846. B. Hydrargyri iodidi viridis, 9ij Adipis, §j. M. Hypnotism. A number of cases of neuralgia have been reported within the past few years as cured by hypnotic suggestion ; the facial and cranial neuralgias are those which have been most frequently subjected to this procedure, although it would seem not less efficacious in other posi- tions of pain. NEURALGIA. SI3 . Iodoform has been recommended for local use in neuralgias in the form of saturated solution in chloroform or ether. Leeches applied along the course of the nerve often afford immediate relief after the failure of anodynes and other local measures. They are par- ticularly indicated when there is inflammatory action of much vascular excitement. Massage has been successfully used in a number of cases of obstinate neural- gia, and Dr. Taylor (Med. News, k^T^ 6, 1889,) reports consider- able benefit in cases of sciatica by a peculiar mode of massage, con- sisting in rolling a glass rod about 1% inches in diameter and 2 feet in length slowly and firmly along the course of the nerve. Mentha and Monarda. Oil of horsemint, in liniment, with camphor and laudanum, sometimes affords prompt relief. Oil of peppermint is at times very prompt and efficient. An alcoholic solution is used. Menthol, or Peppermint Camphor, has been recently introduced for similar purposes. One or other of these substances is included in most popu- lar "pain-killers." Methyl Chloride is given preference to all other freezing means applied by spray, in the opinion' of J acobv (N. Y.Med, your., January 5, 1889). It may also be applied on tampons of cotton. Neuroteny (nerve stretching), Neurotomy (division of the nerve), and Neu- rectomy (exsection of a piece of the nerve), are surgical resources in very obstinate cases. Operative treatment, aside from stretching, breaking, cutting, excising, is to be occasionally directed to the re- moval of pressure upon the offending nerve, tumors, scars, callous ma- terial from bone, etc. Rectal Suppositories of belladonna, hyoscyamus and opium, are sometimes employed, and are of value especially in cases of pelvic pain, as from vesical neuralgia. Absolute rest, with suspension and extension of the leg, has been highly com- mended by Dr. Hunt {Jour Am. Med. Assoc, September 28, 1889,) in cases of obstinate sciatic neuralgia. Stramonium is sometimes employed locally in the same manner as belladonna, to which, however, it is inferior. Sulphur. Enveloping the limb in flowers of sulphur over night for one or two nights is sometimes followed by marked benefit in cases of sciatica. Sulphur, externally, is highly praised by Dr. Fuller, who finds it very generally efficacious and worthy of a trial in every case, when all active symptoms have been subdued or are absent. He sprinkles a piece of new flannel, thickly, with precipitated sulphur, encases the whole limb in this, from the foot upward, and covers it with oiled silk or gutta-percha, which has the effect not only of increasing the warmth 33 514 DISEASES OF THE NERVOUS SYSTEM. and confining the vapor of the sulphur, but of obviating the odor, an- noying to the patient. It should be kept applied night and day. Absorption takes place rapidly, and the breath, urine, stools, and per- spiration, unmistakably attest its presence in the system. Veratria, when there are no active or inflammatory symptoms present, is often beneficial, externally appHed, the ointment being rubbed in dili- gently until it causes a sense of heat and tingling. It is inferior, how- ever, to aconitia. NEURASTHENIA. DR. ROBERTS BARTHOLOW. The division of neurasthenic cases into two main types, the con- gestive and the anemic, is advocated by this writer (Med. and Surg. Reporter, 1884). The latter are greatly more numerous. The treat- ment of both varieties is chieily symptomatic and hygienic. In con- gestive cases the remedies consist in a careful regulation of the diet, in baths, exercise, in a reduction of the hours devoted to work, but not the cessation of work ; in the use of a laxative quantity of sodium phosphate daily, and in the administration of the aqueous extract of ergot, with the chloride of gold and sodium, and a minute quantity of bichloride of mercury. It is of course of the greatest importance that the habits of ex- cess, of work and of worry, which have given rise to the diseased condition, be checked. This is often one of the most difficult points of the management. DR. S. WEIR MITCHELL. In his work entitled "Fat and Blood" (3d ed., 1884), this author gives directions for a treatment of certain forms of neurasthenia by a combination of entire rest and excessive feeding, made possible by passive exercise obtained through the steady use of massage and electricity. Most of the cases — though not all — to whom this method is applicable, are nervous women with little fat and a lack of blood. Success by this method can only be obtained by the punc- tilious observance of a great number of minute details of treatment, and under circumstances and surroundings which are usually out of the power of the ordinary practitioner to commatld. NEURASTHENIA. 515 DR. S. BARUCH, NEW YORK. (New York Med. Jotir., November 30, 1889.) He considers neu- rasthenia a field for the employment of hydrotherapy, the benefit in these cases from the application of water being apparently produced by an increase in assimilative processes and in nutritive and tissue changes. He divides neurasthenia into 2 types — the erethetic and the true asthenic, the former being marked by the instability of the nervous forces, the latter by their enfeeblement. The former is to be soothed, requiring soothing ablutions or prolonged wet-pack, fol- lowed by the half bath, of 65° to 70° F., once or twice daily. The asthenic form requires the stimulus from the active reaction of the cold water bath, as by the shower bath. NOTES ON REMEDIES. Antipyrin is commended by some in cases of so-called "sexual " neurasthenia. Cannabinum Tannicum, or tannate of cannabine, in doses of gr. ^^^-j, is stated by Dr. Eichholt (Deutsche Med. Woch., 1883,) to be especially use- ful in neurasthenic insomnia. It does not derange the digestion, and soothes effectively. Conium in the fluid extract is given where sleep is indicated in these cases, in dose of TtLX every half hour until the patient is asleep. It is not of special value, however, over the bromides and chloral. Napelline, a new product from aconite, is stated by Dr. Laborde (Jour, de Therap., 1883,) to allay the excessive excitability of nervous exhaus- tion with excellent efifect. He employs it in subcutaneous injections of from one to four centigrammes. Strychnia. In exhausted nerve function Dr. J. C. Thorowgood {Med. Times, 1883), has obtained excellent results from small doses of strychnia, long continued, as gr. Vj, two or three times a day. He thinks larger doses rather increase the nervous irritation. Fattening Food. Dr. Cloucton {Lectures, 1883,) advises the free use of fat- tening foods in nervous diseases. He writes : "All acute mental dis- eases, like most nervous diseases, tend to thinness of body, and there- fore all foods and all medicines and all treatments that fatten are good. To my assistants and nurses and patients, I preach the gospel of fat- ness as the great antidote to the exhausting tendencies of the disease we have to treat; and it would be well if all people of nervous consti- tution would obey this gospel." Suspension, as in the fitting of a plaster jacket, several times a week, for ten minutes or more, is recommended in cases of sexual neurasthema. 5l6 DISEASES OF THE NERVOUS SYSTEM. PARALYSIS. The forms of paralysis are numerous, and treatment must always be guided by the character of the changes in the cord, or other pathology of the disease. In general paralysis a plausible plan of treatment has been sug- gested (Berliner Klinische Wochenschrift, No. 2i, 1877,) by L. MEYER, M. D., BERLIN. On the theory that it is a chronic encephalitis, he applies over the great fontanelle, on a space as large as a dollar, some antimonial ointment. He repeats this operation at the end of twenty-four hours, using an amount of ointment the size of a pea, and a little piece of linen. The second friction is manageji with care, so as to save the skin. Generally these two frictions are sufficient ; if not, a third ; a small quantity of the ointment is applied without friction, and a piece of linen to which it is applied may be left on the surface. In the course of three or four days the tumefaction of the scalp extends to the forehead and even to the face, more rarely to the occiput or the nucha. The pustular eruption is insignificant ; the pustules are small, concrete, and dry rapidly. After the swelling has become intense, it may be covered with warm poultices. In a few days the suppuration is so ample that it com- pletely separates the. integuments, which slough off spontaneously. Too resistant adherences are destroyed with caustics or the scissors. To reach this point usually fifteen days are required. From that time the suppuration is treated for two or three months with basili- con ointment. The patient may take during the same time moder- ate doses of iodide of potassium, and should have a substantial diet. Furthermore, he should be in the open air as much as possible, em- ployed in gardening, etc., only taking care to avoid exposure to ex- treme heat. Baths should be forbidden, as conducing to cerebral congestion. During fifteen years this treatment has been employed by MEYER in the cases of seventeen general paralytics, two of whom remain under treatment. Eight of the fifteen were cured, and their cases are given in his memoir. One of them, however, suffered a relapse after two years. The periosteum may be affected and there may occur exfoliations. PARALYSIS. 5 1 7 more or less considerable, of the bone. The author met with this accident a number of times, but attaches to it no special importance. The loss of hair is readily concealed. STRYCHNIA AND ITS ADMINISTRATION Of the numerous drugs which have been used in paralysis, none equals strychnia in efficaciousness. Dr. F. W. Headland, of London, states that it is only successful in paralysis in cases where the injury to the nervous centre has healed up, and when the limb continues paralyzed merely because the motor nerves have lost the power of transmitting the necessary impulse, from having been so long unaccustomed to discharge this office. On the other hand, when the lesion of the nervous centre is of recent occurrence, or when it has been of so serious or extensive a nature as to admit of no repair in the course of time, the remedy will be ineffectual. Sir Thomas Watson lays down the general rule that strychnia can be of benefit in these cases only when the cord is free from dis- ease. Prof. William A. Hammond has employed it very successfully by a new and improved method, in \x&2Axa.% facial paralysis. (St. Louis Clinical Record, May, 1878.) The improvement consists in the administration of strychnia in increasing doses to the point of rapidly — as rapidly, in fact, as is consistent with prudence — bringing the patient under its full physiological influence. For this purpose he makes use of a solution of the sulphate of strychnia in the proportion of one grain to the ounce of water. Every ten minims of such a solution contain ^j of a grain of the medicine. Generally, he begins with ten minims of this solution three times a day for the first day ; the next day eleven minims are given three times ; the next twelve, and so on till the patient exper- iences a sensation of cramp or rigidity in the legs, or in muscles of the back of the jaw. Usually the cramp is first felt in the calves of the legs. The further administration is now stopped, and, if neces- sary, on the following day the solution is given as before, in doses of ten minims, and the doses are again run up to the extent of produc- ing the muscular cramp. Of course, with this, electricity, passive exercise, and support of the affected side of the face by a little hook placed in the angle of the mouth, and attached to the ear by an elastic band, are advantageously combined. 5l8 DISEASES OF THE NERVOUS SYSTEM. ELECTRICITY IN PARALYSIS. DR. G. VIVIAN POORE, OF LONDON, Lays down the following rules as to its application to paralysis : i . If the paralysis to the will remain absolute, and if the contractility of the muscles be perfect, we do no good by persevering with electrical treatment. This condition is often met with in hemiplegia. The patient is absolutely helpless on one side, although the muscles are in no degree wasted, and their irritability remains normal. 2. If the paralysis to the will remain absolute, and if the irritability of the muscles be diminished, then electricity is useful, in so far that it helps to improve the nutrition of the muscles, and restore their normal degree of irritability . The normal degree of irritability being restored, (the paralysis to the will remaining absolute) then electrical treatment may be discontinued. The irritability of muscles may be diminished from mere want of use, and electricity may serve to restore this irri- tability. 3. We should bear in mind the advice of SiR THOMAS Watson, that " our aim should be to preserve the muscular part of the locomotive apparatus in a state of health and readiness, until, peradventure, that portion of the brain from which volition pro- ceeds having recovered its functions, or the road by which its mes- sages travel having been repaired, the influence of the will shall again reach and re-animate the palsied limbs." 4. Whenever we meet with the degenerative reactions, we should employ that form of current to which the muscles most readily respond, which is in- variably the galvanic. We must persevere doggedly, and we may find our perseverance rewarded by the gradual return of the normal muscular irritability. 5. If the irritability to both forms of current has completely disappeared, we are not justified in persevering too long, nor in holding out delusive hopes to the patient. Nevertheless, treatment should not be abandoned without a patient trial. In treating paralysis with electricity, an exact diagnosis is, above all things, necessary, and we should be able to bring our knowledge to decide as to whether or not the paralyzing lesion is of a permanent nature, or one that, according to our pathological knowledge, is or is not removable or susceptible of improvement. If not, then our efforts to cure must of necessity be unavailing. It is in those cases where the paralyzing lesion has disappeared, or has improved, and we have only to combat with the effects produced by it, that our efforts are the most successful. Hysterical paralysis is especially PARALYSIS. ejQ susceptible to electrical treatment, and with it we occasionally work apparent miracles. When a patient, who has no will to move her muscles, sees that her muscles can be made to move in spite of her will, it is no wonder that such a discovery should exercise a whole- some moral influence over her mental condition. Other authors state that it should never be resorted to in recent cases, if there be reason to suppose that effused blood or coagulum remains unabsorbed, nor so long as there are any febrile or inflam- matory symptoms present. It is of no benefit in cases with organic lesion of the nervous system. Its greatest utility lies in cases of purely local paralysis. Great and terrifying shocks are rarely bene- ficial where small and repeated shocks have failed. Both faradiza- tion and galvanism have been employed with success. Electro- puncture has also its advocates. NOTES ON REMEDIES. Ammonii Formas is recommended by Dr. Ramskill as a stimulant in cases of chronic paralysis accompanied by general torpor. Argenti Nitras, in doses of gr. |-j daily, has been employed with success by BouCHtJT in paraplegia and progressive general paralysis, resulting from sexual or alcoholic excess. Arseniosum Acidum in paralysis from cerebro-spinal sclerosis, is well spoken of by Flint. Cantharis. Sir Thomas Watson recommends tincture cantharides in para- plegia. Generally, when it does good, it acts as a diuretic. Cocculus Indicus. According to Phillips, this is a very valuable remedy in partial palsies accompanied by giddiness, as also in hysterical, choreic and epileptic hemiplegia. The dose of the tincture (gj to |j) is gtt. ij-x ; oi pier o toxin, the active principle of the berry, gr. ^ts-iV. Ergoia is recommended in those forms of paralysis arising from spinal con- gestion, in paraplegia complicated with menstrual irregularity, (Mead- ows,) and in the constipation of the paralytic, after the most powerful cathartics have failed. (Waring Curran.) Ferri et Strychnia Citras is serviceable in paralysis associated with anaemia. Phosphorus has been successfully employed in some cases in the form of the oil, (made by gently warming two parts of phosphorus in loo parts of almond oil, in a closed flask, for about twenty minutes, and decanting off, when cool, the oil from the undissolved phosphorus. Dose, gtt. iij-viij, in emulsion, or with cod-liver oil.) Picrotoxin. See Cocculus Indicus. Potassii lodidum proves successful in syphilitic paralysis. It should be given in doses of 3j and more, combined with sublimate, gr. iV. 520 DISEASES OF THE NERVOUS SYSTEM. Strychnia and Nux Vomica. (See p. 517.) Sulphur gives very good results, according to Dr- Graves, in paralysis of an asthenic or chronic character, when employed as a sequel to a course of strychnia. He uses it in the form of an electuary and in baths. Toxicodendron is recommended by Trousseau in paraplegia from concussion of the spinal marrow, administered as follows : gr. v. the first day of treatment, increased daily in the same amount until gr. Ix a day are reached. It is asserted that it strengthens rather than enfeebles di- gestion, and causes no inconvenience other than occasionally slight strangury. EXTERNAL REMEDIES. ArmoracicB Radix. Poultices of fresh horse-radish root form a ready counter- irritant in paralytical affections. Cajuputi Oleum makes an excellent embrocation for paralytic limbs. Dili- gendy rubbed in, it stimulates the parts and relieves pain when present. Myristica. The oil, diluted with soap liniment, forms a useful stimulating embrocation. Nitro-glycerine has served well in some cases of paresis as a general nervous stimulant, given in dose of one drop of one per cent, alcoholic solu- tion. Sulphuricum Acidum. The following ointment, perseveringly employed, has resulted beneficially : S47. R. Acidi sulphuric!, f. 3] Adipis, ij. M. It acts as a powerful irritant. Veratria ointment, diligently used, has occasionally been followed by great improvement. Cold Shower Baths, in cases of paralysis consequent on severe inflammatory attacks of the brain and spinal column, are often attended with benefit, but sometimes fail, and may even aggravate the symptoms. Cantharis. Blisters to the spine are useful when there is reason to expect effusion within the theca. Electricity. (See above, p. 518.) Issues and Setons are sometimes employed with advantage. Leeches at the verge of the anus are beneficial where there is suppression of an habitual discharge, as from piles. Operative procedures are sometimes to be considered, as the monoplegia fol- lowing a fracture, when there may be indicated the necessity of cut- ting down upon the seat of fracture and releasing a nerve that is en- closed in the callous material of the bone wound. Or, it is held by many progressive surgeons that the indications in a case of cortical hemorrhage causing palsy demand trephining and removal of the blood ; so, too, in case of tumors or abscesses located. PROGRESSIVE LOCOMOTOR ATAXIA. i;2i PROGRESSIVE LOCOMOTOR ATAXIA (POSTERIOR SPINAL SCLEROSIS.) PROF. LEYDEN, OF BERLIN. (Internat. Klinische Rundschau, December i, 1889.) Leyden has had few positively beneficial results from the use of drugs. Iodide of potash is sometimes in his hands valuable to allay the lancinating pains ; but mercury is valueless, except in cases of syphilitic origin. Warm baths he regards as the most important means for treatment, but even they are not specifically curative. In giving the baths, the patient's comfort should regulate the temperature, and the duration be between five and twenty minutes. Care is to be exercised lest the patient be chilled, and in many cases the method should be used only in the summer months. The effects of this mode of procedure are, increase of strength, decrease in frequency and force of pains, diminution of excitation of sensory nerves, and, in Leyden's opinion, the baths may check slightly the sclerotic process. ALLEN M. HAMILTON, M. D., NEVi^ YORK. The treatment is entirely empirical. In the early stages, ergot and bromide of sodium control the pain. 848. R. Extr. ergotse fl., f.ijj Sodii bromidi,' f. § jss Aquae camphoree, ad f. § iv. M. A teaspoonful every four hours. A combination of belladonna and turpentine, as suggested by Trousseau, not only relieves the pain, but helps the vesical trouble, if present. 849. R. Extr. belladonnae, gf- \Y Olei terebinth., f-3'3 Butyri cocose, I- *• Make twelve capsules. One thrice daily. M. No one remedy has had so much said in its favor as nitrate of sil- ver. It is well to begin with a one-fourth grain dose, and increase to gr. yi or j thrice daily. It may be combined. 850. R. Argenti nitratis, f!^' ^r""'^ M Extr. nucis vomicae, &'• *'J- Make twenty-four pills. One after each meal. 522 DISEASES OF THE NERVOUS SYSTEM. Or, 851. R. Argenti nitratis, Extr. belladonnae, aa gr. vi-viij Extr. gentianse, q- s. Make twenty-four pills. One after each meal. A salt foot-bath every night is beneficial, and the sulphur-bath has worked wonders in cases of long standing, and deserves a faith- ful trial. A small lump of sulphide of potassium is to be thrown into the water in which the patient bathes, and he is to be well rubbed down afterwards. DR. EDWARD C. MANN. This author (Psychological Medicine, 1884,) is of opinion that some cases of this disease are curable, especially if seen in their early stages. He relies largely on electricity — ^both the galvanic and faradic currents — applied along the spine. He has also used suc- cessfully counter-irritation by small fly blisters along the course of the spine, and the chloro-phosphide of arsenic as exhibited in Routh's formula, a preparation made in London. Cod-liver oil is given freely, and constant rest is enjoined. To relieve the "lightning pains," he puts great confidence in nerve stretching. The painful nerve is reached by incision, laid bare and lifted about two inches, the traction on the nerve being made in a line perpendicular to its axis. Generally immense relief to the pain is afforded, and sometimes it is entire. Dujardin-Beaumetz and Germain-SEe recommend for the re- lief of these pains, respectively, antifebrine and antipyrine. SUSPENSION TREATMENT. This mode of treatment of spinal cord disease was practiced years ago by the elder MITCHELL, of Philadelphia. Within the past year it has been revived by CHARCOT, of Paris (de la Tourette, Le Progres Medical, Jan. 19, 1889) ; and within the year a flood of literature bearing upon the subject has been published. From the cases pub- lished it would seem that in Tabes Dorsalis about 70 per cent, of all cases may be benefited, some markedly ; a considerable number are not influenced, and a few made worse. The suspension in these cases is made in such manner as in ap- plying a Sayre's plaster jacket. The suspension should at first continue but for a moment, to be increased gradually to ten or more PROGRESSIVE LOCOMOTOR ATAXIA. 523 minutes ; the patient is best brought, at least, to the toes. The sus- pension apparatus best suited consists of a tripod with pulley, over which passes the cord attached to a head piece and also to straps passing beneath the arms. The suspending process should be grad- ually performed — ^jerks and jars avoided. Twice or thrice a week is usually sufficient. TREATMENT BY PRECISE NERVE VIBRATION. There has been much evidence brought forward in the last few years to prove that locomotor ataxy may be greatly relieved and perhaps entirely cured by nerve-vibration. This was the discovery of a Parisian physician, and has been reduced to a system by the invention of a "percussor" for the purpose. In a report in the Brit. Med. Jour., 1883, Dr. J. M. Granville states that persisting in the vibration of the irritable nerves, their excitability becomes exhausted ; and, in proportion as this happens, they obey the mandate of the will, and voluntary movements, in short, locomotive acts, are possible. Not infrequently, some de- bility of the nerve power and depression of energy in the centres follow immediately upon the exhaustion of their irritability ; so that, for a few hours, or it may be days, the patient complains of stiffness, and, although he may have lost the jerky feeling in his limbs, he cannot move them more readily. They are heavy and powerless. This, however, quickly passes away, and the case is found to have made decided progress. The walking is easier and steadier, and control, generally, more direct and precise. At this stage, not earlier, it may be advantageous to percuss over the spines of the vertebrae, with the view of vibrating the nerve-centres. He has seen well-marked and severe cases much benefited by this means. NOTES ON REMEDIES. Argenti Nitras, according to Dr. Althaus, is useful in a large proportion of cases. It should be given in doses of gr. h-\, two or three times daily. Its combination with hypophosphite of soda seems to add to its efficacy. After its use has been continued for four or six weeks consecutively, its administration should be interrupted for two or three weeks, and a slightly aperient mineral water given. The mtrate may then be resumed for a month or two. The gums should be care- fully watched, and, on the appearance of the slightest blue coloration, the remedy should be discontinued. Nitrate of silver has been thus employed in ataxia with variable success. 524 DISEASES OF THE NERVOUS SYSTEM. Argenti Oxidum. In the Med. and Surg. Reporter, December i8th, 1875, Dr. Charles Carter, of Philadelphia, reports two cases in which the oxide of silver, gr. y^ t. d., increased to gr. ij, t. d., controlled the neuralgia and apparently arrested the progress of the disease. This drug, also, does not disorder the skin. Argenti Phosphas, gr. J^, is preferred to the nitrate by Dr. A. M. Hamilton. Nitro-muriaticum Acidum is an excellent tonic in these cases. Phosphorus is recommended by Dr. ArriaN and Dr. A. Flint. The adminis- tration of the phosphates of the metals and salts may be conjoined with the use of dilute phosphoric acid as a drink, in the daily allow- ance of water, and with phosphate of soda as an aperient. 852. R. Acidi phosphorici diluti, f. 3yi Syrupi, f- i ")■ M- A teaspoonful in water, thrice daily, gradually increased to a dessertspoonful, to- gether with the application of electricity. (Dr. W. Lambert, New York Medi- cal Journal, February, i86g.) Physostigma has been used with advantage by Dr. Sydney Ringer, and also by Dr. Eben Watson. (Practitioner, September, 1869.) Potassii lodidum has been employed, but not very favorably reported upon. It is useful where there exists a syphilitic taint. external remedies. Electricity has been emplpyed with good results. Dr. Aitkin says it must be resorted to with great caution, and only during the pauses in the dis- ease. Prof. Trousseau highly recommended its use. Later experi- menters seem to have concluded that treating the cord is of doubtful propriety, and that faradization of the extremities, by means of the metallic brush, does the most good. (Beard & Rockwell, 1878.) Dry Cupping. Dr. Henry M. Lyman, of Chicago, says of this means ( Chi- cago Med. y^our., January, 1883) : " Its effect upon the general health and nutrition gives it the right, in this case at least, to rank with hydrotherapy, massage, and the Swedish movement cure, as a method of treatment which deserves trial as a means of retarding the progress and relieving the anguish of one of the most intractable of diseases." Nerve-Stretching. Prof. W. Stokes, of Dublin, has resorted to this pro- cedure in two cases, with rather satisfactory results. In the first case the success was sufficiently encouraging. The operation was followed by the restoration of plantar sensibility, and general improvement. SPINAL IRRITATION. 525 SPINAL IRRITATION. DR. NATHAN S. DAVIS, OF CHICAGO. Regarding spinal irritation as simple chronic inflammation, involv- ing the roots of the nerves of sensation, or motion, or both, what is the appropriate treatment? Dr. DaviS answers, that internally an alterative plan like the following : 853. R. Tincturae cimicifugse, • f. §ij Tincturse stramonii, f. § ss Potassii iodidi, Sii^s Syrupi simplicis, f. |iss. M. A teaspoonful three or four times a day. Or: 854. R. Hydrargyri chloridi mitis, gr. j Potassii nitratis, Pulv. ipecac, et opii, ai gr. viij. This amount, in a powder, three times a day until the mercurial is preceptible in the breath or gums, when it should be discontinued. and externally, dry cupping along the spine, (for which purpose common tumblers are well adapted,) followed by belladonna plas- ters, or hypodermic injections of atropine, are required. The ap- plication of ice to the spine in a CHAPMAN'S ice-bag is likewise indi- cated here. These means, with rest in the horizontal position, will be likely to remove the disease in from four to six weeks. ALLEN M. HAMILTON, M.. D, NEW YORK. In three-quarters of the female cases of this disease, it depends upon some ovarian or uterine derangement, which must be sought out and treated, or the physician's efforts are fruitless. When there is general anaemia, one of the best tonics is : 855. R. Ferri et ammon. citratis, 3"! Tinct. gentianae, f-Siv. M. A teaspoonful in water after eating. Dr. THOMPSON'S solution of phosphorus does excellent service. It is: 856. R. Phosphori, gr. ss-iss Alcohol absolut., q. s. to dissolve Ess. menth. pip., , 3' '' ii,r Glycerinse, adf.giv. M. A teaspoonful after eating. 526 DISEASES OF THE NERVOUS SYSTEM. Nutritious food and stimulants are required. Strychnia often does harm, while opium in small doses is generally of great and immedi- ate value. Galvanization of the cervical sympathetic is an important auxiliary ; so also are Chapman's spinal bags, filled alternately with ice and hot water. NOTES ON REMEDIES. Counter-irritants are, according to Dr. McCall Anderson, (Clinical Lectures, 1878,) the most efficient means of cure, and rarely fail. Blisters and leeches should be applied directly to the spot of spinal tenderness. Digitalis is often of service. Electricity in short sittings, every other day, will reHeve uncomplicated cases. Leeches, said by Dr. Hammond to be hurtftil, have been employed by others with advantage. Dr. McCall Anderson orders half a dozen over the painful spot, repeats them if called for, and follows with a bUster. (Glasgow Medical Journal, August, 1870.) Dr. Armaingaud, of Paris, also recommends this treatment when there is pain or pressure over one or more of the vertebral spinal processes. ( Chicago jour- nal of Mental and Nervous Disease, January, 1874.) Opium in small doses is favored by Hamilton. Phosphorus is often of value. (F. 855.) Sinapis, applied steadily to the spine, is lauded very highly in this disease by Dr. Arthur Gamgee. (Practitioner, February, 1877.) Strychnia is rather a dangerous drug in these cases. Zinc in the following combination forms an admirable revulsive. The for mula is that of Dr. A. Rothrock, of Pennsylvania : 857. R. Zinci chloridi, 5j Zinci cyanureti, gij Cerati simplicis, § j. For a plaster. Apply for an hour or two daily. SPASMODIC DISEASES. DR. W. H. ERB, OF HEIDELBERG. This contributor to Ziemssen's Cyclopcedia considers spasmodic diseases among the most unsatisfactory objects of medical treat- ment. Whatever treatment there is, is purely empirical. Tonic and dietetic measures form an important part of it. Bathing, mas- sage, travel, and the movement cure, all have their applications. SPASMODIC DISEASES. 527 Electricity occupies a prominent place in curative measures, but definite rules for its use cannot be given. Several methods must often be applied in succession before the most effective one is dis- covered. Narcotics and nervines are the most valuable classes of drugs, and all of these have been tried with varying success. In mimetic facial spasm or convulsive tic, brilliant results have sometimes been obtained by neurotomy. Of other means, elec- tricity is of greatest avail. The subcutaneous injection of morphia is important, but satisfactory results are rarely obtained. PROF. WM. A. HAMMOND, M. D., OF NEW YORK. The class of paralyses or spasms produced by the habitual use of a set of muscles for a long time, as in writers' cramp or scriveners' palsy, etc., has been called by Professor HAMMOND, anapeiratic paralysis. He believes rest from the labor causing the disease is indispensable in the treatment, and sometimes sufficient in itself. The constant galvanic current has proved the most effectual agent in his hands. In incipient stages, bromide of zinc is valuable for re- storing tone to the nervous system. It should be used in gradually increasing doses. Phosphide of zinc and nux vomica are also valuable. DR. REUBEN A. VANCE, OF OHIO. This physician has derived great advantage in writer's cramp from the hypodermic use of atropia, combined with rest to the part. The best place in which to inject the remedy is beneath the skin, in the loose cellular tissue over the pronator muscles of the forearm. Either extremity can be used, but when the treatment is to be con- tinued for a length of time, it is better to inject in each arm alter- nately. The hypodermic syringe should be small, and armed with a gold-pointed needle. The solution of atropia should be concen- trated, so that but a small amount of liquid need be injected at a time. The following is a convenient formula : 858. R. Atropise sulphat., gr. j Acid, sulph. dil., q-.s- „ Aquam, ad 3j. M. Dose, one minim. The injections should be administered about three times a week, and when attention is paid to the cleanliness of the needle, and the due concentration and freshness of the solution, no danger of pro- 528 DISEASES OF THE NERVOUS SYSTEM. ducing abscesses need be feared, if the operation is performed with a reasonable degree of dexterity. Dr. F. RuNGE has called attention to some cases of local irrita- tion, which produce these cramps. In one case he found a chronic periostitis at the external condyle of the humerus. This node was extremely sensitive to pressure, and this pressure evoked spasmodic contractions of the extensor muscles, originating there, of precisely the same character as those suffered from when the patient persisted in writing. The actual cautery was applied over the inflamed spot, and this, with six weeks' entire rest, cured the patient, who was still well twelve months afterwards. In the second case, an ingrowing nail (of the right thumb of the patient) was the original cause of the cramps, for it compelled the patient to alter the mechanism— in other words, the position — of his hand in writing. When this was healed, and the matrix of the nail no longer tender, the cramps all ceased, and the patient was well. (Berlin Klin. Wochenschrift, No. 21, 1873.) In cases of writer's cramp, evidently not of any central relation, with tenderness of nerve trunks, tremor, etc., counter-irritation is evidently indicated — applied over the tender sites. Dr. E. Hertzka reports a case of cure oi piano-players' cramp, in the Petersburger Medicinische Zeitung, 1876, by the use of eight drops of tinctura gelsernii three times a day. The treatment lasted three weeks ; hydrotherapeutic and electric methods of treatment had proved insufBcient. Dr. G. Vivian Poore, of London, has derived better results in . writers' cramp, from galvanism than from any other means. (Lancet, January, 1875.) His words are: "For genuine 'writers' cramp,' dependent upon chronic fatigue, I have found the refreshing effects of the galvanic current of the greatest possible service, and I have had four extreme cases of patients who had exhausted all the usual remedies, and had suffered for very lengthy periods, in whom rest and the use of the galvanic current, combined with a rhythmical exercise of the affected muscles, was productive of rapid and marked amelioration of the objective and subjective symptoms." In case of such an affection in one who cannot temporarily leave off writing, it may be advantageous to make use of a pen provided with a large and suitable hand-hold, making the effort at writing call into play a different set of muscles. SPASMODIC DISEASES. 529 HICCOUGH, SINGULTUS, OR SPASM OF THE DIAPHRAGM, In hiccough, singultus, or spasm of the diaphragm, violent mental impressions will often check the nervous action. Hot fomentations, sinapisms, or the electric brush applied to the diaphragmatic region, have the same effect. Internally a very effectual remedy is snow, pulverized ice, or a plate of ice cream. Either of these will relieve ordinary cases. Of drugs, the most effectual are the narcotics and anti-spasmodics. The following combination will often give imme- diate relief in obstinate cases : 859. R. Chloralis hydratis, Potassii biomidi, Potassii bicarbonatis, aa 3j Liq. morpb. sulphatis, f. 5 j Aquam mentb., adf.^vj. M. Two tablespoonfuls every three hours. The internal use of mustard has been highly commended ; one teaspoonful of flour of mustard is to be infused in half a pint of boil- ing water, the infusion filtered, and to be given the patient at one draught. In chronic hiccough from no assignable cause, the following is useful : 860. R. Tinct. physostigmatis, Hlx Pot. carb., gr. x Mist, acacise, 3j- M. S. One dose, ter die. No vegetables should enter into the diet. The food should be non-stimulant, making use of milk, eggs, etc. In some cases, tinct. of Calabar bean alone answers very well. Sometimes a hypodermic injection of morphia cures or relieves. The following combination has been used with excellent effect by Dr. F. Peyre Porcher, of South Carolina, in troublesome hic- cough : 861. R. Oleisuccini, f-3j Spts. setheris nitrosi, rl^ Olei menthse piper., ^3) Potassii bicarbonatis, f 2 — Spts. setheris compos., rz"' vr Mucilaginis, *^'3JJ- "• A tablespoonful every half hour. The other remedies to which we must have recourse in obstinate cases, are: Chloroform, combined with small doses of morphia 34 530 DISEASES OF THE NERVOUS SYSTEM (Ringer), morphia hypodermically, camphor, chloral, ether, jabor- andi, or pilocarpine, belladonna, quinine in full doses, musk, (which has been extolled as a specific in this affection,) and oil of amber (which is said to rank next to musk). Dr. Favier reports a case of very obstinate hiccough that had lasted without interruption for fifty days, and was finally cured by firm compression of the epigas- trium with a tourniquet; and firm pressure with the end of the finger in the sulcus, at the base of the nasal septum, is an always convenient and frequently effective means. Several cases are re- ported in the Compend. of Med., 1884, where a hypodermic injec- tioh of gr. Yi. of pilocarpine checked at once cases of hiccough which had resisted all other remedies. In the condition of tonic muscular contraction, known as tetany, which is closely akin to hysterical contractions. Dr. N. B. EMERSON has made successful use of conium, which is a powerful relaxant. {New York Medical Journal, July, 1876.) Cramp of the Muscles, especially of the gastrocnemius, is a com- mon affection of obscure origin. Women with child are very often subject to it. Rubbing the part, or jumping from the bed and stand- ing on the affected leg, are the usual means employed. If these fail, a hypodermic injection of morphia will give the most prompt relief. When hereditary, these attacks are extremely obstinate. Very often good results may be had in the cramps as well as neu- ralgias of pregnancy by the use of belladonna ointment well rubbed into the perineum. Dr. Frederick James Brown has called attention to the import- ance, in all convulsive disorders, of placing the patient in the sinis- tro-lateral posture. (Practitioner, May, 1877.) He is certain that by attention to this, important results may often be obtained. He gives the following example : " Recently, a man aged fifty-six years, in impaired health from chronic catarrh, was seized with unilateral (right) convulsions. His consciousness and power of speech were intact. He had been convulsed for ten minutes when I entered the house, and he was growing worse. I turned him over upon his left side, and the convulsions seized in about ten or fifteen seconds." Spasmus nictitans. In the Med. Record, 1883, Dr. Friedr. Betz relates the history of a boy, fourteen years of age, who had suffered for several years with a bilateral nictitating spasm of the lids. Several physicians had attempted to relieve him, but in vain. The boy was healthy, and his eyesight good. He had, however, quite VERTIGO. e^j long eyelashes, and the edgesvof the lids were reddened. Betz per- formed epilation of numerous lashes above and below on both eyes. The result was immediately successful. Winking spasm may, how- ever, be due to other affections of the lid, or to intra-ocular strain, and care should be had as to the possibility of such causation. Spasmodic Sneezing is occasionally severe enough to constitute a feature for special treatment. It is usually easily controlled by some such preparation cis Ferrier's snuff: 862. R. Morphias hydrochloratis, gr. ss Pul-veris acacise, 5ss Bismuthi subnitratis, 5iss, jj. Or, 863. R. Solutionis (4 per cent.) cocainae muriatis, f.^ss Acid carbolici, gtt. xx Aq. campfaorse, f. § ss Aquse, f.gj. - M. Sig.— To be snuffed. VERTIGO. DR. EDWARD C. MANN. Vertigo arising from disordered digestion, this author states (Psy- chological Medicine, 1884,) may be effectually relieved by the fol- lowing treatment : The patient should take a cold bath on rising, and use free friction with a Turkish towel or flesh-brush. No malt liquor must be taken. The diet must be plain and regular. Vichy water, with perhaps a little brandy, may be used as a drink. The patient must retire early and sleep in a well-aired room. The fol- lowing may be taken before meals : M. Instead of this, five drops of the tincture of nux vomica may be given before meals. Many cases of vertigo arise from alcoholic indulgence and mental anxiety. They will not improve until these caiises are removed. In 864. R. Pulv. rhei.. f.3j Sodii bicarbonat., Pulv. gentianse, aa 3ii Aquae menth. pip., Aquse destillatx, ia f.Siij. Sig. — ^Tablespoonful thrice daily before meals. 532 DISEASES OF THE NERVOUS SYSTEM. others, an examination of the urine will reveal oxalate of lime, which produces oxaluria, and gives rise to vertigo. This can readily be relieved by fifteen-drop doses of dilute nitro-muriatic acid, given in water thrice daily before meals. Other cases are characterized by an abundance of lithic acid or lithates in the urine. In these the vertigo is severe and often repeated daily or twice daily, accom- panied with confusion of mind and loss of memory. The patient must be placed on a strict diet, using only white meats ; he must rest, exercise freely, and use alkaline purgative waters, as the Sara- toga, Vichy and Poland. Citrate of lithia is an appropriate medi- cine, and a course of small doses of arsenic is advisable. DR. J. M. DA COSTA. In regard to gastric vertigo, this teacher states that it is very often necessary for the patient to make an entire change in his habits and surroundings — e. g., to take a sea voyage or a trip of some duration. After due regulation of the diet, he thinks that the best treatment consists in the administration of bitters and alkalies, the bitters being given before meals, and alkaline waters, etc., after meals. Later on, when the way has been well paved by the regular administration of these, iron, combined with is of a grain of strychnia given three times a day, is to be preferred. Another plan consists in the administra- tion of small doses of corrosive sublimate, while paying strict atten- tion to the bowels and diet. This exerts a most happy influence upon the gastric and cerebral phenomena. Iron should not be given early in the case, when it may not be well digested, and may cause constipation. DR. S. WEIR MITCHELL, OF PHILADELPHIA. This able neurologist, at the close of an exhaustive study of the causes of vertigo (Medical and Surgical Reporter, June, 1877), states that there is no drug which holds to it the same relation that the bromides do to epilepsy. • The nearest approach to specific medica- tion lies in the use of vascular tonics like digitalis ; moderate doses of ergot ; and where pallor occurs, inhalations of nitrate of amyl as a means of relief for the immediate onsets. Cold douches are val- uable ; but, above all, the use, once in five days, of the actual cau- tery on the neck, is the most certain agent. Freeze the part, first, with a piece of ice sprinkled with salt, then press on the insensible part the point of a gas cautery, until it is just felt and no more. VERTIGO. 533 In gastric vertigo, when all other means fail, the thorough adop- tion of milk diet seldom disappoints. Aural vertigos demand points of cautery behind and in front of the ear, alternately. Ocular vertigos require appropriate glasses. Tobacco is a common cause of vertigo, and in all cases, its use must be prohibited. H. V. SWERINGEN, M. D., OF INDIANA. Vertigo is very often dependent upon imperfect digestion ; in con- sequence of this fact I seldom fail to afford relief by the following : 865. R. Potass, bicarb, 3;; Liq. lactopeptin, f_ 5 ; Tr. nucis vom., f. 5 55 Tr. card, co., f_ 5 jj; Syr. simp., fISij Aqua menth. pip., q. s. ad f. % iv. M. Ft. sol. et. Sig. — A tablespoonful in water every three or four hours. For plethoric persons I sometimes add to the above the following : 866. R. Potass, bitart., Svj Jalapse pulv., 5ij. M. Sig. — ^A tablespoonful in milk, syrup or molasses every two or three hours, until it operates freely on the bowels. NOTES ON REMEDIES. Ammonii Bromidum has been found, by Dr. Ramskill, of great help, when given in an effervescing form, with cascarilla, in cases of vertigo from overwork in the well-fed, when there is usually restlessness, insomnia, and depression of spirits, with a sense of impending evil. Cubeba, in doses of gr. j. three times a day, at meal time, is recommended by Dr. Debout, in vertigo occasioned by excessive mental emotion or intellectual labor, and associated with dyspeptic derangement. Ferri et Strychnia Citras is recommended by Dr. Ramskill in essential vertigo (i. e., that unaccompanied with any other head symptoms). The patient should be placed on a long course of it, given in an effervescing form, and alternating, month by month, with tincture ot larch and small doses of digitalis. Hydrargyri Chloridum Corrosivum is recommended in small doses, with bark, by Drs. C. Handfield Jones and T. H. TAN^fER, in the tempo- rary vertigo of old persons. Nux Vomica and Strychnia are available in many cases. Potassii Bicarbonas is very serviceable in dyspeptic vertigo. Potassii Bromidum is, according to Dr. Russell Reynolds, often of service 534 DISEASES OF THE NERVOUS SYSTEM. in vertigo, especially in cases which occur paroxysmally, without the coexistence of obvious spasm or organic disease of the brain. Tonic remedies are recommended by Prof. Austin Ffint; quinine is the most useful drug Dr. Flint has used ; giving it in full doses. Valeriana is very serviceable in that form of vertigo, with cardiac palpitation, which is not an unfrequent accompaniment of the menopause, or of the first establishment of the menses, in which the blood seems to rush into the head and then suddenly back upon the heart. Zinci Valerianas, in doses of gr. i-ij, thrice daily, associated with extract of valerian, is recommended by Dr. Delioux in the treatment of nervous vertigo. PART VI. DISEASES OF THE BLOOD AND INFEC- TIOUS DISEASES.* AncEmia— Cerebrospinal Meningitis— Dengue (Break-bone Fever)— Gout— Injluenza— Intermittent fever (Ague, Chills)— Purpura Hemorrhagica — Rheumatism, Acute — Rheumatism, Chronic— Scurvy— Typhoid Fever— Typhus Fever— Variola— Yellow Fever. ANEMIA. CHLOROSIS. DR. GUERDER, OF PARIS. This author (Therepeutic Gazette, February 15, 1884,) highly re- commends desiccated defibrinated blood. The mode of preparation is described as follows : The blood, taken from well-selected ani- mals, is received at the moment of slaughter into perfectly clean vessels, is immediately defibrinated by whipping, cooked from one to two hours over a sea- water bath at about the boiling point (212° F.) ; it then has a reddish-gray aspect, but being exposed to the air recovers a bright red arterial color, which proves that the hemo- globin has retained all its affinity for oxygen. The cooked blood is then dried in a special apparatus. Cooking is indispensable to de- stroy any morbid germs which may be contained in the blood ; it does not, moreover, alter the digestibility of the preparation any more than that of meat or eggs. Blood powder well prepared is of a beautiful scarlet color. It has no odor when it is sufficiently dried, and may be kept any length of time. Dissolved in water it has a slightly sickish taste, which is easily corrected. In a glass tumbler place a teaspoonful of the powder of blood and add a teaspoonful of sugar; pour on cold water, stirring all the * For Diphtheria and other Infectious Diseases of children, see sections upon Diseases of Children. (535) 536 DISEASES OF THE BLOOD. while till as complete a solution as possible is effected. Add a tea- spoonful of some kind of liquor — rum, brandy, anise cordial, or wine — according to the liking of the patient. It may also be given in the form of an emulsion with milk, syrup, coffee, etc. The dose should be large enough to obtain a definite result. The medium quantity is from three to four teaspoonfuls a day, repre- senting from one-half ounce to an ounce of the powder. In many cases this dose may be exceeded. In the usual dose the patient will absorb as food the equivalent of four to five ounces of fresh blood or of meat, from a quarter to a half drachm of soluble chlorides and phosphates, and hemoglobin in sufficient quantity to give from one to two grains of metallic iron. Recently M. Antiq, (Lyon Medicale, 1889,) claims remarkable results have been obtained by using enemata of defibrinated blood. PROF. DUCLOS, PARIS. (Med. News, 1891.) According to the Paris correspondent of the British Medical Journal, M. DuCLOS believes with Sir ANDREW Clark that chlorosis is a faecal auto-intoxication, which should be treated by purging, prolonged until the intestine is completely freed from all the hardened and decomposed faecal matters. He recom- mends a vegetable rather than a meat diet. When constipation is not very marked, the affection results from the great activity of putrid decomposition, and should be treated with carbonate of soda combined with carbonate of lime, magnesia and charcoal. Iron is beneficial because it forms an iron sulphide with the hydrosulphuric acid in the intestine. Hyposulphite of sodium has been of use in checking faecal fermentation ; naphthol might serve the same pur- pose. JULIUS POLLOCK, M. D., M. R. C. P., LONDON. In a large number of cases, especially in women, this writer (Medical Times and Gazette, 1877,) extolls the following combina- tion: 867. R. Fern ammonio-citratis, gr. v Rhei extracti fluidi, gtt. v Infusi quassise, Aquse menth. piper., 5£ f.3ij. m. For one dose, thrice daily. Dr. P. insists on the rhubarb, as it greatly assists the action of the AN^MtA. 537 iron when the stomach is out of order. Bromide of potassium, gr. X, can be added to the mixture if the patient is nervous. The diet should be light and simple. Pepsin with the meals may often be employed with advantage." A moderate amount of exercise out of doors, when the weather permits, should be insisted upon, but any- thing like fatigue must be avoided. A tepid bath in the morning and a rub-down afterwards with a rough towel is a good thing. By- and-by, in a few weeks, more or less, the steel and rhubarb mixture may be left off, and fifteen drops of the solution of perchloride of iron given after each meal in a wineglass of water. Under the very best and most careful treatment, the improvement in anaemia is not unfrequently slow and tedious, and, to prevent dis- appointment, it is as well to caution patients and their friends that they are not to expect, as a rule, any very rapid change. Once get the patient on the road to health, however, and time and persever- ance will do the rest. DR. FREDERICK SCHOLZ, BREMEN. As the result of years of observation this physician publishes a method of treating chlorosis (London Lancet, 1891,) which he claims has been of pronounced benefit to his cases. He does not regard the blood changes as the primary affection, but the contraction of the blood-vessels, which is usually regarded as a complication. He be- lieves the vessels are too full and the blood abnormally serous. He was impressed a long time ago with the cool and livid skin of these cases, and in consequence employed hot baths and gentle friction to stimulate nutrition and vitality by acting on the skin. He thus re- laxes the vascular system, too, quickening the circulation, thus re- lieving the palpitation, dyspnoea and other symptoms of the disease. In some cases Dr. ScHOLZ practises venesection in addition to the above procedures, and claims to obtain marked benefit at once. If his view of the pathology of the condition be correct, there can be no question as to the propriety of the method. PROF. LifeGEOIS, FRANCE. (Rev. Gen. de Clinique et de Therap., 1891.) LitGEOlS, recalling the experiments practised by Pecholier and St. Pierre upon animals with subacetate of copper, and their observations upon per- sons working about verdigris, that this salt favors fat formation and that the women are not subject to chlorosis, has given copper to 538 DISEASES OF THE BLOOD. thirty chlorotics with excellent results. He employs for this pur- pose the following pill (recommended by LuTON in tuberculosis) : 868. R. Neutral acetate of copper, gr- Ve __ ..- Phosphate of sodium (cryst.), gr. % Powdere4 liquorice, Glycerine, aa q. s. M. For one pill. Where the patients are suffering from excessive uterine or men- strual discharge, LlEGEOlS adds from gr. % to. gr. iss of freshly- powdered ergot to each pill. One or two pills are to be given at the beginning of the noon and evening meal, following the exhibi- tion of fifteen or thirty drops of tincture of nux vomica or other suitable bitter. During or at the end of the meal he suggests that a tablespoonful of peppermint syrup containing dilute hydrochloric acid, also be taken. Suitable hygienic and dietary arrangements are to be made, and the treatment followed carefully for several months unless it be productive of gastric symptoms, which is rare. The color of the skin and mucous membranes improves under this treatment; the emaciation gives place to plumpness, and the dys- pepsia disappears. DR. ROBERTS BARTHOLOW. PHILADELPHIA. As a large consumption of the phosphate of lime takes place dur- ing suckling, the anaemia of the nursing mother may be most ad- vantageously treated with the lacto-pkosphate of lime. The usual remedies for ansemia may be much assisted by central galvanization and local applications to the vegetative organs. Beard and ROCK- WELL employ the method termed by them " general electrization," which consists in faradic applications to the surface of the body, "one pole, usually the negative, being placed at the feet or the coccyx, while the other is applied all. over the surface of the body." In anaemia and chlorosis, wines render an important service by increasing digestion and assimilation. To aid in this process, red wines with a good deal of sugar and extractives are most necessary. When wines produce headache, and the digestion is disordered by them, and the appetite impaired, they are not serviceable in these maladies. Moreover, for the nervous and hypochondriacal, wines must be prescribed with caution, for the habit of indulgence is quickly acquired by such subjects. ANAEMIA. 539 GENERAL SYMPTOMATIC ANEMIA. PROF. EASTON, UNIVERSITY OF GLASGOW. The following formula of our author has become very popular in England since its first publication in Aitken's " Practice of Medi- cine," as a general tonic in anaemia and cachexia. It is known as the Syrupus Ferri, Quinice et Strychnice Phosphatum : 869. {I. Ferri sulphatis, 5v Sodii phosphatis, S^j-Sj Qiiinise sulphatis, gr. ccxij Acidi sulpbnrici diluti, q. g. Aqiue ammoniae, q. s. Stiychnise, gr. vj Saccbari albi, % xiv Acidi phospborici diluti, f. 5 xiT. Dissolve the sulphate of iron in one 6unce of boiling water, and the phosphate of soda in two ounces of boiling water. Mix the solution, and wash the precipitated phosphate of iron till the washings are tasteless. With sufficient dilute smphnric acid, dissolve the sulphate of quinia in two ounces of water. Precipitate the quinia with ammonia water and carefidly wash it. Dissolve the phosphate of iron and quinia thus obtained, as also the strychnia, in the diluted phosphoric add; then add the sugar and dissolve the whole, and mix without heat. The above syrup contains about one grain phosphate of iron, one grain phosphate of quinia, and i^ of a grain of phosphate of strych- nia in each drachm. The dose might, therefore, be a teaspoonful three times a day. The amount of phosphate of quinia might be increased according to circumstances ; . and if eight grains of strychnia were employed in place of six, as in the above, the phosphate of strychnia would be in the proportion of iV of a grain in every flujd drachm of the syrup. A much larger dose should scarcely be ventured upon. DR. CONSTANTIN PAUL, PARIS. (Form, de la Faculte de Mid., Paris.) 870. R. Citro-ammoniated iron pyrophosphate, gr- xlv Fowler's solution, pi" Syrup of orange flowers, , 1 ?? „ Syrup, f-i>)S*- M- Sig : One to two teaspoonfiils a day. PROF. S. D. GROSS, M. D., PHILADELPHIA. 871. R. Tincturae ferri chloridi, '•3 J Quinis, sulphatis. gr- ^f- Twenty drops thrice daily, in sweetened water, through a tube. M. He prefers the tincture of chloride to all other preparations of iron. 540 DISEASES OF THE BLOOD. Prof. Charles D. Meigs considered reduced iron (ferrum redac- tum) to be the most efficient of the chalybeates, in two-grain doses three times a day, after each meal, on a full stomach. DR. JOHN FORSYTH MEIGS, M. D., PHILADELPHIA. 872. R. Ferri et quinise citratis, 9iv Extract! gentiaose fluid!, Spiritds lavandube compositi, ai f. 3 iij Alcoholis, f. 5vj Aquae, f. § ivss. M. A teaspoonful thrice daily. PROF. ELLERSLIE WALLACE, M. D., PHILADELPHIA. 873. B- Ferri pyrophosphatis, 3ij Cura(;oae, f. 5 ss Aquse, f.^ijss. M. A teaspoonful four times a day. TONIC BATH. THOMAS K. CHAMBERS, M. D., LONDON. 874- R- Acidi muriatici, f. gij Aquje calidae, Oxxx. M. In a wooden bath, the patient to remain in it for from ten to twenty minutes. Dr. Chambers has found this bath to confer muscular strength even when employed alone. When used in cases of anaemia, while iron is being given internally, it gives an impetus to the improve- ment of the patient ; more iron is taken up, and the blackening of the faeces ceases. TONIC INHALATION. J. M. da COSTA, M. D., PHILADELPHIA. 875' R- Ferri lactatis, gr. j-ij Aquse destillatae, ' f. § j. M. For one inhalation. To be administered (by means of any form of steam atomizer throwing a fine spray) two or three times a day. Useful in anaemia, when iron given by the stomach is not assimilated. Also in cases of gastric ulcer, when the constitutional effect of this agent is called for, while it is desirable to spare the stomach. 876. R. Ferri pyrophosphatis, 3j Aquae bullientis, f. g 55. Mix and add, Extracti gentianae fluidi, f. § ss CuraQoae, f.Jiss Vinum, ad f.|iy. m. Teaspoonful thrice daily. This preparation, known as elixir gentiance ferratce, is much used and highly esteemed in this city. ANEMIA. 541 PERNICIOUS ANEMIA. DR. HUGUENIN, PARIS. In pernicious ancemia, when iron given internally can no longer be absorbed, Dr. HugUENIN (Gazette des Hopitaux, August 26, 1876,) makes use of the subcutaneous method of its administration. The formula for the injection of iron is £is follows : 877. R. Ferri pyrophosph., Ammon. sulph., aa gr. Ixxv Aquse destillat., § iss. M. So that a subcutaneous syringe holds half a grain of iron. Soon after the injection, redness of the skin, oedema, and often even heart- symptoms are seen, but they soon disappear. Dialyzed iron, fer Bravais, has claimed a high position in the treatment of anaemia, both by the mouth and by hypodermic injec- tion. Dr. J. M. Da Costa has used a daily injection of "Lxv— xxx, at first diluted, later undiluted, if no irritation of the skin is produced. With the best preparations of the so-called dialyzed iron, there is not much danger of abscess. French physicians have expressed doubts as to its value, believing it is not absorbed. A. McPHEDRAN, M. B., TORONTO. (Medical News, 1890.) Since gastro-intestinal derangements are so often associated with the disease, correction of these should first meet our attention. In most cases an occasional calomel purge is beneficial ; and intestinal antiseptics, such as thymol, beta-naphthol, naphthaline, or small doses of bichloride of mercury, may prove use- ful in preventing dyspeptic symptoms. The last drug, too, may act as a tonic as well. As a remedy for the pernicious anaemia, arsenic stands preemi- nent, effecting cures in a number of cases ; and when it fails, re- covery seldom has been attained. The author recommends that the maximum quantity the patient can bear be administered in small doses frequently repeated, intermitting as symptoms of irritation of gastro intestinal canal or other evidences of toxic influence are manifested. The administration should be persevered in until con- valescence is well established, when possibly good care and diet will complete the cure. Where arsenic is not well borne or fails, iron in some form should 542 DISEASES OF THE BLOOD. be administered ; and hydrochloric acid should prove of use, as in most of these cases the digestive juices are deficient. Food should be given often, and in small quantity, so that diges- tion be rapid and little time be given for decomposition. Contrary to the view one would naturally take of the matter, certain authors recommend a farinaceous diet rather than a nitrogenous one, as the latter seems to be attended with a greater degree of blood-destruc- tion. M. PERRONCrrO, OF FRANCE, Describes a form of anaemia occuring among miners, which is due to a parasite, the anchylostoma duodenale. The larvae do not de- velop in the intestine, but in the faecal substances after dejection, and penetrate the organism by the air or water after their develop- ment. The larvae are quickly killed by a concentrated solution of chloride of sodium in sulphuric or hydrochloric acid, in ethylic al- cohol, or in one to five per cent, solutions of carbolic acid, and in one-half per cent, solution of thymic acid, and in ethereal extract of male fern. By any of these means the faecal larvae can readily be destroyed. The male fern, given internally, is always effectual, even in a single dose. Thymic acid may also be given by the stomach for the same purpose. LEUKEMIA. DR. CONSTANTIN PAUL, PARIS. In this affection (Form, de Faculte de Med. de Paris) the treat- ment is essentially symptomatic; no special course of treatment tending to cure can be indicated. Arsenic, iodide of iron, sdine baths, care in diet, and general hygienic measures, are perhaps the most important elements ; but where the case is pronounced any treatment is as a rule but palliative, and has but little influence upon the rapidly fatal tendency of the disease. Prof. THATCHER, of Yale University (Amer. Jour. Med. Set., 1889), and Mayer {Centralbl. /. Klin. Med., 1890.) both report favorable results from the use of arsenic, but do not claim cures. The latter also uses quinine and iron in conjunction with the arsenic. Sticker {Zeitsch.f. Klin. Med., 1888,) believes that good results may be attributed to inhalations of oxygen, and a case is quoted by the latter from KiMBERGER in which recovery followed this course. For the intense dyspnoea of these cases STICKER recommends the employment of quebracho. ANiEMIA. 543 NOTES ON REMEDIES. Arsenicum. In progressive pernicious ancemia, Dr. Byrom Bramwell (Med. Times and Gazette, Sept., 1877,) has succeeded after the failure of iron, cod-liver oil, etc., with liquor arsenicalis, nji], three times a day. Ferrum, in all its forms, has been largely employed, and numerous formula are given above. A few are here added. Ferri Mistura Aromatica. The following formula is an excellent one : 878. R. Pale cinchona bark, powdered, §j Calumba root, in coarse powder, § ss Cloves, bruised, § \ Fine iron wire, § ss. Macerate in peppermint water, f. § xij, for three days, agitating occasionally. Filter, add peppermint water, q. s. ad f. §xijss; then add compound tincture of carda- moms, f. i iij, and tincture of orange peel, f. S ss, and preserve in a well-stoppered bottle. Dose, f. § j-ij. Ferri Peroxidum Hydratum. Dr. S. Ashwell recommends the following for- mula as one which will often agree when other ferruginous compounds cause irritation : 879. R. Ferri peroxidi hydrati, gr. viij Pulveris ipecacuanhse radicis, gr. j Hydrargyri cum creUl, gr. ij. M. Make one powder. Take one twice a day. Ferri Sulphas is a very effective salt of iron in anaemia. It may be combined with gentian, with quinine and strychnia, with a sedative, as conium, with an aperient, as rhubarb or aloes, with hops, as advised by Dr. S. Ashwell. 880. R. Ferri sulphatis, gr. j-ij Extracti humuli, gr. ij-iij. M. Make pill. Three to be taken daily. Albuminate of Iron by sub-peritoneal injection is recommended by Prof. A. Vachetta ( Gazz. degli Ospitali). Manganesii Oxidum Nigrum has been employed with success in simple anae- mia, instead of iron. Oleum MorrhucE is a valuable remedy in all forms of anaemia, its efficacy being increased by combination with a ferruginous salt. Oxygen. Mr. Hayem, of Paris, has observed that in anaemia, when oxygen is inhaled in the quantity of ten litres daily, after two or three inhalations there is a marked improvement in the appetite, digestive troubles dis- appear, and in a weak or two the patient takes a substantial diet, and gains weight. But it is necessary that this treatment be backed by iron tonics, to alter the quality of the blood corpuscles and make the improvement permanent. (Lancet, September 6th, 1879.) 544 DISEASES OF THE BLOOD. Pepsin and Pancreatine act well, by aiding digestion. Phosphorus is valuable in combination. PotasscB Liquor, in pernicious anamia, sometimes succeeds when all other means fail. If improvement is not prompt, it should not be pushed. Sanguis Bovinus Exsiccatus. This is a preparation of dried blood manufac- tured by Messrs. Parke, Davis & Co., from a formula by Dr. Stewart. It presents the nutritive constituents of healthy beef's blood in a readily assimilable form, and has been shown by an extensive experience to be admirably adapted to most cases of anaemia, and in wasting diseases. EXTERNAL MEASIHIES. Hypodermic Injections of iron have been used with advantage. Dr. J. M. Da Costa prefers a double salt produced by the addition of pyrophosphate of iron to a solution of citrate of sodium. Two grains of the salt, in this form, are given every day, varying the points of puncture, but generally administering it under the skin of the extremities ; in this form no abscesses have been observed. With other solutions of iron, including dialyzed iron, abscesses were quite common, even with every precaution as to the cleanliness of the syringe. Transfusions of Saline Solutions. In cases of acute anaemia, Dr. M. Schwarz, (Berlin Klin. Woch., 1882,) says that if ordinary means fail, recourse may be had to a very innocent method, yet one that has proven ex- tremely sure and active ; this is direct injection of feeble alkaline solu-, tions (6 per cent.) of chloride of sodium into the circulatory system. The action of this transfusion on cardiac activity, blood pressure, res- piration, and all the other vital functions, has shown itself with surpris- ing rapidity in rabbits and dogs who had lost from one-half to two- thirds of the entire quantity of blood contained in the body. The minimum quantity of liquid to be injected in the adult should be about five hundred cubic centimeters. This species of transfusion is also indicated in the serious collapse coming on during operations on the abdomen. Since the above conclusion appeared in the inaugural the- sis of the author, five cases of transfusion of chloride of sodium solu- tions have been reported by Bischoff, Kustner, Kocher and Kummel. CEREBRO-SPINAL MENINGITIS. This disease, known also as " spotted fever," " epidemic menin- gitis," etc., is more frequent in children than adults, but by no means confined to those of tender years. In its epidemic forms, it is fre- CEKEBRO-SWN/g, MEKlNGmS. 545 quently very fatal at all ages. The following is the treatment pur- sued by , DR. NATHAN S. DAVIS, CHICAGO. 881. Si. Tinctoiaepbysottigmatis, f.Sj Ejctracti flnidi ergotse, f. § iss. M. Half a teasftoonfhl every two honrs. The Calabar bean is used very freely by Dr. Davis, in this disease, and with more apparent effect in controlling it, than any other rem- edy he has tried. The pulse becomes slower, the respiration more reguMr, the patient quieter, the pain less intense. If the disease assumes a chronic form, with transient and wandering, but severe neuralgic pains, a fretful condition of mind, variable appetite, debil- ity, and disturbed sleep, he has obtained very decided and perma- nent relief from 882. B- Tinctvne pb^sostigmatis, f-Sj Tinctuix opii camphoratse, f. S iss. M. Half a teaspoonful three times a day; and at bedtime, a moderately fiill dose of Dover's powder and quinia. DR. D. C. RAMSEY, OF ST. LOUIS. The salicylic acid treatment is strongly advocated by this practi- tioner in the St. Louis Med. and Surgical Journal, February, 1884. He states that this drug exerts a direct influence for good over the inflarjimation itself, and can be taken in frequent large doses without bad effect : having given a boy 1 5 years of age half-drachm doses every four hours for three or four days, with the only result of a great benefit in all the symptoms connected with the disease, is, he thinks conclusive evidence of its harmlessness. Its good effects are soon apparent, and it does not interfere with the u$e of other measures of relief, as ice, blisters, etc. The best mode of using the remedy is to administer large doses frequently. For adults begin on doses of i S grs. repeated every two hours, and increase the dose as may be found necessary to obtain the desired effect, to 3ij., at intervals of two hours, if need be. When the disease is under control, which will be determined by the reduc- tion in temperature, relief of pain, and placid countenance, decrease the dose, give at longer intervals, but still continue the use of it in smairdoses as long as the least symptom is present indicative of the disease. 35 546 DISEASES OF THE BLOOD. PROF. FELIX VON NIEMYER, M. D., TUBINGEN. In the treatment of acute meningitis, it is not generally proper to bleed from the arm, but leeches may be applied to the brow and be- hind the ears, and, if the strength of the patient permit, the applica- tion may be repeated. The shaven head may be covered with cold compresses, and an active purge of calomel and jalap administered, viz. : 883. R. Hydrargyri chloridi mitis, gr. ij Extrecti jalapae, gr. viij. M. Divide into two pills, and order both to be taken. In the latter stages of the disease, if there be coma and other signs of cerebral palsy, apply a large blister to the nape of the neck, and rub the following pustulating ointment on the head : 884. R. Olei tiglii, Ttlxv Adipis, i ss. M. One-fourth part to be rubbed into the skin every eight hours, until an abundant eruption is produced. Still more efficacious than these derivatives, are douche-baths — pouring cold water over the head from a pitcher held some distance above it. The patient almost always recovers consciousness as this is being done, but it must be repeated at intervals of a few hours, to secure a permanent result ; with each successive employment, the number of pitcherfuls is to be increased. Frictions with mercurial ointment, and continued doses of calomel, are much employed. PROF. J. LEWIS SMITH, M. D., NEW YORK. This author, in speaking of this disease, especially cis it appears in children, disapproves of blood-letting, even by leeches. The one drug he relies upon is bromide of potassium, in doses of gr. v— vj every two, three or four hours, to a child of five years, according to the urgency of the case. After the first week it should be given less frequently, and finally omitted. Small doses of hydrate of chloral are best to relieve the pain. Quinia is of no service. Bismuth, in large doses, controls most effectively the nausea. Frequent counter- irritation along the spine by dry cups or an irritating liniment is use- ful from the first, and also vesication of the nucha later in the dis- ease. Sustaining measures should be commenced early. CEREBRO-SPINAL MENINGITIS. 547 PROF. WILLIAM FULLER, M. D., MONTREAL, Urges strongly (Canada Medical Record, September, 1877,) hotwater to the head, instead of cold, and the use of morphia. The plan he adopts when he suspects meningitis is: i. To regulate the temper- ature, that is, keep the patient cool, but equally warm all over. 2. Unload the bowels by a mild purgative, remove worms, etc., if any cause of irritation is present. 3. Quietude and soothing medicines, the use of which is indicated by flushings and irregular cutaneous circulation, which are the premonitory symptoms of spasms or coma; should the latter symptoms, spasms or coma, supervene, he increases the dose. 4. Frequent bathing the head with warm water. The points he insists upon are: i. That coma is, in most instances, not due to the pressure of effusion, but to irritation. 2. That opiates are not contra-indicated in mejiingitis, even when coma is present or threatened, if there are irregularities of cutaneous circulation or spasms, and that opium actually, by relieving irritation, dissipates the coma. 3. That warm water is more agreeable, more soothing, and more efficacious than ice-caps. DR. J. B. HAMILTON, NEW YORK. In the New York Medical Journal, February, 1875, this writer gives his treatment as follows : For the first twenty-four or forty- eight hours : 885. R. Extract! ergotse fluidi, f.§j Spiritus ammoniae aromatici, f. S ij- M. A teaspoonful in a little water every four hours. 886. R. Potassii acetatis, 5xij Aquae camphorae, f- a ^j- ™' A tablespoonful every two hours, until diuresis is produced. In addition to these remedies, direct a warm bath, followed by wrapping in flannel, or rubbing with dry mustard, every three, four, or six hours, according to the urgency of the case. Stimulants may be necessary from the outset. As soon as the symptoms show any amelioration, the ergot mix- ture may be diminished in frequency, and at the third or fourth day discontinued. Quinine in large doses will then be found of advan- tage, and a more stimulant diuretic, as spiritus ietheris nitrosi, may be substituted for the potassa acetate ; and for the sequels nothing has proved more serviceable than iodide of potassium, as occasion 548 DISEASES OF THE BLOOD. demanded. This writer considers the bromide of potassium " utterly worthless." DR. WILLIAM READ, BOSTON, MASS. One of the most rational and also successful methods of treatment of this disease is described by Dr. Read (Medical and Surgical Re- porter, vol. XXX, page 469). He usually commences with a full dose of castor oil, or other mild laxative, and then prescribes: 887. B. Ergotinse (Bonjean's), gr. x Extract! belladonnse, gr. j-ij. M. Make ten pills. One every three hours. Croton oil is applied to the nucha until a copious eruption is pro- duced, and if the spine is tender it is blistered. Concentrated nour- ishment is ordered. DR. G. LEVITSKY. (Med. News, 1890.) This physician reports very favorable results from the use of iodoform in this disease ; and in an article published in Vratch, 1889, details the evidences of its influence in a severe case in a woman, in whom its exhibition was followed by immediate amelioration. By the end of the fourth week the patient was prac- tically well and the drug was withdrawn ; a relapse then occurred and iodoform was begun again, the disease once more yielding to it. In all about an ounce of iodoform was given this case in the course of two months, .with no untoward effects. PROFESSOR VON ZIEMSSEN, GERMANY. The treatment of this physician comprises leeches behind the ears, and ice-bags to the head, neck and back ; the inunction of fifteen to thirty grains of mercurial ointment twice daily ; frequently rinsing the mouth with chlorate of potash solution, to prevent stomatitis ; and especially morphine, in full doses, gr. >^-ss, hypodermically in adults. Quinine is useful only in those rare cases where the tem- perature ranges very high. It is then required in doses of gr. xv-xxx. In a later period of the disease, iodide of potassium is of great service in producing absorption of the exudation. NOTES ON REMEDIES. Aconite. Bartholow says that in acute inflammation of the cerebral and spinal meninges, and in cerebro-spinal meningitis before effusion has CEiaESRD-SPINAL MENINOTTIS. 549 taken place, aconite is as serviceable as in other acute inflammations. It is generally advisable to combine opium with it, especially in cere- bro- spinal meningitis. Antimonii et Patassii Tartras has been exhibited in repeated firactional doses with benefit. It is contra-indicated if the patient be very young, if there have been prodromic symptoms, and if the inflammatory con- dition be not well marked. Belladonna has been considered by maiiy to be strongly indicated in this disease. (F. 887.) Ergoia has unquestionably a good record in cerebro-spinal meningitis. (F. 887.) Gehemium in small doses (jtlv of the fluid extract) is extremely useful where there is decided febrile action. It should be repeated every two hours. (Bartholow.) Hydrargyrum. In regard to the use of mercury in acute meningitis, author- ities differ. Dr. Russell Reynolds has never seen any good results from its admuustration. Dr. J. S. Ramskill recommends it as a valu- able remedy, and states that the system should be quickly brought under its influence, by combining with its internal administration (in small and frequently-repeated doses), the use of inunctions in the groin and axilla. Iodoform. This is reported by LEVrrSKV to be of decided benefit in this disease, given in doses of gr. ij-iv. Opium is a most valuable agent in epidemic meningitis, when administered at the outset of the attack, in cases in.which the inflammatory pre- dominates over the septic element. (See p. 547.) " Physostigrtia. (See p. 545.) Potassii lodidum is highly esteemed in the later stages. A typical English plan of treatment would be hydrargyrum cum creta, gr. j, every four hours, and gr. ij of the iodide, with gr. iij of the bromide of potassium, thrice daily. (Dr. J. Cross.) On the value of the bromide, see above. Quinine may be used in the beginning ; but if a few large doses— twenty to thirty grains — do not produce a good result, it is useless to repeat them, or to pursue a tentative plan with small doses. Terebinthince Oleum, in stupes, or as an enema, seems occasionally to benefit in the early stages of the disease. 550 DISEASES OF THE BLOOD. DENGUE (BREAK-BONE FEVERX PROFESSOR GREENVILLE DOWELL, M. D., TEXAS. The treatment of this physician ( Yellow Fever and Malarial Dis- eases, Philadelphia, 1877.) is to open the bowels with citrate of mag- nesia, and keep them soluble. This is absolutely necessary. Then : 888. R. Hydrarg. chlor. mitis, Pulv. ip^ac, et opii, Quiniae sulphatis, aa gr. iij. M. For one powder. Two to three powders a day, for two or three days. If there is much debility and a low pulse : 889. R. Tinct. cinchonse, Tinct. gentianse, Tinct. calumbae, , aa f. § ij. M. Tablespoonful every two hours, in a little water, until four doses are taken, every morning. If, on the contrary, the pulse is hard and full, and the fever sthenic, tincturae aconiti fol., gtt. v-xv, may be given every few hours. When the tonsils are enlarged, and the mouth and fauces show a papulous eruption, the following is useful : 890. R. Tinct. capsici, Tinct. guaiaci, ia f. § j. A teaspoonful in a cup of water, as a gargle. Relapses are common, and convalescence usually tedious. The above-mentioned tonic is advisable in such cases. SIR J. FAYRER, M. D., K. C. S., ETC. This distinguished practitioner, speaking of the treatment of dengue, as he has observed it in India ( The Practitioner, December, 1876.) expresses his opinion that neither emetics nor active pur- gatives are necessary. They do no good, but increase the weakness and aggravate the suffering by the muscular movements necessarily induced. Moderate action of the bowels, followed by a warm car- minative aperient, with an occasional dose of calomel, rhubarb, or colocynth, especially if they remain confined, to which there does not appear to be any peculiar tendency, though the alvine evacua- tions are dark, and often slimy and confined, at the outset; salines, such as the acetate of ammonia, citrate of potash, with nitrous ether. DENGUE (break-bone FEVER). 551 combined with aconite, are good in the pyrexia. In cases of very high temperature, 105°, 106°, 107°, cold sponging is beneficial. Belladonna seems to confer great relief in this disease; 10 to 15 drops of the tincture may be given, and two or three such doses, given at intervals of an hour, will sometimes produce excellent effects, and give much relief. The extract may be given, if prepared in doses of ^ of a grain ; or the juice, in similar doses to those of the tincture. For the pains and nocturnal restlessness,, morphia or Dover's powder may be given ; and, as external applications, liniments con- taining opium, belladonna and chloroform, are serviceable, rubbed on the spine, back and joints. Tonics, and a carefully-regulated nutritious diet, are also indi- cated, and all spoliative or depletive measures must be avoided. The tonics_ must be of the bitter vegetable kind, such as gentian and calumba ; with these may be combined a small quantity of quinine, with some mineral acid ; and, in some cases, the dilute phosphoric acid, combined with nux vomica or small doses of strychnine, may prove useful. As to wine, good claret is probably the best, but others may be given if preferred. Quinine is given more for its tonic than for its antiperiodic effects, though, where there is a tendency to relapses, the judicious admin- istration of 5, or even lO-grain doses, may be beneficial in arresting them. Bromide of potassium is recommended by some authorities, and especially when convulsions occur in children. Alkalies, col- chicum, and other remedies in use in rheumatism, have been found to have little, if any, effect in relieving the pains of dengue. For the irritation of the skin, which is sometimes very trouble- some, he recommends the application of camphorated oils. Warm baths also are likely to confer relief on this symptom. PROF. F. PEYRE PORCHER, M. D., SOUTH CAROLINA. This experienced physician believes that break-bone fever can always be treated successfully, if taken early, by a single mercurial purge combined with quinine as an antipyretic, as : 891. R. Hydrarg. chloridi mitis, Quinise sulphatis, aa gr. xv. M. Take at once. 552 DISEASES OF THE BLOOD. This is to be followed by a saline purge. To this is added the early, assiduous and repeated sponging of the head, arms and hands with ice-cold water, to reduce and keep down the temperature, with the use also, at the beginning of the fever, of mustard sinapisms and foot-baths. The only subsequent treatment consists in the enjoining of rest and quiet, and the employment of a mild alkaline mixture with a little morphia, with nourishment carefully administered. A little tinct. of aconite might be beneficially added to the mixture. 892. R. Potassii acetatis, 3) Morphise sulphatis, gr. j Tincturse aconiti, f. 3 ss Aquam, ad f. § vj. M. A tablespoonful every two or three hours. MeleAS (Wien. Med. Woch., 1889,) recommends the employ- ment of antipyrine or salicylate of sodium for the pains, cocaine and chloral locally for the itching, various soothing liniments for the pain in the muscles and joints. During convalescence bitter tonics. MeleAS condemns quinine as useless in dengue. NOTES ON REMEDIES. Antipyrin and its congener antifebrin are both of value in combatting the fever and in relieving the intolerable pains. Calomel \s recommended by many physicians in the beginning of treatment, taken to purgative. (F. 891.) Carbolic Acid may be used in the same manner for the symptom of itching. Chloral is of use applied locally to combat the same symptoms as in the last note, and is often employed to induce sleep during the height of the affection. Cocaine, applied locally, may be of service in soothing the itching, a frequent symptom of the affection. Iodoform, in doses of gr. j-iv, has been used with fairly uniformly beneficial results, combined with some measures to relieve the pain and the fever. Morphia. Where the pain is unbearable, recourse to morphia may be neces- sary, and may be advantageously administered in combination with a mild alkaline mixture. (F. 891.) Quinine is much used in this, as in other fevers, but shows little or no effect, and by some is positively condemned. Sodium Salicylate may be given in doses of gr. x-xxx, for the purpose of allay- ing the pain ; it is regarded as almost specific by some physicians. GOUT. 553 Tartar emetic and ipecacuanha in minute doses are recommended by Granby (Medical Register, 1888), followed by antipyrin until the pains and fever disappear. GOUT. DR. HENRY W. FULLER, LONDON. For the purpose of clinical instruction, Dr. FULLER divides cases of acute gout into two classes, namely: i. Cases in which the ex- cretory organs are originally sound and functionally active — cases in which the attack of gout is due principally to excess and indiscre- tions of diet; and 2. Cases in which the excretory organs are in some way disordered, and fail in performing their elementary func- tions — cases in which the patient is not necessarily guilty of indiscre- tions of diet, but in which the liver and kidneys fail in their action, either as the result of functional disorder, or of organic change in their structure. The first class of cases correspond with those which pass under the name of asthenic gout; the tongue is usually furred, the urine loaded, and the bowels are commonly torpid. In these cases, until the acute symptoms have subsided. Dr. FULLER restricts the diet to liquids, administers a saline draught containing sulphate and. car- bonate of magnesia, and a few drops of colchicum wine ; occasionally gives an aperient pill containing calomel, aconite and opium, and wraps the joints in finely-carded wool, or in flannels steeped in a solution of soda and laudanum. As the acute symptoms subside, a more generous diet is permitted, and some light bitter tonic, such as tincture of gentian or calumba, is added to the mixture. The second class of cases have more affinity with what is termed atonic gout; the tongue is often clean and the urine clear — some- times of low specific gravity — and the bowels are regular. In these cases. Dr. FULLER does not restrict the diet to the same degree ; he allows a little meat without vegetables, and also, if desired, a glass of sherry or a little spirits and water. He acts freely on the skin by means of the hot-air bath ; administers an aperient in the morning, containing taraxacum and sulphate of magnesia, and, during the day, he gives a warm stomachic draught, containing ammonia and a few grains of soda in a light bitter infusion. Occasionally, a dinner pill is prescribed, containing rhubarb and a grain of colchicum ; and 554 DISEASES OF THE BLOOD. in some instances — characterized by pale, clear urine — a draught con- taining quinine, the mineral acids, and taraxacum, is substituted for the mixture just referred to. In these cases, as the acute symptoms have subsided, a drachm of the syrup of phosphate of iron is given each morning after breakfast. DR. H. SALTER, LONDON. The local treatment of this author is all that is peculiar. It con- sists in the application of the following lotion : 893. R. Potassii iodidi, 5 3 Potassii bicarbonatis, § j Aquae bullientis, Oj. M. "To this a little tincture of opium may be advantageously added. Double lint, saturated with this lotion, is applied to the part affected, and covered with oil-silk ; to that is put a layer of cotton- wool, and the whole swathed in a flannel bandage. The lint should be taken off from time to time, and re-dipped in the lotion. The. relief that the patients experience from this application is very great. With or without this lotion, there are three other things on which Dr. Salter insists, in the local treatment of a gouty joint — perfect physical rest, protection, and preventing the part affected being too dependent. The following liniment is recommended in Lyon Msdical (quoted in Med. News, 1891,) for application to the painful part: 894. R. Collodion, Sulphuric acid, Salicylic acid, ia 3j Hydrochlorate of morphia, gr. xt. M. This to be painted over the affected part every three or four hours. In the same order is the following (also quoted in Med. News, 1891): 895. R. Flexible collodion, Ether, aa 5. Salicylic acid, 4. Hydrochlorate of morphia, I . M. S. — This should be applied to the affected toe. PROF. S. D. GROSS, PHILAbELPHIA. 896. R. Vini colchici radicis, f. 3j Morphiae sulphatis, gr. j. M. For one dose, at bedtime, in gouty affections of the joints. GOUT. 555 This treatment should be preceded by purgation or venesection, if indicated, and be followed in the morning by a gentle laxative. These doses are recommended by our author as the most efficient, and as seldom disappointing the most sanguine expectations. Where there is a full, bounding pulse, indicating excessive arterial action, then the following will come into play : 897. R- Tinctutse aconiti radicis, f. 5i Morphiae sulphatis, gr. ij Antimonii et potassii taitratis, gr. j Aquae, f. i iss Syrupi zingiberis, f. S ss. M. A teaspoonful every three hours. Veratrum viride may be substituted for the aconite, in the same, or double the dose. The action of these potent remedies should, of course, be carefully watched, and kept within proper limits. To- gether with the above means, the following should be employed, to neutralize the acid state of the blood : 898. R. Potassii bicarbonatis, 3j Sodii bicarbonatis, 5ij- "*• For sue powders. One to be taken every six hours, in a wineglassful of water. As a local application, nothing will be found better than : 899. B. Tincturse opii, f-S] ^ Linimenti sapoms, '• 3 ')•_ ' ' To be rubbed in twice a day. and constantly kept in contact with the affected joint, by means of a piece of flannel covered with oiled silk. A fly-blister may be used, if the disease manifests a disposition to linger. PROF. DUJARDIN-BEAUMETZ. (Form. Fac. Med. Paris.) 900. R. Tincture of colchicum, Alcoholic extract of fresh aconite root, Compound tincture of jalap, __ -. Quinine sulphate, aa grammes 10. M. Thirty drops morning, noon and night. Or, 901. R. Tincture of colchicum seeds, Alcoholic extract of fresh aconite root, Tincture of guaiacum, grammes 10. M. Quinine, ^ S.— Thirty drops, three times daily. Z?.V^- White meats. No game. Eggs. Fish. Shellfish in small amounts. Legumes in abundance, except sorrel and spmacn. 556 DISEASES OF THE BLOOD. Fruits, strawberries and raisins. No coffee or tea. Very moderate amount of wine. No liquors, no sparkling wines, no beer. Moderate exercise. DR. HENRY G. PIFFARD, NEW YORK. In the treatment of the gouty dyscrasia, the two principal indica- tions are: i, to depurate the blood, and 2, to promote oxidation. I. Depuration of the blood is to be effected by calling into more vigorous action either the kidneys, bowels or skin. If the trouble is due to defective renal activity, a point which may be determined by careful estimation of the amount of nitrogen daily discharged in the urea, uric acid, etc., we must treat these organs with some leniency, and be careful not to urge them too much, since, by undue stimulation, we may increase the difficulties under which they are laboring. We shall be obliged, therefore, to depend upon the skin and bowels to fulfill the first indication. The functional activity of the skin is increased by exercise, bathing and warmth, and is most rapidly and vigorously influenced by the hot-air or Turkish bath. If the bowels are to be stimulated, we may employ various cathar- tics, the most useful in this connection being the ordinary senna and salts, given in sufficient doses to produce one or two loose evacua- tions daily. Professor Hardy, of Paris, praises very highly an in- fusion of wild pansy, viola tricolor, combined with senna, in about the following proportions : 902. R. Violae tricoloris, §j Sennae, § ss Aquae bulUentis, Oij. M. For an infusion. Filter when cold. One-quarter to one-half of this quantity is to be taken daily, and the amount to be diminished gradually, as the necessity for its em- ployment lessens. Professor Hardy states that he has given this purgative two or three months at a time without ill effect. In place of these remedies we may employ some of the natural mineral waters, as those of Seidlitz, Pullna, or of Friederichshall. The native waters which seem to approach most nearly to these in composition, are the Estill and Crab Orchard Springs, in Kentucky. It is, however, but rarely that active purgation is required. If the kidneys are perfectly healthy, we may call upon them to perform the work, and leave the bowels alone. To increase the real activity we have recourse to diuretics. The ones especially serviceable in GOUT. 557 this connection are vinum colchici, infusum digitalis, balsam of co- paiva, propylamine, carbonate of lithia, Vichy water, and wine of green coffee. The latter valuable preparation is prepared as follows : VINUM CAFFEiE VIRIDIS. 903- R- Ground, unbumed coffee. One pound Good sherry wine. One quart. Digest for two weeks. Filter through flannel, press the residue, and add wine to make a quart. Dose, f. § j-ij per diem. PROF. HUCHARD, PARIS. {Med. News, 1890.) In cases of gouty diathesis, with symptoms of nephritis, HucHARD prescribes the following : 904. R. Extract of stigmata of maize, Siss Benzoate of sodium, Carbonate of lithium. aa gr. xlv Oil of anise, gtt. iij. M. Divide into sixty pills. S. — ^Two pills to be taken before meals three times daily for twenty days in each month. According to the Internat. Klin. Rundschau, 1 890, Eloy uses the following in gout: 905. R. Iodide of lithium, gr. iij Extract of gentian, q. s. M. Divide into twenty pills, of which three or four should be taken daily. Or, 906. R, Iodide of lithium, 3is» Syrup of orange, i^S '^- ™' Two or three tablespoonfuls to be administered daily. Dr. Frank Woodbury, of Philadelphia {Coll. and Clin. Record, 1890), says that in lithaemic pains in the internal organs he is ac- customed to obtain good results from 907. R, Colchicine, P- h Quinine muriate, 8^- ''J „ Morphia muriate, P- *• For one pill. S. — One pill every four or she hottrs. These remedies, one and all, exert a marked influence in increas- ing the action of the kidneys, and are among our chief reliances in general gouty and rheumatic conditions. They may be used singly 558 DISEASES OF THE BLOOD. or combined, and for a considerable period. The alkalies, however, have a tendency to impoverish the blood. A good plan, if we an- ticipate a prolonged use of them, is to intermit their employment for one or two weeks out of each month, giving iron, if necessary, in the intervals. If complete oxidation is owing to an excessive amount of nitro- genized food, we must rely chiefly on dieting. Meat should be cut off to a greater or less extent, and in place of it a larger quantity of bread, vegetables and fat should be consumed. If, on the other hand, the patient has been accustomed to but a moderate quantity of meat, it will be necessary to institute measures specially designed to promote oxidation. The use of preparations of iron here takes the first place. But in addition to this we must endeavor to supply a full amount of oxygen by exercise in the open air, a well-ventilated bed-room, and the like. In addition, we may attempt to furnish oxygen directly to the blood, by inhalations of the pure gas, or partly ozonized. Further, we may employ certain medicines which contain oxygen largely, and are believed to be capable of giving it up to the blood, as for instance, the chlorate of potassium. Finally, if tlie liver be torpid, we may have recourse to the occasional or frequent use of those drugs which have the repu- tation of hepatic stimulants, as mercury, podophyllin, etc. ■ MINERAL . WATERS. The prolonged and moderate use of the natural mineral waters has been spoken of as one of the most efficient corrections of the arthritic dyscrasia. They must be used with a proper discrimina- tion, if good effects from them are expected. The waters chiefly employed for this purpose contain either alka- line carbonates, chlorides or sulphates. The Vichy waters, rich in carbonate and bicarbonate of soda, ap- pear to be well adapted for strong subjects in whom the functions of the liver and digestive organs are at fault ; but are contra-indi- cated when there is a tendency to the formation of chalky concre- tions about the joints, and in debilitated constitutions. Waters containing an abundance of chlorides, such as those of Wiesbaden, are less debilitating and more stimulating than those of Vichy ; they are consequently better adapted for cases in which the circulation is sluggish, and the secretions deficient ; also, in cases of rigidity from thickening of the textures. GOUT. 555 The springs, rich in sulphates, a typical example of which are those of Carlsbad, act with considerable force on both the bowels and kidneys. They are often very useful in cases accompanied by de- ficient action of the bowels with a congestive state of the liver ; but should be avoided by weakly patients. In addition to these, the waters containing lithia are claimed to have a peculiar and almost specific power in removing the chalky concretions of urate of soda so frequent in this diathesis. In Europe, the springs of Baden-Baden, and in the United States, the waters of the Buffalo and Farmville Lithia Springsin Virginia, of the London derry Spring in New Hampshire, and the Gettysburg water of Penn- sylvania, have acquired particular reputation in this direction. In all cases the waters should be commenced cautiously, small quantities being taken at a time, with care not to oppress the stom- ach by the presence of too much liquid ; and whenever there are symptoms of exciting febrile disturbance in the system, their use should be suspended. NOTES ON REMEDIES. Aconite. Professor Gross recommends tincture of aconite root, with morphia and antimony, when there is excessive arterial action. Dujardin- Beaumetz insists upon a preparation of the fresh root, extracted by alcohol, by macerating for ten days the bruised fresh root in alcohol. Ammonii Phosphas has been recommended, in 3J dose daily, highly diluted. Dr. Garrod has derived much benefit from the long-continued use of this salt in chronic conditions of the gouty habit. Arsenic. Prof. Da Costa teaches that arsenic, in small doses, is very useful in chronic gout. Arnica. In rheumatic gout very decided curative effects are sometimes pro- cured from arnica ; very probably owing to the fact it contains tnme- thylamine. (Bartholow.) Cajupuii Oleum, in doses of gtt. v-vj, frequently repeated, is serviceable in retrocedent gout. Colchicum, in gout, has been compared to cinchona in ague, but unfortu- nately, unlike the latter remedy, it does not prevent a return of the disease. Dr. A. B. Garrod states that often an almost magical change is produced by a single large dose, without the least increase in any of the secretions, the effect showing itself in the rapid decrease of the pain, and other symptoms of the joint inflammation. Dr. N. S. Davis, of Chicago, recommends forty drops of an equal mixture of the ace- tated tincture of opium and wine of colchicum seeds to control acute 560 DISEASES OF THE BLOOD, paroxysms of gout. This dose may be repeated in an hour, if neces- sary. Oftentimes, one or two doses will abort what threatens to be a very severe attack. When the paroxysm is under control, the same remedies may be continued in smaller doses, three or four times daily, if any gout remains. Fraxini Folia. Ash leaves, in infusion, have been used by Dr. A. B. Garrod with advantage, but, as he remarks, the amount of the infusion given daily being considerable, the action of the diluent must not be for- gotten. Guaiacum is considered by Dr. A. B. Garrod as especially useful in the as- .thenic gout of old subjects. It may be given continually, for a long time, without injury. This remedy is much employed in Germany. Hydrangea. A lithiated fluid extract of this plant has become quite popular in the United States in cases of chronic gout, particularly as a solvent for the uric acid concretions in gouty individuals. Lithii Carbonas is a valuable remedy. So, also, are the natural lithia waters of Baden-Baden. Lithii Benzoas. The benzoate is probably superior to all other preparations of lithium in the treatment of the uric acid diathesis. It is readily soluble in water, and the benzoic acid, by its transformation into the nitrogenous hippuric acid, counteracts the secretion of the uric acid. Instead of the rather insoluble urates, which are generally regarded as the cause of the gouty affection, appear the readily soluble hippuric alkalies and earths, which are excreted from the organism with the urine. Lithii lodidum. Iodide of lithium is said, by a writer in the British Medical Journal, 1883, to be the most useful of the lithium salts in the treat- ment of gout. Not Only is it serviceable in well-developed cases, but also in the varieties of eczema and dyspepsia which are of gouty origin. Magnesii Carbonas, dissolved in an excess of carbonic acid, is an excellent manner of exhibiting magnesia, which is often of great service in chronic gout. Manganese. Cachectic states arising from gout are successfully treated with manganese in combination with the syrup of the iodide of iron. Manna is an excellent aperient, in the following combination : 908. R. Mannse, Jiss Vini colchici, Htxx Potassii tartratis, gij Tinctures cardamomi composltse, f. 3 j Infusi aennse compositi, f. 3x. M. For one draught. Muriaticum Addum Dilutum is strongly recommended by Dr. J. F. Duncan (Medical Press, May sd, 1866,) as acting more directly upon the GOUT. 561 primary cause of the disease, the presence of lithic acid in the blood, and holding out a greater prospect of effecting a real cure, than any antacids. He directs the following mixture : 909. R. Acidi muriatici diluti, f.5iss Spiritfls chloroformi, f. 3;: Tincturse colchici, f. 3 j Infusi cascarillae, f. g yj. m. Two tablespoonfuls every three hours. Oleum OlivcB is strongly recommended by Dr. J. Spencer Ramskiix, of Lon- don. Potassii lodidum is frequently indicated in chronic gout. When fluid effused into the joint cavities is slow of absorption, the iodide often acts to great advantage. Potassii Nitras is recommended by Prof. Bennett, of Edinburgh, in acute gout. QuinicE Sulphas. From his experience in half dozen cases, Dr. C. W. ScHCENEMAN (Pacific Medical Journal, May, 1879,) believes that qui- nine will cut short an attack of gout. He gives : 910. R. Quinix sulphatis, gr. iij Sodii bicarb., gr. xij. M. This amount every two hours during the day. No Other medication is needed, though the joint may be painted with tincture of iodine. Rheum, taken regularly between the attacks, often wards off a return. At the period of an impending paroxysm, Professor Graves, of Dublin, ad- vises the following : 91 1. R. Pulveris rhei, 5j Aurantii corticis, § ij Pulveris aloes c. canella, § ij Spiritfls vini gallici, Oiv. M. A tablespoonful of the strained liquor, in water, night and morning. Salicylic Acid is very useful in acute gout. Sulphur Waters and Baths are useful in gout. external applications. Acid Salicylicum applied locally in some such manner as exhibited in F. 894, exerts a powerful influence in the reduction of the acute attack of gout. Aconitia, applied locally, over the seat of the pain, is an excellent palliative. Alcohol. Sir C. Scudamore recommends a tepid lotion of one part of alcohol and three of camphor mixture. Cajuputi Oleum, externally, is of much benefit. 562 DISEASES OF THE BLOOD. Colchicum, locally, to the affected part, is highly praised by Dr. Laycock. Iodoform, externally applied, has succeeded, in the hands of some practition- ers, in relieving the pain. Iodine, locally, used, is a very valuable remedy. The following formula is said to afford, sometimes, almost instant relief : 912. R. lodinii, Djj Akoholis, f. 5 j AqujE, f.5yj-f.§j. M. Dr. J. Pereira says that no external remedy gives such relief as iodine, but that the skin of different individuals is most unequally sus- ceptible to its influence ; in some it excites great pain, while in others it produces scarcely any. It is especially useful when effusion into the synovial membranes or sheaths has taken place. Morphia. A solution of morphia, applied by means of lint, often affords great relief: 913. R. Morphiae muriatis, gr, viij Aquas, f. §j. M. Pressure. A number of recent writers have borne strong testimony to the value of gentle and equable pressure over the affected limb, in gout. Some diachylon should be spread on felt, and over this a flannel band- age be firmly and equably applied. The great art in this treatment is to have the pressure evenly distributed. Sinapisms to the inflamed part often afford speedy relief. They are also use- ful in retrocedent gout, in inviting a return of the disease to its original seat. Sodii Phosphas. The finely-powdered bibasic phosphate of soda, sprinkled over moistened spongeo-piline, and applied so as to envelope the whole of the affected part, affords immediate relief in many cases. Sulphur. The exposure of the bed-clothes to strong sulphur fiimes, before they are spread over the patient, is recommended to induce copious perspiration and relief of pain. Tabaci Folia. The application of moistened tobacco leaf often affords great relief. Verairia, in ointment, is of occasional service, and is recommended by Sir C. SCUDAMORE : 914. K. Veratrise, gr. xxx Unguenti, |j. M. Zingiber. A ginger plaster placed over the epigastrium relieves the pain of gout in the stomach. INFLUENZA OR LA GRIPPE. 563 INFLUENZA OR LA GRIPPE. (Editorial, Med. News, 1891.) There is no specific against in- fluenza; but the derivatives of cinchona and salicin seem most nearly to act as specifics. Cinchonidine salicylate, in doses of five grains every second, third or fourth hour, is of decided utility. Rest is important even in the milder cases. The diet should be simple, supporting, easily digestible, and readily assimilable. Carbohydrates should be given, preferably predigested, as in peptonized milk gruel, or as alcohol. The frequency of feeding, and the quantity of food, should be governed by circumstances. The skin, kidneys and bowels should be kept in a healthy state of activity — by simple means if possible. Nitre, sodium benzoate and spirits of nitrous ether are among the best diuretics and diaphoretics. In a strong patient, at the beginning of an attack, the attempt to abort by pro- fuse diaphoresis may be made, and, if free perspiration cannot other- wise be brought about, pilocarpine, guarded by digitalis or strych- nine, may be employed. The heart and nervous system should be sustained with strychnine. If indications for decided stimulation of the kidneys exist, either in previous disease or in present tendency to pleural or other effusions, cocaine, digitalis, caffeine or sparteine may be added. Cocaine may find additional indication in gastric irritability, or in a tendency to subnormal temperature. The writer does not admit the necessity for antipyretic remedies, other than cool or tepid sponging, as the temperature is never dangerous, and rarely uncomfortable. The coryza, if troublesome, may be com- batted by atropine or by topical applications of cocaine or menthol. The laryrrgitis is to be treated by inhalations of equal parts of ben- zoin and paregoric from steaming water. Oedema demands scarifi- cation and hydragogue catharsis. For pulmonary complications, the poultice, counter-irritation or the ice-bag, followed by the cotton jacket or wool jacket, constitute the best treatment. The author does not countenance the use of antipyrin, phenacetin or any of the coal-tar products, believing that their employment is followed by depression, and possibly in severe cases, or in weak individuals, by death. For the pains he would use instead opium preparations, especially codeine, or cocaine, guarana', or even sodium bromide guarded with caffeine or guarana. Cannabis indica, hyoscyamus and its derivatives, compound spirits of 564 DISEASES OF THE BLOOD. ether, camphor and its bromide, and hot and cold applications, will be found useful to relieve the pains of grippe. In the convalescence the greatest care must be exercised,- and tonics and nutritious food are demanded. Undue exposure is dangerous, and persons of tubercular tendency must be watched closely for a considerable period after the actual attack is over. PROF. HUCHARD, PARIS. (Rev. Gen. de Clin, et de. Therap., i88g; and Form, de la Fac. de Med. de Paris.) HuCHARD differentiates the disease into the mild and severe types in the question of treatment. In all past epidemics one of the first and principal indications of its presence is a nervous adynamia, and against this our efforts should be constantly directed with drugs such as quinine and alcohol, and where this condition is severe, injections of ether and cardiac stimulants. In the febrile form: 915. £t- Sulphate of quinine. Extract of quinquinia, aa gr. xxx Extract of aconite root, gr. iss. M. Make a mass, and from it twenty pills. Take three pills twice daily. When the neuralgic element, so commonly present, predominates, the patient should take three times a day at intervals of four hours : 916. R. Quinine hydrobromate, gr. iii-v. S. — For one dose. There may be added to this when demanded jj^ grain of crystal- lized aconitine, especially if the febrile disturbance be pronounced, or: 917. R. Antipyrin, gr. cl Bicarbonate of soda, gr. Ixxv. M. S. — Make into ten powders, and take one powder every four hours in a little sweet- ened water between or immediately after meals. Phenacetin may be substituted for the antipyrine, or salol may be given in doses of gr. v-vij, taken 3 to 5 times a day. When inflammatory and catarrhal symptoms predominate, five to ten grains of powdered ipecac may be given at intervals of ten min- utes for 3 times, after which as a rule marked benefit ensues. Where the pulmonary catarrhal and inflammatory symptoms be- come pronounced : INFLUENZA OR LA GRIPPE. 565 918. R. Dover's powder. Powdered squill, Sulphate of quinine, ia gr. xxx. M. For twenty powders. S. — Four or five to be taken daily. Where vomiting and epigastric pains are marked : 919. R. Bicarbonate of soda, ^ Calcined magnesia. Salicylate of bismuth, aa gr. v. M. For one powder. S. — Three to five powders daily. Cool spongings, sometimes tepid, are often of value ; purges of castor oil, salts should be administered, followed by bismuth, mag- nesia, naphthol, or some such remedies. Where collapse threatens, stimulation by digitalis, whiskey, caf- feine, should be practiced, perhaps hypodermically, and heat should be applied to the body. PROF. J. M. DA COSTA, PHILADELPHIA. {Med. News, 1 890.) Prof. Da Costa, in a lecture before the class, outlined the following general plan of treatment of epidemic influ- enza. For the relaxed and irritated throat, a gargle of salicylate of sodium, glycerin, and water he finds very serviceable ; for the nasal catarrh, occasionally very unpleasant, a two per cent, solution of cocaine. The bronchial catarrh is to be treated as a bronchitis any- where else, according to the exact seat and amount of rales. A good deal of the paroxysmal cough is laryngeal, and small doses of opium or bromide and opium, or broken doses of Dover's powders, are valuable in allaying it. One-fourth grain of codeine repeated as found necessary by the circumstances of the case allays the cough, induces sleep, and does not cause much sweating. The depression of the nervous system is to be combatted, and it is good practice to give ten or twelve grains of quinine or cinchon- idine daily. Nourishment should be kept up, and the bowels kept regular, but not over-purged. For the headache and pains in the bones the author mentions two remedies as of especial advantage. One is antipyrin in gr. v doses, with a grain or two of quinine to prevent depression, repeated ^very two or three hours until the headache is relieved; the other is phenacetin in similar doses. Where these have failed. Dr. Da Costa has found gelsemium of service. 566 DISEASES OF THE BLOdD. The general strength and circulation must be looked after, and especially during convalescence the patient must receive nutritious food, alcohol, small doses of strychnia, and, later on, iron. The lecturer did not take up the complicating pneumonias, but advised the class to keep patients for a long time upon tonics to prevent relapses ; and, indeed, commended placing the entire family on tonics such as quinine or cinchonidine as a preventive when the disease appears in one member of the household. At any rate, if this practice does not ward off the disease, it appears to render the attack light. DR. LONG. (Med. Brief, Jan., 1892.) Dr. Long, in British Med. Jour., says: During the recent epidemic, when I had an average of 1 50 cases a week under my care, I had ample opportunity of testing the effi- cacy of various methods of treatment. My first idea was to try to alleviate the most prominent symptoms — namely, backache and general pains, with sod. salicyl. ; headache, etc., with analgesin, combining either of the above with a sedative or stimulating expec- torant if the chest was affected. I also used ergot and digitalis in combination in a few cases, believing the disease to be simply due to a vaso-motor change, but I afterwards came to regard it as a zymotic disease, with probably a special bacillus of its own. Amongst other drugs I tried camphor, and with so much success that I rarely prescribed anything else afterwards, six doses or less usually being sufficient. I administered it as follows : 920. R. Sp. camph., 2 drachms Tinct. lavand. co., 2 drachms Sp. chlorof., 1 drachm Mucilag. tragacanth, 2 ounces Aquae, ad 6 ounces. One ounce quartis horis sumend. This costs very little, and, by leaving out the flavoring agents, the effect is the same and the cost nominal. Mannott, in the Lancet, reports satisfactory results from the use of the chloride of ammonium in the treatment of epidemic influenza. The advantages are that it brings about a complete and definite cure ; in those cases where there is pulmonary congestion or en- gorgement of the lung structures or mild inflammatory action it is especially serviceable. From fifty to eighty grains is given every twenty-four hours. INFLUENZA OR LA GRIPPE. jg- PROF. H. C. WOOD, PHILADELPHIA. (Univ. Med. Magazine, 1 890.) Dr. Wood recommends in uncom- plicated cases a diaphoretic treatment. The results that have been published from this plan h^ve been generally strikingly successful, when used in simple cases. Dr. Wood suggests the following dia- phoretic formula, followed by quinine : 921. R. Pilocaipinae hydrochloratis, gr. ss Morphinse sulphatis, gr' j ^ig- — A teaspoonful every fifteen minutes pro re nata. The following formula he suggests where pulmonary complications exist : 922. R. Ammonli chloridi, 3;.- Apomorphinae hydrochloratis, gr. j Mist, glycyrrhizae comp., Syrupi, i5 f.|iss. jyf. Sig- — A dessertspoonful every two or three hours. He controls diarrhoea when present by : 923. R. Bismuthi snbnitratis, gr. x Acidi carbolici, gr. jsj. jj. Ft. capsula. Sig. — ^A capsule every two, three or four hours. The persistent bronchitis of these cases is treated by Gendre (Les Nouv. Remedes, 1890) by the following formula: 924- R- Terpine, gr. xxx Tar, gr. xxx Balsam of tolu, gr. xc Benzoate of sodium. q. s. ut ft. pil. No. Ixxx. Sig. — Take six or eight pills daily. NOTES ON REMEDIES. Ammonli Chloridum is of marked service as an expectorant. Antipyrine. It seems the consensus of opinion that this drug, in doses of gr. v-xv, is of the greatest service in controlling the pains and headache, as well as the febrile disturbance of la grippe, but it is asserted" by a large portion of the profession that its employment is unjustifiable be- cause of the depressive influence which follows as an effect of its ad- ministration. This depression is occasionally serious, sometimes even fatal, in weak subjects, and when the drug is employed there is no question but that it should be guarded by proper doses of some other remedy, as quinine or cinchonidine. 568 DISEASES OF THE BLOOD. Antifebrin. Very much the same is to be said of this drug, except that it is perhaps less apt to depress severely, nevertheless it is not free from such influence. It may be administered in a manner similar to that in which antipyrin is given. Aconite may be found serviceable in very minute doses in sthenic and febrile cases, where there is no cardiac complication. Atropia or Belladonna may be used with benefit in opposing the catarrhal symptoms, especially in the upper air passages, when there is a large amount of liquid exudate. In the pneumonia complicating the disease, atropia is often necessary as a respiratory stimulant. Cannabis Indica is recommended as a means of controlling the pains char- acteristic of the early stages of the disease. Camphor is not infrequently employed as a stimulant in order to overcome the depressive effect of antipyrin or some other of the coal-tar pro- ducts. Chinoidinum may be used as any of the cinchona derivatives in the treatment of the disease as a tonic and antipyretic (gr. v-xv). Cinchona, Cinchonina, and Cinchonidina, and the salts of the last two, as well as Quinina and its salts, find the widest recognition in the treat- ment of the grippe. They are also administered with a view of pre- vention of the disease in those exposed. Caffeina is often of great service in the treatment of the headache of the early stages, and may be used to correct the depressive effects of an- tipyrin or phenacetin. Codeina is highly commended to overcome the headache. Digitalis is frequently used as a stimulant and as a diuretic in the treatment of influenza, and is of service where a depressed circulation for weak heart is a compUcation. Gelsemium may be found serviceable in persistent headache, and may be given in the form of the fluid extract, in doses of i to 8 minims. Hyoscyamus is recommended as a drug exerting favorable influence upon the neuralgic symptoms of the disease. Nux Vomica and its alkaloid, strychnine, are particularly indicated in the stage of convalescence, and in the course of the disease where ner- vous depression is a prominent feature. Opium, in any of its preparations, is a highly proper remedy as a calmative, analgesic and soporifacient agent, when indications demanding the use of such influences arise. Salicin, Salol, and their allies, are of great value in dissipating the rheumatoid pains of influenza, and exert a very favorable influence upon the entire course of the case. Of the salicylic compounds, perhaps salicylate of INTERMITTENT FEVER. 569 sodium, in doses of gr. x-xv or more, is used most widely ; salol, in somewhat smaller doses, is highly commended. Sodii Bromidum, and the other bromides, occasionally are found useful in the early stages where there is much restlessness. Menthol counteracts the dilatation of the vessels of the passages of the nose and throat in influenza, arresting the sneezing and rhinal flow, and re- lieves the fullness and pain in the head. It is best used by inhalation. INTERMITTENT FEVER (AGUE. CHILLS). THE PERSONAL PROPHYLAXIS OF MALARIA. The general belief that the cinchona alkaloids are reliable prophy- lactics against the malarial poison, is so far from correct that it should be renounced. It is even dangerous, for it has been well established by the observations of the English surgeons in West Africa and elsevi^here, that when long used as a preventive, it not only loses its prophylactic, but also its therapeutic powers. (See Surgeon GORE'S Medical History of the West African Campaign, page 164.) The best prophylactics are a generous diet, plenty of .work, mental and physical, but not to exhaustion, avoidance of night air and wet, proper clothes, and a cheerful disposition. The free use of pepper in the food, and the habit of taking a small cup of strong cofifee on rising, may be favorably mentioned. Dur- ing the night, doors and windows should be closed, and an open fire should be lighted in the evening and early morning. The drinking water should be filtered, or thoroughly boiled before using. From the experience of English surgeons in India, (Indian Medi- cal Gazette, March, 1871,) quinoidine is the alkaloid of bark that ranks highest in prophylactic qualities. Three grains daily was the amount prescribed. Small and regular doses of strychnia have been highly praised as a prophylactic by Dr. C. W. WayLEN, of the East India Service. PROF. S. M. BEMISS, M. D., NEW ORLEANS. This writer (New Orleans Medical and Surgical Journal, Sep- tember, 1876,) states that in the treatment of malarial fever, three objects must be held in view : i . To restore to the blood its norma constituents; 2. To rid it of impurities ; and 3. To ward off malarial paroxysms. 570 DISEASES OF THE BLOOD. For the first of these, iron suggests itself. A combination from which great benefit is often obtained, is : 925. R. Ferri redacti, Quinise sulphatis, ai 3ss Acidi arseniosi, gr- j- M. Make fifteen pills. One two or three times a day, with the meals. Another is : 926. R. Ferri et quinise citratis, 9i-3ss Infusi gentianse, f- % iv. M. A tablespoonful two or three times a day. Or: 927. R. Quinise sulphatis, 9i Tinct. ferri chloridi, f. 3 'j Aquse cinnamomi, f.5^- M. A teaspoonful two or three times a day in sweetened water. Where there is much tendency to serous effusion, the following is an excellent formula: 928. R. Ferri ammonio-sulphatis, 9ij Quinise sulphatis, 9j Acidi sulphurici diluti, f. 3 j Aquae cinnamomi, f. 3 vij- M. A teaspoonful in sweetened water twice daily. The second indication includes measures of treatment so often called for, that the medical attendant should constantly observe for the presence of symptoms justifying a resort to them. These symp- toms are a coated tongue, with vitiation of the sense of taste ; a muddy skin ; cephalalgia, or vertigo ; slight feverishness ; and urine, for the most part, highly-colored and heavy. These symptoms con- tra-indicate the employment of analeptic remedies. Eliminants and alteratives should be appealed to. Mercurials are our most efficient remedies. From one to five grains of calomel may be given, com- bined with 'bicarbonate of soda and white sugar, or with the soda alone. These small doses may be repeated at intervals varying from four to forty-eight hours, according to the urgency of the case. In certain cases, it is desirable to avoid the nausea and free catharsis liable to be produced* by calomel and soda. A very efficient, as well as mild mercurial dose, will be found in the combi- nation of three grains, severally, of blue mass, compound extract colocynth and castile soap ; make two pills, and give at one dose. Restorative and eliminant remedies may be combined, as : INTERMITTENT FEVER. S7I 929. R. Magnesii sulphatis, §j_ij Ferri sulphatis, 9ij Acidi sulphurici diluti, f. 5 j Syrupi aurant. cort., f. 3vij Aquam, ad f. | vj. M. A teaspoonful, in water, twice daily. The third indication is best subserved by the preparations of cin- chona. These may be given habitually, as, for example, from 3 to 5 grains of quinine in i or 2 ounces of cofifee daily. The alimentation of anaemic malarial patients, is a most important consideration. They should be liberally supplied with carefully- selected and well-prepared animal food, to which such vegetables and fruits may be added as are regarded suitable to their condition. Digestion may be aided by acid solutions of pepsin, or by mineral acids, diluted in some bitter infusion. The list of promoters of digestion is incomplete if we omit alcoholic drinks, or, for many patients, coffee and tea. A good prescription is the following : 93°- R- Tinct. cinchonse comp., f. §iv. Dessertspoonful, in water, after each meal. Whenever considered indicated, from 5 to 8 drops of nitro-muri- atic acid may be added to each dose. Alcohol may also be given, in the form of wine or beer. In violent forms of congestive chill, or algid pernicious malarial fever. Dr. Bemiss states that opium, chloroform, belladonna, chloral hydrate, and bromide of potash, prove more or less valuable, accord- ing to the idiosyncrasy of the patient, or the circumstances under which they were used. Opium is the most valuable of the agents, and may be combined with other drugs, as an adjuvant. It is better to use it in moderate doses, and repeat these at short intervals. Twenty drops of laudanum, with >^ teaspoonful of chloroform, is an efficient prescription. One-sixth of a grain of morphia, with h of a grain of atropia, may be injected subcutaneously. Nitrite of amyl is highly recommended. These remedies may be used at any stage of the chill, without fear of prejudicing the subsequent career of the case. PROF. GREENVILLE DOWELL, M. D., TEXAS. During the chill, put the patient to bed, and keep the skin warm with sinapisms to the stomach, hot bricks or bottles to the feet and hands, blanketing, etc. Little else can be done. 572 DISEASES OF THE BLOOD. During the fever give cold water freely, and small quantities of sweet spirits of nitre and tincture of aconite. If the pain in the head is severe, a mercurial is indicated. 931. R. Hydrarg; chloridi mitis. Extract! taraxaci, Pulveris rhei, aa gr. xij. M. Make six pills. Give three at once, and the other three in three hours. This combination usually acts well without an additional laxative. About six hours before the next chill he prescribes : 932. R. Quinise sulphatis, Extracti sarsaparillse, aa gr. xij. M. Make six pills. One every hour until all are taken. If the patient is not seen until an hour or two before the expected chill, the whole amount should be given at once. When there is a tendency to dropsical effusion and enlarged spleen, he prescribes : 933- K- Quinise sulphatis, Ferri lactalis, aa gr. xij Ext. digitalis, gr. iij. M. Make six pills. One every hour. In cases of long standing, the following combination hardly ever fails to break up the chills : 934' R- Quinise sulphatis, 3j Acidi arseniosi, gr. ij Extracti sarsaparillse, 3ss. M. M ake thirty pills, One every two hours, until five are taken each day, continuing daily until all are taken. If required, after ten days of rest, these pills may be repeated. When the tongue is foul, and covered with white fur, the quinine should be combined with a stimulant, as : 935- R- Quinise sulphatis, gr. xviij Olei piperis nigri, gtt. iij Extracti sarsaparillse, gr. xij. M. Make six pills. One every hour. Piperine may be used instead of the oil. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. In chronic malarial infection, important changes have been pro- duced in the intestinal canal, liver, spleen, kidneys, cerebro-spinal INTERMITTENT FEVER. 573 axis : the paroxysms of fever occur irregularly ; various abnormal manifestations of the infection take place (dumb ague, enlarged spleen, etc.). Under these circumstaoces, quinine is less curative than when the infection is recent, and the paroxysms will recur from time to time notwithstanding its use, unless these structural altera- tions are corrected. In chronic malarial disease, salicylate of quinine and salicylate of cinchonidine are especially effective : 936- B- Cinchonidinse salicylat., 5ij Acidi arseniosi, gr. j Eerri sulph. exsic, ^j. m. Ft. Pulv. (Wafers) No. xx. S. — One three times a day. Also: 937- R- Chinoidin, 3ij Quinise salicylat., 5j Ferri sulph. exsicc, Qj. M. Ft. Pil. No. Ixxx. S. — ^Two pills three times a day. Or: 938. R. Quiniae sulph., Chinoidinse, aa 3j Res. podophylli, gr. v Ferri sulph. exsicc, 3 ss. M. Ft. Pil. No. k. S. — Two pills three times a day. As an antipyretic, this author prefers the benzoate of sodium to the salicylate of the same, because it is safer. In the convalescence from malarial fever, and in chronic malarial poisoning, the various bitters are useful in promoting constructive metamorphosis. Dog- wood possesses the most positive antiperiodic properties, and is con- sidered by the physicians of the Southern States as next to quinine in efficiency. An excellent tonic combination of decided utility in chronic malarial disease is the following; 939- R • Dogwood bark, Calumba, Poplar (liriodendron). Wild cherry, aa 6 ounces Soneset (eupatorium), Cayenne pepper, aa 4 ounces. Mixed and sifted. Of the mixture, a teaspoonfiil in warm or cold water, three or four times a day. A useful tincture, to serve the purpose of a tonic, and as a remedy in malarial affections, may be prepared from the above combination of bitter tonics. 574 DISEASES OF THE BLOOD. The following is prescribed by Bacelli in malarial cases (Cen- tralbl.f. d. Gesammte Ther.apie, 1890). 940. R. Sulphate of quinine, gr. xlv Tartrate of iron and potassium, gr. cv Distilled water, f.iiii Fowler's solution, Tllxxiv. M. Sig. — One teaspoonful from one to three times daily. In the graver forms Bacelli recommends intervenous injection of quinine, preferring this method to subcutaneous medication or to ad- ministration by the stomach. The solution he uses is made after the following formula : 941. R. Quiniae muriatis, gr. xv Sodii chloridi, gr. iss Aquae destillatae, f. 3iiss. M. About half the quantity here indicated is sufficient for one admin- istration. The operation is carefully done, under strict antiseptic precautions. The skin is washed off with a sublimate solution, and a band put about the arm, as in venesection. The solution is forced by a hypodermic syringe into the most prominent vein, slowly, and permitted to diffuse slowly, the band being gradually loosened. The time for the quinine is immediately after the paroxysm, not before or during it. The following is a valuable restorative in the malarial cachexia: 942. R. Quiniae sulph,, Ferri sulph. exsicc, Magnesii sulph. exsicc, 55 9j. M. Ft. pil. No. XX. S. — One pill three times a day. When the malaria has produced jaundice, the author has seen excellent effects from the following : 943- R- Chinoidin, 3j Magnesii sulph. exsicc, Bij. M. Ft. pil. No. XX. S. — One three times a day. Recent experience has conclusively shown the curative power of iodine in malarial fevers. Thus three hundred consecutive cases were, with few exceptions, promptly arrested (ANDERSON). In some cases, no paroxysm occurred after the medicine was adminis- tered ; sometimes the attacks persisted for two or three days, but INTERMIITENT FEVER. 575 then the relief was complete. The official compound tincture of iodine may be prescribed — for adults, ten to fifteen minims, three times a day, well diluted and before meals. Carbolic acid, itself hav- ing considerable antiperiodic power, may be combined with the compound tincture of iodine : 944. R. Tinct. iodinii comp., f. |ij Acid, carbolic, f. 3j. M. S. — ^Ten to fifteen minims three or foSr times a day. The officinal tincture of iodine is given by many practitioners. If quinine be necessary to break up the paroxysms, iodine is highly useful in the interim, as has been indicated. PROF. MCLEAN, M. D., INDIA. This distinguished authority speaks in the highest terms of War- burg's tincture. His words are : " I have treated remittent fevers of every degree of severity, con- tracted in the jungles of the Deccan and Mysore, at the base of mountain ranges in India, on the Coromandel Coast, in the pestilen- tial highlands of the northern division of the Madras Presidency, on the malarial rivers of China, and in men brought to Netley Hospital from the swamps of the Gold Coast; and I affirm that I have never seen quinine, when given alone, act in the manner characteristic of this tincture. And, although I yield to no one in my high opinion of the inestimable value of quinine, I have never seen a single dose of it, given alone, to the extent of g}i grains, suffice to arrest an exacerbation of remittent fever, much less prevent its occurrence, while nothing is more common than to see the same quantity of the alkaloid in WARBURG'S tincture bring about similar results." The following is the formula, as made known by Professor McLean : 945- R- Aloes (socotr.,) fto Rad. rhei (East India,) Sem. angelicae, a. Confect. damocratis, aa § iv Rad. helenii (s. enulse,) Croci sativi, Sem. foenicul., b. Cret. prseparat., aa § ij Rad. gentianae, Rad. zedoarix, Pip. cubeb., Myrrh, elect., Camphorse, . c. Bolet. laricis, aa §]. 576 DISEASES OF THE BLOOD. The above ingredients are to be digested with 500 oz. proof spirits in water-bath for twelve hours; then expressed and 10 ounces of disulphate of quinine added ; the mixture to be replaced into the water-bath till all the quinine be dissolved. The liquor, when cool, is to be filtered, and is then fit for use. a. This confection, which consists of an immense variety of aro- matic substances, was once officinal, and is to be found in the Lon- don Pharmacopoeia, 1746. b. Dr. Warburg states that this ingredient was added to correct the otherwise extremely acrid taste of the tincture. Many other substances were tried, but none answered so well as prepared chalk. c. This is the Polyporus laricis (P. officinalis. Boletus purgans, or larch- agaric), "formerly," says Pereira, "used as a drastic purga- tive, and still kept by the herbalist." The tincture is of a deep brown color, has an aromatic and slightly " terebinthinate odor, and an intensely bitter and warm aromatic taste ; a noteworthy point about it is that there is nothing spirituous in either taste or smell, and it seems as if the alcohol employed in its manu- facture were entirely saturated, and, so to speak, extinguished, by the substances taken up. The tincture evaporates readily, leaving a copious brown residue. DR. J. MILNER FOTHERGILL, LONDON. The great remedy in malarial attacks is quinine. It is best given in an acid solution. The following is an agreeable dose : 946. R. Quinise sulphatis, gr. x Acidi sulphurici diluti, ITlx Sy rupi auraat., f. 3 ij Aquam, ad f. 3j. M. This amount three times a day. In some cases where the quinine seems powerless to break up the chill, the administration of an emetic each morning brings the dis- ease at once under the control of the drug. Some patients manifest a marked intolerance of quinine, especi- ally those who have resided in the tropics. In such patients, arse- nic, strychnine, berberin, and the eucalyptus must be resorted to. The following combination is highly extolled by a writer in the American Medical Bi-weekly, March, 1877, in order to prevent the return of the chills after they have been broken by quinine : INTERMITTENT FEVER. 577 947- R- Quiniae sulphatis, Jij Tinct. ferri chloridi, f. | jj Liq. potassii arsenitis, f. § jss Tinct. opii, , f. § ss Strychniae sulphatis, gr. ij Alcoholis, f. § viij Aqus, f.ixxiv. M. One tablespoonful three times a day. An experienced practitioner says of this prescription that when administered after the liver has been acted on by a mercurial, it will cure any case of enlarged spleen or chills, if persisted in. JOHN HERBERT CLAIBORNE, M. D., VIRGINIA. 948. R. Hydrargyri chloridi mitis, Pulveris ipecacuanhse et opii, aa gr. iv Quinix sulphatis, gr. xyj. M. For four pills. Two to be given at bedtime, and two the following morning. This is Dr. CLAIBORNE'S usual first prescription in quotidian in- termittent and remittent fever, and it rarely fails. Various physicians have lately extolled chloroform in obstinate chills : 949. R. Chloroformi, Tincturae cinchonse, aa f. Sj. M. One or two teaspoonfuls in water hourly, for four hours preceding the expected chill. For breaking up chronic chills, the following combination has been highly praised by Dr. W. O'Daniel, of Georgia (Atlantic Medical and Surgical Journal, February, 1 872 ) : 950. R. Quinise sulphatis, 3ij Ferri redacti, 3 'ss Extr. aeoniti, gr. xxx Morphias sulphatis, Strychniae sulphatis, Acidi arseniosi, aa gr. iij. M. Make sixty pills. One after breakfast and one after supper. PROF. HARVEY L. BYRD, M. D., BALTIMORE. In the treatment of that much-dreaded and often rapidly-fatal condition, the "Congestive Chill," Prof. Byrd knows nothing of equal value to chloroform and opium, used as follows : 951. R. Chloroformi, 1- *■ Inhale to anaesthesia, or to the restoration of the circulation in the extremities. The doctor often prescribes inhalation of chloroform to a limited extent, to mitigate or curtail the cold stage in intermittent fevers. 37 578 DISEASES OF THE BLOOD. Or: 952. R. Pulveris opii, CT. ij Pulveris capsici, 9j. ' M. Make four powders. One powder every hour, in severe cases, until the re-establisb- ment of the circulation. He is accustomed to give between the powders 10 to 15 drops of aromatic,sulphuric acid, in a little water. When reaction of the circulation is established in " congestive chill," the case should be treated in the usual manner. DR. BENJAMIN LEE, PHILADELPHIA. This practitioner recommends a full dose of quinine about an hour before the chill, and half an hour before it the following : 953- R. Chloral hydratis, 9j Aquse camphor^e, § j. M. For one dose. 954- R- Quinise sulphatis, Ferri redacti, aa 9j Acidi arseniosi, gr. ij Piperinse, 9iss. M. Make twenty pills. One three or four times a day. A favorite prescription, in ob- stinate chills, with some Southern physicians. DR. A. R. HALL, INDIA. The use of emetics, in intermittent fever, should not be neglected. Often, the anti-periodic will not act until the stomach is thus emp- tied. Dr. Hall also states (The Practitioner, May, 1875,) that, in India, it is customary to give an emetic at the commencement of the cold stage, when shivering first begins. Sulphate of zinc (gr. xxx), followed by copious draughts of hot water — say three or four pints, if the patient can be induced to swallow them — ^will generally induce free vomiting, and cut short the paroxysm at once. Ipecacuanha may also be employed, but the depression it leaves behind it is much greater than the zinc : THE HYPODERMIC USE OF QUININE IN INTERMITTENT. The subcutaneous injection of quinine in malarious fevers has been frequently tested at home and abroad, the efficacy of the drug in controlling fever, and the saving effected in consequence of the smaller quantity required, being sufficiently important to fully justify the share of attention which the subject has received. When rapid INTERMITTENT FEVER. 579 action is called for, or when, from irritability of the stomach, idio- syncratic or symptomatic, quinine is not well borne ; or, again, when its exhibition per viant naturaletn is resisted, the hypodermic injec- tion of the drug may be advisable, By this plan, there is a great saving in the quantity used, the cases being usually conducted to a satisfactory conclusion, so far as fever is concerned, with a very moderate expenditure of quinine, say 3 grains or so. On the double ground of checking the fever and economy in the consumption of the drug, this mode of treatment would seem to be superior to the old method ; but, unfortunately, a drawback presents itself in inflammation at the point of insertion of the syringe. This may be avoided, to some extent, by a careful solution and administration. Surgeon Major GEORGE Y. HuNTER, (Lancet, March, 1876,) of Bombay, uses : 9SS- R- Quiniae sulphatis, gr. Ixxx Acidi citiici, gr. ccc Aquae destillatae, f. S j- M. Dissolve with the aid of heat. Hlvj contain one grain of quinine. The formula of Dr. Leorust, of Bremen (which is recommended by Dr. AUSTIN Flint) , is : 956. R. Quinise sulphatis, gr- Hcxiij Acidi sulphurici, ^2 ."J ^ AquEe destillatae, f- 5 )• "^• Mix the acid and water, and gradually add the quinine, stirring with a glass rod; if the solution is not clear, it may require one, possibly two drops more of the acid. Filter through paper, and it is ready for use. Ten drops of this mixture are equiv- alent to fifteen minims, which contain one grain of quinine. One grain hypoder- mically, is equivalent to three or four by the mouth. As regards the best place for insertion, it is stated that the region of the collar-bones is the most preferable. Any spot will do that is at all suitable for hypodermic injections ; but when it is inserted where the muscles are in constant use just beneath the skin and fascia, it will be apt to occasion soreness and swelling. Abscesses are rare when the solution is kept free from particles and sediment. If care is not taken, the instrument used may be spoiled by the acid acting on the piston and other parts ; to avoid this, it should be washed after using, first in clear water, then in a solution of soda (a teaspoonful in a glass of water), then in clear water again. Ether, perhaps, will answer for the same purpose, but is not always con- venient. 58o DISEASES OF THE BLOOD. There is considerable pain on forcing out the solution, for the acid is irritating to the tissues, and there are frequently hard, indu- rated spots, where the fluid is' forced out, lasting a few weeks, or even months, but they always gradually disappear. Dr. J. M. FOTHERGILL recommends as not liable to cause ulcer- ation : 957- R- Quinise sulphatis, gr. x Acidi sulphurici diluti, lllx Aquse destillats, gtt. c. M, The hypodermic method does not produce ringing in the ears, deafness, or other unpleasant effects of quinine taken by the mouth. It ought, as a rule, to be used only in those instances in which the ordinary method is inapplicable, as the following: ist. Those in which quinine by the mouth has failed to stop the fever. 2d. Those in which there is great irritability of stomach, or great disgust for the remedy. 3d. Those in which the fever, though controlled by quinine in the ordinary method, yet requires large and repeated doses. 4th. Those in which the effect on the head or nervous irri- tability produced by the drug is distressing, sth. Cases in which death seems to be imminent, and in which it is necessary to produce a decided and rapid effect upon the fever. The following formula, containing gr. iv to f.3j, is an appropriate one : 958. R. Quinia; sulphatis, gr. xxxij Alcoholis diluti, f. 3 vijss Aquae ammonise, f. 3ss. M. Dr. Lente'S formula is : 959- R- Quinise sulphatis, gr. 1 Acidi sulph. diluti, xi\,c Acidi carbolici liq., TI^v Aquje, f.ij. M, Dissolre the quinine by the aid of heat, and, after filtration, add the carbolic acid. All acid solutions, however, cause considerable pain, and it is probably better to dissolve the pure alkaloid quinia in ether. Prof. W. Bernatzik recommends : 960. B. Quinise, gr. vij Etheris sulphurici, IUxv. M. The alkaloid can be obtained by precipitation from a solution of the sulphate by ammonia. INTERMITTENT FEVER. 581 HEMORRHAGIC MALARIAL FEVER. DR. R. D. WEBB, ALABAMA. The indications of treatment are — to arrest the paroxysms ; to re- lieve the nausea and restlessness, so as to facilitate the administra- tion of medicines and add to the comfort of the patient ; to sustain the patient by appropriate food and stimuli ; to assist the emunc- tory functions of the liver and skin, and, in the latter part of the disease, to promote the action of the kidneys, so as to avoid the accumulation of deleterious matters in the blood, and to prevent a recurrence. He usually commences with a mercurial purge, and follows with a full amount of quinine, grains xxx, in four doses, one every two hours, if the stomach will retain it. If it will not, the drug should be used hypodermically. Chloral hydrate and bromide of potas- sium, by enema, will lessen the gastric irritability, or small doses of morphine may be given for that purpose. Of the objections to qui- nine, on the ground that it increases the blood in the urine. Dr. Webb says : " I have ever looked upon the mere fact of blood in the urine as of minor importance, and have never directed remedies specially to the arrest of this symptom. I believe it to be depend- ent upon the condition of the nervous system, and, by directing my remedies to the source of the evil, I expect to remove the cause, and the effect will cease. This, I believe, is best accomplished by the use of quinine, and if, in its administration, the haematuria is tem- porarily increased, as I have no doubt it is at certain times, I do not, upon this account, hesitate to use it. I regard it here, notwith- standing this temporary increase, as the great hemostatic, by its power of removing or counteracting the condition upon which the haematuria, in common with other symptoms, is dependent." {Hemorrhagic Malarial Fever — A Monograph, Selma, 1876.) DR. THOMAS J. PUGH, LOUISIANA. This writer states that he became dissatisfied with quinine and mercury in this troublesome form of malarial poisoning, and now uses instead : 961. R. Vini ergotse, ■•3j Tinct. fern chloridi, g*'- ^ Olei terebinthinae, gt'- ^ Spiritfls etheris nitrosi dulcis, gtt- xx- ™- This amount, in a gill of water, every two hours until the urine clears. 582 DISEASES OF THE BLOOD. After this omit the ergot and oil of turpentine, but continue the iron and nitre, and add to them a preparation of nux vomica — the fluid extract — in five-drop doses, every four hours, until the patient is safe from a recurrence of the disease, and then direct it every eight hours, or before meals. The danger in this disease is not from an excessive flow of bloody urine, but rather from a suppression of urine, {Atlantic Med. and. Surg. Jour., January, 1877.) ANTI-QUININE TREATMENT OF INTERMITTENT FEVER. DR. BEARDSLEY. At a recent meeting of the Medico-Chirurgical Society of Montreal, Dr. Beardsley gave the results of fifty years' experience in treat- ing intermittent fever without quinine. Briefly, it is as follows : First, brisk alterative purgatives, aloes, blue-mass and capsicum, jn equal parts, made into pill-form, or calomel in place of the blue- mass. An alterative purgative was to be taken at the outset, and repeated as the nature of the case demand. This was to be fol- lowed by an aromatic bitter, and perhaps an alkali with it, or in combination with bonset tea, drunk very freely, was an element in the cure not to be overlooked. He stated that this method had been very satisfactory in his and others' hands, and was often suc- cessful where quinine had utterly failed, and that, too, where it had been pushed, indeed, as far as twenty-grain doses three times a day, or even oftener. PROF. FELIX DE WILLEBRAND, FINLAND. Prof De Willebrand believes that malarial fever can be com- batted by other specifics besides cinchona, and that iodine is one of them. He directs : 962. R. lodinii, 3j Potassii iodidi. 5ii Aquae destillatae, f.giss. M. Five drops in a small glass of water every two hours during the day. DR. J. B. SCRIVEN, LAHORE, INDIA. This English surgeon reports very favorably of the nitric-acid bath in malarial disorders. ('Zawt:^/, November, 1876.) He has used it with the best effect, in a vast number of cases. For children, it is an extremely pleasant remedy, though it often produces a slight irritation of the skin. They generally sleep soundly after it, and INTERMITTENT FEVER. 583 rapidly improve in health. It is always necessary to continue the baths daily for at least a fortnight — often for a month or six weeks. With adults, of course, it is less manageable, but not less efficacious. As pure nitric acid is very expensive, it may be well to add that he has found the impure acid, which is very cheap, and readily pro- curable, quite good enough for the acid bath. It contains a little hydrochloric acid and iron. A wooden tub should, of course, be used in preference to a metal one, or, in the absence of this, an earthen vessel. THE TREATMENT OF ENLARGED SPLEEN OR AGUE CAKE. DR. BABIEFF. This author regards (Mediz. Obozr., February, 1882,) systematic faradization of the spleen as one of the best adjuvant means in the treatment of intermittent fever, and adduces some cases of his own in which the usual antiperiodic remedies had remained unsuccessful until the electricity had been added. The faradization not only diminished the splenic tumor, but also acted beneficially on the malarial process. This favorable influence the author attempts to explain as follows : i. Faradization gives rise to contractions of the splenic vessels, and, in a reflex way, acts tonically on the vaso-motor centres. 2. It counteracts blood-stagnation, and possibly accumu- lation of miasmatic products in the spleen. 3. It acts indirectly on the neighboring kidney, increasing correspondingly the secretion of urine. 4. It prevents the formation of infarcts and ruptures in the spleen. The editor of the Mediz. Obozr., Dr. V. F. SPRIMON, also testifies to the high value of faradization and galvanization in cases of chronic malarial tumor of the spleen. He saw its prompt disap- pearance, as well as a great improvement of the general state, in four out of five of his patients treated by this method. In four of the eight of Dr. SPRI^tON'S cases which presented intermittent of re- cent standing, and were treated by faradization alone, the fever dis- appeared and never returned after five to ten sittings (half an hour daily). According to some authorities, mercury, in any form, is contra- indicated when malarial enlargement of the spleen exists. The hyposulphite of soda is recommended by Dr. THOMAS HiLL, of Missouri. (Louisville Medical and Surgical Journal, 1 872.) 584 DISEASES OF THE BLOOD. 963- B- Quiniae sulphatis, gr. ix_ Sodii hyposulphitis, gr. xvj Acidi sulph. aromat., gtt. vj Aquae, f-SJ. M. A teaspoonful every two bours to a child. Ten grains of the soda, thrice daily, may be given to an adult. In the enlarged spleen, often associated with leucocythemia, which so frequently follows malarial disease, the iodide of ammonium, gr.v three times a day, with inunctions of the red iodide of mercury, has been found efficient. Dr. Da Costa prefers, however, the treat- ment by the hypodermic administration of ergotine, gr. iij-v daily, which has certainly produced excellent results. Dr. J. B. C. Gazzo, oi 'Lomsia.na,' ( Medical and Surgical Reporter, March, 1877,) reports favorably of throwing the injection into the tissues of the spleen itself. He uses : 964. R. Fid. extr. ergotae ether., f. 3ii Glycerini, f. 3 j. M. This solution is injected into the spleen, two syringefuls at once, and repeated after twenty-four hours. The more deeply the needle is driven the less is the sensibility. Constipation must be avoided. Professor MOSLER, of Switzerland, has also employed parenchy- matous injections to reduce the spleen. He employed carbolic acid in a two per cent, solution, and liquor potassii arsenitis, one part to ten of distilled water. The former caused so much pain that he did not continue it; the latter, however, was repeated a number of times, and brought about a very decided diminution of the organ. (Eui-ENBURG, Die Hypodermatische Injection, Berlin, 1875.) According to Dr. R. WILLIAMS the bromide of potassium has re- markable powers in the reduction of splenic hypertrophy. It is given internally, in full doses. Dr. R. Bartholow believes that small doses of the iodide of am- monium, combined with arsenic, will reduce an enlarged spleen from malarial causes ; as : 965. R. Ammonii iodidi, 5j Liq. potassii arsenitis, f. 3ss Tincturse calumboe, f. § ss Aquae, f.|iss. M. A teaspoonful three times a day before meals. Paint the side with tinct. iodin. compos. The iodide of lead, gr. \ thrice daily, has testimony in its favor. Very excellent results have been reported by Dr. L. McGuiRE, of INTERMITTENT FEVER. 585 California, from the use of strychnia or nux vomica (Pacific Medical Journal, February, 1873,) in ague cake. He gives tV of a grain of the former, or "Lxx of the tinct. nucis vomicae, three times daily, combined if need be, with iron or quinine. In splenic and hepatic enlargement, Dr. EVERS (London Medical Record, ]\me, 1875,) reports the best results from a milky juice of the unripe fruit of the paw-paw, carica papaya. About a teaspoon- ful of the juice is mixed with sufficient sugar and divided into three boluses, one to be taken thrice daily. If it causes symptoms of gastric irritation, a little opium may be added. From twenty to twenty-five days is sufficient for a cure in nearly all cases of ague cake. Of external remedies, blistering, painting with the compound tinc- ture of iodine, inunction of ointment of biniodide of mercury, local abstraction of blood, etc., have each been lauded, but it is doubtful whether any of them is particularly useful. In Germany, the " dry- packing" method is employed at hydropathic establishments, and is said to reduce the spleen at a rapid rate without any other medi- cation. It is certainly a simple and excellent derivative. In India, puncture of the spleen with long, sharp stilets of consid- erable thickness, is a common and successful practice with native physicians. It is not followed by bad results, and has been com- mended by some English physicians. Dr. W. T. Gadbury, of Mississippi, speaks in the highest terms of a solution of oxy-sulphate of iron. He says that in an extensive practice for many years he has never had a case of malarial splenic hypertrophy which resisted it. (Medical and Surgical Reporter, April, 1866.) 966. R. Ferri sulphatis, i ) Acidi nitrici, f-Sj- ™- Stir until it ceases to effervesce, then add Aquse, ^- 3 '^• This is used as a part of the following combination : 967. R. Liquoris oxy-sulphatis ferri (above), ^•§"J.. Aquae cinnamomi, ^5 "'] Quinise sulphatis, Ofs Potassii nitratis, 3ijss. M. One tablespoonful three or four times a day. In obstinate cases an iodine ointment or some other counter- irritant should be rubbed in over the enlarged viscus, and a roller 586 DISEASES OF THE BLOOD. worn round the body, so as to make compression on all the organs supplied by the cceliac axis. In cases of children suffering from lumbrici, it is well to commence with anthelmintics. In the Atlanta Medical and Surgical Reporter, 1876, Dr. D. L. Phares, of Mississippi, highly recommends the root of the Ceano- thus Americanus as a remedy for enlarged spleen. He exhibits it in form of a tincture, made by filling a bottle loosely with the root and root bark, pouring whiskey upon it, and allowing maceration to continue for a week. The dose is f.l'Jss— j ter die. The same tinc- ture is rubbed over the spleen twice daily. NOTES ON REMEDIES. Aconitum. Dr. S. Loving (Ohio Med. Jour., August, 1878,) says that he knows of nothing which promotes the comfort of patients in the hot stage more than a combination of aconite and morphia, in small doses. Ammonii Carbazolas. It is stated by Dr. Dujardin-Beaumetz that this agent acts very efficaciously in intermittent fever. The daily dose is gr..ss-j, in pill form. Dr. Slane, of Goalpara, India, finds carbazotate of am- monia to be a very efficient remedy. It does not increase the appetite, but like quinine, after a few doses, it produces tinnitus aurium and slight deafness. The urine becomes tinged of a deep orange color, and occasionally the skin and conjunctiva acquire a jaundiced hue, but the discoloration soon disappears. It rnay be given in pill, with ex- tract of gentian, and combination with a quarter of a grain of extract of nux vomica seems to increase its efficacy. Being perfectly soluble in water, it may be given in solution, but it has an intensely bitter taste. The largest quantity Dr. Slane ever gave was eight grains in twelve hours. (Indian Medical Gazette, April, 1876.) It has also been favorably reported upon in this country, especially on the Pacific coast. Ammonii Chloridum, in doses of gij daily, as an average, was once very pop- ular in ague, and is still employed by some. Amyl Nitrite. In intermittent fever, amyl has aborted the chill, but only shortens the latter stages : it may be given even after the algid stage has fairly set in. Some bold exhibitions have been tried, even to the extent of thirty drops, with good rather than bad effects, in this form of fever. The ordinary dose has been six drops. Arsenicum undoubtedly stands second only to quinine in the treatment of malarial poisoning ; its especial field is the chronic forms. It may usefully be combined with iron : 968. ]J. Pill, ferri carbonatis, 3j Acidi arseuiosi, gr. j. M. For twenty pills. One three times a day. rNTERMITTENT FEVER. 587 Or: 969. B. Quinise sulphatis, Qij Ferri sulph. exsic, 9j Acidi arseniosi, gr. j. M. For twenty pills. One three times a day. When used alone, ten drops of Fowler's solution may be given three times a day after meals. The diet should be abundant and nourishing. Airopia. Some writers state that, in the cold stage of intermittent or con- gestive fevers, atropia injected under the skin will bring about reaction with more certainty than any other means commonly used in such cases. It will abort the chill, if applied at the onset, in most cases. Berberin. This alkaloid, from the Hydrastis Canadensis, Berberis vulgaris, etc., is highly esteemed in chronic malarial poisoning. Buxinm Sulphas. The alkaloid of the Buxus Sempervirens, in doses of gr. XV, has achieved some reputation in Italy. Camphora. A tablespoonful of the tincture of camphor, about the time the chill is expected, will occasionally prevent it. Capsicum. Prof. Wm. H. Thompson says that either capsicum, ginger, or other aromatics, combined with quinia, will diminish the amount re- quired of the latter. "A good dose of capsicum, combined with 20 grains of quinine, will act as well as 30 grains of quinine without cap- sicum." Carbolicum Acidum. This has rather disappointed expectations. It may be given in doses of gr. iv, in infusion of gentian, and no doubt occasion- ally acts well. M. Declat, of Paris, has used it hypodermically, with success, in obstinate cases. (Comptes Rendus, No. Ixxv.) Chloroformum, in doses of f.gss-j, in a small glass of milk, every two hours, about the time of the expected chill, will frequently abort it. Chinuidine. This is the cheapest of the cinchona alkaloids. From gr. xv-xx, daily, for five or six days, and then gradually reduced, will cure mild intermittents very satisfactorily. Chloral Hydratis has been highly recommended by Dr. P. Bailey, of South Carolina, (Charleston Medical yournal and Review, October, 1873,) and others. When the fever heat is intense, its refrigerant and calm- ative influence is undoubted ; and while it quiets the nervous system, it rather promotes the secretions — in this particular, being far superior to the opiates. In the malarial fevers of children, with a tendency to convulsion, or when this unfortunate complication has supervened, it can scarcely be excelled. Although the first impression on the gastric surface is rather to excite emesis, nothing can be more demonstrable than its promptness in arresting the vomiting, in these fevers, when all other efforts have been fruitless. 588 DISEASES OF THE BLOOD. 970. R. Chloral hydratis, Sjss Potassii bicarbonatis, 99 Spts. seth. nitrosi, f- 1 fs Syrupi tolutani, f- 3 'jss Aquae, f-SJ- M. A tablespoonful every hour or two. Cimicifuga Racemosa. Dr. Edward R. Mayer, of Wilkesbarre, Pa., states that the tincture of cimicifuga, alone or combined with tincture of kalenia, is one of the most efficient remedies known for the malarious neuralgia of the first branch of the fifth pair, commonly called brow ague. (Hints in Specific Medication, 1876, p. 17.) Cinchonina. A cheap and useful alkaloid, about half as strong as quinine. It has the great advantage that it can be rendered quite tasteless with- out impairing its efficiency. Dr. Samuel Ashhurst, of Philadelphia, combines it thus : 971. R. Cinchoninse, gr. j Sacchari lactis, gr. iv Sodii bicarbonatis, gr. yV- ^• This is readily miscible with water or milk, and has no other than a slightly sweetish taste, while it is very nearly or quite as efficient as quinine itself. CinchonidincB Jodidum. Dr. Vansant {Am. Pract., 1879,) states that this salt, in malarial fevers, is more efficient and prompt than twice the weight of any of the alkaloids of cinchona, combined and administered as they usually* are. The prescription usually given is as follows : 972. R. Cinchonidinse sulph., Potassii iodidi, Acidi citrici, aa grs. xxiij Aquae destill., f. § vj. M. Dissolve the cinchonidine and acid in water, then add the iodide of potassium and agitate. Dose, a tablespoonful, in water, three or four times a day. CinchonidincR Sulphas. This is a valuable alkaloid of the bark, and in all usual and milder cases, answers quite as well as quinine, and is cheaper. In congestive and pernicious forms, it is not so reliable, however. Dr. Wharton Sinkler's formula is : 973- R- Cinchonidinae sulphatis, gr. iv Acidi sulphurici aromat., Tlliv Aquae, f-3j. M. This dose every four hours, beginning as early in the day as possible, until gr. vj have been taken. Continue the amount five or six days after the last chill, then reduce one dose every other day. (Medical and Surgical Reporter, February, 1874.) It is said to produce less nausea and less cinchonism than quinine. Cornus Florida. The extract and tincture of dogwood are employed in the Southern States as a substitute for quinine. INTERMITTENT FEVER. jgp Eucalyptus Globulus. The celebrity attained by the eucalyptus as a curative agent in malarial disease is doubtful. The tincture is recommended in f.3 j doses, three times daily ; of the oil, f.gss may be given two or three hours before the expected attack. Farina Maiciis. A tablespoonful of commeal in a glass of water, just before the chill, is a useful domestic remedy. A decoction of com shucks or fodder is popular in the South. Ferri Persulphatis Liquor. This has been successfully used in obstinate in- termittents, in doses of gtt. viij-xvj, every four or six hours. Almost all the preparations of iron are valuable as tonics in prolonged malarial cases. The taste of the patient and the convenience of their adminis- tration, should be the guides in selecting from them. Gelsemium. Several writers have praised, very highly, the jasmine as an anti- periodic. The dose recommended by Professor. William VV. Murray, of Baltimore (Medical and Surgical Reporter, January, 1873), is y\v of the tincture every hour, until it produces heaviness of the eye- lids, dilated pupils, or double vision, the same course to be pursued for four or five days successively. He adds that it is superior to qui- nine in preventing the recurrence of the attacks. Grindelia Squarrosa. The fluid extract of this plant has been used success- fully in hypertrophied spleen. The dose is f.3J four times a day. Hydrastis. In obstinate recurring intermittents. Dr. Edward R. Mayer has found the following recipe more effective than quinia : 974- B- Hydrastinae sulpbatis, Ammoniae carbazotatis, aa gr. \. According to Dr. Bartholow, "hydrastin ranks next to quinia as a remedy for intermittents." Hydrocyanicuni Acidum. " Peach-leaf tea " is a popular remedy in intermit- tents in Maryland and Delaware. On this hint. Dr. James H. Pea- body, of Omaha, has used with great success hydrocyanic acid. In chronic intermittents it has served him when cinchona and its alkaloids have entirely failed. A favorite prescription is : 975' R- Acidi hydrocyanici dil., gtt. xlviij Tr. cinchonse comp., Tr. gentianse comp., Syrupi pruni virginianae, aa § ij. M. Two teaspoonfuls four times daily. lodinium. Recommended by Dr. De Willebrand as curative, (F. 962,) but its especial and great value is after the ague has been checked by qui- nine, to prevent its recurrence. For this purpose, tinct. iodinii, gtt. v-x, three times a day, in a spoonful of water, before meals, is said by Dr. James Y. Shearer, of Pennsylvania, (Medical and Surgical Re- 590 DISEASES OF THE BLOOD. porter, January, 1874,) to surpass all other agents yet suggested. Nothing disguises the taste of iodine so well as sweet milk gj to gtt. x of the tincture. Ipecacuanha. In both intermittents and remittents, accompanied by congestion of the portal circulation, ipecacuanha is often very serviceable. It is probably the most suitable emetic which can be administered at the outset of a malarial attack, when such an agent is called for, and where the consequent depression is not to be feared. Leptandra Virginica. This is said to be an invaluable remedy to prevent the return of intermittents after they have been broken up by quinia. It is a favorite ingredient of secret remedies for this purpose, and should be combined with the cinchona alkaloid, and continued some weeks. (Dr. Edward R. Mayer, Hints in Specific Medication, 1876.) Nitricum Acidum. In old and obstinate cases, says Dr. Lyman (Chicago Medical yournal and Examiner, December 7, i86r,) we want to ad- minister something powerfully oxidizing in character, to wash or cleanse the body of the remains of the disease. We should administer first a diuretic. The acetate or the citrate of potassa is useful if quinine alone has failed. But if they are not, a course of nitric acid may relieve for years. Opium, in full dose, three hours before the expected chill, will frequently stop its appearance. Morphia may nearly always be advantageously com- bined with quinine. Dr. Meriwether Lewis, of Tennessee, lays down these aphorisms in the American journal of Medical Science, July, 1878 : I St. The combination of an opiate with quinia insures an earlier and more complete cure of intermittent and remittent fevers than quinia alone ; 2d. Less quinia is required, and hence there is less cere- bral disturbance ; and 3d. Any paroxysm of intermittent or remit, tent fever may be aborted by the use, at the proper time, of a decided dose of morphia and quinia, with reasonable certainty. Piper. In doses of gr. v-xx, pepper has been found of considerable value, especially for combining with quinia when the stomach is not suscept- ible to the latter's action. Potassii Nitras. This has been highly praised. It is administered in doses of gr. X in brandy and water, or dry on the tongue. Dr. Sawyer, of St. Louis, states he has never failed to arrest with it an uncomplicated paroxysm of ague. QuinicB Bromohydras. Professor Gubler, of Paris ( J^ournal de Therapeuti- que), points out that the proportion of quinine in the neutral brom- hydrate is more considerable than in its analogue, the neutral sulphate of quinine. It is also six times as soluble in water. Thus its greater solu- bility and richness in alcohol give it superior advantages for the purposes of hypodermic injection. The new compound also is alleged to offer INTERMlTfENT FEVER. 59 1 the valuable combination of the. properties, in part synergic, of quinine and of the bromated preparations. M. Gubler orders about r J^ grains, in pill, not exceeding six grains daily, as an ordinary dose, and rarely if ever, giving as much as 15 grains a day. Its effects are those of quinine, producing ultimately headache, singing in the ears and deaf- ness, or those of slight bromism, muscular languor, accompanied by .a strong tendency to sleep. M. Gubler has sometimes employed with success hypodermic injections of bromhydrate of quinine in a solution of the strength of ,?„ in water slightly alcoholized. Notwithstanding the presence of a small proportion of alcohol, the bromhydrate of quinine, in subcutaneous injection, has always shown itself inoffensive to the tissues, which is contrary to that which occurs with sulphate of quinine. Dr. W. E. Forrest, of New York, has combined hydrobro- mic acid with sulphate of quinine, and finds the distressing symptoms of quininism are thus wholly avoided. 976. Et. Quininas sulphatis, 3j Acidi hydrobromici, Aquae, aa f.giss. M. Two teaspoonfuls contain 5 grains of quinine. The hydrobromic acid used must not be that usually sold, (Merck's,) but that prepared according to Dr. J. Milner Fothergill's formula : 977- R. Potassii bromidi, §xj Aquae, Oiv. Dissolve, and add : Acidi tartarici, § xiij. The hydrobromic acid remains in solution, and potassium bitartrate is precipitated. M. Latour's formula is : 978. R. Quininae sulphatis, gr. x Acid, sulph. diluti, Slxx Aquae, f- § j- To this, add : Potassii bromidi, gr- xx. This forms a neutral bromohydrate. Quinince Salicylas. The salicylate and carbolate of quinia have been recom- mended on theoretical grounds. Quinina Sulphas. This is the standard remedy, the typical specific, in all phases of malarial diseases. In regard to the form of its exhibition, the most active is in solution. Its bitter taste is best concealed by liquorice, glycyrrhizin, chocolate, tannic or malic acid. Sugar-coated pills and chocolate caramels, containing quinia, may readily be ob- tained. Frequently, a clear solution, free from turbidity, is a deside- 592 DISEASES OF THE BLOOD. ratum. With aromatic sulphuric acid, we get a passable solution, but the acid is often objectionable, if not absolutely contra-indicated. Dr. Isaac Smelt, Jr., (N. Y. Medical journal, August, 1876,) finds that, in practice, the sweet spirits of nitre is all that is desired. One ounce of it will dissolve about two drachms of quinine, giving a transparent solution. The following is said to disguise the taste well : 979. R. Quininse sulphatis, 9j Cocoae, 3j Syr, aurant. cort., f. 3xx. Triturate well the cocoa, after which add the quinine and orange peeL Mix thor- oughly. Sweetened hot tea, drawn strong, will almost entirely conceal the bit- terness so much complained of. The tannic acid is the efficient agent, which may be utilized as follows : 980. K- Quininse sulphatis, gr. xxiv Syr. sarsap. comp., f. S iij ■ ' Acidi tannici, gr. iij Olei menth. piper., gtt. v. M. Milk, in the proportion of f.gj to gr. j of quinine, will conceal its taste tolerably. In giving quinine to children, it is frequently better done by enema : 981. R. Quininse sulphatis, gr. ij-x Acidi tannici, gr. ij-vj Aquae, f-Sj- M. For one injection. The tannin aids the retention. Or the endermic method may be very successfully employed : 982. R. Quininse sulphatis, 3s^ Alcoholis, f. 3 ss Adipis, Svij- Rub well into the skin. (Dr. AUGUSTE NoNAT.) Often, the action of quinine is greatly aided by stimulant and aro- matic adjuvants, as alcohol, ether, capsicum, pepper, ginger, etc. Dr. Fuller has found that when there is splenic enlargement the addition of colocynth and rhubarb greatly increases the energy of the alkaloid. Dr. Roberts Bartholow (Prize Essay on the Use of Quinine) lays down the rules : \. Quinine is equally effective, whether administered in the interval or during the seizure. 2. Its maximum effect is five hours after taking j hence, it should be administered about this long be- fore the expected paroxysm. 3. It is better to give the whole amount in a single dose, than in a succession of small doses. In ordinary in- termittents, gr. x in the sweating stage, and the same quantity five hours before the time of the next paroxysm, is the most effective plan. An important practical point in the administration of quinine has INTERMITTENT FEVER. 593 been noted by Dr. ScHiLLtNG, (Glasgow Med. Jour., 1883). This is that the ringing in the ears and deafness produced by large doses may be counteracted by combining ergot with the cinchona salt, in equal quantities or about two to one. This association is said also to prevent the amblyopia which sometimes supervenes after large doses of quinine. Some useful suggestions are made by Dr. Auguste Nonat (Practi- tioner, September, 1871). The older the case, the larger the dose required ; whenever the spleen is enlarged a double dose is required ; quartan fever requires a much larger dose than quotidian or tertian. The total time required to eradicate the disease will generally be three weeks ; the first week, the maximum dose must be given daily ; the second week, one-third less, and the third week, two-thirds less ; even after this, small doses, from time to time, are needed. Salicin was extensively used during the Civil War by the Confederate sur- geons, and has recently been revived ; gr. xxx, three or four times a day, is an average dose. On account of its alterative effect on mucous surfaces, it is deemed particularly applicable in malarial haematuria. Resorcin, in doses of gr. xxx-xl, or larger, has been found by Dr. Bassi, of Venice (Compend. of Med. Set., 1884), to check intermittent cases with almost the certainty of quinine. No harm resulted from these large doses, but sometimes there were temporary deafness and singing in the ears. The rapid absorption of resorcin, which was noticed in all cases, makes it necessary to give the remedy half an hour to. one hour before the expected access ; if given at a longer interval it seems to exhaust its special action, and fails to influence the access. Resorcin seems to have the same value as quinine in this disease and in the same cases ; where one fails, the other fails. It has the advantage of being comparatively much cheaper. Sodii Bisvlphis. This has been employed with good effect. Dose, 9j in water, every two hours. It is only available in mild cases. Sodii Chloridum. Dr. Brookes recommends the following (Zeitschrift fiir Praktische Median, 1876, No. 33) : Heat table salt in a pan until it turns brown ; dissolve a tablespoon ful in a glass of hot water ; take the whole at one draught, on an empty stomach, the day after the chill, or, in the quotidian type, two hours after the fever. Avoid drinking water and diet low. One such dose is usually enough. In doses of gviij-x, in the apyrexia, it was recommended as far back as 1854, by J. C. Hutchinson, of New York. Strychnia Sulphas. In India, cases of intermitttent have been successfully treated with this agent alone. It is also freely used in this country, in numerous anti-periodic combinations. (F. 947, 950.) Sunflower. A tincture (1:5) prepared from the fresh flowers and bark of the ordinary sunflower has proved of excellent value as an anti- 38 594 DISEASES OF THE BLOOD. malarial agent by Maminoff {Provincial Med. jpour., 1890), given in doses of gtt. x-xxv three or four times daily. Tela Aranece. In the Cincinnati Lance land Observer, 1877, Dr. L. M.Jones reports that having failed in treating a case of chronic intermittent, he adopted the suggestion of Dr. Jackson, in the U. S. Dispensatory, to use spider-web. A bunch of spider-web, collected from a dark cellar, (as it is the web of a species of spider which inhabits dark places that . possesses medicinal properties) about the size of a large hulled walnut, was put into four ounces of whiskey and allowed to macerate forty- eight hours, when it was filtered. The patient took a teaspoonful four hours before the expected chill, and at hourly intervals until she had taken four doses, and then took a like quantity before each meal and at bedtime, until all was taken. Although the anticipated chill came, it was very light, and was the last one experienced up to the time of the report, a period of foiir months. PURPURA HEMORRHAGICA. DR. THOMAS HAWKES TANNER. This writer says the treatment should consist in the exhibition of full doses of sulphate of soda with sulphuric acid, or of castor oil, until the bowels are thoroughly cleared. Then quinine, iron, the mineral acids and arsenic, as in the following combination : 983. R. Quinise sulphatis, gr. ix Acidi phosphorici diluti, Tincturae ferri chloridi, aa- f. 3 iss Liquoris arsenici hydrocWoridi, TUxv-xl Syrupi zingiberis, f.3vj Infusum quassiae, ad f. § viij. M. One-sixth part directly after breakfast, dinner and supper. The patient should be given nourishing diet, fresh fruit or vegeta- bles, and a fair allowance of malt liquor or wine. The oil of turpen- tine, or gallic and aromatic sulphuric acids, where there is internal hemorrhage, are often quite effective. DR. POULET, PARIS, (Bull. Gen. de Therap., 1889.) PouLET publishes the records of two severe cases of purpura hemorrhagica which he treated with marked success by nitrate of silver internally. In the first part of PURPURA HEMORRHAGICA. 595 the disease, perchloride of iron, tannic acid, gallic acid and other anti-hemorrhagic remedies were tried without effect ; and only after repeated failures with other remedies did he resort to argentic nitrate (gr. l-^) incorporated in bread crumbs. The relief came rapidly and without relapse. He strongly recommends further trial of the remedy. It is best given in bread pills at the close of each meal, thrice daily. DR. MARTIN DE GUIMARD, FRANCE. (Pans Medical, 1888.) In a thesis on the subject, De Guimard speaks of the treatment of simple purpura. He recognizes two prime indications : ( i ) to arrest the hemorrhages and (2) to remedy the weakness of the patient. For the first indication he recommends tincture of the chloride of iron (gtt. xx— xxx to an adult), freshly powdered ergot (gr. xv throughout the day) or ergotine, the juice of four or five lemons given by the spoonful with sugar, and above all oil of turpentine (gtt. x— xx) in emulsion. To sustain the patient, the second indication, Muscat or Malaga wine may be given, or brandy and water; quinine in large doses (gr. xvj daily), bouillon or meat extract. In children, transfusion may be attended with suc- cess. Locally, for the hemorrhages, insufflations of antipyrine or tamponing the nares, lemon juice to the gums, ice to the abdomen, etc., may be used. If gangrene occur, antiseptic lotions of carbolic acid (2 per cent.) or bichloride of mercury (i : 1000) may be em- ployed. {Annual of Univ. Med. Sc, 1889.) PROF. DESCROIZILLES, PARIS. In a child : 984. R. Brandy, 10 Lemon juice, 3° Mint water. Syrup of quinquina, Sig. — Teaspoonful at a dose. I 60. M. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA, Says that in purpura and the hemorrhagic cfiathesis, digitalis is use- ful when given conjointly with restorative medicines; but, as a dyscrasia exists on which the extravasations of blood depend, it is obviously necessary to correct this state of things, in order that the patient shall be benefited by a remedy which gives tone to the 596 DISEASES OF THE BLOOD. heart and vascular system. Gallic acid is useful, and the following mixture is highly recommended : 985. R. Acidi gallici, 3|S Acid sulphuric diL, (• 3 j Tinct. opii deod., f- 3 j Inf. rosse comp., f- 3 'v- J*- S. — A tablespoonful every four hours or oftener. NOTES ON REMEDIES. Arsenic is mentioned by Prentiss, (Med. News, 1890,) as the remedy which showed the most favorable results in a case published by him ; salol he ranks next. Ergot should be combined with tonics, and will be found of value. Ferrum is always useful. The following prescription is a good one : 986. R. Ferri sulphatis exsiccat., 9ij Quinise sulphatis, 9) Strychnise sulphatis, gr. ss. Make twenty pills; one thrice daily. Sulphuricum Acidum sometimes acts happily in purpura. Terebinthina Oleum is an important agent in the treatment of purpura. It should be given in emulsion. RELAPSING FEVER. CITY HOSPITAL, RIGA. In the decade 1865-75, two thousand cases of relapsing fever were treated in this hospital. The therapeutics adopted are de- scribed in the Deutsches Archiv fur Klinische Medicin, Bd. XIX., (March, 1877,) by Dr. X. GiRGENSOHN. After frequent attempts to abort or shorten the disease by quinine, aqua chlorinii, acids, etc., all of which failed, a pure symptomatic plan was adopted. During the febrile stadia, acids, in mucilaginous decoctions, were exhibited, and in the intermissions, some preparation of iron. Wine and brandy, in moderate quantities, were given throughout, and also a simple but nourishing diet, consisting of milk, bouillon, eggs, flesh, etc. For the vomiting, ice pills were found most efficacious, as also subnitrate of bismuth, in doses of gr. iij-v. For the attacks of diarrhcEa — which, however, often proved cf favorable indication— r- opium was at first used, but later, usually, tannin, gr. iij— v. For the RELAPSING FE^'ER. 597 profuse hemorrhage — sometimes of decided gravity — ice water in- jections, ice to the breast and back of the neck, and large hypoder- mic injections of ergot, were occasionally called for. The muscular pains which the patients complained of, especially during convales- cence, were tre'ated with the warm bath, or rubbing with a mixture of oil and chloroform. The severe pain occasionally felt in ' the splenic region, could usually be allayed with a bladder of ice to the part. Morphia injections were rarely employed. The delirium was usually mild, and if not, was easily controlled by the ice-bladder and chloral. The last-mentioned drug was also very satisfactory in overcoming insomnia, in doses of gr. v-xiv. The icterus and gas- tric symptoms rarely called for special attention. The parotitis and abscesses occurring during convalescence, demanded a prompt use of the knife to give exit to the pus. The neuralgia which some- times remained after the disease, yielded most rapidly to a judicious application of electricity. DR. R. MURCHISON, ENGLAND. This author states his opinion that we may prevent the occurrence of ursemic intoxication, which is one of the main causes of death in uncomplicated cases, by keeping up the action of the kidneys from the first. He prescribes : 987. K- Spiritds aetheris nitrosi dulcis, f-5ij Acidi nitrici diluti, f. 5i Syrupi simplicis, f. Sj Decocti hordei, Oij. M. To be taken in the twenty-four hours. Should symptoms of jaundice manifest themselves, hydrochloric acid should be substi- tuted for the nitric. DR. HENRY HARTSHORNE, PHILADELPHIA. Relapsing fever was very prevalent in Philadelphia and New York, in 1870, with a mortality of a little over fifteen per cent, of the cases. From the experience of this epidemic. Dr. H. recommends, after a mild cat hartic atthe beginning — and if headache be severe — a few cups or leeches to the back of the neck. Cooling diaphoretics may be given, as solution of citrate of potash or acetate of ammonia. After the crisis, which occurs from the fifth to the seventh or eighth day, quinine may be given in moderate doses, at least until the re- 598 DISEASES OF THE BLOOD. lapse. Many persons will require support, especially in the third week, by beef tea, alcoholic stimulants, etc. It has been proved that any amount of quinine will not prevent the relapse, and it is, therefore, useless to administer it with this object in view. ACUTE RHEUMATISM. SALICIN AND SALICYLIC ACID TREATMENT. DR. T. J. MACLAGAN, DUBLIN. This author (Lancet, March, 1876,) praises the action oi salicin in acute rheumatism. Relief is afforded in forty-eight hours or less. 988. R. Salicin, gr. xv. This amount ii) water every three hours. Later observers corroborate this statement ; gr. x every two hours, is preferred by some. Decoction of the inner bark of the willow (salix fragilis, etc.,) which contains the active principle, salicin, has also been used with excellent results. Salicylic acid, now produced by synthesis, was formerly derived from salicin. Dr. L. Traube, of Berlin, and many following him, give it high praise in acute and subacute rheumatism. It disperses the fever and soothes the pain. Grains xv to xxx, in powder, in a capsule, may be given every hour. Or : 989. R. Acidi salicylici, 5 ss Sodii boratis, 3j Glycerini, f. § j Aquae menthae, f. § v. M. A tablespoonful as occasion may require. The borax makes the acid more soluble. Dr. N. B. Kennedy, of Texas, remarks in the Med. and Sur. Re- porter, 1883, that he has for a number of years used the following formula, ^yith the happiest effects. It is quite pleasant to take. 990. R. Sodii bicarbonatis, 5ij Acidi salicylici, 5iij Glycerini, Aquae purae, 55 f. | ij. M. S. — One teaspoonful every four hours, ACUTE RHEUMATISM. 599 The carbonic acid gas is set free, and the sodium uniting with the salicylic acid forms salicylate of sodium, which is held in suspension by the glycerine. In administering the salicylates, lasting troubles with audition are often found to remain, owing to thickened tympanum, brought about by the vaso-paralytic action of these remedies. Dr. SCHILLING, (Glasgow Med. Jour., 1883,) has discovered that in most cases — at least in three-fourths — this may be prevented by combining ergot with the salicylate. He prescribes : 991. R. Ergotinse, gr. xv Sodii salicylatis, Siiss Aquae, f-lvj. M. A tablespoonful every hour. J. P. Martin suggests the combination of cascara sagrada (Land. Lancet, 1888,) with sodium salicylate in acute rheumatism: 992. g. Extracti cascarae sagradse fld., gtt. xxx Sodii salicylatis, gr. xv Aquam aurant. flor., ad f. 3 j- M. Sig. — One such dose every three or four hours. Dr. Stricker, of Berlin, in a resume of his experience with salicylic acid, says : 1. If the saliclic acid act thoroughly in the manner expected of it, there should be, during the treatment of articular rheumatism by a certain quantity given internally, no return of the disease in a hitherto unafifected joint, nor any secondary inflammation of the endocardium or other serous membranes. 2. In order to prevent a relapse, it is necessary to continue the use of the salicylic acid in small doses for some days after the end of the principal treatment. 3. Salicylic acid is of doubtful use in chronic articular rheu- matism. 4. It is not likely to be useful in gonorrhoeal and dysenteric rheu- matism, or in septicsemic inflammation of the joints. The following is an eligible formula, which forms the salicylate of soda: M. 993- R- Acidi salicylici, Spts. eth. nit., Sodii bicarb., Spts. lavand. comp.. Aquae, Syr. aurantii corticis. 3i f.3vj gr. Ixx f.5ij f.|ij q. a. ad f. 3 vj. One teaspoonful every three or four hours. 600 DISEASES OF THE BLOOD. In preparing this prescription, mix the acid and the spirits of ether in a bottle, then add the soda, and afterward the water, gradually, and after effervescence ceases, the spirits of lavender and syrup. This prescription agrees well with the stomach, and is pleasant to take. In large doses of salicylic acid, there is danger of producing severe cerebral symptoms, sick stomach and rapid collapse. Dr. E. Prideaux (Practitioner, September, 1878,) has found this can be obviated by giving salicylate of ammonia. He prefers to produce a combination of salicylate of soda and ammonia, as in the following prescription : 994. 5t. Sodii bicarb., Ammon. carb., aa gr. v Acid, salicylic, gr. xx Aquam, ad f. Sj. M. For one dose. This avoids successfully the unpleasant symptoms alluded to. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA. In summing up the testimony, it is clear that salicylate of soda is a most valuable remedy in acute rheumatism, but various unpleas- ant, even dangerous symptoms arise in some cases. Violent head- ache, vertigo and tinnitus aurium are common ; wild delirium is an occasional symptom; weakness of heart, obscuration of the first sound and profound anaemia, are especially noted by Greenhow ; very great gastro-intestinal disturbance is now and then produced. Empis narrates a fatal case of acute rheumatism which was treated with salicylic acid. Great depression of the powers of life, in rare instances approaching collapse, has been observed. Sufficient is now known of the danger attending the salicylic medication of acute rheumatism, to justify the author in urging circumspection on the attention of his readers. The robust and vigorous rheumatics are proper subjects for this treatment, whereas in the pale, feeble and cachectic, especially those with weak hearts, this treatment must be pursued cautiously or must not be undertaken at all. Relapses are frequent, probably because of the very rapid elimination of the remedy, as suggested by Prof. See, and hence its administration must be continued for some time after all of the local and systemic symptoms have subsided. The mineral acids, especially the hydro- chloric, have lately been proposed as remedies for acute rheumatism. ACUTE RHEUMATISM. 6oi It is highly probable that the mineral acids check the formation of lactic acid in the blood. Whatever may be the nature of the action, good results from the treatment have been reported. LEMON OR LIME JUICE TREATMENT. One of the recent advocates of this practice, DR. A. H. CHANDLER, NEW BRUNSWICK, Gives the following as the details of his plan, (Canada Lancet, Novem- ber, 1877) : Without regardto the condition of the bowels, unless pre- viously much constipated, he usually begins with at least 10 ounces of lime-juice, increasing rapidly up to 18 or 24, in the twenty-four hours — from ^ an ounce to an ounce or more every hour, with not less than double or treble the quantity of cold, soft water — usually diluted and sweetened, however, to the patient's taste. Very often, on the second day, the amendment is decided, and the disease, in acute cases more particularly, sthenic or asthenic, generally subsides on the fourth or fifth day of treatment. One grain of opium is usually given, with or without lead, and tannin, night and morningi in order to restrain the bowels, which the juice has a tendency to relax. The first effects of such heavy doses is the rapid diminution of joint swelling, the diminished perspiration, together with steady falling of pulse, the latter often quite slow, with a slight tendency to syncope. The majority of the cases require quinine, and support- ing food about the sixth or seventh day, when convalescence ad- vances rapidly. THE ALKALINE TREATMENT. DR. H. W. FULLER, LONDON. The treatment of rheumatic fever adopted by Dr. FULLER, at St. George's Hospital, is essentially alkaline, and consists not only in administering salines and small doses of alkalies, but in pushing alkalies, as rapidly as possible, to the point of producing alkalinity of the secretions. He usually prescribes : 995- R- Sodii bicarbonatis, 3iss Potassii acetalis, 3*'... Liquoris ammonise acetatis, f.3"J Aquse, f- 1 iss. M. For one dose. To be taken in a state of effervescence, in combination with : 996. R. Acidi citrici, 3|s . Aquae, '-3 'J- ^- 602 DISEASES OF THE BLOOD. The quantity of the fluid not only takes off" from the nauseous quality of the medicine, but promotes its absorption, and thereby facilitates its action. As soon as the urine manifests an alkaline re- action, the dose is repeated three times only in twenty-four hours ; and on the following day, if the urine still remains alkaline, twice only. After three days, two doses only of this mixture in twenty- four hoursusually suffice to keep the urine alkaline; and then Dr. Fuller adds two grains of quinine to each dose ; or, if quinine be not well borne, he substitutes : 997- R. Sodii bicarbonatis, Potassii acetatis, aa 5ss Tincturae cinchonie, f- 3 jss Decocti cinchonae flavse, f- S iss. M. For one dose. Day by day, as the tongue cleans, and the other symptoms sub- side, the quantity of alkali is cautiously diminished, until a simple quinine draught is taken ; but the condition of the urine is con- stantly watched, with a view to the immediate administration of a small quantity of alkali, should the least acidity call for its use. The diet is another point on which Dr. FULLER lays particular stress. He gives beef tea or broth throughout, and, if stimulants appear to be needed, does not object to their being administered cautiously; but he withholds solid food until the tongue is quite clean, and has often proved to his class in the wards that a too early recourse to meat will induce a relapse, and prevent convalescence. Under this treatment. Dr. FULLER says the pains commonly sub- side in five or six days, and the patients are seldom ten days in bed. Moreover, the heart may be regarded as safe from attack ; for in two instances only, in the whole course of his hospital experience, has inflammation, either of the endocardium or pericardium, arisen after the patient has been twenty-four hours under treatment. DR. FINCHAW, WESTMINSTER HOSPITAL, LONDON. 998. R. Potassii bicarbonatis, §j Potassii nitratis, 3ij Liquoris ammoniae acetatis. Aquae, aa f. § iij. M. A tablespoonful, in water, every four bours, with a full opiate at night, if the pain be severe. He does not think it advisable to continue the alkaline treatment for any lengthened period ; but to give quinine, in doses of two or ACUTE RHEUMATISM. 603 three grains, every six hours, when the urgent symptoms begin to yield, especially if the sweating is over-profuse. He believes that, by giving quinine earlier than is generally the custom, convalescence is less tedious, and there is less chance of relapse. As regards car- diac complications, if pericarditis supervene, and there be sharp, catching pain, he applies a few leeches, followed by linseed poulti- ces ; should the pain be slight or absent, he omits the leeches. In all cases he applies, subsequently, one or more blisters. As to medicines, he continues the alkalies, giving at the same time a grain of opium every four or six hours. Should endocarditis manifest itself, he contents himself with the alkaline treatment, as he cannot satisfy himself that local remedies have any effect. DR. F. J. FARRE, LONDON. Dr. Farre's ordinary mode of treating acute rheumatism is the " alkaline." He usually commences with three five-grain doses of calomel, followed by : 999- R- Magnesise sulphatis, 3ii Tincturae sennae, f. 5 ij Spiritfls ammonise aromatici, IHxx Infusi sennse compositi, f. § iss. M. For one dose. He repeats this daily till the evacuations are natural. At the same time, he gives the bicarbonate or acetate of potash, in 20 or 30- grain doses, every four or six hours, according to the severity of the attack, generally using the former, but preferring the latter when there is synovial effusion. When there is little or no perspiration, or when the heart is much excited, he adds 10 or 15 grains of nitrate of potash. He not un- frequently, also, gives i grain of opium every night. For local treatment, especially of the smaller joints, he relies chiefly on the tincture or liniment of iodine, using the tincture for women and chil- dren, the liniment for the robust; one or the other of these is used in almost every case, and with nearly certain relief. When, how- ever, there is synovial effusion. Dr. Farre uses either mustard or cantharides plaster. Mustard is always useful, especially when ap- plied to the larger joints, as the shoulder. The appetite being always faulty. Dr. Farre gives milk diet until the tongue is clean, or cleaning. Meat given before it can be digested, immediately brings back pain in the joints. He keeps the patient between 604 DISEASES OF THE BLOOD. blankets. As soon as the pain has gone, and the tongue is clean, he gives bitter tonics, omitting or diminishing the alkali if the urine is alkaline or neutral. DR. FLEMING, BIRMINGHAM, ENGLAND. 1000. "g^. Fotassii bicarbonatis, gr. xxx Aquse, f. § ij. M. For one dose, before each meal. Add X *° ounce of fresh lemon juice, and take the mixture during effervescence. If there be high fever, from i to 3 minims of Fleming's tincture of aconite are added to each draught. If there be much pain in the mus- cles, in place of aconite, from 5 to 10 minims of tincture of hemlock are added to each dose of the alkaline. If, on the other hand, the periosteum be affected, from 2 to 6 grains of the iodide of potassium are given. To relieve pain and secure sleep, Dr. FLEMING orders, at bedtime, a full draught of morphia and Indian hemp ; as a drink, potassa water, or lemonade, freely. If necessary, colocynth and hyoscyamus pill is given to relieve the bowels. Cotton wadding is applied to the affected joints. Active and repeated counter-irrita- tion, and poultices over the heart, are employed in cardiac inflam- mation. During convalescence, warm clothing, full diet, with qui- nine and iron. After considerable experience. Dr. FLEMING has found that this treatment has furnished very good results, and that the number of those attacked with cardiac inflammation after their admission into the hospital, is undoubtedly small. Placing the pa- tient between blankets materially promotes perspiration, and pre- vents chills. DR. W. C. BOTELER, OF MISSOURI. This practitioner writes (1884) : I will ask that you give fuller credit to the following treatment in acute and subacute inflammatory rheumatism than is, as yet, given in any of our works : 1001. ]J. Ammon muriat., Pot. brom., aa § ss Huxham's tinct., f. §ij Syr. zingiberis, AquK destil., aa f. § j. M. Ft. S. — 5 j every two hours. 1002. R. Deodorized iodoform, 3iss Vaseline, § j. M. Ft. S. — Apply well e. i. 1. to inflamed and swollen parts. The great superiority of this internal and external treatment, has ACUTE RHEUMATISM. 605 . been attested to me by innumerable cases annually. Just what the "modus medendi" of the iodoform locally is, I cannot positively say, but, I never have cases, even of the worst and some very chronic, under treatment longer than twelve days, with this combination. I have used it with inmediate relief on patients who had for twenty- nine weeks resisted the " alkalies " and "salicylates." Trying either alone, I find more virtue in the ointment. THOMAS KING CHAMBERS, M. D., ETC., LONDON. This author calls rheumatic fever " a pleasant disease for the doc- tor to treat, though not for the patient to bear," and gives a very simple, uniform plan of treatment, which, he states, hardly ever re- quires modification. Bedding. — The patient's bed is made in a peculiar fashion. No linen should touch the skin. A slight calico shift or shirt may be allowed ; but if the patients possess underclothing only of the pro- hibited sort, they are better naked. Even a linen front to the shirt is dangerous. The sheets should be removed, and the body care- fully wrapped in blankets, the newest and fluffiest that can be got. The head is to be carefully protected from currents of air. Fomentations. — Those joints or limbs which are swollen, red or painful, are to be wrapped up in flannels, soaked either in hot water or a decoction of poppy-heads, with one-half ounce of carbonate of soda to each pint. Curative Drugs. — If the skin is red, swollen or painful about the joints, if motion is impossible or the cause of exquisite suffering, and especially if these phenomena are metastatic, then the " alkaline treatment" is employed, as follows: 1003. R. Potassii carbonatis, 9j Aquae camphorse, f. 3 ij- M. For one dose. To be repeated every three tours, day or night, when awake. If, however, the above symptoms are insignificant, and the pain is felt more in the bones, being intensified by pressure rather than by motion, and fixed, not metastatic, then two grains of iodide of po- tassium are to be added to each dose. So soon as the symptoms take a favorable turn, the alkali is to be omitted altogether, and only the iodide of potassium given. Palliatives. — Opium is to be administered in amounts propor- tionate to the subjective sensation of pain — from i to 2 grains at a 6o6 DISEASES OF THE BLOOD. dose. Immediately upon the relief of the pain, the quantity is diminished. Pure opium, in the pill and the tincture, are the best preparations. If the pain remains fixed in one joint after it has left the other places, leeches are to be applied there, and the part kept poulticed. Bruised laurel leaves may be mixed with the poultice. If the heart becomes affected, leeches and poultices are to be applied to the cardiac region. Diet. — The food is to be varied to some extent by the social and personal state of the patients. If they have been hearty and well-to- do persons before the attack, simple diet is proper, i. e., bread and butter, gruel and tea. If they have been ill-nourished, a pint of broth or beef tea is added. DR. CARPANI, OF FRANCE, Thus formulates his experienee in the treatment of acute rheuma- tism: 1. Salicylate of soda is useful in cases of acute febrile poly- arthritis, attended by highly localized articular manifestations. It is contra-indicated by the concomitance of cardiac affections, nervous troubles, or gastro-intestinal or renal difficulties. 2. Bisulphate of quinine is indicated in cases where rheumatism is a manifestation of, or associated with, malarial infection. 3. Benzoic acid should only be used when nephritis is a compli- cation of acute articular rheumatism, attended by fevers. 4. Blisters are the most reliable agents for curing mono-articular rheumatism, or that form in which but few articulations are inter- ested. DR. J. MORTIMER GRANVILLE, ENGLAND. This writer (Brit. Med. Jour., 1883,) says: "In acute rheuma- tism, as early as possible in the case, give the mixture described be- low, in the diluted form in which I have prescribed it. Do nothing else, except to pack the painful joints in wraps of very loose cotton- wool, covered with light flannel ; not oil-silk or any other vapor- proof material." 1004. R. Tinct. aconiti (B. Ph.), Tllxij Ammonii sulphidi, nixvj Aquae menth. destil., f. § vj. M. A fourth part every fourth hour till the fever is abated. ■The mixture should not be prescribed in larger quantity than will ACUTE RHEUMATISM. 607 suffice for four doses, on account of the tincture of aconite, and, more especially the tendency of the sulphide of ammonium to de- compose and deposit sulphur. J. M. DA COSTA, M. D., PHILADELPHIA. 1005. R. Ammonii bromidi, §ss Tincturse aurantii corticis, f. § ss AquK, f. I ijss. M. A dessertspoonful every three hours, except at night. In acute rheumatic fever, the beneficial influence of the bromide of ammonium is undoubted. Over the pains and aches of acute rheumatism, this remedy exerts an unquestionable control ; but in chronic rheumatism, it is de- cidedly inferior to iodide of potassium. But slight amelioration follows its use, in persistent swelling of the joints of rheumatic origin, and none in rheumatism due to a venereal taint. 1006. R. Atropise sulphatis, gr. ^'j Aquse destillatse, IHx. M. For one injection. To be thrown under the skin, in certain forms of muscular rheum- atism, particularly -wry neck, over or into the rigid parts. To be repeated once a day. Sometimes, the most marked and speedy relief follows this treatment, after ordinary remedies have failed. 1007. R. Potassii iodidi, 3j Vini colchici radicis, f. 3 ij Morphise sulphatis, gr. iij Syrupi, f. § j Aquae, f. § ij. M. A teaspoonful three times a day, after meals, in muscular rheumatism. 1008. R. Potassii carbonatis, Si) Potassii acetatis, 3 iij Vini colchici seminis, f. § j Syrupi tolutani, f. § is3 Aquae, f. § ss. M. A teaspoonful thrice daily, in lumbago, the following liniment to be nibbed in night and morning : locg. R. Chloroformi, f. §s9 Linimenti ammonise, f- S jps Linimenti saponis, f. § ij. M. In a week or ten days, after the pain has subsided, apply : loio. R, Emplastri picis cum cantharide, Emplastri logani, • aa equal parts. M. The quickest way of treating lumbago is by throwing 3^ of ^ g^"^'" of atropia under the skin, near the affected muscles. This will sometimes dissipate the attack as if by magic. 6o8 . DISEASES OF THE BLOOD. ion. R. Tincturse guaiaci, '•'S Vini colchici radicis, f- 3 ij Potassii bicarbonatis, S ss Syrupi aurantii corticis, f. S ']• M. A dessertspoonful in water, thrice daily, in rheumatic arthritis. Also have the joints wrapped in cotton, and painted, morning and evening, with equal parts of tincture of iodine and alcohol, until they become sore. Sulphur baths are beneficial. Small blisters are also of service in the neighborhood of the joints, frequently re- peated and dressed with : 1012. R. Morphiae acetatis, gr- _} Pulveris marantx, gr- ]• M. Arsenic is an excellent remedy in rheumatic arthritis. It may be administered as follows : 1013. R. Liquoris potassii arsenitis, f-Sij Potassii iodidi, 3ij Syrupi, f. S iij. M. A teaspoonful thrice daily, between meals, in water. 1014. R. Vini colchici seminis, f. §j Potassii acetatis, 3 vj Spiritfls setheris nitrosi, Syrupi, aa f.gj. M. " A teaspoonful thrice daily, in pleurodynia. Also use a stimulating liniment, and keep the parts warm. 1015. R. Potassii iodidi, -3^ Vini colchici radicis, f. 3 ss Extracti cinchonas fluidi, Elixir cinchonse, aS f. § iss. M. A dessertspoonful thrice daily, in muscular rheumatism. Cinchona disguises the taste of the iodide of potassium. Quinine is often serviceable alone in those cases in which the joints are not affected, and in which there is pallor and loss of strength. 1016. R. Potassii iodidi, 3ij Tincturse belladonnre, f. Siss Syrupi aurantii corticis, f. § ss Aquam, q. s. ad f. § iij. M. A teaspoonful thrice daily, in muscular rheumatism associated with vesical inconti- nence. In case of swelling and stiffness of the joints following acute rheu- matism, nothing does so much good as sulphur-baths. When prac- ticable, send the patient to the sulphur-baths of Virginia, to get rid of these remnants of the acute attack. Artificial sulphur-baths are also useful. When these are not practicable, great benefit will be obtained from the iodide of potassium and compound tincture of guaiacum. ACUTE RHEUMATISM. 6C9 1017. B. Potassii iodidi, 3ij ' Tincturae guaiaci compositae, f-ivj. M. A dessertspoonful thrice daily. This prescription is very efficient, though not an elegant one. It is very unpleasant to take. There are few who will go on with it for a long enough time to get its full therapeutical effects. In the treatment of the subacute form of muscular rheumatism, nitrate of potash is very valuable. This is an old remedy, but the advance of therapeutics has shown no other, in this form of rheuma- tism, of which our author thinks so highly. It may be conjoined with Dover's powder. 1018. B- Potassii nitratis, gr. xv Pulveris ipecacuanhse compositi, gr. iij. For one powder, to be taken every fourth hour. NOTES ON REMEDIES. Aconite is, according to Reith {^Edinburgh Medical Journal), ordinarily given in too large doses in acute rheumatism. He obtains good re- sults in mild cases by its agency alone in small and often-repeated doses ("i,^ of the tincture every two hours). In some cases he com- bines it with the full alkaline or blister treatment. Chloral has been extolled in cerebral rheumatism by M. Boucmrr. Cimicifuga was brought forward as a remedy in acute rheumatism_ by Dr. F. N. Johnson, of New York. It is less employed in the acute than in the chronic form, but in the form of the fluid extract, in doses of n^x-xxx, is of marked value in the latter form of disease. Colchicum relieves the symptoms and shortens their duration when combined with small doses of calomel, ipecacuanha, alkalies and opium. It is less beneficial, according to Dr. Fuller, in the weak and nervous than in the robust ; less in purely fibrous rheumatism than in that compli- cated by synovial inflammation ; less in proportion as the fever exceeds the articular swelling and as the urine is less highly charged with the lithates. During its use, its operation must be carefully watched, the bowels kept regulated, and if the lithates disappear from the urine, if the pulse become weak, if faintness, or nausea, or purging supervene, it must be discontinued. The acetous extract, or the inspissated juice, (gr. j-iss) or the wine (ni,xv-xx), may be given twice or thrice daily. Ergota, in full doses internally, is a very efficacious remedy in many cases of acute rheumatism. Ferri Chloridi Tinctura has been employed by Dr. Russell Reynolds, of London, in doses of alwut tij xxx every six hours, with the effect of shortening the duration of the disease, and reHeving the joint affection. 39 6lO DISEASES OF THE BLOOD. Ex. Hydrangea Fluidum, particularly in the lithiated form, exerts i very happy influence in the subacute and chronic forms of rheumatism. Kairin is said by Dr. H. Menxhe, of Berlin {Blatt. Klin. Med., 1883), to act more quickly in reducing the temperature in acute inflammatory rheu- matism than the salicylic compounds. He gave large doses, as much as 3J a day, in divided amounts every two or three hours. Litnonum Succus. (See page 601.) Lithium. Garrod first introduced the lithium salts into medical practice for the treatment of rheumatism, and in his recent Lumleian lectures has demonstrated anew their exceptional value. Recently the compound of lithium and salicylic acid has been brought forward as a more effect- ive remedy in the rheumatic diseases. The sub-acute and chronic cases, and the so-called rheumatic gout, are the forms of disease in which the lithium salts are most serviceable. Manaca. This is a preparation of the root of Franciseea uniflora, a Brazilian shrub, introduced by Messrs. Parke, Davis & Co., Detroit. It is officinal in the Brazilian dispensatories as an anti-syphilitic. The dose of the fluid extract is gtt. x-xx, of the powdered root, gr. x. Ad- ministered in chronic rheumatism, it is stated to have exerted a favor- able influence on most cases. In some cases of acute rheumatic arthritis it is also said to have shortened the attacks. Dr. George Herschell, of England, has had excellent results in gonorrhceal rheu- matism from five -minim doses, every three hours, of the fluid extract. He has also used it successfully in simple acute rheumatism. Opium, in large and repeated doses, is given by Sir D. Corrigan, of Dublin. He commences with gr. j every two or three hours, and increases the dose, both in frequency and quantity, until the patient feels decided relief, when it should be kept at that dose until the disease is steadily declining. The average quantity required in twenty-four hours is about gr. xij, and even that amount does not affect the head ; occa- sionally it produces diarrhoea, when astringents are required to check it. The tolerance of opium, in this disease, is remarkable. Potassii Acetas is much employed. The dose usually given is about gr. xxx every four hours. Potassii Bicarbonas is a favorite remedy. Dr. A. B. Garkod, of London, gives gr. xxx in solution, every four hours, until the joint symptoms and febrile disturbance have completely disappeared. Dr. Fuller, of London, considers that giss is the minimum dose, which will suffice to overcome the acid condition of the blood during the first twenty-four or forty-eight hours of treatment, and in sthenic cases, gij are often needed. Small doses he regards as useless. Potassii Bitartras, in doses of gr. xv-xx, every four hours, given in mint- ACUTE RHEUMATISM. 6ll water, alone or in combination with tincture of hyoscyamus (m,xxx-xl), is said to produce good results. Potassii Nitras. Dr. Basham, who instituted a series of experiments to ascer- tain the real value of nitre in acute rheumatism, arrived at the follow- ing conclusions: i. That it is a most valuable remedy in doses of gij-iij, in Oiv of barley-water, daily. 2. That it acts by restoring the saline constituents of the blood, and by lessening the excess of fibrine. 3. That there is a certain amount of exemption from cardiac compli- cation, and that cardiac inflammation, when it supervenes, is more amenable to remedies. 4. That the tendency to collapse is much diminished, and the acute or inflammatory symptoms usually give way on the third or fourth day. Potassii Permanganas. Dr. Finn (Canada Medical Journal, January, 1868,) writes in the highest terms of the efficacy of the permanganate of pot- ash, in the treatment of rheumatism, gr. J^ thrice daily, which he be- lieves to be due to the large proportion of oxygen which it contains. This salt promotes the transforma'tion of lactic into carbonic acid. Propylamine. See Tri me thy la mine. Quinice Sulphas, according to Dr. Fuller, should, ordinarily, only be used as a restorative when the febrile paroxysm is beginning to abate, and not as a cure during the active stages of the disease. Salicin, Salicylic Acid, the Salicylates and Salol, constitute a group of com- pounds all of the highest remedial value in rheumatism, acute and chronic. Perhaps the most valuable is the salicylate of sodium or the acid itself. An acute attack of rheumatism is not infrequently cut quickly off by the employment of one of the agents ; and where relief in the acute attack does not promptly follow in several days, the rem- edy should be at once forsaken for other treatment. (See p. 598.) LOCAL APPLICATIONS. Baths. Dr. R. J. Butler (Medical Press, August 5th, 1868,) has found great benefit in acute rheumatism, from baths containing valerian. He directs : 1019. K. Valeriana radicis, tbj Aquae, Oj. Boil together for a quarter of an hour, strain the liquor, and add to an ordinary bath, at 98°, the patient remaining in it for twenty or thirty minutes. For any remaining inflammation about the joints, he applies linseed- meal poultices, prepared with a strong decoction of valerian. In the arthritic form of the disease, he considers valerian of extraordinary efficacy in subduing the pain and inflammation. Prof. Da Costa, of Philadelphia, recommends sulphur-baths, artifi- 6l2 DISEASES OF THE BLOOD. cial or natural, for the swelling and stiffness of the joints following acute rheumatism. Blisters. The blister treatment has been prominently advocated. Dr. Her- bert Davis directs armlets, wristlets, and even fingerlets of blister- plaster, to be applied at the time the inflammation is most acute, lin seed-meal poultices being subsequently applied to keep up the serous discharge. He places these blisters entirely around the affected limbs, and in the case of the knees, orders them at least three inches wide, regarding any slight strangury which may arise as of little importance, compared with the benefit afforded by the free vesication. This treat- ment may be aided by a mild course of alkali, but he does not regard this as essential, excepting when the rheumatic virus attacks the heart in the first instance, and seems to hesitate in fixing itself upon the joints. Dr. Ringer, of London, considers all the alleged good effects may be obtained by the use of " flying bhsters." Dr. A. Fleischman {Lancet, May ist, 1869,) looks upon a blister about two inches square, placed an inch and a half belbw the left clavicle, as an almost certain preventive of cardiac mischief. Cold Packing. Applying a mixture of pounded ice and salt to the swollen joint for not longer than five minutes at a time, will sometimes relieve the pain promptly. Or, the cold pack may be employed. Two dry blankets are laid on a bed, and over these a sheet, wrung out as dry as possible with cold water, is laid so that when folded it will completely embrace the affected limb or limbs. The patient is placed upon the sheet, which is tightly folded over the rheumatic parts and covered im- mediately with the blankets. This may be renewed every two or three hours. Hot Packing. This is much esteemed by some practitioners. As employed in Mount Sinai Hospital, New York City, the method is as foDows : The bed is prepared by spreading over it a sheet of rubber cloth, and over this a blanket. Hot blankets are then wrung out of water of a temperature about as hot as the hand can bear, and with these the patient is enveloped. Two or three thicknesses of dry blankets are superimposed, and the whole retained in position till the patient is free from pain — a time varying from two to six hours. When the pack is applied, the patient sweats very profusely, as might be supposed, and after its removal no danger has been found to occur. If the pain is confined to one joint, that joint is enveloped by the hot blanket, which is removed as soon as the pain disappears. One case of chronic rheumatism, extending over a pertod of seven months, was treated .by means of local packings, and after slight relapses, occurring at inter- vals for five weeks, was discharged perfectly cured. This method pre- sents the advantage in private practice of not shocking the friends of the patient as much as the ice and ice-water packings. CHRONIC RHEUMATISM. 613 Local Applications of Salicylic Acid. Salicylic acid, or the salicylates, may cc- casion an undue gastric disturbance when ordinarily administered. Under these circumstances, Randolph and Dixon (Med. News, 1885) advise that the acid be rubbed up with sufficient sweet oil, and applied upon a piece of leather or muslin about the swollen joint. Cutaneous absorption takes place quite rapidly and to marked extent, several cases of rapid relief being mentioned by the writers. CHRONIC RHEUMATISM. PROF. FRANCIS DELAFIELD, M. D., NEW YORK. Cases of this disease are apt to be extremely obstinate. A fair general plan of treatment is to give increasing doses of iodide of potassium, commencing with gr. x, thrice daily, together with coun- ter-irritation over the affected muscles. The very best form of counter-irritation, and one almost sure to produce decided relief, is massage, shampooing or kneading, by a skilled manipulator. Where the services of such a person cannot be obtained, the next best plan is to apply a succession of blisters, together with painting the part for a long time with tincture of iodine. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA, Says that the alkaline springs have long had a deserved reputation for the cure of chronic rheumatism. With the internal use of the waters should be conjoined baths, douches, etc. Rheumatic affec- tions of internal organs are equally amenable to the same treatment. The Turkish bath is Highly useful. In the so-called rheumatic gout, colchicum with alkalies is extremely serviceable. Attacks, without decided pain and inflammation, of soreness of joints, which have been the seats of gouty attacks, or. about which nodosities have been de- posited, are relieved by colchicum. Manganese is useful in rheu- matic patients of gouty antecedents. DR. HENRY HARTSHORNE, PHILADELPHIA. This author considers the treatment of chronic rheumatism largely experimental. Local treatment generally does more for it than medicine. He has found a liniment containing turpentine, oil of sassafras, ammonia and laudanum, diluted with soap liniment, of 6l4 DISEASES OF THK BLOOD. great use. Where pain is considerable, chloroform or aconite lini- ment is better. Blisters may be applied in bad cases. For rigidity of the joints, and for pain in them, pouring hot water continuously over the parts affords great relief. The hot or vapor-bath, as well as the hot dry-air bath (130° to 200°) will sometimes prove very effective. DR. FULLER? LONDON. In attacks of lumbago, this author recommends brisk purgatives at the commencement of the attack, when the bowels are costive and the urine scanty, high-colored, or loaded ; but when the urine is abundant and light-colored, the bowels regular, and the dejections natural, the value of purgatives is not so apparent. Cupping on the loins is of essential service — dry cupping when it is not thought de- sirable to extract blood. Baths rendered alkaline by carbonate of soda or potash ; hot fomentations formed by placing across the loins flannels wetted with an alkaline and opiate solution, and covered with a piece of gutta percha. In obstinate cases, stimulating and opiate embrocations. As excellent liniments in these cases he gives : 1020. R. Olei cajuputi, Tincturse opii, aa f. 3ij Olei terebinthinae, f. 3 iv Linimenti ammonue, f. S j. M For a liniment. Or: 1021. ]J. Liquoris ammonise, f. 3j Tincturae opii, f. 3 ij Tincturse cantharidis, f.3iij Linimenti saponis, f. 3 ^- M. For a liniment. Guaiacum has an old repute in chronic rheumatism. Dr. J. MlL- NER FOTHERGILL is said (Kansas City Med. Index, 1890,) to have prescribed the following frequently in chronic rheumatism : 1022. R. Acidi arseniosi, gr. iij Pulv. guaiaci, 3 iij Pulv. capsici, 5 ss Pil. aloes et assafoetidse, 3 iij. M. Divide into 120 pills. Sig. — One thrice daily. Dr. William Aitken gives the following formula: CHRONIC RHEUMATISM. 615 1023. g. Pulveris guaiaci, g; Pulveris rhei, 5;; Potassii bitartratis, Sulphuris sublimati, aa 3j Pulveris nucis moschatae, 5ij Mellis, j^j. M, Of this compound, two large spoonfuls are to be taken night and morning. It is used in some large hospitals, both civil and military, in the treatment of old chronic cases. The beneficial effects of guaiacum are obtained in those cases which are unaccompanied by perspira- tion, and in which the secreting organs are gently excited by this drug. When the diaphoresis is free, it does little good. The fol- lowing is used in the Philadelphia hospitals : 1024. R. Pulv. guaiaci resin., Potass, iodidi, aa gr. x Tinct. colchici semin., f. 3ss Aq. cinnamomi, Syrupi, aa q. s. adf.§j. M. A dessertspoonful to a tablespoonful thrice daily. 1025. U. Fl. ext. polymnije uvedalias, 3ij Adipis, §j. M. It should be applied twice daily. (Med. and Surg. Reporter, 1878.) ' MINERAL WATERS IN RHEUMATISM. Of the mineral waters which exercise favorable influence in the treatment of rheumatism, the alkaline waters are to be mentioned first, and the simple hot waters, the latter as baths. Dr. JUDSON Daland has classified the mineral springs of the United States, and states that sometimes brilliant results are obtained in chronic rheu- matism by their use. He mentions as a type of the alkaline springs, the Vichy (Grand Grille and Hospital) springs of France, and in the United States such as Saratoga Vichy, Ojo Caliente springs of New Mexico, and a number of others, especially along the Pacific slope. Of the hot springs, those of Virginia, Arkansas, Colorado and New Mexico are the most prominent. NOTES ON REMEDIES. Cajuputi Oleum. In doses of gtt. j-ij, in pill form, this has been given inter- nally, in chronic rheumatism, with alleged good efTects. It is also an ingredient in liniments. Cimicifuga. In some cases of this disease, this drug exerts a prompt and very positive healing action, but, as it frequently fails, it is impossible to point out the indications for its use. 6l6 DISEASES OF THE BLOOD. Guaiacum has long been esteemed in this disease ; f. gj of the tincture may- be administered thrice daily. (Or F. 1023.) Iodoform has been recommended by Dr. Knoll. 1026. B- lodoformi, Ferri redacti, aa gr. xliij Extr. glycyrrhizae, q. a. M. Make sixty pills. Two to be taken thrice daily. Kerosene. See Petroleum. Morrhuce Oleum is one of the most efficient remedies in chronic rheumatism with dyspepsia and general exhaustion. Opium and its alkaloids are especially valued in the form of hypodermic in- jections, as additions to liniments, etc. Petroleum has been used with much advantage, locally, well rubbed into the affected parts. Internally, a teaspoonful of kerosene, in water, every other night, has cured some cases. (British Medical 'journal. May, 1872.) Phytolacca Decandra. The poke-root has quite an extended reputation in this disease. No doubt it cures certain cases with astonishing prompt- ness. The indications for its use are, however, not definitely known. Polymnia Uvedalia, in ointment, is highly -esteemed. (F. 1025.) Potassii Jodidum is the most generally successful of all remedies, in this dis- ease. Sir James Paget has pointed out that the addition of carbonate of ammonia greatly increases its therapeutic action. Five grains of the iodide may be combined with three of the carbonate. Rhus Toxicodendron. Drs. Phillips and Piffakd give high -praise to this plant, in sub-acute muscular or tendinous rheumatism. The former says it is "positively invaluable." The latter has found it most useful in non-syphilitic cases, where the pain is worse at night. He gives "L /^-K of ^ tincture made by macerating one part of fresh leaves to two of alcohol. Sassafras. This is stated to be an efficacious remedy when the circulation is languiti, the skin dry, and the kidneys, liver, and bowels, inactive. It has the advantage over guaiacum, of not being purgative. Dr. Fuller, of London, recommends the following formula : 1027. R. Sassafras radicis, 3iss Mezerei, 3 iv Taraxaci radicis, § iij Aquae ferventis, Oj. M. Dose. f. S j-iss, conjoined with a plentiful use of diluents. Sulphur, internally, is often of benefit and is also beneficial in baths. TerebinthincB Oleum is a valuable addition to liniments and stimulating em- SCURVY. 617 brccations. Dr. Bremond, of Paris, recommends the employment of baths of the vapor of turpentine, which may be administered by plac- ing the body of the patient in a wooden' chest, the head remaining free. Into this chest, the vapor of water is conducted, loaded with a fine spray of oil of turpentine. The temperature of this vapor-bath is 105°-! 10° F., and the time during which a patient may be exposed to it is about fifteen minutes. Xanthoxylum. The bark of the prickly ash has long enjoyed a popular rep- utation in chronic rheumatism. Electricity, in its various forms, has been very extensively tried in chronic rheumatism. Sometimes the results are most satisfactory ; but Drs. Beard and Rockwell state that, on the whole, in cases of long stand- ing, they have been disappointed in its effects. SCURVY. Dr. Frederick P. Henry /J/^^. and Surg. Reporter, 1888,) in treating of this affection, lays stress upon the importance of diet in the aetiology of the disease. Just as prominent a place in the treat- ment is the question of diet, the list of articles which should be urged upon the patient including such articles as potatoes, onions, lemons, etc., as necessary to a cure. For the bleeding and spongy gums Dr. Henry is accustomed to prescribe a mixture of tincture of myrrh and chlorate of potassium, and painting with nitrate of silver if necessary. Internally Blaud's pills of iron should be prescribed in addition to the diet and such remedies as may be demanded by the symptoms of the case. Dr. CONSTANTIN PAUL (Form, de Facult. Med. de Paris) cautions that the patient must avoid dampness and preserve the hygiene of the body and house at as high a level as possible. He uses per- chloride of iron as an anti-hemorrhagic remedy, and orders acid fruits and legumes as a prominent part of the dietary. Faulkner (Indian Med Gez., 1887,) reports favorable results from the use of salicylic acid in the treatment of the disease. 6l8 DISEASES OF THE BLOOD. TYPHOID FEVER. PROF. ALONZO CLARK, M. D., NEW YORK. An average case of typhoid fever needs no medication whatever, except for the relief of symptoms. For the diarrhoea he gives : 1028. £1. Bismuth, subnit., 3j Morphise sulph., gr. j. M. M. et div. in chart. No. xij. One to four a day. The common astringents, tr. kino and tr. catechu, may be em- ployed ; and the decoction of blackberry root is sometimes very serviceable. In some cases, it requires the moderately free use of opium to restrain the diarrhoea. For the cough, the toxic expectorants will be most likely to do good. Perhaps one of the best that can be used, is the compound tincture of benzoin, in doses of ten drops on sugar, once in three or four hours. A very good combination is the tincture of the balsam of tolu and the mistura guaiaci* 1029. R. Mist, guaiaci, 3j-Sss Tr. balsam tolu, gtt. vj-x. M. This can be repeated every two, three or four hours. Sometimes the inhalation of the vapor of warm water seems to be required for one or two hours each day. Restlessness is one of the prominent features of the disease. This will very frequently be entirely quieted by sponging the surface of the body with warm or cold water. If the temperature is high, cold water is better than warm ; and in some cases a Dover's powder will be required. In regard to the temperature, if it be so high that the temperature of the body is 105° F., the patient may be placed in a bath having a temperature of 95° F. ; then some of the warm water can be re- moved, and be replaced by cold water until the bath has been re- duced to 80° F. If the patient is permitted to remain in such a bath twenty minutes, the temperature is usually reduced one, two, three, four, or even five degrees. He is then removed from the bath, put back into bed, and it will be several hours, usually, before the tem- perature will rise as high as it was before using the bath. When it rises, another bath is to be given, and in that manner repeated as TYPHOID FEVER. 619 often as may be necessary to keep the temperature below the point of danger. For' the hemorrhage of the bowels there is but little that can be done, unless, in. addition to absolute rest, the fluid extract of ergot be administered. For perforation, full doses of opium offer the best and only chance. The diet must be liquid, and nutritive. Milk, beef essence, etc., are demanded. Fresh air and free ventilation must never be ne- glected. BRAND'S TREATMENT. The method originated by BRAND, in Germany, some years since, has been slowly gaining favor, although at first it was regarded with positive dislike by the profession at large. In a clinical lecture (Internat. Clinics, 1891,) Dr. J. C. Wilson, of Philadelphia, details the results obtained by this method in the German Hospital of that city, in which the ratio of death is exceedingly low. The method of Brand, according to this eminent authority upon fevers, is, if it is to be depended upon at all, to be begun in the very early stages of the disease and continued throughout with persistent care. In cases past the first two weeks it does not appear to be followed with re- sults in any way so favorable, and it is advised that in such cases the ordinary symptomatic course of treatment be continued. The method of treatment by Brand's system is that of cold bathing. It is a rule that whenever the temperature is 103° or over the patient shall be placed in a bath near blood temperature, and the bath then cooled gradually but quickly, by permitting a stream of cold water to enter, to about 75° F. The patient is removed from the bath, placed quickly between blankets, dried under cover without permit- ting exposure of the surfaces. The temperature of the patient quickly falls after this procedure, but is apt to quickly rise again, when the bath is to be repeated. This repetition may be necessary as often as every two or three hours, or it may suffice if practised two or three times in the 24 hours ; some authorities insist, too, that if the temperature be excessive the patient be wakened in order to be bathed. After a very brief employment of the bath in a patient, beginning as prescribed above, the type of the case is changed, the severe nervous symptoms so characteristic of the disease are de- cidedly moderated, and many grave features are removed. It is true that this method has met with considerable opposition by various 620 DISEASES OF THE BLOOD. practitioners, but its steady growth in favor would suggest that these oppositions have been poorly based. In combination with the baths, the general symptomatic care of the case and the details of diet usually insisted upon are to be systematically and sedulously observed. Juhei.-Renoy practices Brand's method systematically (Form, de Fac. Med. de Paris, Steinheil.) He takes temperature every three hours, day and night, and every time the thermometer reaches 39° C, (i02.°2 F.) in the rectum he gives a bath lasting for fifteen min- utes, the water being at a temperature of 68° F. Three different times, each time lasting two minutes, at the begin- ning, in the midst and at the end of the bath, water at the tempera- ture td^ F. is poured gently down over the back of the neck. He has the patient drink during the bath. Then the patient is removed from the water, enveloped in dry covering, using precautions to avoid undue pressure over the abdomen. In twenty minutes the temperature is again taken. In grave cases baths are given every two hours in water 60° or 62° F. DR. ETHAN SPENCER, OF INDIANA. This author (Therapeutic Gazette, April, 1884,) has found the hydropathic treatment almost the only successful treatment in cases of typhoid fever, where there is much involvement of the bowels, and where almost all food or medicines irritate and distress the pa- tient. The surface in these cases is dry, the tongue dark and dry, the energies of the system fail and the functions are suspended ; the temperature need not be excessive. Here the tepid pack should be applied. Great care should be observed, by means of warmth to the extremities, to aid the system to react and thus to relax the surface and bring about a natural perspiration. The patient will often fall into a quiet sleep and rest for twelve hours. The pack should then be repeated*. In three days the tongue usually becomes moist, the dark color disappears, and every symptom becomes more favorable. professor BOUCHARD, OF PARIS. The therapeusis of typhoid fever comprises four indications, viz. : general antisepsis, intestinal antisepsis, antipyretic medication, and diet. At the beginning of the case he recommends that a saline purga- tive be administered. Every day for four days he would give about TYPHOID FEVER, 621 five or six grains of calomel in twenty doses — one every hour or so — watching, of course, that salivation should not ensue. Quinine is not indicated unless the rectal temperature exceeds 104° (F.) in the morning, or 1051^° (F.) at night. Quinine once given should not be repeated under seventy-two hours. Ordinary doses are gr. 30 for first and second weeks, twenty grains for the third week, and fifteen grains for the fourth and thereafter. Bouchard is in the habit of giving general baths — temperature of the bath to be about 3° or 4° (F.) below the central temperature of the body, and then it is cooled gradually at the rate of about the one-fifth of a degree a minute until it has reached about 86° (F.), below which he does not consider it safe to go. This he repeats as often as eight times in twenty-four hours. The baths are contra-indicated by intestinal hemorrhages and pneumonia; they may be continued during the menstrual period. All food except milk is withdrawn. Chloride of sodium, phosphates, vegetable acids such as lemon juice, are beneficial. Peptone and glycerine may be added to the dietary. BOSTON CITY HOSPITAL. The treatment at this hospital, as practiced under the surveillance of Drs. Stedman and DRAPER, is a modification of the bathing pro- cess, occupying an intermediate position between the full carrying out of cold-water bathing and the expectant treatment. On en- trance, patients are immediately put to bed, and their diet restricted to milk, of which they are expected to drink about two and a half quarts in twenty-four hours. This is perhaps the most fmportant part of the treatment ; at first they may object to milk, but on be- coming accustomed to it they take it freely. To keep up the strength is the chief aim, and if insufficient nourishment is taken, by giving a small amount at regular intervals, the end sought for is ac- complished. This diet is continued till the temperature has been normal for several days, when light soups and easily-digested fari- naceous articles are given ; in a few days more, a gradual return to regular, though still somewhat restricted, diet is allowed. To lower the temperature, sponge-baths, of equal parts of cold water and alcohol, are quickly applied to the surface of the body, which is immediately dried. In mild cases of diarrhoea nothing is done, two or three loose de- jections per diem not being considered harmful ; when, however, it 622 DISEASES OF THE BLOOD. becomes excessive, it is quickly checked by a pill composed of a grain of opium and a quarter of a grain of sulphate of copper. In delirium and wakefulness, when the patient can be made to tolerate it, the ice-cap is of great benefit. The frequent use of a mouth-wash, of equal parts of glycerine and rose-water, is very pleasant to the patient, relieving the foul taste and dryness of the mouth. In very mild cases, 20 drops of dilute nitro-muriatic acid may be given every two hours. Excepting the medicines above mentioned, no drugs are given, but every attention possible is shown to the comfort, nourishment, sleep and general welfare of the patients. Legroux (Le Bull. Med., 1888) practices the following method, which he believes has produced very, excellent results, both locally and generally. To all cases a good dose of calomel is given in order to sweep out the irritating and specific matters contained in the intestine. If the diarrhoea persist to undue amount or extent : 1030. R. Naphthpl, Bismuthi subnitratis, aa gr. xl. M. S. — Make ten powders and give one everj' hour in capsule or suspended in milk. If there be less diarrhoea the bismuth may be dropped from the formula. Where there is a tendency to constipation the following : 1031. R. Naphthol, Magnesii salicylatis, aa gr. xl. M. Hake ten powders — taken as above. This treatment possesses numerous advantages, as disinfection of the stools and intestines, diminution of the gaseous distension of the gut, the improvement of the general condition. PROF. WILLIAM PEPPER, M. D., PHILADELPHIA. This practitioner (Boston Medical and Surgical Journal, Oct., 1877,) recommends, in the second week of the disease, when the abdominal symptoms of pain and diarrhoea have fully set in, the use of nitrate of silver. 1032. Jl. Argent! nitratis, gr. M Extract! belladonniB, gr. X(, Extracti opii aquosi, gr. i^-V. M. For one pill. Three times a day after food. TYPHOID FEVER. 623 Under this treatment, diarrhcEa and tenderness diminish, and patients make very rapid recoveries. In most cases very little stim- ulant is used. Milk and beef tea are the only articles of food he allows. Quinine is given with other tonics. Fever is reduced by frequent spongings of the skin of the entire body. When the high fever resists sponging, cool baths are employed. Indiscriminate bathing in typhoid fever is often extremely injurious. The best time for the use of the cold bath is in the early stage, during the first week or ten days, in cases where the temperature rises above 103°, and is not controlled by frequent spongings, large doses of quinina, diaphoretics, etc. When the fever in subsequent stages runs high, it is of the nature of a sympathetic fever, largely dependent on the amount of intestinal lesion ; hence, cold baths are lefss valuable at that time and attended with more risk. Nitrate of silver is used, both with the hope of limiting the amount of specific follicular catarrh of the intestines, and with the intention of favorably modify- ing the secondary sympathetic symptoms. Dr. PEPPER has cured thirty-nine out of the forty cases of typhoid fever in which it has been employed, by this nitrate of silver treatment. THE TURPENTINE TREATMENT OF TYPHOID. The oil of turpentine has been very largely used in this disease, but in different manners. The typical turpentine treatment is thus described by Dr. A. Maffitt, in the Lancet, February, 1876: As soon as the disease is diagnosed, oil of turpentine, in one-half- drachm doses, made up with mucilage of eggs, is given four times a day, and continued throughout its course ; and nourishment in the liquid state, such as beef tea, milk, chicken broth, eggs beaten up, etc., is given freely, and a stimulant, generally brandy, administered as the symptoms indicate. Prof. H. C. Wood (Med. News, 1890,) claims the credit of the first use of turpentine in typhoid fever for his uncle. Prof. GEORGE B. Wood. He recommends two periods when it is indicated, first at the end of the second week, when the tongue is dry and glazed and tympanites is present, with or without diarrhoea. The second is during convalescence when ulceration of the intestine persists, as shown by impaired digestive power and diarrhoea. The following formula may then be prescribed : 624 DISEASES OF THE BLOOD. I033- R- 01. caryophylli, lUvj 01. terebinthinje, f-Siss • Glycerini, Mucilaginis acacire, aa f. 3iv Syrupi, f. i j Aquffi, q. 3. ad f. § iij. M. Ft. emulsio. Sig. — ^Two teaspoonfuls every two or three hours. Dr. R. P. White, of the Meath Hospital, Dublin, (British Medical Journal, December, 1877,) reports flattering success with this method. He gives the following turpentine mixture : 1034. R. Olei terebinthinee, Liquoris potassx, 55 f. 3 ij Mucilaginis acacise, f. 3iv Syrupi papaveris albi, Syrupi ttoris aurantii, 55 f. 3 viij Aquse camphorae, q. s. ad f. § viij. M. A tablespoonful to be taken every fourth hour, the bottle being first shaken. Since he commenced this treatment, he has never lost any case of typhoid from either bronchitis or diarrhoea, or from its sequelae of ulceration or hemorrhage. He does not know any symptom which contra-indicates the adoption of this plan. According to the majority of writers, there are two conditions in typhoid when turpentine is of the utmost value. About the end of the second week, the tongue sometimes becomes very dry, red, chapped, perhaps coated in the centre with a brownish fur, and at the same time marked meteorism develops. Ten d.rops of turpen- tine every two hours during the day, and every three hours during the night, will, in the majority of cases, remove these threatening symptoms. Again, when the diarrhoea persists after the acute stage of the fever is passed, when the convalescence is protracted, and, evidently, the ulcers of Peyer's patches are slow to heal, turpentine acts almost as a specific. It has been recommended in S to lO-drop doses, frequently repeated, for the intestinal hemorrhage, and in doses of f.5j, every six hours, when there are tympanites and pros- tration, but no diarrhoea. THE SPECIFIC OR ANTISEPTIC TREATMENT OF TYPHOID FEVER. This method of treatment, based upon the theory of the origin of the disease from germs, has found favor with some recent observers. The following is the plan pursued by TYPHOID FEVER. 625 DR. J. C. WILSON, OF PHILADELPHIA, as set forth in the Med. and Surg. Reporter, 1884. He orders the patient to bed, and gives fluid food in small amounts at intervals of 2 or 3 hours. At night he gives gr. vj-viij of calomel. This dose is repeated eveiy second evening until three, or rarely four, doses have been given in the course of the first six or eight days. It is given alone, or in connection with sodium bicarbonate. There is commonly a slight increase of diarrhcEa, if it be present, without aggravation of other symptoms ; and in some instances the tendency of the temperature at this time to steadily rise appears to be controlled. If no diarrhoea had been present, the calomel usually produces two or three large evacuations on the following day. If the case does not come under observation until after the tenth day, one only, or at most two, doses of calomel are given. In only one case in sixteen was there observed mercurial fetor, and slight swelling of the gums. Excessive diarrhoea is controlled by opium. The author lays down the invariable rule of maintaining a hori- zontal posture. From the beginning of the attack, one, two, or three drops of the following mixture are regularly administered in a wine- glassful of ice-water, after food every two or three hours, during the day and night : '°35- R- Carbolic acid, gtt. jj Tincture of iodine, gtt. iv. Sponging with aromatic vinegar and tepid or cold water is advis- able, because cleanly, grateful to the patient, and to a slight degree refrigerating. When the axillary temperature reaches 104° F., quinine in 24 to },o grain doses should be given on a falling tem- perature, and repeated in from forty-eight to seventy-two hours if necessary. Alcohol is not recommended in the early part of the sickness, unless the patient be used to it. The average duration of the disease was twenty-eight days. As salicylic acid is of all remedies known one of the most poison- ous to bacteria, and as bismuth is indicated for the bowel affection. Dr. H. Desplats, of Lille, has prepared a salicylate of bismuth, and found that it may be given in large quantities with good results (New Remedies, 1883). The following working process will furnish a good product : 626 DISEASES OF THE BLOOD. 1036. R. Subnitrate of bismuth, 4 parts Salicylate of sodium, 7 P"ts. Nitric acid, \^a,ter, each a sufficient quantity. Mix the subnitrate of bismuth, in a flask, with twenty-five parts of water, and gradually add nitric acid, constantly stirring, until the subnitrate is dissolved, avoiding an excess as much as possible. Dissolve the salicylate of sodium in two hundred and fifty parts of water. Then, while stirring the latter, pour the solution of nitrate of bismuth gradually into it. Collect the precipitate on a filter, wash it thoroughly, and dry it. Average yield : 3.75 parts, or about 94 per cent, of the subnitrate. Grimshaw (London Lancet, 1888,) prescribes the following mix- ture : 1037. R. Carbolic acid, lUxij Tinct. iodine (B. P.), IUxvj Tinct. orange peel, f. 3iss Syrup, f. 3iij Water, f. § viij. M, S. — Two tablespoonfuls every four hours for the first fortnight, or until urgent symp- toms yield, when the same dose is administered three times a day. This mixture usually causes an improvement almost immediately; and in a very few days the pulse falls to a more nearly normal rate, gains in strength, the temperature recedes, the tongue becomes moist, diarrhoea ceases, and the general symptoms of the patient im- prove rapidly. He states that of 1 16 cases thus treated, but one has failed to result in complete recovery; and in this single instance death did not occur until some time after the disease was apparently over, from which he is disposed to regard it as due to some adven- titious cause. DR. G. WILKES, ENGLAND. Although the antiseptic method of treatment cannot be considered as established, there has been enough testimony in its favor to com- mend it to careful consideration. In 1870, Dr. G. WiLKES, of Eng- land, recommended the administration of sulphurous acid, acidum sulphurosum, in enteric fever ; and in this country. Dr. J. WESLEY BOTKIN, of Illinois, (Medical and Surgical Reporter, May, 1876,) and others, have testified to its efficacy. The dose is from gtt. x-xx, every three or four hours, in lemonade. It can be combined with opium or digitalis. It should be continued until the tongue is per- fectly clean. TYPHOID FEVER. 627 In the Practitioner, September, 1873, Mr. Stephen Skinner re- ports very excellent results from the sulpho-carbolate of soda. He generally commenced with gr. xx every four hours, gradually in- creasing, during the next four days, to the full dose of gr. xxx. A larger dose than this may produce cerebral symptoms. When the diarrhoea was excessive, opium was combined with the salt. He also claims that, by its early use, the premonitory symptoms of the disease are dispersed, and the threatened attack aborts. PROF. HARLEY, ENGLAND. In his Lumleian lectures, Harley, (London Lancet, 1889,) urges a decided course of treatment. To stimulate the functions of the skin, and to assuage thirst, he advises : 1038. R. Ammonii citratis, gr. 1 Spts. ammonii aromatic!, IIlxx Sodii bicarbonatis, gr. xx Aquae, q. s. M. Sig. — Add to the above, when to be administered, several spoonfuls of lemon juice, so as to make an effervescing draught. Such a dose every 3 or 4 hours. He applies hot flaxseed poultices to the trunk, abdomen, and to the chest, now anteriorly, now posteriorly, to prevent congestions. He does not favor either hot or cold bathing, believing the latter in- creases internal congestion. Alcohol is beneficial moderately used ; and the light, nutritious, fluid diet a necessity. DR. WOOLBRIDGE. (Jour. Amer. Med. Assoc, 1888.) Before the meeting of ^he American Medical Association in May, 1888, the author discussed the treatment of typhoid fever from an antiseptic point of view, seeking to fulfil two indications : (a) to destroy or alter the progress of the germs of the disease ; (b) to combat the ptomaines which are developed during its course. In carrying out these he uses an anti- septic mouth-wash with listerine added, and occasionally (about three or six times daily) red iodide of mercury in doses of ^j^ grain, triturated with sugar, are used. The antiseptic influence of this is, doubtless, felt in the mouth, oesophagus, stomach and bowels. But the main dependence for intestinal antisepsis is sodium salicylate, in doses of 10 grains every two or three hours. As the best antiseptic for the bowel below the ileo-caecal valve he improvises a decoction of chamomile flowers and borax — a handful of chamomile flowers in 628 DISEASES OF THE BLOOD. three pints of water, allowed to simmer for an hour, strained through cheese-cloth, and a teaspoonful of powdered borax added. TYPHO-MALARIAL FEVER. DR. ROBERTS BARTHOLOW, OF PHILADELPHIA, Has seen excellent results from small doses of Fowler's solution three times a day in typho-malarial fever. When there is much diarrhoea, a few drops of tincture of opium should be added to each dose of arsenic. In doses of half a drop to one drop of FoWLER'S solution, the tongue cleans, the skin becomes moist, and the de- lirium lessens, in a most remarkable manner, sometimes. DR. JEFFERSON D. WILLIAMS. This writer, practicing in Mississippi, relates an extensive exper- ience in this disease. (Virginia Medical Monthly, March, 1877.) In its treatment, he condemns quinine, believing that it aggravates the symptoms. The most essential point, he has found, is to control the diarrhoea, tympanites, and pain in the bowels. To this end, he administers subnitrate of bismuth, gr. xxx ; pulvis ipecac, et opii, gr. X, every few hours; this failing, and the diarrhoea becoming exces- sive, he checks it by injections of opium, acetate of lead, subnitrate of bismuth and glycerine. When the red and dry tongue, the tym- panites and pain, denote active inflammation of the intestinal tract, he trusts to frequent doses of chlorate of potash, a teaspoonful of a saturated solution, every one, two or three hours. Turpentine he haE| not found to be of value. Abundant, easily-digestible food, and moderate stimulation, are required throughout the disease. DR. ALONZO HARLOW, DETROIT, MICHIGAN. In typho-malarial fever, this physician states (Peninsular Medical Journal, December, 1873,) that he has used, with much satisfaction, the following: •039- R- Quinise snlphatis, gr. xxx Olei piperi nigri, gtt. xxiv Acidi sulphurici aromatici, 3j Syrupi simplicis, f. § iv Alcoholis, f.|j. M. Tablespoonful every hour, until half the quantity haa been used; afterward, every other hour. If the chill recur, repeat in same or less quantity ; milk-punch to TYPHOID FEVER. 629 be used freely. He used aconite, or veratrum viride, or gelsemium, for the fever, and did not believe in too general stimulation with alcoholic stimulants. At a later stage, and in some cases, diffusible stimulants, as ammonium carbonate and brandy, are necessary. NOTES ON REMEDIES. Adda. The mineral acids have been, at times, much prescribed in typhoid fever. Dr. George Johnson, of London, however, discountenances them, on the ground that they must irritate the ulcerated mucous membrane of the intestines, cause pain and griping, and increase the diarrhoea. Acidum Phenicum is highly commended as an anti-febrifuge by M. Van OYE,of France. He commences with a dose of seven and a-half grains, per rectum, and progressively increases, until he reaches half a drachm, six times daily. Alcohol. The value of alcoholic stimulants, in typhoid, has been much dis- cussed. The following judicious rules are those laid down by Dr. Alfred L. Loomis, of New York : First. They should never be administered indiscriminately — that is, never give a patient stimulants simply because he has typhoid fever. Second. When there is a reasonable doubt as to the propriety of giving or withholding srimulants, it is safer to withhold them, at least until the signs which indicate their use become more marked. Third. In every case — but especially when stimulants are not clearly indicated — watch, carefully, the effect of the first few doses. There are few whose experience in the treatment of typhoid fever is such as to enable them to positively determine, from the appearance of the patient, when the administration of stimulants should be commenced. Should you commence the administration of stimulants, it is neces- sary to see your patient every two hours, and note carefully the effect produced. If you find the tongue becoming dry, the patient more restless, the delirium more active, the temperature ranging higher, and the pulse more and more rapid, you may be certain that stimulants are contra-indicated. If, on the other hand, the pulse becomes fuller and more regular, if the first sound of the heart is more distinctly heard, or if having been absent, it has returned, if the restlessness and delirium are less marked, the tongue more moist, and the patient mere intelligent, you may be certain that the time for the administration of stimulants has arrived. When you have commenced their use, it is of the greatest importance that you administer them at stated intervals, especially during the night. In a severe case of typhoid fever, a free administration of stimu- lants, just at a critical period (which may not last more than twenty- 630 DISEASES OF THE BLOOD. four hours), will often be followed by a refreshing sleep, and your patient may rapidly pass from an apparently hopeless condition to one of convalescence. Alumen may be employed to check the diarrhoea. Ammonii Acetas and Carbonas are often exhibited, the former as a febri- fuge, the latter as a stimulant. Prof. Baktholow, however, considers that all salts of ammonium are distinctly contra-indicated by the ex- cess of that element in the blood jn this disease. Aniipyrin and Antifebrin have both been tried in typhoid fever as antipy- retics, but the results have not been as favorable as might be desired, because of the depressive influence of both drugs. Argenti Nitras is recommended by Pepper as of especial use in aiding in the healing of the ulcers in the convalescent stage. Bismuthi Subnitras finds imporant use in controlling the diarrhoea of typhoid fever. Borax is recommended by Dr. Woolbridge as an antiseptic agent, adminis- tering in enema for cleansing the bowel below the ileo-caecal valve. Caffea. Dr. Pigne-Dupuytren, of Cal., speaks in the highest terms of coffee in this disease. (Pacific Med. and Surg. Jour., April, 1879.) His rule is as follows : Give (to an adult) two or three tablespoonfuls of strong, black coffee (without chicory) every two hours, to be alter- nated with one or two spoonfuls of good claret or Burgundy wine. Make the patient take, in the course of the day, a few wineglasses of lemonade or citrate of magnesia : then sulphate of quinia. Dr. Rad- CLiFFE, of London, has used it for years in this disease as a stimulant, in the place of alcohol. Caffeine in a 25 per cent, solution, combined with an equal part of sodium benzoate to help the solution and render it more nearly painless, is used by Huchard subcutaneously in cases where circulatory failure demands the use of stimulants. Camphora is frequently excellent in allaying the nervous agitation. Carbolic Acid is very favorably mentioned by Grimshaw (F. 1037) in the treatment of typhoid fever. Chloral is often serviceable, in small doses, to induce sleep. Digitalis. Dr. Wtjnderlich has recommended this drug to lower the tem- perature and slacken the pulse. Other German writers have also \irged its claims, sometimes for its alleged antipyretic effects, some- times as a roborant of the heart, but as yet no positively favorable opinion can be pronounced for its exhibiiion in this disease. Ergota. This is of great value in the hemorrhage of typhoid. A common prescription in St. Thomas Hospital, London, is : TYPHOID FEVER. 63 I 1040. R. Tincturse opii, Olei terebinthinje, Spts. chlorofonni, 55 TUx-xx Acidi tannici, gr_ ^ Mucilaginis et aqiuc, q. s. M. For one dose. When this is not retained by the- stomach, the following may be tried: 1041. R. Acidi tannici, gr. x Ext5acti ergotje fluidi, 3ss-j. M. For one dose every hour. Or, gr. V of ergotin may be used hypodermically. In 1883 Dr. Du- BONE, of Pau, published a brochure in Paris claiming that sound, fresh ergot (preferably in powder) would reduce the mortality of the severe type of typhoid to less than six per cent. The dose is gr. x-xx, thrice daily. Concentrated and abundant nourishment fills the remaining indication. Eucalyptus Globulus, a teaspoonful of the tincture, well diluted, at regular intervals of three or four hours, is highly recommended by Dr. Benja- min Bell, of Edinburgh. lodinium. In St. Francis Hospital, London, iodine is given internally in ail cases of typhoid fever. It is thought to lessen the troublesome gastric irritability so often present, and to diminish the number of evacua- tions from the bowels. The following formula is usually employed : 1042. R. lodinii, 3j Potassii iodidi, 3>j Aquse dest., f. 3". M. Gtt. iij in a wineglassful of water every thr^e hours. Lugol's solution, the liquor iodinii comp. of the Pharmacopoeia, may be used in doses of six drops every three hours. The cold bath, quinine, and iodine, with close attention to the diet and the exhibition of stimulants, when indicated, constitute there the main features in the treatment of typhoid fever. Hydrargyrum. The old practice of giving small doses of calomel at the com- mencement of the disease has largely fallen into desuetude. It is, however, recommended on the high authority of the late Dr. Parkes. The gums should not be touched. Sometimes the diarrhoea will yield to gr. 1^5 of corrosive sublimate every two or three hours. Drs. Kalb and Bartlett (Brit. Med. your., 1888,) report a rapid deferves- cence in cases of typhoid treated by daily inunctions of 15 grains of mercurial ointment. 632 DISEASES OF THE BLOOD. Hypodermic doses of calomel are said to very favorably influence the course of cases of typhoid fever. Kairin has been tried as an antipyretic, but is condemned as dangerous in this disease by Dr. F. W. Draper, of Mass. (1884.) Naphthol is stated by a number of writers to be a valuable adjunct in treat- ment as an intestinal antiseptic. CEnothera Biennis. Dr. J. F. Sullivan says of this remedy, in the Pacific Medical and Surgical Journal, January, 1878 : "I am convinced that it essentially modifies the inflammatory condition which precedes ulceration of Peyer's patches, and that its use may frequently prevent ulceration. The usual dose in typhoid fever is from fifteen to thirty drops every three hours." Opium is of great value to allay the nervous jactitation and insomnia. One- eighth of a grain of morphia in an ounce of camphor water is an ad- mirable draught. It may also be given in the diarrhoea. Neverthe- less, it must be used cautiously. Dr. George Johnson has pointed out that although the direct effect of opium is soothing, yet that, when given in sufficient doses to render the intestines torpid, it acts indi- rectly as an irritant by retaining the putrid morbid secretions until they decompose and give off noxious gases, which distend and irritate the bowel, and thus increase and prolong the diarrhoea. Phenacetin, according to Lepine (La Sem. Med, 1888), has had no unfavor- able effects, except in profuse sweating, when given in eight-grain doses, in powder. It is a powerful antipyretic, arid is perhaps the safest of the coal tar products, but in employing the drug constant care should be had lest it dangerously depress. Polassii Bromidum is one of the best agents to combat the restlessness. Quinia. The use of quinia as an antipyretic and its administration have been discussed above. Its value is far from proven. As a tonic in the later stages it is highly and justly esteemed. Plumbi Aceias is sometimes useful in checking the diarrhoea. Salicin and Salicylic Acid have been largely employed for their antipyretic and antizyraotic properties. The salicylates are regarded with grow- ing favor, particularly the sodium saHcylate, in ordinary typhoid fever. In the " typho-malarial " cases ammonium salicylate is especially ef- fective. Serpentaria. Dr. Bartholow considers that in typhoid fever serpentaria is indicated, and is unquestionably serviceable when much depression exists. It is apt to increase the diarrhoea, however, and must be given with caution when the intestines are very irritable. The fluid extract is an appropriate form. TYPHUS FEVER. 633 Sulphocarbolate of Zinc is regarded as of great value internally in this disease by Prof. Waugh, of Philadelphia. Terebitithince Oleum. f'See above, p. 623.) Verairum Viride has been lately urged by Dr. A. W. Nelson, of Connecticut, as of much value in typhoid as a cardiac sedative. His method of treatment is to administer the officinal tincture in doses of one to two drops every hour, from the commencement of the disease to convales- cence. As veratrum viride is eliminated rather rapidly from the sys- tem, he estimates that these patients were usually under the influence of from three to twelve drops continuously. His conclusion is that : "A tendency of the typhoid ferment to exhaust itself at about fourteen days, the veratrum viride emphasizes; so that very many cases determine at twelve days, some at fourteen or fifteen, a smaller number at three weeks. Very few determine indefinitely, as do a large proportion in other treatments." (Compend. Med. Sci., 1883.) TYPHUS FEVER. DR. JAMES TYSON, OF PHILADELPHIA. The treatment is exceedingly simple. In the first place, we know that the greatest danger arises from asthenia, especially during the eruptive stage, which we might say is the most important period. To guard against this, we must use stimulants freely. If there is one disease in which the free use of alcohol is especially indicated, it is typhus fever. The quantity to be used should, of course, be gov- erned by the condition of the patient. In some cases it may be necessary to give an ounce every hour. In addition to the use of alcohol, quinine is absolutely indispensable. Digitalis should also be given, both as an antipyretic and as a heart-strengthener. When the temperature becomes high, sponging of the body is necessary. After the crisis, which, in this disease, is strikingly well marked, it is simply necessary to treat symptoms as they arise. Of the compli- cations, one of the most frequent is bronchitis, which, of course, should be treated as any other bronchitis. Diarrhoea is an unusual symptom. HENRY HARTSHORNE, M. d!, PHILADELPHIA. The treatment should commence wkh a mild laxative, as citrate of magnesia or rhubarb. Small doses of oil or enemata may be needed throughout the attack. 634 DISEASES OF THE BLOOD. To combat the depression of the middle stage, the mineral acids have considerable reputation. Either dilute sulphuric, nitric, or nitro-muriatic acid may be used : '043' R- Acidi nitrici, gtt. xl Aquae, f. S iv. M. One or two tablesponfuls every three hours. 1044. g. Acidi nitro-muriatici, f. 3ss Spiritfls setheris nitrosi dulcis, f. 5 ss Aquae camphorae, f. § vss. M. A tablespoonful every two or three hours. Quinine acts well in one or two-grain doses, four or five times daily, after defervescence has begun. Dr. H. is satisfied that the plan of treating typhus early with large doses of quinine is not only futile, but unsafe. The diet, at first, may be of gruel, toast water, etc., but very soon must milk and beef tea^ or chicken or mutton broth (or an alternation of these), be given to support the strength. Before the first week is out, half the cases will need wine in modera- tion, some brandy or whiskey. In the second and third week more than half the cases will require steady support of a positive kind. In such cases the proper routine is a tablespoonful of brandy or whiskey punch (one part of spirit to three, two, or one of milk) every two, three, or four hours, and the alternate hours a table- spoonful or two of beef essence or beef tea. The great point of skill will be to determine when and how far to stimulate. Delirium favors the probability of its being needed, es- pecially a low, muttering delirium. Of course a very feeble pulse indicates it. On trial, when the pulse grows slower, the skin more moist, and the restlessness or delirium is quieted, the stimulus has done good, and should be continued. If, on the contrary, a more hurried or a harder pulse follows, with heat of head and dryness of skin, and wilder delirium or deeper stupor, it should be stopped, for a while at least, or, if given, be diminished in amount. Hypostatic pneumonia, in typhus, cannot be treated actively. Even abstraction of blood by cups is hardly ever to be ventured upon. Dry cups, between the shoulders, and a blister upon the the breast, will be as far as we can go. PROF. M. CHAKTERIS, M. D., GLASGOW. This author approves of the plan pursued by the late Dr. J. Hughes Bennett, of giving an emetic in the early, incubatory stage TYPHUS FEVER. 635 of the disease, which, he believes, will often abort the attack. When the fever once sets in, he confines himself to treating symptoms. He gives a purgative at the outset, of rhei pulveris, gr. xkx-lx ; subsequent constipation he relieves by enemata of tepid water. The head should be shaved, and cold lotions applied. Stimulants are called for when there is rapid, feeble pulse, and weakness of the first sound of the heart. If the debility is marked, the patient must be roused to take them. When there is much nervous irritability, with. sleeplessness, a sedative, such as the following, ig required : 1045. R. Potassii bromidi, 3"! Chloral hydratis, 3 ) Aquse, f. | viss. M. A tablespoonful every two hours. H. McNAUGHTON JONES, M. D., DUBLIN. This practitioner has derived great advantage, in typhus fever, horn, digitalis. (Dublin Journal of Medical Science, April, 1875.) His usual prescription is: 1046. R. Tincturfe digitalis, ' ^theris chlorici, aa gtt. xx. M. In water, every three or four hours. This has a well-marked effect in strengthening the pulse, lowering the temperature, preventing delirium, and improving the secretions. He believes cases to do better, under this drug, without alcohol in any form, and formulates the following conclusions : 1. That in the treatment of fever, typhus and other forms, too much reliance has been placed on alcoholic stimulants, and that fashion, rather than reason, has swayed many in their indiscriminate employment. 2. That the percentage of cases requiring such stimulants is a low one, and that while our administration of them, as regards quantity and kind, must depend entirely on the condition of the patient, still, the utmost caution is required. 3. That in digitalis we have a powerful cardiac stimulant, which, while it gives force to the heart, does not do so at the expense of the system, but rather is a conservative agent, which controls expendi- ture and limits waste of vital action. 4. That digitalis appears to be indicated in the early periods of many cases of typhus, in which we have a rapid pulse and high 636 DISEASES OF THE BLOOD. temperature range, regulating our administration by its efifects on both, using it rather with the object of guiding the patient up to a certain point, than of curing the disease. TREATMENT BY COLD BATHS. The cold-bath treatment has been strongly urged by Professor MOSLER. He gives the following manner of applying it: The pa- tient is placed, as far as the neck, in a water-bath at a temperature of 64° Fah., or of one or two degrees lower than this. When the temperature of the water is raised by the heat of the body, it is im- portant to restore it to its original state — that is, to 64°. During the bath, the cold water should be poured over the head of the pa- tient ; this douche should not be warmer than the water in the bath, but sometimes even a little colder. This plan of treatment is to be carried out whenever the thermometer placed in the patient's axilla marks 103° Fah. The duration of the bath must be regulated ac- cording to the nature of the sensations of the patient, and should be suspended whenever complaints are made of intense cold. The ordinary duration is from ten to thirty minutes ; th,e patient is then to be dried with great care, and placed in a well-warmed bed. It is a good plan to administer to the patient, after the bath, some strong red wine. Dr. SCHOLZ, of Bremen, has carried this plan out very success- fully, in both typhus and typhoid, with some modifications. He uses a bath from 50° to 70°, and considered it indicated whenever the axillary temperature rose to 102°. (Medicinische Rundschau, 1872.) When immersed, the patient either moved himself or was lightly rubbed. The duration of the bath was from ten to fifteen minutes, or, in many cases, not more than five or six minutes. He was placed in bed without being dried, and was covered with a woolen coverlet. When the brain was much affected, cold douches were directed against the head whilst the patient was in the bath, and ice-caps were occasionally used. Cloths dipped in cold water were placed, at intervals of a quarter or half an hour, upon the chest and belly. These appeared to exert a favorable influence upon the diarrhoea, and were felt to be agreeable to the patient. Scarcely any drugs were administered. The diet was light, but nutritive. In very severe cases, where there is no material augmentation of the animal heat. Dr. ScHOLZ does not think it right to use the baths, but brings the skin into action by powerful thermic and mechanical TYPHUS FbVER, 637 irritation (frictions). Dr. ScHOLZ distinguishes two periods in the treatment of the disease — in the first, or early period, the patient must not be bathed at night, and not more than five times during the day ; whilst, in the second or later period, the number of baths may be sufficient to keep down the temperature of the body to near its normal degree. NOTES ON REMEDIES. Alcohol, in some form, is recommended by most authors. The indications for its use are given above. Belladonna is recommended by Dr. Graves when stupor with contraction of the pupil supervenes. Digitalis has been highly praised by Dr. H. McNAUGirroN Jones. (F. 1046.) Erythroxylon Coca. From the ascertained fact that this drug diminishes the amount of urea secreted. Dr. SA^^;EL McBean has recommended it in typhus and typhoid fever. (British Medical journal, March, 1877.) He gives f 3J of the tincture every four hours, combined with a little ginger if it causes flatulence. Moschus. Dr. Murchison considers that musk is a stimulant of very great value, which has fallen into unmerited neglect. It may be given in the following formula : 1047. R. Pulveris moschi, gr, x Mucilaginis acaciae, Syrupi aurantii, ai f. 3 ij AquK camphorse, f. S S8. M. This amount at a dose every five or six hours. Opium. The use of opium in typhus varies greatly. Some authorities con- sider it always dangerous. Dr. Murchison discriminates between three forms or stages of the disease ; when the delirum is active and the pulse of good strength, he would combine opium with a depres- sant and push it ; e. g. ; 1048. R. Liq. opii sedativi, f-Sj AntimMartratis, ^i' • w Aquae camphone, f. 3 yj, M. A tablespoonful every hour until sleep is induced. When the pulse is feeble, and the delirium wandering, the opium should be combined with stimulants ; e. g. : 1049. R, Liq. opii sedativi, (•??' Splritfls ffitheris, ••3) AquK camphorse, f- 9 "»*■ "*• Two tablespoonfuli every hour until sleep is induced. 638 DISEASES OK THE BLOOD. Finally, when there is dyspncea, a livid face, nervous congestion and a contraction of the pupil, opium is wholly contra-indicated. Potassium Nitras may be given alone or in combination, to stimulate the secretions. Dr. Murchison recommends nitre whey, prepared by boiling gij of nitre in Oj of milk, and straining. QuinicB Sulphas is given by some physicians in large doses, gr. xx-xxx at the outset, to abort the fever and as an antipyretic. The effect of this treatment has not been generally satisfactory. The same may be said of the adminstration of an equal amount in the twenty- four hours, in divided doses. Small doses at regular intervals are more beneficial, as : 1050. R. QainJEe sulpbatis, gr. ss-j Acidi sulphurici diluti, gtt. xx-xxx Athens sulphurici, gtt. xx Syrupi, f. 3j Aquam, ad f.gj. M. For one dose, eveqr three or four hours. Su/phuricum Acidum, and the other mineral acids, are largely used and favor- ably spoken of. (F. 1050.) VARIOLA-SMALL-POX. DR. TALAMON, PARIS. i^La Med. Moderne, 1890.) Talamon has endeavored to dimin- ish the tendency to pitting in small-pox by spraying various antisep- tics held in ethereal solution upon the pustules. Where the erup- tion is slight and the type of the case generally a mild one, salol does well ; but in all other cases his preference is for corrosive sub- limate. He uses a solution made as follows for this purpose : 1051. R. Corrosive sublimate, Citric acid, 5a gr. xr Alcohol (90 per cent.), IH. viij Ether, As. ad f. § iss. M. This is to be sprayed over the surface three or four times a day until desiccation takes place, the eyes being well protected by pledg- ets of cotton squeezed out of a saturated solution of boracic acid. In the intervals the surface may be brushed with a glycerole of cor- rosive sublimate (i :iS). In grave caseswhere the eruption is con- fluent, tepid baths should be administered, an ounce of corrosive sub- limate being added to the amount of water usually used for a bath. VARIOLA — SMALL POX. 639 DR. W. R. CLARIDGE, OF PENN'A. The use of salicylic acid as an abortive is highly lauded by this writer (Med. and Surg. Reporter, June, 1883). The dose was gr. x every three hours. In the case described, on the third day of its administration, the pustules began to abort, their contents absorbed gradually, leaving a pale, thin scab, or scale, much resembling a minute fish-scale. These scales separated so rapidly that large quantities were removed each morning when changing the bed linen. In two weeks the patient was convalescent, after which the remedy was continued one week longer in same dose three times a day. DR. LEWENTANER, OF CONSTANTINOPLE. Lewentaner (Therap. Monatshefte, 1889), writing of variola in children, recommends that a paste of carbolic acid in starch and oil of sweet almonds be applied to the face by a linen mask. The trunk and extremities are to be frequently anointed with 1052. R. Glycerini, 70. Amyli, 30. Acidi salicylici, 3. M. In addition he gives the following internally, partly for its local effect on the pharynx : '053- K" 01. amygdal. dulc, 15.0 parts Syr. aurant. flor., 30.0 parts Aq. laurocer., lo.o parts Quinina; hydrocblor., 0.3 parts Solve in Acid, hydrochloric, q. s. f, emulsio. Sig. — Every quarter to half hour several drops to be instilled into the throat. DR. E. PRIDEAUX, ENGLAND. This writer gives in the Lancet, \2>TJ, the treatment of small-pox which he has employed with much success. On entering the small- pox hospital under his charge the patients were ordered : 1054. R. Acidi salicylici, _ gr. xx Sodii bicarbonatis, Ammonii carbonatis, aa gr. Iv. M. This amount in water every two or four hours, according to the severity of the case. In the later stage of the disease gr. v of citrate of iron and ammo- nia were added to this mixture. In the first stage of the disease the patients were placed in baths 640 DISEASES OF THE BLOOD. of 90° and cooled down to 70°, they being allowed to remain in them about fifteen or twenty minutes. These baths were adminis- tered every day, and in severer cases twice daily. After each bath they were painted over with a mixture of glycerine, gelatine, and carbolic acid, in the following proportions : 1055. R. Acidi carbolici, f. Sj Glycerini, f- S yj Gelatinje, f. § j Aquas, f. § xx^^j- M. For local use. As soon as the pustules were full, those on the face were picked, if necessary, and the gelatine mixture painted on frequently. All the patients had at their own desire a pot of the mixture, with a brush, in order that they might paint their faces frequently. They said it relieved the pain, and entirely prevented any itching. It kept the skin soft and moist, acting as an antiseptic, and preventing any unpleasant smell. In this stage of the disease each patient had a warm bath daily. Later on, soda in considerable quantity was put into each bath, and the patients well washed with carbolic soap, to aid the desquamation, and so expedite their removal from the hospital. The results were very gratifying, in that there was almost an en- tire absence of pitting, whilst the marks left even in the most se- verely confluent cases were such as would almost disappear after a short time ; and the number of confluent cases was rendered much smaller by the eruption being checked both by the local and consti- tutional measures employed. DR. W. HITCHMAN, ENGLAND, States (British Medical Journal, February, 1879,) that he has at- tended hundreds of cases of small-pox without a single fatal issue, which he attributes solely to treating it with full doses of belladonna or atropia. He adds that he has suggested to several professors in France, Germany, Holland, and Italy the value of atropia in small- pox, all of whom have communicated to him their high opinion of its therapeutic value. In fact, the medicine, when appropriately given, neutralizes the disease, and no morbid remedial augmenta- tion, however temporary, is usually witnessed, unless the doses have been unnecessarily, and therefore injuriously large. VARIOLA — SMALL POX. 641 PROF. GUENEAU BE MUSSY, PARIS. 1056. R. Tannin, Oxide of zinc, aa gr. xxx Calomel, gr. iv Extract of opium, gr. iss Cerate, |j. M. Sig. — ^Apply upon the eruption to prevent severe pitting. NOTES ON REMEDIES. Ammonii Carbonas is indicated if there is manifest depression, especially during the suppuration period. Belladonna. See above. Calomel powdered over the skin in the beginning of the affection does not prevent the formation of vesicles from papules ; but in the vesicular and pustular stage it is said to cause them to dry up almost immedi- ately, thus preventing pitting. Camphor is advantageously employed, particularly in confluent or mahgnant small-pox, when the vital power is greatly depressed. It may be given alone or in combination with opium. Carbolic Acid has been administered with marked benefit. It is more useful at an early stage of the disease, although, given afterward, it much modifies the symptoms, and hastens the curative process. Particularly does its internal administration lower the temperature, and if begun early diminishes the extent and duration of the eruption. Chloral is highly useful and necessary when there are high temperature, wake- fulness and delirium. 1057. R. Acidi carbolici, Acidi acetici, aa f. 3j-iss Tincturse opii, Spiritfls chloroformi, aa f. 3 j Aquam, ad f. § viij. M . A tablespoonful every four hours, till the fever subsides. After the first dose, the mixture is rather grateful to the patient than otherwise. Schwimmer recommends .the local application of carbolic acid and thymol. He prescribes as follows : 1058. R. Acid carbol., f-3j 01. oliv., f. 3 viij Crette prep., § iss. M. Or: 1059. R. Thymol, 3j ... OLlini, f-3viij Cret. prep., i iss. M. Coiaine is highly commended as a local medication upon the eruption. Mustard. Dr. E. S. Lyndon, of Athens, Ga., (Medical and Surgical Reporter) 41 642 DISEASES OF THE BLOOD. believes that a mustard plaster applied to any part of the body will bring out the eruption twenty-four to thirty-six hours earlier than usual, so that a diagnosis can be made on the first day of the fever. Opium often fails to procure rest in the early stage of small-pox, but in the advanced stage of the disease, patients who are wakeful, but otherwise doing well, are benefited by it, given once or twice. But neither it, nor any other anodyne, is to be given when there is copious salivation and mucous expectoration, as the patient may die asphyxiated during sleep, from the secretion accumulated in the air passages. Quinine is useful, in small doses as a tonic, in fiill doses for the suppuration, and in antipyretic doses if the temperature is high. Salicylic Acid is indicated from a theoretical standpoint. It is used in com- bination to form a number of pomades or pastes to prevent pitting ; and in this use is said to be of distinct service. Sodii Sulphis. The sulphites are recommended by Professor Polli, of Milan, as mitigating the febrile action, rendering the confluent and malignant forms benignant, shortening the course of the milder forms, and in all cases accelerating convalescence. Sulphuricum Acidum Dilutum. In confluent small-pox, treatment by dilute sulphuric acid, rn,xv-xx, with gr. j of quinine, every three or four hours, together with stimulants and nutritives, is an excellent one. TO PREVENT PITTING. Amylum. A thick mucilage of starch, has been used as a local application to prevent pitting, with excellent effect. The entire surface of the body should be first sponged with tepid water. Argenti Nitras. Velpeau and other French writers recommended the prac- tice of opening each vesicle on the third or fourth day of the eruption, and touching each with a stick of the nitrate scraped to a point. This, however, is a tedious and painful process, not unattended with danger. It has been recommended to wash the face on the fourth or fifth day with a strong solution of the nitrate. Calcis Aqua. The application of cotton-wool, soaked in a mixture of equal parts of lime-water and olive oil, is said to be an efficacious one. Carbolicum Acidum. Dr. H. Ya'ies reports a case (Lancet, January 25th, 1868,) treated with success by the folloAving ointment: 1060. R. Acidi carbolic!, f. 3ij Adipis, §ij. M. The ointment was colored with lamp-black, and applied thickly spread on wadding. It was changed every second day, the parts first washed with soap and warm water, and then with warm water impreg- nated with carbolic acid. VARIOLA — SMALL POX. 643 Glycerinum. The following application is recommended by J. F. Marson : 1061. R. Glycerini, I part Aquse rosae, 2 parts. M. Apply (after the pustules have discharged, and the discharge has begun to dry) freely for a few days, until the scabs begin to loosen. Hydrargyri Unguentum. Inunction of mercurial ointment has been advised by Prof. Bennett and others, but excessive salivation may follow its use. The following ointment is employed in the Children's Hospital, Paris : 1062. R. Unguenti hydrargyri, S'kv Cerae flavoe, 3 x Picis nigrtE, 3yj. M. lodinium. The tincture, applied once or twice a day, is a remedy which has been long used. Although it does not absolutely prevent pitting, it usually renders the marks and cicatrices less evident. Iodoform applied as in ethereal solution, or better in a vaseline ointment is soothing to the patient, and an antiseptic of value preventing the for- mation of foul smelHng scabs and ulcers, and lessening the consequent pitting. (CoLLEViLLE, Amer. Med. Digest, 1886.) Zinci Carbonas. Prof. Bennett, of Edinburgh, prefers the following to all other ointments : 1063. R. Zinci carbonatis, Siij Zinci oxidi, §j Olei olivae, q. s. M. The same object is said to be obtained by treating the whole surface thickly with powdered calamine. This application has a very soothing effect. Xylol has been recommended in variola as of value in lowering the general severity of the case. EXTERNAL MEASURES. Cold Baths. Dr. Curshmann, in Ziemssen's Cyclopadia, maintains that baths are only useful in the premonitory and eruptive stages. But consider- ing that the greatest danger in small-pox is during the suppuration fever. Dr. Clement, of Lyons, thinks that it is to this period of the disease that treatment should be directed. The most noticeable effects produced by baths on small-pox patients are, a fall in the temperature, often sudden and of some degrees ; cessation of the delirium soon after the first bath ; and a great reduction of the pulse-rate and of the respirations. The first baths should always be of a temperature from 80° to 85° F. The effect of the bath must be carefiiUy gauged by the thermometer. The patient should be submerged beneath the water up 644 DISEASES OF THE BLOOD. to his shoulders ; and when he is put to bed he should be enveloped in a sheet, and covered only with a simple woolen covering. Two or three baths may be given in the twenty-four hours. YELLOW tEVER. DR. DOMINGOS FREIRE, OF BRAZIL, As he found in the dejections, the saliva, and the blood of yellow fever patients numbers of microscopic organisms, bacteria and cryptococci, he comes to the conclusion that the disease is of an infectious nature. And as the salicylate of soda has been much re- commended in analogous affections, such as septicaemia, variola, and typhoid fever, he determined to investigate its effects in yellow fever. He has used it, hypodermically, in doses from 2^ to 22 grains, ac- cording to the intensity of the fever, in the first period of the malady. In the second period the dose should be smaller, as it then acts as an antiseptic; it is of no service in the third period, when black vomiting has commenced. He reports several cases with favorable issue under this treatment. More recently (Pacific Rec, 1886,) Freire has suggested inocu- lation with an attenuated virus of his own discovery as a means of prophylaxis, and has published statistics showing an enormous di- minution in the mortality of epidemics. His position is sustained by some investigators, but is opposed by others, among whom are GiBiER and Sternberg. (Jour. Am. Med. Assoc, 1890.) The latter gentleman questions his statistics, and using Freire's own figures is able to demonstrate that the mortality among the inocu- lated is really greater than among the non- inoculated. The matter is in so questionable a position that no positive decision can be stated at present. DR. G. M. STERNBERG, U. S. ARMY, (Therap. Gazette, 1889.) STERNBERG, from personal observations of yellow fever at Havana, Cuba, had evolved an alkaline and anti- septic method of treatment as meeting indications of the disease, and has had opportunity of observing its favorable results in the recent epidemic in our own Southern States. His formula is as follows ; YELLOW FEVER. 645 1064. R. Sodii bicarbonatis, 5iv Hydrarg. bichloridi, gr. ss Aquae, . Oij. M. Sig. — ^An ounce and three-fourths to be taken every hour — to be taken ice cold. This treatment seems to protect the kidneys and stomach from the hemorrhagic tendency of the disease, and to keep the kidneys active. It has produced a very favorable impression by the com- paratively low death rate where the formula has been employed. In Havana, at the Mercedes Hospital, STERNBERG'S formula was used recently with the result that the mortality was diminished more than one-half. It should be begun early if the best influence is to be obtained. DR. DE LACAILLE, OF RIO DE JANEIRO, Claims to have cured thirty-eight consecutive cases of yellow fever by the use of Declat's preparation of pkenic and stdpho-phenic acids, and in grave cases, the phenate of ammonium. In the early stages he gives the remedies by the mouth, but in the advanced stages the hypodermic method is necessary. He contrasts very favorably his recent experience with his former sad failures without these drugs. GREENSVILLE DOWELL, M. D., GALVESTON, TEXAS. This experienced physician directs that as soon as the first symp- toms come on, the patient should be put to bed at once, and com- fortably covered. If the stomach is full, it should be emptied by an emetic of ipecac, or mustard. If such is not the case, a moder- ate dose of castor oil or other mild laxative should be administered. Should inceptive chilliness be followed by perspiration, the patient should not be disturbed, but if the skin is dry, and there is much thirst, warm teas of orange leaf or sage may be given. Should there be vomiting at the outset, neither emetics nor warm drinks should be given, but instead of them sinapisms should be ap- plied to the epigastrium, and small pieces of ice be swallowed. Should these measures not check the vomiting, the patient should be cupped freely over the stomach. When the fever is high and the pain in the head and back is great, he prescribes the following: io6j. R. Hydrargyri chloridi mitis, Quinise sulphatis, _. Pulveris opii et ipecacuanhoe, aa gr. xij. M. Make four powders. One every three hours. 646 DISEASES OF THE BLOOD. This is to be continued with more or less frequency as long as the fever lasts. If the fever continues high and the skin hot, it may be reduced by: 1066. R. Tinct. aconiti fol., gtt. x Spts. seth. nitrici dulcis, 3j. M- This amount in a wineglassful of water, every three or four hours. In forty or fifty hours after the commencement of the disease, the fever subsides and the stage of calm comes on. If this is associated with much exhaustion, stimulants are demanded ; if with marked restlessness, valerianate of zinc, gr. v-x, or morphia, gr. %, will be called for, repeated as necessary. When there is retching and vomit- ing, the following mixture may often be used with the best results : 1067. R. Morphise sulphatis, gr. iv Creasoti, 3 j Spiritds vini gallici, f. § iv. M. A tablespoonful every three hours, as needed. The stomach, at this stage, is generally swollen and sore, which should be met by mustard or blisters. If black vomit appears, the above brandy and creasote mixture should be alternated with tinc- ture of chloride of iron, gtt. xv, or solution of the perchloride of iron or tannic acid. In the stage of calm. Dr. DOWELL never gives qui- nine. When there is suppression of urine, nitre or buchu is called for. The patient should have light and nutritious food, regularly ad- ministered, and should be rigidly kept in bed, and prevented from any but the most necessary movements. Relapses are easily pro- voked, and are far more dangerous than the first attack. Embolism is a frequent cause of death, and must be guarded against by com- plete quiet. DR. DAY, (New Orleans Med. and Surg. Jour., 1888,) believes that the dis- ease should be met symptomatically, without reference to the name of the disease. He regards it favorable to his own practice that he conducted his first four cases of yellow fever to a favorable termina- tion without really knowing that they were yellow fever. If the skin is dry and hot, the patient in bed should be given a warm or hot mustard pedeluvium under blankets to retain the vapor, supple- mented by warm drinks to promote diaphoresis. He would give at YELLOW FEVER. 647 the start enemata of warm water with camphorated oil, to clean the bowel. When the attack begins with marked cerebral symptoms, as delirium or unconsciousness, he would bleed at the arms. Where the tongue is much furred, saliva thick, eyes injected, temperature high and respiration rapid, with pain in the head, back and limbs he gives : 1068. R. Hydrargyri chloridi mitis, gr. xx Quininse sulphatis, gr. xxx-xl. M. Ft. pulv. dividenda in chart, no. iv. Sig. — One powder every four hours. For nausea and irritability of stomach he applies a fly-blister, with small doses of morphia, and enemata of water and bicarbonate of soda. Where the tendency to hemhorrhage becomes marked, or " black vomit " appears, he gives tincture of chloride of iron with crushed ice and brandy or champagne. Dry cups over the kidneys when there is suppression of urine, and frequent rubbing of the back with warm whiskey, digitalis and turpentine. Under this treatment he states that his death rate has not exceeded 3)^ per cent. DR. CHARLES BELOT, HAVANA. This writer. Director of the Hospital for Yellow Fever at Havana, considers local blood-letting, at the outset of the disease, indispens- able in most cases. Cuppings are preferable to leeches. Eight cups on the nape of the neck, ten on the loins, and eight on the stomach generally suffice to alleviate the symptoms, and if, for four hours after the first application, there is not sensible amelioration, let it be repeated. For the pains of the head and loins, sinapisms and mustard foot- baths are needed. Tincture of aconite, given in doses of six drops in twelve ounces of water, administered by spoonfuls every hour, should never be neglected in the first or congestive period. If the disease has commenced with vomiting, if the tongue is charged with mucous deposits, let an emetic be given, composed of an infusion of thirty-six grains of ipecac, in four ounces of warm water. When this commences to produce its effect, the vomiting will be assisted with warm water, and continue until the ejections are clear as water. If the tongue is not charged with mucous deposits, if the patient complains of great pain in the epigastric region, vomiting must be avoided, as its consequences would be grave. 648 DISEASES OF THE BLOOD. About four hours after the vomiting, the patient will have less fever, the pulse will be less frequent and strong, the skin will be moist, or there will be general transpiration. It is necessary to take advantage of this moment, to administer a purgative of castor oil or of sulphate of magnesia. If this remedy fails to act after two or three hours, its action should be promoted by injections of warm sea-water, or of sweetened water and olive-oil. With free ventilation, quiet, and warm drinks to aid transpiration, this treatment will often disperse the alarming symptoms in three days. When, however, the disease continues its progress, the symp- toms of the second period are presented. The headache should be resisted with flying blisters on the nape of the neck, with compresses of brandy with camphor and bella- donna on the forehead. To soothe the oppression of the stomach, apply compresses of brandy with camphor and belladonna, and give internally tincture of nux vomica, in very small doses. When, de- spite the compresses, the pain in the stomach persists, a flying blis- ter is applied at this point. If nausea occurs, bicarbonate of soda alternated with nux vomica is the most useful remedy. If the dis- ease advances and vomitings occur, they must be treated according to their character. If they are white, foamy, acid, holding in sus- pension flakes of mucous membrane, black vomit is not far off. It is often arrested by bicarbonate of soda in small doses repeated every half hour, alternated with carbonate of magnesia. If the vomitings are bilious, nux vomica and arsenical solution will be em- ployed in preference, and will be continued if black vomit occurs. A little fresh water, slightly sugared, may be allowed, and thirst may be appeased with small pieces of ice. Sometimes hemorrhages occur without black vomit. They con- stitute of themselves a grave condition. Limited hemorrhages, for example buccal and nasal hemorrhages, are combated with tonic applications, ice and astringents, as dilute sulphuric acid, etc. When hemorrhages have not taken place, if the symptoms in- vade the brain, cold water to the head, blisters to the nape of the neck, and calomel internally, are remedies to which recourse should be had. But this will be frequently useless, because the disease progresses with frightful rapidity. The remittent and intermittent types begin with or without chills. This is a very important therapeutic indication. The first symptom (the chill) coming on perhaps after a meal, perhaps in the morning YELLOW FEVER. 649 between two and three o'clock, an emetic, administered at once, dis- embarasses the stomach of ingesta and saburral deposits, and de- termines a favorable transpiration. After the emetic, the patient should be allowed repose and sudorific drinks. If the symptoms call for an application of cupping to the nape of the neck, to the loins, or the abdomen, according to the indications of local conges- tion, it is rarely that twelve hours pass without the patient showing marked relief. If the congestive symptoms do not yield to the first cupping, they will be overcome on the second application, and by completing the effect of the emetic with a purgative. In most in- stances, after this treatment, the remission will be found to come, and this is the most important moment for the physician. This re- mission often occurs after the first twenty-four hours — in other in- stances it is delayed two or three days. When, after the emetic and purgative, a general relaxation is observed, but insufficient to bring on transpiration, use should be made of diaphoretics, and preferably of Dover's powder, taken every hour in doses of a grain until sweat- ing begins. In this remission sulphate of quinine must be administered in a dose of thirty-six grains, taken at once in a half-cup of black coffee without sugar. When the intermission is complete its action is mar- velous ; the disease is immediately moderated. When the disease commences with chills, followed by abundant sweats after the emetic and purgative, there is assurance that there will be another remis- sion, and the quinine is in order. In cases where sulphate of quinine cannot be employed, calomel is an excellent remedy, especially when, in the absence of remission, the tongue shows itself humid, loaded, white, large, the gums en- gorged, the stools difficult, or when there is bilious diarrhoea. Dr. B. administers from twenty-four to thirty grains, in two-grain doses every half hour, until the characteristic stools appear. Very often, after the administration of calomel, remission of the fever and of the congestive symptoms takes place ; the skin becomes moist, and sul- phate of quinine, the effect of which will be more sure in proportion to the distinctness of the remission, may then be appropriately used. Its effect is assisted by oil and by emollient injections. If there was no chill in the commencement, aconite and tincture of digitalis will be pressed. These are ordinarily sufficient to bring the patient into full convalescence. Dr. B. disapproves of combining calomel and quinine. 650 DISEASES OF THE BLOOD. DR. F. PEYRE PORCHER, CHARLESTON, S. C. This writer sums up the treatment of yellow fever as follows, (Transactions of the South Carolina Medical Association, 1872) : I. The treatment must begin early. 2. The first step should be a large mercurial purge, followed by a saline cathartic, thus emptying the bowels, and disgorging the liver and the glandular apparatus. 3. Simultaneously, and from the very beginning, use revulsives to the surface of the abdomen, hot stimulating baths to the lower extremi- ties — with the assiduous and protracted application of ice-cold water to the head, hands and arms, as long as there is a continuance of ab- normal heat. 4. All purgatives, all active depressing agents, must now be discontinued absolutely, and give place to a mild alkaline diuretic and diaphoretic, containing morphia. Cold sponging, and the use of sinapisms, and hot mustard pediluvia, are to be continued so long as headache, morbid heat of surface, with high thermome- tric range, indicate the existence or progress of combustion and de- structive tissue metamorphosis — fever, in other words. Then, too, the recuperative powers of nature are to be trusted to, aided, if need be, by mild tonics, moderate stimulants, and nourishing diet. EDWARD FOWLER, M. D., NEW YORK. This writer (Medical Record, September, 1878,) from an experi- ence of several severe epidemics in cities of the Southern States, distrusts the line of treatment usually pursued, as laid down by most authors. He does not believe that the perspiration sought to be produced at all helps the case ; mercury, he regards in all cases of true yellow. fever as "hurtful to an extreme degree," and only valuable when the fever is mild and blended with an intermittent ; he is wholly adverse to blisters ; quinine, in the therapeutics of the true disease, has no place whatever. Having thus discarded the traditional treatment, he adopted one which he states to have been much more satisfactory. During the first hours of the attack, he recommends hot acid drinks in teaspoonfuls at a time, to allay thirst, Small quantities of broths at regular intervals will prove the best nutriment. For the costiveness which usually attends the disease, Seidlitz powders are unobjectionable. For the tympanitic condition of the abdomen, enemas containing carbonate of soda, gum fcetida, and minute quantities of aloes, act not only promptly and delightfully, but YELLOW FEVER. 65 I often snatch the patient out of a state of great danger, and estab- lish improvement. For the prominent and distressing symptom of nausea, pouhices to the epigastrium are demanded, and the following mixture, which should be given throughout the entire disease, beginning with the second day: 1069. R. Potassii iodidi, gr. ij Liquoris potassii arsenitis, gtt. ij. M. This amount for a dose every two or three hours, in any convenient vehicle. The effects of this combination are uniform in relieving the ten- derness of the stomach and keeping black vomit at bay. Another important feature of Dr. F.'s treatment is to give a full dose of opium at the commencement of the disease, as much as mor- phiae sulphas gr. i-ij. Of the use of this remedy he says : " It is a drug that depends for its remedial action on the stage of the fever in which it is given. Administered with the accession of the fever, and when the sufferer is writhing in universal pain, and given in suf- ficient quantity, it will not only relieve and give gentle rest, but clear up the troubled atmosphere of the brain, and roll back every darkening cloud from the mind, and leave no vestige of opium stupor or even drowsiness. But if given to check vomiting or diar- rhoea, or restlessness after the first twenty-four hours, and then in small quantities even, it induces new symptoms, and endangers the patient." NOTES ON REMEDIES. Arsenicum. Dr. Charles Belot says that, toward the end of the second period, when the vomiting cannot be arrested, when the patient has continual nausea, when the vomit contains bile or mucosites filled with blackish or sanguinolent streaks — in a word, when the characteristic signs of pronounced yellow fever are developed — there is no better remedy than arsenic. It is given by him as arsenious acid dissolved in water. It will be seen above, that Dr. Fowler uses it throughout the disease. Belladonna. According to Dr. Belot, compresses of camphorated alcohol and belladonna, placed upon the epigastric region, diminish beating of the coeliac trunk, the epigastric pain, and the vomiting. Laid at the bottom of the abdomen, they quiet the colic pains and facilitate the passage of urine. Camphora, combined with belladonna, finds its use, internally, in combating hiccough, and camphor alone is especially useful in the typhoid period of the disease. 652 DISEASES OF THE BLOOD. Hydrargyrum Chloridum Mite. There is great discrepancy, not only as to the value, but even as to the safety of giving calomel in yellow fever. The safest plan is to confine its exhibition to those cases where obvi- ous evidence of malarial poison co-exists, and to use moderate doses. For the various opinions, see above. Ipecacuanha. As an emetic, at the outset of the disease, this drug is preferred by most physicians. Nux Vomica has been found by Dr. Belot to act very favorably on the epi- gastric distress. Opium, in all forms and doses, is discarded by many. Dr. Aitken especially warns against it when there is tendency to suppression of urine. For Dr. Fowler's employment of it, see above. It will be noticed that he is directly at issue with Dr. Dagnino, in the use of it for the latter symptoms. Plumbi Acetas. For the gastritis. Dr. G. B. Woot) knows nothing better than the acetate of lead — i or 2 grains every hour or two, and continued until from 30 to 40 grains have been taken ; the astringent properties of this remedy may also render it useful in preventing the black vomit, which is now admitted to be a sort of hemorrhage. Quinice Sulphas is given by Dr. M. Dagnino (Monograph on Yellow Fever, New York, 1878,) in small and repeated, by Dr. Belot in large and rare, and by Dr. Dowell in medium doses. Various practitioners aim to establish cinchonism promptly, in all cases ; others, and the more recent observers of the complaint, would confine the early exhibition of quinine to cases with obvious malarial symptoms, and employ the drug later, merely for its tonic properties. In the continuous form of the fever, quinine certainly exerts little or no effect. Poiassii Chloras. Dr. H. R. Frost ( Charleston Medical Journal and Re- view, vol. viii,) has found the chlorate of potash an excellent remedy in the febrile stage of the disease. After having freely evacuated the bowels, he gives the chlorate in the quantity of 3 or 4 drachms, in divided doses, during the twenty-four hours, employing, at the same time, when necessary, leeches to the temples and iced water to the head. Potassii lodidum is employed with marked success against the. nausea, by Dr. Fowler. (F. 1069.) Ricini Oleum is generally given the preference, as a laxative. Salicylicum Acidum. Dr. Hartwig Bunz, of Savannah, states (Berliner Klinische Wochenschrift, September 2d, 1878,) that in the epidemic in that city, of 1876, finding that the fever was of an intermittent type, he resolved to make an experiment with salicylic acid. He gave adults a dose of ij^ drachms, either in solution, in capsules, or rubbed up in YELLOW FEVER. 653 sugar ; and if the stomach rejected it, he gave a double dose per rec- tum. The result was excellent. Of one hundred and seventy-nine patients, only four died. He regards the acid as the most powerful antipyretic against yellow fever, both of the intermittent and remittent type, but has no experience of it in the continuous form. Sodii Bicarbonas has been recommended highly by Sternberg, and is the most important element of his treatment. (F. 1064.) Sulphuricum Acidum is advantageously used in small, dilute doses, in threat- ened black vomit. Tannicum Acidum. Dr. Belot recommends its employment where nitric acid reveals the commencement of albuminous deposit in the urine. Its use must be suspended if the albumen persists or increases. Tannin is administered every hour, in grain doses, in a spoonful of water. When the twelfth grain has been given, and it works no favorable change, it is replaced by arsenic, in his method. Turpentine is indicated when there is cardiac weakness, depression of the vaso-motor nervous system, and a dissolved state of the blood. PART VIL TOXIC DISEASES. Alcoholism (^Inebriety; Delirium Tremens) — Arsenicism {Chronic Arsenical Poisoning) — Opiism {Opium Eating; The Opium Habit) — Hydrargism {Chronic Mercurial Poisoning) — Plumbism {Chronic Lead Poisoning) . ALCOHOLISM (INTOXICATION : DELIRIUM TREMENS; CHRONIC ALCOHOLISM). The therapeutics of alcoholism embraces the treatment of this form of poisoning as it is presented in three distinct forms: i. Drunkenness, including the gastritis, headache, etc., it leaves behind it. 2. Acute Alcoholism, known as delirium tremens, mania a potu, etc., and 3. Chronic Alcoholism, including the numerous and grave structural changes brought about by the prolonged consumption of alcoholic fluids. I. DRUNKENNESS. In cases of drunkenness or coma from alcoholic intoxication, the first indication is to empty the stomach. This may sometimes be accomplished by tickling the fauces writh a feather ; by the free ad- ministration of warm water, or mustard and water, if the patient can swallow ; or, in some instances, by the hypodermic injection of apo- morphia, or the internal use of brown emetine, gr. ij-iv, which acts very promptly. These failing, the stomach pump is the next resort. Cold affusion, especially cold water, poured from a height of five or six feet upon the head, is a powerful revulsive, and may often advantageously be employed. Galvanism or electricity may also be resorted to. It is generally important to promote warmth, especi- ally when the face is pale and the extremities cold. Sinapisms to the feet, bottles of hot water around the limbs, and mustard to the epigastric and cardiac regions, are then required. It is a great mis- take to take a man who is partially intoxicated into the cold air under the impression that it will restore him. The change and sud- (654) ALCOHOLISM. 655 den checking of the cutaneous transpiration are very apt to render him completely drunk. When the stomach can retain fluids, the patient may take very strong, hot coffee, without milk' or sugar, in tablespoonful doses every five minutes. Or one of the following mixtures : 1070. R. Ammonii acetatis, 5iij Syrupi aurantii florum, f. § iss. M. To be taken in tablespoonful doses, in a small cup of tea, at quarter of an hour inter- vals. 1071. B. Ammonii acetatis, 5ijs3 Sodii cbloridi, 3j Syrupi, f. I iss. M. To be given in a small cup of strong coffee in two doses at quarter of an hour inter- vals. The following is recommended by Dr. JaMIESON, of the Mercer Hospital, Dublin, as very efficacious in dispelling drunkenness: 1072. Jt. Sesqui-carbonate of ammonia, 3i Table vinegar, f. §j. M. This amount for one dose; to be repeated in half an hour if necessary. This is a cheap extemporaneous plan of preparing spirits of min- dererus. The nausea, vomiting and irritable stomach consequent upon alcoholic excess, may be treated with iced milk diluted one-half, with Vichy, ApoUinaris, or Saratoga water, or with lime water, a tablespoonful five every five or ten minutes. A bladder of ice to the epigastrium is also efficient. In the persistent retching and vomiting that sometimes follow a debauch, liquor potasses arsenitis, in one-drop doses every hour or half hour, either alone or combined with a few grains of capsicum, is extremely efficacious. For the nervous prostration, sense of anxiety and of impending misfortune, nux vomica, gtt. v-xv of the fluid extract, has been highly commended. This amount may be taken three or four times a day. Dr. Alfred L. Loomis, recommends the following in cases of "rum stomach," with gaseous distention of the stomach and bowels: I073' R- Tr. nucis vomicae, gtt. v-xv Tr. gentianse comp., Tr. columbse comp., aa f. 3 )• ™' Take before meals. The bowels are kept soluble by an aloetic and mercurial purge. 6s6 TOXIC DISEASES. "Bitters" of different kinds are very popular as restoratives. Quassia is supposed to be peculiarly efficacious, but almost all the vegetable bitters are employed. The following is a palatable com- bination : 1074. R. Liquoris ammonias acetatis, Tincturse aurantii amari, Syrupi aurantii amari, ai gtt. xx Aquse, f.SJ. M. For one dose; to be repeated every half-hour or hour. For the headache and wakefulness which follow a debauch, Dr. A. McLane Hamilton prescribes monobromide of camphor, finding that it possesses peculiar hypnotic power. '°75- R- Camphorae monobrom., 5j Confect. rosse, q. s. M. Make twelve pills. One or two as required. Dr. A. A. Smith, of New York, states that the first indication is to remove the alcohol from the intestinal canal. For this give of rhu- barb and magnesia calcined, each a half drachm, and then give the following : 1076. R. Spiritus ammoniae aromat., f. Si] Tincturse camph., f. 3 iss Tincturse hyoscy ami, f. 3 ijss Spiritfis lavanduUe comp., q. s.ad f-Sij. M. f. 3i every hour until the headache is relieved, and then give capsicum, gr. ij, and quinine, gr. iij, before each meal, for several days. If there be sleepiness, give : 1077. R. Sodii bromidi, § ss Chloral hydrat., 3 ijss Syrupi aurantii cort., f. g ss AquK, f. I iijss M. f. S ss at night; repeat in two hours if necessary to produce sleep. {N. Y. Medical Record.') The following " quieting mixture " has been long used with the greatest success by Dr. F. Peyre Porcher, of Charleston, S. C, and is confidently recommended : 1078. R. Chloral hydratis, 3 iss Potassii bromidi, 3ij Spts. astheris compos., f. 3 ij Tincturre Valerianae, f, 3 iij Aquse, f. § vj. M. A tablespoonful every two, three or four hour* In the nervousness following a de bauch, commencing delirium tremens, excessive nervous excitement, etc. Dr. J. H. NOWLIN, of Arkansas, has found the following of great value (Louisville Medical News, July, 1878) : ALCOHOLISM. 657 1079- R- Chloral hydratis, Potassii bromidi, aa 5 iss Tinct. capsici, f. § jj Aqaam, adf!§viij. M. f.5j or f.5ij, largely diluted with water or milk, every hour or two till sleep is pro- duced in cases of delirium tremens, or till the nerves are quieted in other cases; and afterward repeat as needed. II. ACUTE ALCOHOLISM OR DELIRIUM TREMENS. DR. JOHN S. MARSHALL, OF OHIO. In insomnia and extreme nervousness incident to alcoholism, opiism, and acute mania, when not unfrequently, both food and medicine are absolutely refused, the following treatment is most satisfactory, both in the mode of administration and the effect upon the patient. A hot bath, temperature 105° to 115° (F.), or steam- vapor bath, lasting ten to twenty minutes, with thorough rubbing often, after which administer the following : 1080. R. Chloral hydrat., 3vj Gum camph., 3 iss Morphias sulph., gr. iv 01. olivse, q. s. ad f. § iv. M. Sig. — f. 3 jj per enema every four to six hours. This treatment persisted in for twenty-four to forty-eight hours, will, in a large majority of cases, produce marked beneficial results. This mode of administration gives the stomach relief from the vari- ous hypnotic mixtures, and produces a most quiet and refreshing sleep. In the treatment of the opium habitue, the morphia is to be omitted very early, while the remainder of the mixture may be con- tinued a longer or shorter time as the case requires. Also the fol- lowing is a very valuable tonic and stimulant combined, in the early treatment of alcoholism and opiism. 1081. R. Cocte, iij Tr. nux vomicse, f. 3 j Quiniae sulph., 3 iss Acid. phos. dil., f. § ss Tr. cinch, co., ad f. § iv. M. Sig. — f. 5ij every four hours, gradually emitting the coca from the combination. The above, combined with good nursing, nutritious food adminis- tered every two or three hours in moderate quantities, with large and frequent draughts of a mineral water, will accomplish the de- sired result, while the patient will undergo but little suffering. 42 658 TOXIC DISEASES. J. WARING CURRAN, M. D., DUBLIN. 1082. R. Zinci oxidi, 9j-ij Confectionis Tosse, q. s. M. For ten pills; one thrice daily. When morphia or cannabis has done its duty in this disease, the after treatment by oxide of zinc is something to be observed rather than described ; the constant dread, restlessness, and disturbed sleep, are quickly overcome by the bracing agency of the drug. (London Lancet, October 24, 1868.) In administering the oxide of zinc, care must be taken not to give it upon an empty stomach, as it produces nausea and a dislike for the medicine. PROF. R. J. GRAVES, M. D., DUBLIN. 1083. R. Antimonii et potassii tartratis, gr. iv Tincturae opii, f. 5j Camphorae, gr. xv Alcoholis, f, 5ss Aquas destillatse, f. § viij. M. Powder the camphor by the aid of the alcohol, add the water, pass through a piece of fine linen, and then add the tartar emetic and the laudanum. Give a teaspoonful every two hours. DR. LYONS, HARTWICKE HOSPITAL, DUBLIN. 1084. R. Pulveris capsici, gr. xx-xxx Mellis rosae, q. s. M. Make a bolus. For one dose. This usually suffices to produce quietude and sleep. In excep- tional instances, however, a second and even a third dose is required before full tranquillity is secured. The drug is well borne, and quiets the stomach in cases in which irritability and vomiting are present. Our author sums up (British Medical Journal, November 7, 1869,) his experience as follows : ist. Capsicum is a valuable and reliable drug when opium fails, or is for any cause contra-indicated. 2. It is a safe drug for general employment in delirium tremens, and as such may be confidently recommended. 3d. It is not open to the objection which attaches to the continued use of opium, which, when it fails to tranquilize and produce sleep, adds to the state of excite- ment, and when pursued beyond a certain limit may induce opium coma. 4th. Capsicum has been employed in the delirium- of fever when opium has failed to cause sleep, and with marked success in certain cases. ALCOHOLISM. 6S9 DR. GEORGE W. BALFOUR, EDINBURGH. This writer (Lancet, February l, 1879,) speaks in the most de- cided terms of the superior efficacy of chloral hydrate in delirium tremens. He recommended it in all cases, from the lightest to the most severe. After a full trial of it for nine years, he pronounces it most satisfactory. He states, however, that there are very few cases, indeed, which yield to a less dose than fifty grains, and a consider- able number which require a great deal more ; those cases requiring the largest doses being those ushered in by the status epilepticus, which chloral arrests as rapidly and safely as it does delirium tre- mens itself. But, even in these cases, he has not found it necessary to give more than 120 grains of Liebreich's chloral, in divided doses ; and this dose, though large, is not a dangerous one. From the irri- tated condition of the mucous lining of the stomach of a drunkard, it is probable that the absorption of ingested fluids is not so rapid as usual ; it is but fair, therefore, for that reason also, to allow a mod- erate interval between the doses, so as to avoid, as far as possible, any risk of giving more than enough. At the same time we must shun the opposite extreme of giving doses in themselves too small to have any decided effect, and which have any possible cumulative effect, destroyed by too long an interval being permitted to elapse between the giving of each dose. Acting upon these principles, he is in the habit of treating cases of delirium tremens by giving gr. xl chloral hydrate every hour, for three times, if necessary. Some- times, but rarely, the first dose is enough ; most commonly two doses are required, and it is only in the very rarest instances that the third dose is necessary. If the attack be ushered in by the status epilepticus, he shortens the intervals between the doses to half an hour, as, in these cases, time is of the utmost importance, and a large dose is sure to be required. Should the heart be feeble, he gives each dose of chloral in half an ounce or an ounce of the infu- sion of digitalis. Under this treatment the results are flattering. Unquestionably fatal cases must occasionally occur under this, as well as under other modes of treatment, but the number of them is much decreased, because, from the rapidity with which a cure is brought about, many dangerous risks are averted. Thus we avoid all the risks arising from a long continuance of maniacal excitement, or from a suicidal state of mind, all risk from the exhaustion follow- ing persistent sleeplessness, or defective nutrition, the result of long- continued insufficiency of food, etc. 660 TOXIC DISEASES. III. CHRONIC ALCOHOLISM. PROF. WILLIAM A. HAMMOND, M. D., NEW YORK. In the treatment of chronic alcoholism, the physician should per- emptorily insist upon entire cessation from the use of alcoholic liquors. A mild purgative should commence the treatment, the bowels being always more or less deranged : 1085. B- Pulv- aloes, Ext. fel. bovis exsic, ia gr. xv Resinae podophylli, gr. ij. M. For five pills. One every alternate day. For the special treatment of the condition the oxide of zinc has been highly commended, and certainly possesses great power (gr. ij-iij ter die). But the bromides are yet more efficacious, especially the bromide of zinc. 1086. R. Zinci bromidi, gr. ij Syrupi simplicis, Aquae, aa f. Sj- M. This amount three or four times a day, gradually increased as rapidly as the stomach will permit to two or three times the quantity. Digitalis is an important adjunct to the treatment. It is the most active agent we possess as an eliminant of alcohol through the kid- neys, and is also a heart tonic. It may be given in the infusion, f.i^ss thrice daily; or of the tincture, gtt. xv— xxx, as often. In the acute form of alcoholism, that which follows the sudden cessation of the wonted stimulus, the main indication is to procure sleep as soon as possible. No means in such cases is so effectual as the hypodermic injection of a full dose of morphia, gr. ^— J^, as often as may be required, combined with the internal administration of brandy or whiskey in moderate quantities. When, however, the affection has come on during a debauch, these substances add fuel to the flames. In such cases the bro- mides, in large doses, combined with digitalis, are the most effective remedies : 1087. R. Fotassii bromidi, gj Infusi digitalis, f.fss. M. This amount every hour or two until the patient sleeps. The monobromide of camphor, gr. iv in capsule, every hour, has been well spoken of. ALCOHOLISM. 55 1 With the medical treatment of either form of alcoholism, the strength should be supported by beef tea, and after convalescence, quinine, iron, and strychnia will prove of service. DR. T. D. CROTHERS, HARTFORD, CONN. In the practice of this able specialist, the liquor is taken from the patient at once, and the following given : 1088. ]J. Ammonii bromidi, gr. xl Tincturae zingiberis, f. 5 j Aquae, f.| ss. M. This, with the addition of tinct. cinchonse, is often given every three hours. The first and second night the following is used : 1089. R. Chloral hydratis, gr. xv Tinct. zingiberis, f. 5j Aquae aut syrup., f.§j. M. If this acts well, it is used until natural sleep is restored. In some cases the following is prescribed : 1090. ]J. .Spiritfls aetheris sulphurici compositi, f. 5j Syrupi cinchonae , f- 5 ]• M. This is often a substitute for liquor, and if it does not disturb the stomach may be freely used. Congress and mineral waters are given freely. 1091. R. Ammonii bromidi, gr. \xx Infusi quassise, f. 3 ij. ^■ Is often used with good results. Phosphoric acid and cinchona form the basis of all the tonics given. The iodide and bromide of potassium are valuable, but are not cer- tain, and often disagree with the stomach. Bathing and electricity are always good, although the latter is not well borne in many cases. Remedies that derange the stomach are avoided if possible. The first want of the disordered system is rest. Neuralgia and ob- stinate insomnia follow in nearly every case. Of the iron prepara- tions, the citrate is the most useful, with cinchona; quinine, unless indicated by the presence of malaria, frequently causes cinchonism. No effort is made to cause sleep until night, then one of the above remedies is given. Fluid extr. lupulin is excellent with bromide of ammonium. All tinctures and alcoholic extracts are carefully avoided after the 662 TOXIC DISEASES. first few days. Infusions and other preparations are used. Fruits of all kinds are recommended. Bathing and reclining, with some of the above remedies, will often suspend the depression complained of. As a gentle tonic, nothing is more useful, after the system recovers from the immediate effect of liquor, than : 1092. R. Potassli chloridi, gr. x Infusi calumbae, f-lj- M. Taken four times a day for a long time. After the patient has been under treatment a few days, the fol- lowing cathartic is excellent : '093- B- Hydrargyri piluls, gr. x. With Seidlitz powder in the morning. The treatment varies somewhat with each case. In some instan- ces, no medicines are tolerated, and only external means, with ex- act hygienic rules, can be applied. In others, general alterative plans of treatment give good results. Narcotics are always trans- ient in their effects, and more or less uncertain ; and stimulants are frequently irritating and complicate the trouble. In delirium tre- mens, constant nursing, nutritious food, chloral bathing at night, with the bromides, mineral waters, etc., are the most effectual means. Occasionally, Dr. C. gives milk-punch in protracted delirium, but does not think it the most valuable remedy. A steam-vapor bath is equally as good. Milk, and tea, and coffee, are given ad libitum. Beef tea, etc. DR. N. KEELER MORTON, physician to the New York Inebriate Asylum. This physician gives the following plan of treating the partial nausea, loss of appetite, nervous irritation, prostration and headache, which follow prolonged excessive alcoholic indulgence, symptoms to which the Germans apply the significant name Katzenjammer. (Medical and Surgical Reporter, April, 1875.) If, in such cases, we continue the exhibition of alcohol (brandy and soda, etc.), we temporarily alleviate the suffering, but are surely adding fuel to the fire. Experience has shown that if we can sub- stitute the stimulus of nourishing food for liquor, we can accomplish our end without running any risk to our patient. But, to do this, we must create an appetite for the food, and cause it to be retained gtt. XV f.5ss gtt. iij f.iss f. i iss. ALCOHOLISM. 55, and assimilated. For this purpose, Dr. Morton universally pur- sues the following plan : A double Seidlitz powder is administered in as large a quantity of water as possible, for the purpose of producing a rapid and thor- ough evacuation of the stomach and bowels. This is followed by : 1094. ]J. Etheris chlorici, Glycerini, TincturiE capsici, Syrupi zingibeiis, Tincturse cinchonae comp., ii AquK, f.|iss. M. For one dose. This is only given two or three times, once each morning, fol- lowed, during the day, by a teaspoonful of the following, every three hours : I095- R. Lactopeptini, §iij Acidi hydrochlorici, gtt. xxx Glycerini, f § ss Aquse aurantii, f. § iij. M. For a mixture. The result of this treatment is almost always satisfactory. DR. S. B. MARKEL, PENNSYLVANIA. 1096. Be. Quiriise valerianatis, gr. v Ferri sulphatis, gr. x Spiritfls myristicse, f. § ss Aquae menthae piperitae, f. § iij. M. A teaspoonful whenever the craving for drink is felt (Tilden's Journal of Materia Medica, May, 1877.) The following formula, similar to the above, has been considerably employed for the same purpose : I097- R- Ferri sulphatis, gr. y Magnesiae, gr. x Aquae menth. pip., f. 3xj Spirit, myristicae, f. § j. M. This amount twice daily, to appease the craving for liquor, is said to remove it en- tirely, and to prevent the physical and mental prostration that accompany the absolute cessation. Or the following : 1098. R. Pulv. calumbae, Pulv. pruni virginianae, ia % iij Pulv. capsici, Sj- M. Mix well and sift. A teaspoonful in a glass of cold or hot water, when needed to allay the desire for stimulants. • 664 TOXIC DISEASES. 1099. R. Tinct. capsici, '•51'j Tinct. digitalis, f-oj _ Aquam camphorae, ad f. § vj. M. A teaspoonful, as required. Iioo. R. Tinct. capsici, f. 3ij Tinct. nucis vomicae, Acidi nitro-hydrochlorici diluti, aa f'3J.. Infusum gentianse, ad f. § xij. M. Two tablespoonfuls, as required. Either of the above preparations is stated by writers in the Lan- cet (June, 1877,) to be very useful in allaying the craving for alco- holic stimulus, and removing the sense of sinking and faintness so much complained of by intemperate persons who have ceased in- dulgence in their wonted stimulus. The oxide of zinc has also proved of much service in these casesv Dr. Roberts Bartholow recommends that it be combined with pepper: iioi. R. Zinci oxidi, 3j Piperins, 9j. M. For twenty pills. One three or four times a day. These, he says, relieve the trembling and gastric catarrh, and diminish the appetite for stimuli. When commencing the adminis- tration of oxide of zinc, it should be given on a full stomach, other- wise it is apt to produce nausea. MR. C. O., GROOM NAPIER, ENGLAND. This gentleman pointed out, in a paper read before the British Association for the Advancement of Science, in 1875, that a vege- table diet materially decreases the desire for alcohol in those ad- dicted to its use. Most people find that they can take wine with animal food, but not with farinaceous or amylaceous food. Hence, vegetarianism is a valuable aid in checking habits of inebriety. Mr. Napier. states that certain articles of vegetable diet are espe- cially antagonistic to the taste for alcohol. They are : Macaroni, haricot beans, green dried peas and lentils, soaked for twenty-four hours and well boiled, onions, celery, rice, and highly glutinous bread. It is well known that nations who consume but little meat, subsisting principally on fruits and vegetables, are conspicuously temperate ; and individuals who, for other reasons, adopt an exclu- sively vegetable diet, soon lose their desire for even an accustomed stimulant. ALCOHOLISM. 66s NOTES ON REMEDIES. Alcohol. Most practitioners used to believe that in acute alcoholism in feeble subjects, moderate doses of alcohol are indicated. The latest authori- ties generally deem it needless. Amtnonii Bromidum has been employed in delirium tremens. Ammonii Carbonas is valuable in inebriety. (See above.) Amtnonii et Potassii Tartras is much employed by German physicians, in this affection, but little used in America or England, excepting in combina- tion with opium, when it often induces sleep after the failure of opium alone. Arsenicum. Fowler's solution, in i-drop doses, proves serviceable in the vomiting after a debauch, and in the morning vomiting of chronic alcoholism, either alone or combined with from 3 to 5 grains of capsi- cum. Asarum Europmum. The leaves of this herbaceous plant enjoy a great repute in Russia as a remedy for the deranged state of health consequent on habits of intoxication. They are used in infusion, (sij-iv to aquae Oj), or powder, (gr. iij, in pill.) Atropia, hypodermically, is recommended by Bartholow when there is obsti- nate insomnia with great restlessness, weakened action of the heart, coldness of the surface, clammy sweat, and a failure of nutrition with bromide of potassium, chloral and hypodermic injections of morphia. Camphora is recommended by Dr. Laycock in delirium tremens in persons of a nervous habit, where the exhaustion is great, and morphia inad- missible. The monobromide of camphor has been praised also. Cannabis Jndica is regarded by Dr. Anstie as preferable to opium when there is any reason, from the quality of the pulse, to believe the circulation much enfeebled. He prescribes gr. X~^ °f ^ good extract. Tyrrell records (Medical Press, March 13th, 1867,) a case of delirium tre- mens, -in which, after three doses of ni,xx of the tincture of cannabis indica, every third hour, the benefit was marked after the failure of capsicum, and when opium was contra-indicated. Capsicum, in large doses, is strongly recommended by Dr. Lyons and others. Chloral has been successfully combined with bromide of potassium in the indescribable nervousness, uneasiness and malaise which supervene in chronic alcoholism : 1 102. IJ. Chloral hydratis, gr- * Potassii btomidi, 9i Syrupi simplicis, f-3j Aquse, adf.gj. M. This amount every hour. Very much larger doses have been given by some physicians, (gij of 666 TOXIC DISEASES. chloral at a dose, Dr. F. Bkadnack, in the Buffalo Medical and Surgi- cal Journal, September, 1877.) But the practice is undoubtedly dan- gerous. It has been shown beyond reasonable doubt, by Dr. Madison Marsh, of Louisiana, and later by Dr. Ernest Magnan, of Paris, that drunkards do not bear chloral at all well. Its use by them even in moderate doses is liable to be followed by sudden death. The latter physician abjures it entirely in alcoholic cases. (See, however, p. 659.) Cinchona, in strong infusion, is said to act very happily in inebriety and in the tremulousness which affects habitual drunkards. Conium is recommended by Dr. Harley, in combination with opium, thus : 1 103. ]J. Succi conii, f. 3 iv-yj-viij Tincturae opii, fllxx-xxx. M. For one dose. Dr. Kitchen recommends full doses of the fluid extract of conium to control the muscular action in alcoholic nervousness and delirium tremens. Fermentoleum Solani. Dr. Magnus Huss recommends the empyreumatic oil, which gives that special flavor to Irish whiskey or potato brandy, the fermentoleum solani, in doses gtt. j-ij, five or six times a day, in a cap- sule or in pills. This remedy seems to act principally in diminishing the epigastric pains and pyrosis, and appears to have given much sat- isfaction. Herba Serpylli. The wild thyme is a popular remedy for habitual drunken- ness, in Russia. A teacupful of an infusion, f.gj to Oj, is given every half hour the first day, every two hours the second day, and then four to six times a day for two or three weeks, when the cure is complete. The thyme at first causes vomiting, diarrhoea, diuresis and diaphore- sis ; afterwards, increased desire for food and acid drinks, for which lemonade^, etc., should be supphed. Ipecacuanha has been very successfully used in delirium tremens by Dr. W. L. ScHENCK, (N. Y. Medical Journal, Oct., 1872,) in doses of Bj of the powder every fifteen minutes until sij are taken. Emesis is not necessary, and is often not produced by these doses. It has also been used with success to destroy the appetite for liquor in inebriates. The patient is confined to his room, on a low farinaceous diet, but allowed his favorite stimulus in any quantity. After a preliminary purge of calomel, he is given, the next day, gj of powdered ipecac, and this daily repeated. Its effects are said to be almost certain and perma- nent. (Cincinnati Lancet and Observer, July, 1877.) Nux Vomica is a valuable tonic in the nervous prostration of inebriates. (F. 400.) ALCOHOLISM. 667 Oleum MorrhucB. Prof. Ltebig, in his Animal Chemistry, long since pointed out that the use of cod-liver oil has a tendency to promote the disin- clination for the use of wine. It is, therefore, especially useful in the exhaustion from prolonged alcoholism. The great art in giving it, is to commence with small doses (f.gss-j), and it is rarely necessarv to increase these to more than double this quantity. Opium is no longer employed indiscriminately in heroic doses, in every case of delirium tremens. To give it in large and repeated doses, on the principle that sleep must be produced at all hazards, is to nm the risk of killing the patient. Dr. Anstie (The Practitioner, July, 1868,) as- serts that great mischief was formerly done by the custom of plying the patient with larger and larger successive doses of opium, to drown the delirium in narcotic stupor, and says that opiates should never be given by the mouth when the hypodermic injection of morphia is pos- sible. Prof. Graves recommends, in young, robust subjects, when there is much vascular excitement, the following combination : H04. R. Tincturae opii, Vini antimonii, aa IRxx. M. To be repeated every three or four hours, according to circumstances. When the patient is old, and when there is much depression, the opium may be advantageously combined with carbonate of ammonia (gr. iij-iv), or quinine (gr. ij-iij), or with camphor. Prof. Stille says the best method of administering opium in delirium tremens, is to begin with gr. }£,ot its equivalent, and progressively augment the dose by small and hourly additions, until sleep is produced, or a sufficient degree of tranquilhty obtained. Phosphorus is a very useful remedy in the treatment of chronic alcoholism, according to Dr. D'Ancona. (Jour, d' Hygiene, February 21st, 1878.) It is perfectly tolerated in doses which no one has dared to give heretofore — 10 centigrammes (nearly i>^ grains) a day, for many weeks. He says the remedy gives to drinkers a feeling of com- fort and strength, and furnishes the force necessary to carry on their organic functions, which they have been accustomed to get from alco- holic liquors. Potassii Bromidum is recommended as of conspicuous benefit, by reraovmg delusions, calming the delirium, and procuring sleep, in the eariier stages of mania-a-potu, before the delirium has become furious. It is also of service in removing any delusions that may remain after the attack has been partially subdued. QuinicB Sulphas is the nervine tonic in which Dr. Anstie has the most confi- dence, in grain doses, two or three times daily. It should be given from the first, if possible, being, if the stomach is very irritable, ad- ministered in effervescence with bicarbonate of potash and citnc acid. 668 TOXIC DISEASES. Sinapis. In that stage when a timely emetic will cut short the attack, none is so appropriate as mustard. Strychnia. On account of its excellent powers as a nerve tonic, strychnia is often given to restore the tone of the system after alcoholic excesses. It is said to be an ingredient in several of the "bitters" used as "pick-me-ups," among habituts of saloons. Dr. H. C. Morey relates a case of a drunkard who, after'long habit, would take a number of grains at once, to restore his tone ! (Pacific Medical Journal, 1875.) Zinci Oxidum is a most valuable nervine sedative, in the tremor and exhaust- ion from alcoholic excess. (See above.) ARSENICISM (CHRONIC ARSENICAL POISONING). Chronic arsenical poisoning is probably often overlooked. It is produced by the dust thrown off by many kinds of wall papers, from the consumption of candies, etc., colored with arsenical pig- ments, among laborers in arsenical manufactures, etc. Varying de- grees of fever attend the attack, the digestion is deranged, the appetite impaired, bowels irritable, tongue white, furred and sore, mouth and throat dry and sore, and conjunctivitis frequent. Pain and weakness in the back and limbs (arsenical paralysis), are not uncommon, as well as other nervous symptoms. DR. GUENEAU DE MUSSY, PARIS. It is well to commence the treatment with free bathing and a moderate purge, so as to eliminate any remains of the poison de- posited on the skin or mucous membranes. This done, the phos- phide of zinc should be administered in regular doses. It has been found to act as an efficient antidote in these cases, and the arsenical reaction, which is usually quite marked in the patient's urine, will, under the influence of the zinc, rapidly diminish. The phosphide may be given in pill form, combined or not with nux vomica. Its beneficial effects should be perceptible in a week's time. In some instances, the nervous symptoms disappear with astonishing rapidity under its use. DR. A. S. TAYLOR, LONDON. When arsenic has been taken into the system in a gradual manner, no reliance can be placed on the chemical antidotes usually recom- OPIISM. 669 mended. The treatment should begin with emetics, purgatives and baths, so as to remove as much of the poison from the surface as possible. Orfila has recommended that diuretics be employed, in order to promote the secretion of urine, and thus favor the more speedy elimination of the poison from the system. In some cases the urinary secretion is deficient or suppressed, when proper meas- ures are required to restore it. OPIISM (OPIUM EATING: THE OPIUM HABIT), SIR ROBERT CHRISTISON, EDINBURGH. After considerable experience in the management of opium- eaters, this author doubts if success can be obtained by the gradual reduction of the amount consumed. He believes the drug can safely be left off abruptly, even after many years' indulgence. The nervous irritability which ensues he treats with full doses of bromide of potassium ; and the insomnia with chloral. For the first three days after the cessation of the habit, the patient suffers from great mental depression, nausea and vomiting ; but by the fourth night these symptoms usually disappear ; the patient obtains a refreshing sleep, after which the progress is satisfactory. The diarrhoea apt to occur he treats with suppositories of morphia. He acknowledges, however, that there is great danger of a re- lapse after apparent cure. DR. T. D. CROTHERS, HARTFORD, CONN. This physician is accustomed to reduce the amount of opium gradually in some cases, rapidly in others. The more rapid the reduction, the more marked the insomnia, anaemia and nervous ex- haustion ; but if these can be combated successfully, the final recov- ery is more positive and permament. After the opium is discontinued, the following nerve-tonic is often used with good effect. 1 105. R. Tincturse nucis vomicas, 6tt, xlj Acidi phosphorici diluti, £''• "* ^ Syrupi pruni virginianse, f- 3 ss. "*• This amount, at one dose, twice a day. 670 TOXIC DISEASES. Another very excellent tonic for the nerve depression, always present in these cases, is: 1 106. JJ. Acidi phosphorici diluti, gtt. xx Tincturae cinchonse, f- 3 ss Syrupi simplicis, f. Sss. M. This amount three or four times a day. The following is also a favorite for the nerve depression : 1 107. R. Ammonii bromidi, gr. xxx , Tincturse cinchonse, f. S ss Syrupi, f-SJ- M. To be taken every three or four hours. Also the following, which is varied from time to time, combining with it fluid ext. lupulin, or valerian, or some of the bitter tonics: 1 108. R. Chloral hydratis, gr. xx Syrupi cinchonse, f. §j. M- Taken every three hours. The ferri et quiniae citras is given in many cases, but cinchona and some of the vegetable tonics seem to work best. In addition to medicines, he orders a hot or tepid bath every day, enjoins out-door exercise, light, nutritious diet, and the galvanic current over the spine. For the insomnia, he only gives remedies at night, after a warm bath, usually one of the following : 1 109. R. Chloral hydratis, gr. xxv Syrupi, f. § ss. M. To be repeated in two hours if it does not act well. If this does not work well, but is followed by nausea, or other disturbances, next day the following may be used : 1 1 10. R. Ammonii bromidi, gr. xl Tincturse zingiber., f. 3} Aquse, f. § ij. M. This may also be repeated. No other remedies in his experience seem more certain than these. Electricity frequently increases the insomnia. Valerian, belladonna, and lupulin occasionally work well, but are not alike in their effects, and derange the stomach. Tea, coffee, and port wine act well in many cases, taken just before bed-time. Rubbing and bathing and perfect quiet, in good surroundings, and the entire con- OPIISM. 671 fidence of the patient, are essentials. The diarrhoea seldom requires particular attention ; if it does, the following is usually sufficient : lili. ^. Eismutbi subnitratis, 9j Acidi tannici, gr. x. M. For one powder every three hours. The excessive sweating will usually yield to acid mixtures, of which the dilute phosphoric acid is always the base. In both these conditions, the free use of subacid fruits, such as lemons, oranges, limes and grapes, is extremely advantageous. Special attention must be given to the mental condition, as melan- cholia and brooding are prominent symptoms, and require to be met by light occupation, cheerful conversation, amusements, varied so- ciety, etc. J. B. MATTISON, BROOKLYN. (Tkerap. Gaz., 1890.) This noted specialist upon the various toxic "habits" details his method of treatment of morphinism. He withdraws the drug from the habitue rapidly, but before doing so gives full and, during the days immediately after the withdrawal, increasing doses of bromide of sodium, so as to bring the times of the greatest nervous disturbance and of greatest bromide sedation together. He begins with 30 grains of bromide twice daily, until in eight or ten days 100 or 120 grain doses have been reached. He not infrequently produces decided "bromism." By the eighth or tenth day all opium has been withdrawn and entirely abandoned. The reduction is first one-fourth or one-third the previous dose ; later the removal goes on more or less rapidly according to the case and the degree of bromide sedation. On the last day of using the opium a full dose of morphia is given at bedtime to secure a good night's rest. Toward evening of the next day reflex symptoms are apt to show, which are counteracted by 20-grain doses of quinine, followed by half-ounce doses of fluid extract of coca. This failing, cannabis indica in full doses is given (60 minims) every two hours. Hot baths or a cold douche may be required. For pain, electricity, ether spray or hot water may be used, or antipyrin, phenacetin, ex- algine, menthol, etc., locally. Twenty-four hours after final with- drawal of opium, the patient is put to bed for several days. Diet is not restricted unless the condition of the stomach and bowels de- mand it; If the stomach rebels, use rest, lime water and milk, malted milk, ice, bismuth, chloroform, faradism and sinapisms ; or. 672 TOXIC DISEASES. in failure of all, a full dose of opium. Coca with strychnia, iron, mineral acids, etc., for debility ; this may be required to be continued for weeks. For insomnia, chloral, bromides, cannabis indica, sul- phonal, etc., are employed ; often a hot bath, a light meal, a hot glass of milk, will answer. Surroundings should be cheerful, and freedom from worry is essential. Usually the duration of treatment is four weeks. peck's anti-opium pills. These are used by the author (China Med. Missionary, 1890,) at a Chinese medical mission, to counteract the opium habit among the natives. About 100 pills, commencing with from two to eight, and gradually reducing, are required to break the opium smoking habit. 1 1 12. R. Sodii pbosphatis exsic, gr. M Abstract! nucis vomicae, gr. DCL Pulv. opii, gr. DCCL Trituratis ipecac, gr. CL Abstract! belladonnae, gr. CCL Piperine, gr. D. M. Ft. pil., No. M. COCAINE HABIT. The cocaine habit is also worthy of mention, but in its treatment follows so closely upon morphinism that in principle it is nearly identical. No further space is therefore given it. HYDRARGISM (CHRONIC MERCURIAL POISONING). PROF. WILLIAM A. HAMMOND, M. D. The earlier symptoms of chronic mercurial poisoning are saliva- tion with swollen gums, foetid breath, loosening teeth, and ulcera- tions. Mental and physical weakness, paralysis and convulsions, and caries and necrosis of the bones, are results which manifest themselves later. The specific treatment, in all cases, is by the internal administra- tion of iodide of potassium, which as Melsens has shown, separates mercury from its combination with the tissues of the body, forming with it the iodide of mercury, which is eliminated with the urine. The iodide of potassium must be given in full doses, say gr. xxx, MERCURIALISM. 67, in divided doses, every day. The urine can be readily tested for the mercury eliminated under its influence, by placing a few drops, excreted during the second day, on a bright copper plate, and add- ing a drop of hydrochloric acid. A bright metallic stain will be found on the plate, if mercury is present ; the iodide of mercury is decomposed, and the metallic mercury is precipitated. Of course, while under treatment, the patient must not be sub- jected to continued poisoning by mercury, either medicinally or through his avocation. Tonics, such as iron, quinine and strychnia, are useful adjuncts. The prognosis, under favorable circumstances, is generally good, even in severe cases. JAMES E. GARRETSON, M. D., D. D. S. Mecurial ulitis, when confined alone to these parts, will generally disappear on the cessation of the drug. If this should not prove the case, nothing better can be done than to scarify and paint the gums with tincture of iodine ; as a rule, the officinal tincture, di- luted one-half. Chlorate of potash as a wash, and also used inter- nally, may be employed ; to an adult, gr. x in a tablespoonful of water, four or five times a day, is an appropriate dose. As a local application, oj to aquae f..5j, is a very good strength. The bowels are to be kept in a lax condition by saline cathartics. When the mercurial poisoning passes to that stage which results in the breaking down of the tissue, the treatment must be more active, and directed quite as much to the constitution as to the mouth itself. Locally, the fcEtor will urgently demand attention, and one of the best means to correct this will be found in the permanganate of pot- ash in solution, gr. ij-x to aquae f.§j. Constitutionally vigorous tonic medicaments are required. If hemorrhage intervenes, tincture of Erigeron Canadensis, gtt. j-ij, repeated occasionally until such bleeding is controlled. Locally, cobweb saturated in alum water may be used. Laid carefully upon the bleeding part, and retained in position, it will seldom be found to fail. Monsel's solution, etc., should not be used, owing to the great liability to sloughing. Incisions may still be made, but few in number and cautiously, and the tincture of iodine applied should be diluted with two-thirds water. The dilute aromatic sulphuric acid is also a happy local remedy in such cases, say f.oj to aquae f.^viij. A combination for local use, of beneficial effect, is : 4- 6/4 TOXIC DISEASES. 1 1 13. R. Potassii chloratis, Sss Sodii biboratis, Aluminis pulveris, aa 5 ij Potassii pennanganatis, gr- xxv Aquae coloniae, f. % j Tincturse cinchonae, f. S ij Tincturte myrrhEe, f- § j Tincturse capsici, f- 3 j Tincturae krameriae, f- i j Aquae, f- S viij. M. For a mouth-wash. If, in defiance of all that is done, the parts should slough, one of three things occurs — the disease will seem to have exhausted itself, and the parts, after a little rest, give evidence of recovery ; or the bone follows the ulcerative action and sloiighs likewise ; or the pa- tient dies from irritation and exhaustion. In the second case, it is important that the dead bone be left to detach itself, and not be removed by the surgeon. Mercurial glossitis and ulceration of the tongue are also condi- tions frequently demanding treatment. In rapid swelling of the tongue, it may be necessary to leech the throat vigorously, to sweat the patient thoroughly, and follow this with a saline cathartic. These measures, combined with an arterial depressant, aconite, digi- talis, or veratrum, will usually relieve from immediate danger. Great lassitude and depression are apt to follow. Locally, sage tea, saturated with chlorate of potash, common table tea, and the internal use of bromide of potassium, gr. xx, three or four times a day, are grateful measures. For the mercurial ulcer, equal parts of bismuth, red bark and borax act sometimes very happily. Chlorate of potash, tannic acid and glycerine form another excellent combination. Solutions of sulphate of copper or zinc, gr. j to aquae f.5j, are cleansing and stimulating applications. PROF. JAMES SYME, SCOTLAND. Persons whose constitutions have been injured by the use of mer- cury, frequently suffer from sores, either superficial and confined to the integuments, or deep-seated and affecting the periosteum or bones. In both cases the condition concerned is distinguished by characters which a practical eye readily recognises, and which prove very obstinate under ordinary treatment. For these ulcers Prof James Syme recommends blisters, which shall not extend much beyond the ulcerated surface, in connection MERCURIALISM. 675 with small doses of iodine, gr. ij, three times a day, in simple solu- tion. This simple and powerful mode of treatment has, in his hands, completely restored limbs which had been condemned to amputation by other surgeons, for ulceration and disease of the bones. (Surgical Works, 1866, p. 916.) Dr. Jukes Styrap, physician extraordinary to the Salop Infirm- ary, has found the following prescription exceedingly efficacious in controlling ptyalism — in fact, a positive " specific " for it : 1 1 14. R. Sulphur prsecip., 3ij-iv Potassii chloratis, 9ij-3j Liq. morphioe, f. 3j-iss Mist, amygdala, f. Iviij. Mix well. Two tablespoonfuls every three or four hours. Shake well. Especial care must be taken to diminish the quantity if any relax- ation of the bowels supervene. In thirty-six hours the secretion and tenderness of the gums become very sensibly diminished. PROF. S. D. GROSS, PHILADELPHIA. 1 1 15. R. Liquoris plumbi subacetatis, f. 5j Aquae, f. Iviij. M. To be used as a mouth-wash every hour or two, in cases of viercurial stomatitis. The only objection to this lotion is that it discolors the teeth, which effect, however, quickly disappears. At the same time, inter- nally, the chlorate of potassa should be administered. Fifteen to thirty grains are to be taken ter die, in mucilage or lemonade. Dr. Fahnestock, of Pennsylvania, has stated that an infusion of the inner bark of the root of the sumac, Rhus glabra; is almost a specific for the sore mouth attending inordinate mercurial salivation. The hypodermic injection of the sulphate of atropia is a powerful agent in arresting mercurial salivation. Dr. Ebstein, of Breslau, arrested by this means, in seven minutes, a case which had con- tinued a month ; on doubling the dose, the secretion was arrested for twelve hours.- This action of the drug is explained through its inhibitory influence on the permanent irritation of the secretory fibres of the salivary glands. Pilocarpin has been found useful to relieve the system of the drug. 6j6 TOXIC DISEASES. ' PLUMBISM-LEAD POISONING. PROF. WILLIAM A. HAMMOND, M. D. In the numerous forms of chronic lead poisoning — whether this assumes the character of lead colic, paralysis, encephalopathy, hy- persesthesia, or anaesthesia — the specific treatment consists in the administration of the iodide of potassium in full doses. Although some claim that the resulting compound — the iodide of lead — is very poisonous, Dr. H. has never seen the least untoward result, and he has always used the potassic salt in large doses from the very beginning. In the treatment of lead encephalopathy, the free administration of the iodide of potassium, combined with the bromide of potassium, affords the best prospect of success. In lead colic, the hypodermic injection of morphia, in doses suffi- cient to keep the pain in check while the iodide of potassium is doing its work, with an occasional purgative, will generally be all the treatment required. But in lead paralysis, in addition to the iodide, we must use direct measures. Chief among these is electricity. The induced current, if it will cause the muscles to contract, is to be preferred. Each para- lyzed muscle must be acted on for two or three minutes every alternate day. In ordinary cases, two months will suffice to effect a cure. When the electric contractility of the muscles is completely abol- ished, the primary interrupted current must be used until contractil- ity is established. Friction's, kneading of the muscles and passive exercise, are also useful. PROFESSOR WILLIAM PEPPER, M. D., PHILADELPHIA. This practitioner remarks that the treatment of lead colic should have several points in view. First, the removal of lead from the intestinal canal ; second, its elimination from the tissues ; and third, the treatment of special manifestations. For the removal of lead from the intestinal canal he prefers the sulphate of magnesium with dilute sulphuric acid. This converts it into an insoluble salt, and acts also as a purgative. Internally, to eliminate the lead from the tissues, he gives the iodide of potassium in full doses. This forms the iodide of lead, which is excreted by PLUMBISM. ^n the skin and kidneys. With regard to the treatment of special symptoms, if there is severe colicky pain it must be relieved by ano- dynes or anaesthetics. The following is a preparation which acts well: 1116. R. Ext. colocynth. comp., gr. ij Ext. opii, gr. ss Ext. belladonnse, gr. \. M. This pill repeated until the pain is relieved and the bowels opened. The palsy may be relieved by the internal administration of strych- nia, and locally by the application of the faradic current to the affected muscles. The ansemia is best treated by the iodide of potassium and the salts of iron. PARIS HOSPITALS. Sulphuric acid is much employed in the Paris hospitals in the treatment of saturnine poisoning, with the most marked success. Mild cases yield in about three days, severe ones in six or seven days. H17. R. Acidi sulphurici diluti, f.3ij Aquae, Oij. M. This quantity is given during the day. The stomach soon becomes accustomed to it, even when the first dose or two is rejected. The abdominal pains are relieved after the first or second day, the con- stipation yielding soon after. This treatment should be combined with the repeated use of sulphur baths. DR. LUTZ, PARIS. 1 1 18. R. Sulphuris loti, Mellis despumati, aa § iv. M. Give an ounce and a half of this electuary three consecutive days in lead colic, then give in doses gradually lessened. On the third day the acute pain has disappeared. 1 1 19. R. Chloroformi, f. 3ss Alcoholis diluti, f- 3 ss Mix and add. Aqua, f.Sviij. M. To be given as an enema in lead and nervous colics. 1 120. R. Podophyllin, Extracti nucis vomicae, _ ... Extract! belladonnae, aa gr. iij. M- Divide into ten pills. One twice or thrice a day, to relieve the painful constipation of workers in lead. At the same time sulphur baths are to be administered. 6/8 TOXIC DISEASES. PROFESSOR NIEMEYER. 1121. R. Olei ricini, f-iij Old tiglii, gtt. iij. M. A tablespoonful every two hours in lead colic. The patient also to take in tb^ twenty-four hours three opium pills of from gr. J-J. Warm baths, narcotic fomen- tations, enemata, sometimes purgative, sometimes narcotic. GEORGE HAY, M. T>., PHILADELPHIA. This writer (Medica/ Times, 1878,) objects to the exhibition of potassium iodide in cases of chronic lead poisoning, on the ground that the iodide of lead is more insoluble than the chloride of the same metal. Preferably he would exhibit sodium chloride in drachm doses three times a day, because, as he says, the kidneys eliminate the chloride of lead freely, or an oxide of lead dissolved in a solu- tion of a chloride. In addition to this a tepid bath ought to be em- ployed daily, for three reasons, viz., to keep the skin active, to remove whatever lead has been excreted in that way during twenty- our hours, and to prevent its re-absorption. The use of a soft flesh-brush would be a great assistance to the bath by removing mechanically from the skin any lead, in whatever form, adhering to its surface. Sponging of the body might be substituted if the pa- tient is too weak to bear the fatigue of bathing. During the course of recovery from chronic lead poisoning, to improve the nutrition and build up the strength of the patient, analeptics, nervine tonics, and nutrients are indicated, such as tinctura ferri chloridi, liquor strychniae (not the sulphate), or tinctura nucis vomicae, tinctura cinchonae, or the alkaloid quinia (not its sulphate), together with animal broths, milk, eggs, etc. JOHN SYER BRISTOWE, M. D. This author advises, in the treatment of lead colic, that the pain and discomfort be relieved by opiates and fomentations, and that no purgatives whatever be administered, but the bowels be left to act of themselves, which they usually do in a few days. At most, copious enemata of warm water or warm gruel may be given. The recommendation of Dr. Pereira was baths medicated with potas- sium sulphide. 1 122. Jl. Potassii sulphidi, gij Aquae, Oxvi M. The theory is that the lead escaping from the surface of the skin PLUMBISM. 679 is converted into an insoluble sulphide. Dr. Bristowe, however, doubts whether the baths promote the escape of the lead in any- important degree. For the restoration of the paralyzed and wasting muscles, galvan- ism is the only effectual remedy. The most effectual is the slowly interrupted constant current, used three times a week, ten or fifteen minutes at each sitting. Each muscle should be separately galvan- ized. THERAPEUTICS OF DISEASES OF CHILDREN, GENERAL REMARKS. DR. EDWARD HENOCH, OF BERLIN. This author, in his work ^^ Lectures on Diseases of Children !' gives some very important and valuable points on the therapeutics of in- fancy and childhood. He says that the conditions of life in early childhood are of such a nature that even the most rational and faith- ful treatment of its diseases is useless in an extremely large number of cases. Even the most persistent study and ripe experience will not save you from disappointment in reference to therapeutic re- sults. The enormons mortality, especially in the first six months, is explained by two sets of causes, the first of which is found in the natural development of the child, the second in extrinsic circum- stances. While children of the upper classes, who are carefully nourished, more readily pass through these developmental changes, they are apt to become pathological under the adverse circumstances to which the lower classes are subject. The foul air of narrow, crowded rooms, the more or less improper food, the influence of cold, hunger, the lack of natural care — all these influences tend to impede the natural course of development and to produce the har- rowing pictures of disease with which we come in contact. Many of these unfortunate beings carry with them the seeds of death, and die of exhaustion the first few days after birth ; others succumb to hereditary syphilis; the majority become puny on account of persistent diarrhoea, or repeated attacks of bronchitis, with enlarge- ment of the bronchial glands, which finally leads to cheesy degen- eration and general tuberculosis. (681 ) 682 DISEASES OF CHILDREN. The examination of the urine is very difficult in the new-born and nurslings, as it is always passed into the diapers, and an estimation of its quality and color is very uncertain. But in some cases it be- comes necessary to examine for albumen or sugar, and the urine must therefore be gathered in special vessels (in girls, well-cleaned sponges placed in front of the genitals ; in boys, in condoms or rub- ber bags fastened around the penis) or by the introduction of an elastic catheter. Vigorous, continued crying, which does not excite a coughing spell, is a favorable sign in diseases of the respiratory organs, be- cause it indicates a comparatively slight degree of irritation of the respiratory mucous membrane. Loud crying spells, with vigorous movements of the lower limbs, especially flexion on the abdomen, usually, in nurslings, indicate colic pains. Writing of the atrophic conditions of children, this author lays great stress upon the most important factor of nutrition. If vomiting and diarrhoea are con- stantly recurring in an infant, no time should be lost in securing an- other nurse. He makes the condition of the child his criterion in judging of the suitableness of the milk it is receiving, relying but little upon chemical or microscopical examination. During the first three months the proportion of milk to water should be as I to 3, in the second three months as i to 2, and in the third half and half. After the ninth month you may give two parts of milk to one of water, or undiluted milk ; both the milk and water used should be first boiled, in order to destroy any fermentation germs that they may contain. When cow's milk cannot be used, he gives the next place to condensed Swiss milk. During the first three months, one part of condensed milk is given to twenty-two parts of water, from the third to eighth months one to eighteen, and later one to twelve. Oatmeal or barley water may be used as the diluent. After the tenth to the twelfth week he recommends Nestle's flour as a very suitable article of diet. One tablespoonful may be boiled with nine or ten tablespoonfuls of water. Nothing need be expected from the use of drugs in the treatment of atrophy, except when complicated with diseases of the respiratory organs or intestinal canal. DR. ARMAND SEMPLE, OF LONDON. This author in his work on "Diseases of Children "gives us some valuable points in reference to the CLINICAL EXAMINATION. 683 CLINICAL EXAMINATION OF CHILDREN. Inspection. — If the child is asleep: Note the attitude, whether the posture is natural or the reverse. The color of the face. Is it pale or flushed? The color of the lips. Are they livid or white ? The condition of the skin. If it is moist or dry, and whether the moisture limited to the forehead and head, or is it general? The expression of the countenance. Is it natural or indicative of pain? The action of the alse nasi. Are they quiet or twitching? Is there any moaning, starting or grinding of the teeth ? The respirations. What is their number? Are the eyes staring, closed, or partially closed ? The state of the fontanelles. If they are open or closed, re- tracted, distended, or strongly pulsating. The pulse under two years should vary from 90 to 130, but con- sistently with health after three years it is seldom above 100. Al- though not more than 70, it may still be healthy. The absolute number of beats is of slight importance ; but a slow pulse in a child is a serious indication. The shape and size of the head must be observed, if this part is hot or large, or presenting enlarged veins. If the child is awake : Is it smiling or frowning, is it excited or quiet, languid or fretful, are the eyes surrounded by a dark circle? Is there any suffering? An infant in perfect health should sleep 20 hours out of the 24. It is, therefore, important to discover if a child's illness began with broken rest or sleeplessness. Upon stripping a child, the following appearances should be noted : the surface of the skin should be mottled, the flesh firm, the skin elastic to the touch, and smooth, never flabby, the legs and arms should move with freedom. The joints should be examined, whether large, small or swollen. The respiration in a child from i to 3 years of age should be 24 to 36 per minute, and in their charac- ter diaphragmatic. The chest walls should not recede in an ordi- nary respiration. Eruptions should be looked for, especially around the anus. The stools of an infant should be yellow, and the mo- tions, three or four times a day. The gums should be examined, whether hot, swollen or otherwise. The first incisors should be 684 DISEASES OF CHILDREN. present by the 7th month, the first molars by the i2th, the canines by the i8th, and the second molars by the 20th month. A child seldom lifts its head from the pillow until about the second month ; it is unable to sit erect until the 4th or 5th month. The Respirations. — In a child the respirations vary, per minute, from 30 to 50. The actual average in infancy is 39. From 2 months to 2 years the respirations are about 35. From 2 years to 6 years the respirations are, during sleep, 18; awake, 23. I'rom 6 to 12 years the same. When practicable, both the front and back of the thorax should be examined, but the back of the chest in the sick child is the most important part to examine, and auscultation should be performed before percussion. If the back presents no indications of bronchitis or pneumonia, it is very improbable that the front of the chest will show any. Dullness posteriorly on the right side is a normal physiological state, due to abdominal pressure, by which the abdominal viscera, (and, upon the right side especially, the liver,) are pressed upwards. The Expression of the Countenance. — ^The lower part of the face suffers chiefly in abdominal disorders, the cheeks are sunken and puckered, the lips are pale or livid. The middle parts of the face are altered by lung and heart affec- tions, the nostrils twitching, distended or sharp. There are dark rings under the eyes, and a blue circle round the mouth. The upper part of the face is mainly affected in cerebral diseases, producing contraction of the forehead, knitting of the brow, and pur- poseless rolling, or fixed eyes. In addition to the above signs must be noted pallor or redness, unequal dilatation of the pupils, and ptosis. Gesture. — This is often of significance. In abdominal diseases the child draws up the legs and picks at the clothes ; the face is anxious and sunken. In cerebral disease he puts the hand to the head, beats the air with uncertainty, rolls the head on the pillow and pulls at his hair. In severe dyspnoea, when the tongue is much furred or when a false membrane is forming, the child clutches at its throat, or puts the hand in the mouth. The Cry. — This varies. It is labored or choking in capillary bron- chitis or pneumonia. In brain disease it is sharp and shrill, charac- teristic in acute hydrocephalus (the "hydrocephalic cry"). In CLINICAL EXAMINATION. 685 laryngitis it is metallic or brassy, and in tubercular peritonitis or marasmus it is wailing or moaning. Crying for several hours always indicates one of two conditions — hunger or ear-ache. A cry which precedes defecation, or is accompanied by writhing or wrig- gling, is "intestinal." A dry, low, peevish cry attending suppressed cough indicates pneumonia. A louder shrill cry upon coughing or moving the child is an indication of pleurisy. In diseases of the alimentary canal moaning is highly characteristic. Posture. — In addition to the upright position or orthopncea, the most noticeable position is the " en chien de fusil," the child lying on its side, the arms drawn close over the chest and the legs flexed powerfully. This position is conspicuous in some cerebral diseases, and in the late stages of tubercular meningitis. The Evacuations. — In health, an infant's " motions " should vary in color from light yellow to greenish yellow. Their reaction is always acid. The odor should be similar to that of sour milk ; but it should never be offensive. Its consistency varies considerably within the limits of health. The Tongue. — A red, hot, dry tongue indicates inflammation of the mouth and stomach. A furred tongue, over which white curd is spread, shows indigestion and intestinal irritation. Aphthae or thrush may occur from neglect or starvation ; white fur usually points to fever. A flabby, pale tongue, with marked edges, is an indication of great weakness. Yellow fur shows long-standing de- rangement of the stomach and liver. A brown tongue points to a low typhus state. In addition to the above, must not be forgotten the so-called "strawberry" tongue of scarlatina. Temperature. — Twenty-four hours after birth the average temper- ature is 100.4° F-i 3nd forty-eight hours after, it is about 99.6" F. During the first few days of life it varies very little from the forego- ing. At a later period the average must be considered about 99° F. ; 98° to 99.5° F. is perfectly normal. Some abnormal condition must be suspected when it is below 97° F.,or above 100° F. The temperature is a more reliable guide than the pulse in young children. The thermometer alone will indicate the suspicion of scarlet fever, or enteric fever, or some incipient pneumonia, or even worms. Rigors do not occur in young children, and in these sub- jects, delirium and convulsions to a great extent correspond to the headache and rigors of the adult. In typhoid fever, a gradual in- crease of temperature for the first four days, with morning remis- 686 DISEASES OF CHILDREN. sions, is diagnostic. In tubercle, the evening temperature is as high or may be higher than the morning. A steady fall of temperature, toward the evening especially, must be considered a very favorable indication in the continued fevers, and in inflammations generally, if the general condition of the patient corresponds. A fall of temper- ature, with a rapid pulse, and aggravation of the symptoms, indi- cates danger from exhaustion. A sudden rise or fall of temperature always precedes death. The Eye. — Strabismus or squinting is a serious symptom. It may result from paralysis, reflex irritation or convulsions, but after the subsidence of the convulsions, the squint may remain for a time or even permanently. When squinting is observed in acute hydro- cephalus it is nearly always a fatal symptom, A large pupil is more common than a small. The latter occurs in sleep, in opium poison- ing and in cerebral congestion. Inequality of the pupils occurring in acute diseases is always of grave import, but large pupils, if equal in size, are only to be considered serious if they are insensible to light. The pupils have been noticed to be irregular in children who were suffering from intestinal worms. The Pulse. — An extremely slow pulse indicates brain disease. The following facts should always be borne in mind in connection with diseases of children : In early childhood, the intensity of the symptoms bears no rela- tion to the existing affection. Very intense fever, with restlessness, screaming, and convulsions, may paSs off in 24 hours, not leaving the least trace. Copious perspiration is never seen in young children ; moisture entirely replaces it. Fever, in acute diseases of young children, always exhibits con- siderable remissions. Fever is almost always intermittent in the chronic diseases of in- fancy. During sleep, the pulse of a child falls from 15 to 20 pulsations. The pulse may be raised 15, 30, or even 40 pulsations, by the muscular movements which accompany convulsions, cough or cry- ing. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. These distinguished authors, in the last edition of their work on " Diseases of Children," very truly say that the clinical examination CLINICAL EXAMINATION. 687 of children, and particularly of young infants, cannot be successfully practiced by the same method as that habitually made use of in the case of adults; the helpless silence of the infant — the wilful silence, or the loose and inconsistent answers of the older child, which lead astray the mind rather than guide it to true results^ — the agitation and fright produced by the examination, rendering it im- possible at times to ascertain the real state of the different functions of the economy — and lastly, the difficulty of obtaining accurate and reliable accounts of the history of the case from the attendants, all combine to make the duty of the physician most perplexing, and, unless he be gifted with a large share of patient and philosophic calmness, most irksome and trying to temper. After the age of eight or ten years, the physical and intellectual development have progressed to such a point as to render the method of diagnosis nearly the same as that employed in adults. It is important that the examination should be made in two differ- ent conditions, ist, while the child is calm and quiet, and 2d, while it is disturbed and agitated. If possible, therefore, the physi- cian should always see the child when asleep, and if the mother or nurse propose, on the occasion of his visit, to hurr}' up stairs to pre- pare the child, or to bring it down into the parlor or lower room, he should ask as a favor that he may see it asleep. If, in spite of hav- ing just been nursed, the child be awake and fretting, we should en- deavor, by the attraction of toys, by gentle and soothing words and manners, by fondling or by having it carried about the room, to get it quiet. We shovld be very particular to elicit from the parents or attendants a clear history of the case and all that may have trans- pired between our visits. We must not disregard what the mother may tell us, even though we do not at once see its substantiation, for we must ever remember that maternal instinct will sometimes discover that which has escaped the search of the most acute and rigorous medical observer. When we have reason to suspect the onset of any of the eruptive fevers, we should carefully question the mother as to the date of beginning of the illness ; by well directed questions we can determine this. It will be well to elicit all the information that we can from the mother or attendant before we go into the presence of the child, in order to avoid the risk of alarming the child, by the presence of a stranger, during an unnecessary length of time. The most important points to be attended to during the clinical 688 DISEASES OF CHILDREN. examination, are the countenance, noting its expression, color, the presence or absence of furrows and wrinkles from pain, from emaci- ation, or from disordered muscular action, the appearances presented by the nasal orifices, and especially by the alae nasi, and the charac- ters exhibited by the mouth ; the sleep, the cry, the state of plump- ness or emaciation ; the condition of the skin as to color, tempera- ture, moisture or dryness, the presence of swellings of any kind, such as those produced by dropsy, or by affections of the joints, and the existence of eruptions ; the pulse ; impulse of the heart ; the respi- ration ; the signs furnished by the state of the mouth and throat, and by the disposition towards and power of sucking, or by the manner in which drinks are taken ; and lastly, the state of the abdomen. In diseases of the brain, the expression of the upper part of the face, the forehead and the eyes, are chiefly affected, while in diseases of the thoracic organs, the middle portion of the face (especially the nostrils) is affected. Dr. M. HALL tells us that pain in the head causes a contracted brow, pain in the belly an elevation of the upper lip, while pain in the chest is chiefly denoted by sharpness of the nostrils ; but our authors consider that it is impossible from the expression alone to tell where the pain is located. In chronic cases of all kinds where the nutritive functions are enfeebled, the face as- sumes a pallid and waxen hue ; in the various digestive derange- ments, it becomes muddy or sallow, and in affections of the liver more or less yellow. In pneumonia, bronchitis and pleurisy the movements of the alae nasi become rapid and energetic. The pulse of the child, in order to be judged of to any real ad- vantage, must be examined during the stage of quiet, and, if possi- ble, it should be felt while the child is either asleep or dozing. The physician should never think his examination of a sick child concluded until he has inquired as to the occurrence of vomiting, and as to the state of the discharges by stool. Not only should he in- quire as to these symptoms, but he ought by all means to inspect personally the appearance of the matters ejected. This is especially important in regard to the dejections, since no description of a mother or nurse, however intelligent, can impart to the physician the precise and accurate idea of the state of those discharges which even a very rapid inspection would give him. DR. POLITZER, OF VIENNA. This distinguished authority, who has had forty years' experience CLINICAL EXAMINATION. 689 with the public Institute for Sick Children, at Vienna, calls attention in Jahrb. f. Kinderh, 1 884, to the value of certain isolated symptoms in making the diagnosis of many of the diseases of children. 1. One which is likely to attract attention at once is a strongly pronounced nasal or palatal resonance in a child's cry, and this is, in many cases, the first symptom which should lead to a timely diag- nosis of retro-pharyngeal abscess. The symptom is present, how- ever, in some other affections, for example, in the ozaena of con- genital syphilis, and in hypertrophy of the tonsils. 2. A greatly prolonged and loud sounding expiratory act, with normal inspiration and complete absence of asphyxia. Upon this symptom alone the author is willing to base a diagnosis of chorea major. 3. A sighing inspiration which is continuous, and seems to origi- nate from the upper portion of the thorax. It has not been suffi- ciently considered by the profession, bearing in mind its importance with reference to diagnosis, and prognosis, and also to treatment. It indicates the beginning of heart weakness and paralysis, and sometimes a developing acute fatty degeneration of the heart. 4. A strongly pronounced diaphragmatic expiratory act, shrill and penetrating in character. This is spoken of as strongly contrasted to the preceding symptom, but equally valuable in diagnosticating the bronchial asthma of childhood. 5. The occurrence of pauses between the end of expiration and recurring inspiration. This might be taken as a symptom of croup, but in most cases the probabilities are more favorable to the pres- ence of laryngeal catarrh of a pronounced type. Associated with this symptom as an important condition is the "spasmodic catarrhal stenosis, with its accompanying sub-mucous oedema. 6. Continuous stridulous respiration from the time of birth. This is not infrequently seen, but is often without important significance, and is supposed by the author to be due to some fault of innerva- tion, especially with respect to the inhibitory fibres of the "vagus." 7. A series of individual symptoms is next referred to which have reference mainly to the diagnosis of diseases of the brain. The first of these is a very pronounced drowsiness, which is unattended by fever or any other noticeable disturbance, and which lasts some time. When occurring in children who are pale, unusually quiet and apa- thetic, it is very often an initial symptom of basilar meningitis. A second symptom of this series is a resistant and non-compressible 44 690 DISEASES OF CHILDREN. anterior fontanelle which is considerably elevated above its ordinary level. It is an important and too little appreciated symptom, for it is present in cerebro-spinal and vertical meningitis, in acute, simple and complicating hydrocephalus, with tumors of the brain, and in intermeningeal apoplexy of infants. It is a Noteworthy symp- tom too in fevers, and in various inflammatory conditions, but its especial value consists in its indicating that there is independent disease of the brain aside from any other concurrent processes. The deeply-depressed anterior fontanelle, with which is almost always associated a sunken condition of the eye-balls, is indicative of inanition and diminution of the volume of the blood. The third symptom of this series consists in a remarkably slow movement of the eyeballs, a staring, vacant expression, and slow, infrequent mov- ing of the lids. It is considered by the author as an important indication of the beginning of basilar meningitis. 8. Another series of symptoms may also be noted with advantage in respect to the crying of children. The first of these is a violent, penetrating cry, lasting two or three minutes, accompanied with a most anxious expression of countenance, and occurring an hour or an hour an a half after the child has gone to sleep. It is an indica- tion of what is commonly known as " night terrors," and is very apt to occur among senemic and irritable children. Again there is a cry which lasts five or ten minutes, which comes periodically both by day and by night, and may indicate colic or dyspepsia, but it is more likely to be caused by spasmodic action of the bladder, espe- cially if it be observed that strangling accompanies it. Another cry seems to be associated with fear whenever the' act of defecation takes place. In such cases obstinate constipation is very likely to be present, and fissure of the anus will often be found to be a suffi- cient cause. Another severe, painful, continuous cry, with restless- ness of the head upon the pillow, and frequent grasping of the head serves to indicate an otalgia, or an otitis externa or media. An- other variety lasts for days and weeks, is exaggerated by touching and movement of the limbs, and is associated with paroxysms of sweating and fever. The author looks upon this as indication of acute general rachitis. Still another cry is associated with constant sleeplessness. This may be one of the phenomena of congenital syphilis, but is more likely to proceed from errors in diet, and in still other cases it is due to the viciousness of nurses. Finally there is a form of cry which is kept up day and night, which is associated CLINICAL EXAMINATION. 69 1 with a history of exhausting discharges, and consequent thickening of the blood. 9. A final series of symptoms includes some which are not noticed by the parents of the child, or not as early as would be desirable for the child's interests. First is mentioned the peculiar physiognomy of congenital syphilis. Second is a decided falling together of the nostrils, with total absence of motion in them during inspiration, and significant narrowing of the nasal cavities. This is an indication of hypertrophy of the tonsils of a decided type. Next, a disinclination or inability to move, on the part of certain children, is referred to, which is associated with pronounced weakness, and all of which is out of proportion to the apparent gravity of the child's disease. The symptoms indicate, however, an approaching or existing spinal paralysis. Weakened power of hearing sometimes indicates the presence of circumscribed meningitis. Depression of the physical activity after certain brain affections, in small children, may be an indication of the beginning of acquired idiocy. An indication of rachitis is sometimes seen in the delayed ossification of the cranial bones. An anxious, awkward posture in walking, sitting, rising, and bending, and, in those who cannot walk, a painful contracting of the facial muscles, is said to be a valuable sign of the beginning of spondylitis. A constant vomiting, lasting for several weeks, oc- curring in children with closed fontanelles and large cranial circum- ference, indicates a chronic hydrocephalus which has taken an acute form. Finally, an attack of convulsions may occur, which is the primary indication that the child has epilepsy. In such a case it is important to know as many symptoms as possible before rendering a positive diagnosis, hence all the points in relation to the convul- sions should be taken into consideration before a diagnosis of epi- lepsy is given. PROFESSOR LEDAMENDA. This author publishes the following valuable aphorisms on the management of diseases of children in El Dictamen, 1884: 1. Children are like the mob: they always complain with reason, although they cannot give the reason why they complain. 2. Always look at the lips of a pale and sickly child ; if they are of a deep red color, beware of prescribing tonics internally. At the outset you will congratulate yourself; but in the long run you will repent having employed them. 692 DISEASES OK CHILDREN. 3. As a general rule, a sad child has an encephalic lesion; a furious child an abdominal one ; a soporific child has both, though indistinctly defined. 4. An attendance on children produces in the mind of an observ- ant physician the conviction that the half, at least, of adult trans- gressors are so through morbid abdominal influences. 5. A sunny living-room, a clear skin, and an ounce of castor oil in the cupboard — these are the three great points of infantile hygiene. 6. To dispute the clinical value of tracheotomy in croup is d waste of time to no good purpose. Croup or no croup, if there be a positive obstruction to respiration in the larynx, it is but according to reason to open a way for sublaryngeal respiration. In the days of more knowledge and less nonsense, tracheotomy will be ranked among the minor surgical operations. 7. In dentition it is not the direct or eruptive pressure, but the lateral pressure of all the teeth together, that is most dangerous. It is from this that so many cerebral symptoms appear which can in no way be relieved by incisions in the gums. The only recourse against the dangers of this transverse pressure is to give the child more nourishment, in the hope that, as the general condition is bettered, the local condition will also be improved. 8. If the incisors of the first dentition are serrated, it is bad, but if those of the second formation are the same, it is worse. It fore- tells a number of lesions, arising from deficiency of mineral salts in the tissues. There is only one exception, and it is an important one. When the serrated incisors are seen in strong children in whom the fontanelles have closed early, it is a sign of a robust constitution. Instead of a number of small and sharp indentations, there are a few large blunt ones. 9. To regard the eruption of the teeth as the sole factor in the general process known as the first dentition, is to perpetrate a sort of medical synecdoche. Children get their first teeth because they are at the same time getting a second stomach and second intestines. 10. The body of a child possesses such a degree of "acoustic transparency," that, in case of necessity or convenience, auscultation may be practiced with the hand, converting it into a telephone, which will reveal as much to the physician as even his ear could do. 11. In practice it is well to distinguish with precision a casein which disease is due to lumbricoides, from one in which lumbri- THERAPEUTIC MEASURES. 693 coides are due to the disease ; for in the former case anthelmintics are of service, but in the latter they do harm. 12. Since, until the child is able to talk clearly, his relations with the physician are purely objective, it is very necessary that we should study as carefully as do the veterinarians, the exact corres- pondence between the lesions and the expressions of the patient. 13. If you wish to cure rapidly and well joint diseases in infants, you must treat them as you would a conflagration — douches, douches, and more douches, until you have succeeded in extin- guishing them. 14. The entire system of the moral relation between children and adults should be changed. To speak to them incorrectly, merely because they cannot pronounce well ; to excite their fears, and to arouse their weird imaginations, simply because they are easily frightened and impressionable ; to stimulate their vanity because they are naturally inclined to be vain — these and other similar actions are not only wrong, but absurd. THERAPEUTIC MEASURES. EDWARD JOHN WARING, M. D., LONDON. In childhood (as in old age) the same doses of medicine are not generally as well borne as in youth and manhood, and much nicety is sometimes necessary in regulating the dose. Several exceptions, however, present themselves; thus, in childhood (and in old age) much larger quantities of mercury are necessary to induce salivation than in manhood ; indeed. Dr. Clarke states that, in a practice of twenty years, he never saw a child truly salivated, an observation corroborated by the experience of others. Prof GRAVES ascribes the difficulty of inducing salivation in children and in old persons to the undeveloped state of the salivary glands in the former, and to their atrophied state in the latter. On the other hand, in infancy and childhood, opium in every form is a remedy that requires the utmost caution in its administration. Two and a half drops of laud- anum have destroyed an infant three days old ; three drops, a strong child of fourteen months, and four drops, a child of a few weeks old (Christison). In infancy and childhood, blisters allowed to remain long in contact with the skin are apt to induce ulceration and gan- grene, and leeches, on account of the thinness of the skin, and the vascularity of the subjacent tissues, draw more blood, and conse- 694 DISEASES OF CHILDREN. quently make a more decided impression on the system in an infant than a proportionate number would produce in an adult. EDWARD ELLIS, M. D., LONDON. Children bear emetics well, but blood-letting badly. Blisters should be resorted to very seldom, as their consequences are often most injurious. More than one potent remedy should not be ad- ministered at a time. Remedies should be of moderate bulk and as palatable as possible. Narcotics and irritants of all descriptions should be given with caution. Of particular remedies in cliildren Dr. E. comments on Ferri Phosphas. This preparation of iron, especially in the com- pound syrup, with the phosphates of lime, soda and potash (Par- RISH's Chemical Food), is often tolerated in infancy when other ferruginous preparations are not. Its pleasant taste and pretty color are to its advantage. Dr. ELLIS has given it in thousands of cases, and states that its value in general debility, rickets, scrofula, etc., cannot be over-estimated. Morphia. The very best preparation of opium we have for chil- dren is the bimeconate of morphia. The most suitable form is in solution. Hyoscyamus is of the greatest service in children's diseases, as a safe and efficient sedative, without the deleterious effects of the preparations of opium. For instance : "23. R. Tinct. hyoscyami, Syrupi papaveris, aa TUv Aquae menthae, ad f. 3 j. M. As an anodyne for a young infant. 1124. R. Tinct. hyoscyami, IHv-xv Liquoris ammonii acetatis, Tllx— xxx Vini ipecacuanhae, Tllx-xv Aquae camphorae, f. 3 ij-iv. M. In bronchitis, etc. Aconite is one of the most valuable of remedies in the early stage of acute inflammations in children. It is anodyne and antiphlogis- tic. It should be administered in small and frequent doses to pro- duce its best effect, say one-fourth or one-half a drop of the tincture of the root every hour. An experience of years has confirmed Dr. Ellis in his opinion of the value of this method in almost all acute inflammations. It is of less service, however, in the first three years of life than after this period has passed. SPECIAL THERAPEUTIC METHODS. 695 Quinics Sulphas is probably the most potent tonic, with which we are acquainted, for children. Small doses answer best for them, and it is often well, particularly after very exhausting diseases, to precede the quinia with gentian, chiretta, columbo, or some of the other minor tonics. DRS. PENZOLDT AND SARTORIUS, OF GERMANY. These gentlemen have made a number of trials of antipyrin in the treatment of children's diseases, and report the conclusions in the Berliner Klinische Wochenschrift, 1884: 1. Antipyrin is to be regarded as a very effectual remedy in the pyretic diseases of childhood. 2. In suitable dose it lowers the temperature several degrees, and the effects continue for several hours. 3. The pulse-rate is never reduced in a degree corresponding to the fall of temperature. 4. The effect upon the general condition is usually good. 5. The only disturbance that it ever causes is occasional vomiting. When this occurs the remedy may be given by the rectum. 6. Antipyrin should be given in three doses at intervals of an hour. Each dose should consist of as many decigrammes (one and a half grain) as the child has lived years. If this dose is insuffi- cient, as may often be the case in small children, it should be in- creased a decigramme at a time until the desired effect is obtained. When administered by the rectum, a single dose of from three to six times as many decigrammes as the child counts years may be given. 7. When the use of the drug has been long continued, the organ- ism seems at times to become tolerant, and then the dose must be increased cautiously. . SPECIAL THERAPEUTIC METHODS. As it is often difficult and sometimes injurious to the child to force it to swallow medicines by violence, it is desirable to employ other methods as much as possible. Remedies in the form of small powders can be dropped on the back part of the tongue. Hypodermic injections are easily given and rapidly absorbed, but are painful. 696 DISEASES OF CHILDREN. The delicacy of the epidermis renders inunction a most conve- nient and useful mode. Half a drachm of castor oil rubbed over the abdomen will usually promptly relax the bowels of an infant. Dr. Dewitt C. Wade has recently laid before the profession a suggestive article on this subject. (Michigan Medical News, July loth, 1878.) He has iound glyceroles the most effective forms. He applies them to any part of the body, first cleansing the skin of its oily secretions by sponging with the following alkaline solution : 1 125. R. Liquoris ammoniae, IHx-f. 3j Aquse, f- S iv. M. Having carefully washed off this alkali, he immediately applies the glycerole. As examples he gives : 1 126. B. Morphine sulphatis, Glycerinae, For an anodyne endermic glycerole. 1 127. R. Quinise bromidi, Glycerinae, For tonic or anti-malarial glycerole. H28. R. Extracti carnis, Glycerinae, For a nutrient glycerole. It is astonishing, says Dr. W., how quickly this last is absorbed and how promptly its effect is noticed in strengthening the pulse. Dried albumen and extract of malt may also be given very success- fully to the most feeble infant in this manner. Medicated baths, lotions, liniments and poultices are far more effi- cient in children than in adults. Very feeble infants derive much benefit from nutritive baths of milk, beef tea, etc., which should be of the temperature of the body, and in which they should remain for hours, if need be. The steel-bath is an excellent tonic. 1 129. R. Ferri sulphatis, §ss Aquae (temp. 95°), gall. iv. M. For a bath. So also is the salt-bath; four ounces of sea-salt to four gallons of water. For the night-sweats of children, rubbing the chest and neck with Jialf a drachm of tincture of belladonna at night will be found most serviceable. In all other inflammatory affections of %r M. gr. xx-Sj M, f.iiij. M. ALIMENTATION. 697 deep-seated organs, warm poultices and fomentations will prove to act much more positively than in the case of adults. In children at the breast, certain medicines are successfully given by administering them to the nurse, and thus introducing them to the child through its food. Iron, iodine and iodide of potash can all be exhibited in this way, and in weak, rachitic infants it is by far the best method. DR. R. L. MOORE. This writer tells us in the Journal of the American Medical Asso- ciation that one of the watchwords in treating diseases of children is "elimination." Don't lock up the secretions. Give nature, that grand old mother, a chance. Very rarely should opium, or any of its preparations or derivatives, be used in the treatment of children. He who abides the nearest to this rule will have the best success in treating them. Look after them closely. Stand by the small and frequently repeated doses of tasteless medicines. Never forget that a sick child is always dangeroiisly sick. ALIMENTATION OF YOUNG CHILDREN. The following are the conclusions on this subject that were pre- sented by the committee appointed for the purpose to the Eleventh Congress of the German Physicians' Association (Quarterly Compen- dium, 1883). 1. The natural food of children — mother's milk — is to be pre- ferred above all others. 2. Only in case of positive contra-indication, or non-appearance of the milk, should a wet-nurse be employed. 3. Only in case of impossibility of procuring a wet-nurse, should artificial food be employed. 4. The contra-indication against a mother nursing is actual dis- ease or a predisposition to disease. 5. Hereditary syphilis demands the milk of the mother; that of a wet-nurse should only be used with great caution. 6. Examination of a given specimen of milk furnishes no clue as to its value in a given case. 7. All children's foods, including Liebig's soup (food), on account of the large quantity of starch contained in them, are unfit for chil- dren during the first month. 698 DISEASES OF CHILDREN. INFANT FEEDING-WEANING. T. M. ROTCH, M. D. The following remarks, on this important subject, are abstracted from writings of the above author, which were printed in the Ar- chives of Pediatrics and Cyclopcedia of the Diseases of Children, Vol. I. (Keating). The author says that in reviewing an immense amount of literature, he finds that the superiority of breast-feeding is acknowledged so generally, that it may be said to have become a scientific truth. On the other hand, the opinions expressed regard- ing artificial feeding are so diverse, and so opposed to one another, that it is evident that much which has for years been taught, must be admitted to be untrue. The great number of artificial foods used by physicians, proves that bottle-feeding has not as yet arrived at that state of perfection where it can compete with breast-feeding. The feeding problem is one which is hedged about with many difficulties on account of the great diversity of individual circum- stances and idiosyncrasies. In those cases where for one reason or another human milk is not available, the question of feeding is this : What may be given to take the place of nature's food? In supplying a substitute, we should copy in every possible way the physical and chemical characteristics of the food which is uni- versally acknowledged to be the best. * » * What is of the first importance is, that we should recognize our ignorance and, keeping our eyes opened to all possible scientific advancement, be ready to sweep aside preconcieved ideas not rest- ing upon established facts. • • * A healthy baby empties the breast with easy and almost uninter- rupted sucking in about fifteen minutes. The quantity ingested is determined by various methods, such as careful weighing before and after nursing and by the determination of the actual capacity of the average stomach at dififerent ages and with different weights. * * The intervals of feeding constitute a very much more important factor in breast-feeding where the quantity is regulated by the breast itself. The first month being the most critical period for the in- fant's nutrition, as it is the time when the equilibrium of its meta- bolism is being established and its chance for life the least, especial value should be attached to the series of careful investigations made at the Children's Hospital in St. Petersburg, by Ssnitkin,* to deter- ♦ Reitz, Physiologic des Kindesalt, S. 40. INFANT FEEDING. 699 mine the amount of food which should be given in the first thirty days of life, and from which is deduced the rule, " The greater the weight, the greater the gastric capacity." Ssnitkin's general results show also that one one-hundredth of the initial weight should be taken as the figure with which to begin the computation, and to this should be added one gramme for each day of life. The following table represents merely approximate average figures which are the result of computations made by a number of observers in different parts of the world, and of Dr. Rotch'S investigations, both clinical and anatomical, during the past ten years. The average initial weight of infants is 3,000-4,000 grammes^ about 6.6-8.8 pounds. The average normal gain per day in the first five months is 20-30 grammes, or about two-thirds to one ounce. TABLE I. Gineral Rules for Feeding. Age. Intervals of Feeding. Number of Feedings in Twenty-four Hours. Average Amount at Each Feeding. Average Amount in Twenty-four Hours. 1st week. 2 hours. 10 I ounce. lo ounces. 1-6 weeks. 2)^ hours. 8 i^ to 2 ounces. 12 to 16 ounces. 6-12 weeks, and possibly to 5th or 6tb month. 3 hours. 6 3 to 4 ounces. 1 8 to 24 ounces. At 6 months. 3 hours. 6 6 ounces. 36 ounces. At 10 months. 3 hours. 5 8 ounces. 40 ounces. The only point in the feeding problem where artificial feeding seems to have the advantage of the breast is in the intervals of nurs- ing. Irregularity in nursing, frequent nursing and too prolonged intervals, often so disturb the quality of the human breast tnilk as to transform a perfectly good milk into one entirely unfitted for the infant's powers of digestion, while the element of intervals does not of course influence the question of chemical composition in a prop- 70b DISEASES OF CHILDREN. erly prepared artificial food. Thus too frequent nursing lessens the water and increases the total solids in human milk, making it re- semble, in a certain way, condensed milk ; while too prolonged in- tervals results in such a decrease of the total solids as to render an otherwise good milk too watery, and unfit for purposes of nutrition, however well it may be digested. The lesson that may be drawn from these facts is, that some general rule for intervals of feeding should be enforced, such as is represented in Table I., in order that the mother should neither interfere with the infant's digestion by nursing it too frequently, and thus giving it a too concentrated food, nor, by neglecting to feed it often enough, interfere with its nutrition by giving it a too largely diluted food. We must recognize two dis- tinct elements in infant-feeding, neither of which can with impunity be interfered with at the expense of the other, namely, digestion and nutrition, it being possible for the milk to be easily digested but non-nutritious; and, again, to be highly nutritious but difficult to digest, and it is the equilibrium of these two elements which makes up a perfect infantile development. • * • The younger the infant, the greater the metabolic activity, and hence the greater need for frequent feeding ; for nutriment is re- quired not only for repair of waste, but also for the rapid propor- tionate growth ; and we thus see that the intervals of feeding accord- ing to the age, as shown in Table I., become essential in successful feeding. The next question to be considered is the quality of the food which is provided for the human infant. The later analyses, and those upon which most reliance is to be placed, are those of J. KONIG, FORSTER, Meigs, HARRlNGXdN and Others, and give the following approximate results : TABLE II. Human Milk, Reaction Slightly alkaline Specific gravity 1028-1034 Water 87-88 Total solids 13-12 F»' 3-4 Albuminoids i_2 Sugar,. 7.0 Ash 0.2 Reasoning from the strong analogy which must exist between human milk and cow's milk, and being- aware of the great variations INFANT FEEDING. 701 which occur in the latter, we may assume that human milk is liable to vary in its composition considerably with different milkings on the same day, and also with the milking of the same hours on different days, so that we, at present, are not in a position to state that our knowledge of human milk is sufficiently exact to justify an attempt to formulate a table to show the composition of woman's milk at different ages, however valuable such information may in future prove to be. * • * That both the secretion and the character of the milk are strongly influenced by the nervous system, is a matter of common clinical experience, but the exact nervous mechanism which controls it, has not yet been fully worked out — the clinical result, however, being recognized, that emotional mothers do not make good nurses. There are certain other facts known regarding the milk, which it will be well to mention here as having a bearing of more or less im- portance on what remains to be said concerning breast-feeding. Bunge's investigations on the comparison of tissues* show ttiat the mammary gland abstracts from the blood just about the amount of salts found in the tissues. • * * With the aid of such facts as have been stated above, we can now judge more intelligently as to the various questions which arise in connection with the subject of infant feeding. The general rule de- duced from these facts is, 'manifestly, that a healthy woman should nurse her child. The younger the infant the more important the breast-nursing, the gastro-intestinal canal being in a more active state of development and certain of its functions being still unprepared for use in the early months of life. It is much more difficult to adapt an artificial food to the sensitive growing infantile digestive apparatus at this early age, thus accounting in a measure for the rule that the younger the child the greater the mortality. There is no doubt, however, that the mother's milk in a considerable number of cases met with in the practice of physicians among civilized nations, ap- pears to be entirely unfit for her offspring, and it at times becomes a question of considerable judgment as to whether the infant shall not be withdrawn from the mother's breast, either temporarily or entirely. It is here, in my opinion, that in the future, the careful and repeated analyses of the milk will play a great role in aiding us to determine wisely this question. ''Archivfur Fhysiologie, 1886, 539. 702 DISEASES OF CHILDREN. I am fully convinced that a large number of infants are deprived of their natural food and placed on artificial foods, on insufficient grounds. We thus assist to keep up the resulting high mortality figures ; and I believe that these figures will be sensibly reduced when, in consequence of our taking a more enlightened view of the subject, the number of infants who are fed from the breast during the first three or four months of life, shall be increased. A particular reason, among many, for waiting at least four or five months before beginning with artificial feeding, is presented by the fact that the stomach after a rapid growth has become, by the fifth or sixth month, a more perfect receptacle both as to size and as to function. * • » Instances not infrequently arise where such continual shocks are brought to bear upon the mother in her daily life, or where her own temperament is such an undisciplined one, that her milk, ordinarily good, becomes totally unfitted for her infant, and at times acts as a direct poison, with most disastrous results, so that the welfare of the infant in such cases unquestionably demands the change to a wet- nurse. * • • We must next consider the question of the variation in the milk, which takes place from natural causes, such as the return of men- struation. Does such a return necessarily contra-indicate the con- tinuation of nursing ? As in all other questions of this kind, we cannot adopt and follow an inflexible rule, but must be guided by what seems best for the individual case. Infants are at times af- fected so seriously by the alteration in the constituents of the milk, which occurs once in four weeks, that their nutrition is markedly in- terfered with, and a change to more stable food is indicated. Again, the only disturbance which may arise, is a temporary and slight di- gestive attack for a day or two, which apparently does not materially affect the infant, and makes us hesitate to run the risk of depriving the infant of a food on which it thrives for twenty-six days out of the twenty-eight. We must also not be too hasty in concluding from the bad symptoms in the infant, that we should at once with- draw it permanently from the breast, for the catamenia may appear once and then not again for a number of months, the infant's powers of digestion in the mean time becoming so much more fully devel- oped that they are unaffected by the catamenial milk. Even where the catamenia recur regularly, the disturbance which may have been marked at one period may for many reasons fail to recur at the INFANT FEEDING. 703 next ; so that the question is reduced to whether the composition of the milk shows a recovery of the equiHbrium of its constituents within a few days, or remains affected to such a degree as to en- danger the integrity of the infant's nutrition. My own experience, so far as it goes, is in favor of allowing the infant to continue the breast, unless it is decidedly contra-indicated by circumstances such as have just been mentioned. A much more serious state of affairs arises when the nursing mother becomes pregnant ; for here the almost universal clinical ex- perience is that the infant, for various reasons, cannot continue to be fed by its mother, it being unusual for a woman to have suffi- cient vitality to nourish properly her living child and growing foetus. The danger of reflex miscarriage from the continual irritation of the mammary gland by nursing I personally have never met with, but this is mentioned as one of the dangers contra-indicating the continuation of nursing by a pregnant woman. We must, however, here also not judge hastily, but take all the circumstances of the case into consideration before deciding on a measure of such vital importance to both child and foetus. If the mother remains strong and vigorous and the analysis of her niilk shows no deterioration, while the infant is a delicate one just begin- ning to thrive on its rightful supply of natural food, or if it is during a hot period of the year, and especially where a wet-nurse cannot be procured, it will often be wisest to take some risks and continue the nursing for a certain time, perhaps six or eight weeks, and then, according to circumstances, gradually substitute an artificial food. Almost all cases will differ in the questions to be decided, and must be judged on their own indications and contra-indications, always, however, recognizing the generally accepted rule that lacta- tion and pregnancy are incompatible. * * * It not infrequently happens, especially among women of the upper classes and nursing women of all classes when their general health is not in a perfectly normal condition, that the supply of milk is not sufficient to satisfy the infant, and the question arises whether the mother's milk shall be entirely given up or whether it shall be supplemented by some other food. My own individual ex- perience, both in private and in hospital practice — and so far as I ascertain, this experience agrees with that of other observers-— is in favor of assisting the mother to nurse her infant during the earlier months of its life. I have found that where the artificial food is 704 DISEASES OF CHILDREN. carefully regulated by frequent analysis until the infant is making decided progress in its weight and general condition, this method of rearing infants is far superior to withdrawing the mother's milk and feeding the child exclusively on artificial food. • * • From what has already been said, we need hardly state that if for any reason a mother cannot nurse her child, the food which will be most likely to give satisfactory results is that provided by a wet- nurse. The question as to whether a wet-nurse shall be employed, is, however, one of serious import, and must in each individual in- stance, be decided by giving full weight to all the many circum- stances which are involved in the case. It is the duty of the physician fully to explain that a good nurse is far superior to any artificial method of feeding, while the reverse of this statement must always be kept in view, that a poor nurse, whether from temper- ament, or age, or general health, or quality of her milk, had better be set aside where the conditions are favorable. for a successful arti- ficial feeding. It is, perhaps, better that the age of the nurse's milk should correspond somewhat nearly to that of the infant she is to suckle, but a difference of some months need not necessarily be a contra-indication, as we are not yet in a position to say definitely that the milk differs sufficiently in different months to be of vital importance in choosing a nurse. A feeble child will nurse more easily, and probably have better care, from a multipara than from a primipara. The preferable age of the nurse is between twenty and thirty years. Her other requisites are a good condition of health, and a quiet temperament. It will save much trouble and will often obviate the frequent necessity for changing, if we have before her engagement, a chemical analysis of her milk; and all the points which have been above referred to for a successful maternal nursing are of equal significance in the wet-nurse. Quite a nuqjber of nursing women, especially those in the higher classes, find that at variable periods in the course of their year's lactation, their milk begins to fail, and they are forced first to lessen the number of their nursings, and then to wean entirely. The time then when the infant should be weaned almost always settles itself without our intervention at varying periods. The period of lactation, however, and the one which might be called physiologically normal, can, when the breast- milk remains of good quality and quantity, be carried through the first year with benefit. We have certain guides which aid us in de- termining the proper time for beginning to wean. Physiologically, INFANT FFEDING. 70s we are told that certain functions, such as that which converts starch into glucose, are but slightly developed in the early months of life, and that they exist and are gradually being established during the first year, not, as a rule, being perfected and in a condition in which we can call upon them with impunity until the "last two or three months of the year. Another sign which aids us somewhat as an index by which we can judge of the progress of this functional development is the appearance of the teeth, calling our attention to the fact that nature is preparing a means for the infant to digest and assimilate a different form of food from that which it has so far re- ceived by sucking, the presence of six or eight incisors usually in the normally-developed infant corresponding to the full development of the pancreatic secretion. Again, a most valuable index, which assures us that we need not be anxious to change the infant's food during the first year, is the continuous increase of weight, which, with the general blooming condition of the infant, represents a normal lactation. As in the case of all physiological rules, however, we must admit of certain variations, which, in the especial case, are as important for the in- fant's welfare as the rule itself, namely, the curtailing or lengthening of the period of lactation by a month or two, according to the season of the year, the eruption of the teeth, or the condition of the child (as in recovery from an illness), it being wiser to feed the infant from the breast during the heated portions of the year, and to wean in cool weather, either before or after the hot season, according to the individual circumstances of the case. An interdental period also is preferable to a dental period, on ac- count of the possible disturbances which may arise in the latter and interfere with the proper action of the new functions which are be- ing called upon to perform their duties. Where there is any uncer- tainty as to the character of the milk which the infant is taking, especially in the latter months of lactation, a chemical analysis should be made at once, and repeated, with an interval of some days, several times ; for the latter months, though not so difficult to man- age intelligently as the early period of the infant's life, are much more likely to need careful supervision than the middle period, which, from its uninterpreted tranquillity, has been called the period of normal nutrition. Where the infant has, through an insufficient supply of milk in the mother, become for some time accustomed to several meals of artificial food daily, the matter of weaning becomes 45 706 DISEASES OF CHILDREN, a very simple one, for we know that we have a food which will agree with it ; but where we have to begin to wean directly, and to adapt a food to the infant's digestive capabilities, as in cases of sudden failure of the milk, or sickness of the mother, this procedure becomes' much more intricate, and is at times fraught with considerable dan- ger. It is in these cases that an analysis of the milk made when the mother was in good condition often proves to be of great assistance, for it is not very difficult to make an artificial food which shall cor- respond to this analysis in its percentage of fat, albuminoids, sugar, total ash, and water. Unless under very exceptional circumstances, sudden weaning is to be deprecated, though of course we must allow that it is often done with impunity. The safest method, so long as we can never judge beforehand what infants will be likely to be un- favorably affected by sudden weaning, is to take plenty of time, and gradually ascertain, perhaps by frequent changes, which form of food is best adapted to the case. We then gradually accustom it to this food, omitting, one by one, the breast-feedings, until finally we are sure that we have an artificial food upon which the infant will thrive, with the proportion of starch, the new element which may now usu- ally be introduced into the dietary, carefully adapted to its amylo- lytic function, which has but lately arrived at its full development, and which varies in different infants. When this change has been accomplished, the breast can with safety be entirely withdrawn. * * Our scientific knowledge and clinical investigations have not yet enabled us to follow nature exactly, and we therefore have not yet obtained an ideal method of artificial feeding, We must, neverthe- less, go as far as the present state of our knowledge will allow, thus gaining a little ground every year, and we must be especially care- ful not to be led astray by the fictitiously brilliant results which are reported from time to time in favor of certain foods. Instances are continually occurring where one food will fail, and another, when substituted for it, succeed, and yet these successes are merely tem- porary, and the mortality always remains far above that from human breast-milk. In nature's method of feeding we have, first, a receptacle, the human breast, which provides a, fresh supply of food at proper in- tervals, absolutely, prevents fermentation of the food before it enters the infant's niouth, incites to action the necessary digestive fluids, avoids a vacuum by collapsing as it is gradually emptied, thus al- lowing the food to flow continuously, and finally, is practically self- INFANT FEEDING. 707 regulating as to the amount of daily food according to the infant's age. Secondly, the food itself is adapted to the infant's digestive function and for its development, by its temperature, 98° to 100° F., its alkaline reaction, and its chemical constituents. Given these factors, how nearly can we approach them artificially? Human in- genuity has not yet been able to devise anything which approaches the perfection of nature's receptacle, and the best that we can do to offset this complex mechanism is to adopt that which is exactly the reverse, namely, a receptacle of absolute simplicity, and thus com- bat the tendency to fermentation by preventing, through perfect cleanliness, the receptacle from becoming a source of fermenta- tion. * • » * The object to be accomplished in the preparation of cows' milk is to make it resemble human milk as much as possible in chemical composition and physical properties. To do this, it is necessary to reduce the proportion of caseine, to increase the proportion of fat and sugar, and to overcome the tendency of the caseine to coagu- late into large, firm masses on entering the stomach. Dilution with water is all that need be done to reduce the amount of caseine to the proper level ; but as this diminishes the already insufficient fat and sugar, it is essential to add these materials to the mixture of milk and water. Fat is best added in the form of cream ; and of the sugars, either pure white loaf sugar or sugar of milk may be used. The latter is greatly preferable, as it is little apt to fer- ment, and contains some of the salts of milk which are of nutritive value. • * * For the successful management of children, the mother or nurse must not only be familiar with the theory of feeding, but must prac- tically understand the methods of preparing food. To this end, a schedule of the diet of an infant from birth upward, with a sketch of the modifications that have to be made most frequently, will serve as a useful guide. Diet during the first week : Cream 2 teaspoonfuls. Whey 3 teaspoonfuls. Water (hot) 3 teaspoonfuls. Milk sugar i teaspocnful. For each portion; to be given every two hours from 5 a. m. to 11 p. m., and in some cases once or twice at night, amounting to twelve fluidounces per diem. ♦ Hygitne of the Nursery, Starr. 708 DISEASES OF CHILDREN. Diet from the second to the sixth week : jlilk I tablespoonful. Cream * teaspoonfuls. Milk sugar i teaspoonful. \yater 2 tablespoonfuls. For one portion; to be given every two hours from 5 a. m. to ii p. m.; amount- ing to seventeen liuidounces per diem. Diet from the sixth week to the end of the second month : Milk 2} tablespoonfuls. Cream • ' tablespoonful. Milk sugar i teaspoonful. ■^^ater 2 J tablespoonfuls. For each portion; to be given every two hours; amounting to thirty fluidormces per diem. Diet from the beginning of the third month to the sixth month : Milk 5 tablespoonfuls. Cream i tablespoonful. Milk sugar i teaspoonful. Water 2 tablespoonfuls. For each portion; to be given every two and a half hours, or thirty-two fluidounces per diem. Diet during the sixth month ; six meals daily, from 6 or 7 a. m. ito 9 or 10 p. m. Morning and midday bottles each : Milk 9 tablespoonfuls. Cream I tablespoonful. Mellin's Food i teaspoonful. Hot water 2 tablespoonfuls. Dissolve the Mellin's Food in the hot water and add, with stirring, to the previously mixed milk and cream. 'Other bottles each : Milk 9 tablespoonfuls. Cream I tablespoonful. Milk sugar . .1, i teaspoonful. Water 2 tablespoonfuls. This gives an equivalent of thirty-six fluidounces of food in a day. In the seventh month the Mellin's Food may be increased to two teaspoonfuls and given three times daily. Throughout the eighth and ninth months five meals a day will be sufficient : INFANT FEEDING. 709 First meal at 7 a. m. : *''"' 13 tablespoonfuls. Cream , tablespoonful. Milk sugar j teaspoonful. Water 2 tablespoonfuls. Second meal at 10: 30 a. m. Milk, cream and water in the same proportion; Mellin's Food, one tablespoonful. Third meal at 2 p. m. Same as second. Fourth meal at 6 p. m. Same as second. Fifth meal at 10. p. m. Same as first. This gives forty fluidounces of food per diem. Instead of Mellin's Food, a teaspoonful of " flour-ball " may be added. Two meals of flour-ball daily — the second and fourth — are all that can be digested. To prepare these, rub one teaspoonful of the powder with a tablespoonful of milk into a smooth paste, then add a second tablespoonful of milk, constantly rubbing until a cream- like mixture is obtained. Pour this into eight ounces of hot milk, stirring well, and it is then ready for use. The other meals should be composed of milk, cream, sugar of milk and water, as already given. For Mellin's Food and flour-ball may be substituted oatmeal or barley, or any of the infant foods in which the starch has been converted, by Liebig's process, into dextrine and grape sugar. Diet for the tenth and eleventh months : First meal, 7 a. m. : Milk ■ ■ 1 7 tablespoonfuls. Cream I tablespoonful. Mellin's Food i tablespoonful. (Or flour-ball or barley jelly) 2 teaspoonfuls. Water (used only with Mellin's Food) 2 tablespoonfuls. Second meal, 10:30 a. m. A breakfast-cupful of warm milk (eight fluidounces). Third meal, 2 p. m. The yelk of an egg lightly boiled, with stale bread crumbs. Fourth meal, 6 p. m. Same as first. Fifth meal, 10 p. m. Same as second. On alternate days the third meal may consist of a teacupful (six fluidounces) of beef tea containing a few stale bread crumbs. 7IO DISEASES OF CHILDREN. A further variation can be made by occasionally using mutton, chicken or veal broth instead of beef tea. As much more difficulty is experienced in feeding infants during the first twelve months than during the second, it would be well to pause here to consider what had best be done, in case the food described should disagree. If, after feeding, vomiting should occur, with the expulsion of large, firm clots of caseine, the effect of adding lime-water or barley- water must be tried. For instance, at the age of six weeks, make each bottle of: Milk 2^ tablespoonfuls. Cream i tablespoonful. Milk sugar i teaspoonful. Lime water 2} tablespoonfuls. Or of: Milk 2^ tablespoonfuls. Cream I tablespoonful. Milk sugar J teaspoonful. Barley water 2} tablespoonfuls. Sometimes, particularly if there be diarrhoea, boiling makes the milk more tolerable, and in this condition it may be used instead of fresh milk in either of the above mixtures. Condensed milk, too, can be employed temporarily, making each portion of: Condensed milk i teaspoonful. Cream i tablespoonful. Hot water 5 tablespoonfuls. Should further alteration be necessary, goat's or asses milk may ' be substituted for cow's milk, the strong odor of the former and the laxative properties of the latter being removed by boiling. One ass is capable of nourishing three children for the first three months of life, two children for the fourth and fifth months, and one child after this period, up to the ninth month. The milk should be used warm from the udder. " Strippings " is another good substitute for cow's milk. It is obtained by re-milking the cow after the ordinary daily supply has been drawn, and contains much cream and but little curd. Assimi- lable proportions of this are : Strippings 2 tablespoonfuls. Water 4 tablespoonfuls. INFANT FEEDING. 71I And if the small amount of caseine in such a mixture be still un- digested : Strippings 3 teaspoonfuls. Barley water 3 tablespoonfuls. Another good food is that recommended by Dr. A. V. Meigs. It consists of a combination of two parts of cream, containing from fourteen to sixteen per cent, of fat; one part average milk; two parts lime water, and three parts sugar water, the latter consisting of seventeen and three-fourths drachms of milk sugar to one pint of water. This makes an alkaline mixture with the percentage of its ingredients closely corresponding to human milk. When, in spite of careful preparation, all of these foods give rise to indigestion with fever, and to the expulsion, by vomiting and diarrhoea, of hard curds from the stomach and intestines, the ex- pedient of predigesting the milk must be resorted to. The best method is to peptonize the milk by the use of pancrea- tine. That manufactured under the name of extractum pancreatis has proved most efficient in my hands. To accomplish this artificial digestion, put into a clean quart bottle five grains of extractum pan- creatis, fifteen grains of bicarbonate of sodium, and four fluidounces of cool, filtered water ; shake thoroughly together and add a pint of fresh, cool milk. Place the bottle in water, not so hot but that the whole hand can be held in it for a minute without discomfort, and keep the bottle there for exactly thirty minutes. At the end of that time put the bottle on ice to check further digestion and to keep the milk from spoiling. The fluid obtained, while somewhat less white in color, does not differ from it in taste ; if, however, an acid be added, the caseine, instead of being coagulated into large, firm curds, takes the form of minute, soft flakes, or readily broken-down feathery masses of small size. Such milk may be sweetened with sugar of milk, and given pure or diluted with water. For an infant of six weeks each meal may consist of: Peptonized milk 6 tablespoonfuls. Milk sugar i teaspoonful. Y\rater 2 tablespoonfuls. To this, cream may be added when desirable, and by diminishing the quantity of water and increasing that of milk, the strength ot the food may be made greater at any time. • * * 712 DISEASES QF CHILDREN. Instead of this ordinary peptonizing process, I have for the past year or more employed the " Peptogenic milk powder," prepared by Fairchild Brothers & Foster. The mode of employment is as follows : Take of Milk 4 tablespoonfuls. Water 4 tablespooniuls. Cream I tablespooDful. Peptogenic milk powder i measure.* This mixture is to be heated over a brisk flame to a point that can be comfortably sipped hy the preparer (about 1 15° F.) and kept at this heat for six minutes. When properly prepared, the resultant, so-called " humanized milk," presents the albuminoids in a minutely coagulable and digestible form ; has an alkaline reaction ; contains the proper proportion of salts, milk sugar, and fat, and has the ap- pearance of human milk. LEEDS gives the following analysis of this prepared milk: Water 86.2 per cent. Fat 4.5 " Milk sugar y. " Albuminoids 2. " Ash (salts) 0.3 " This corresponds very closely with his average analysis of human milk. In using this powder, too, one can readily return to a plain milk diet by gradually shortening the time of heating ; by slowly diminishing predigestion. Great and deserved stress has recently been placed on a method of preparing, or rather preserving, cows' milk, known as "Steriliza- tion." As milk exists in the healthy cow's udder it is aseptic, /. e., free from any poisonous or dangerous ingredient, but during milking and subsequent handling and transportation, particles of manure or var- ious forms of dirt get into it, and are apt to set up fermentation or other injurious change. To deprive these accidentally introduced organic impurities of their activity, or in other words to sterilize, it is necessary to subject the fluid to high heat under pressure. Sterilization should be performed in the morning, as soon as pos- sible after the milk has been served. * Measure provided with each can of powder. INFANT FEEDING. 713 Sterilized milk will remain sound for several days, and when the heating is continued for thirty minutes, it will remain pure for two or three weeks. Sterilized milk is especially useful in traveling, when fresh milk cannot be obtained ; for use in cities during the heat of summer, when milk is most apt to undergo injurious changes ; for the feed- ing of delicate children, or for those suffering from disease of the stomach or intestinal canal. Sometimes milk in every form, and however carefully prepared, ferments soon after swallowing and ex- cites vomiting, or causes great flatulence and discomfort, while it affords little nourishment. With these cases, the best plan is to withhold milk entirely for a time, and try some other form of food. The following are good substitutes : Mellin's Food i teaspoonful. Hot water 6 tablespoonfuls. For each portion; to be given every two hours at the age of six weeks. Veal broth Q lb. meat to the pint) 3 tablespoonfuls. Barley water 3 tablespoonfuls. For one portion. Whey 3 tablespoonfuls. Barley water 3 tablespoonfuls. Milk sugar J teaspoonful. A teaspoonful of the juice of raw beef every two hours will usually be retained when everything else is rejected. Such foods are only to be used temporarily until the tendency to fermentation within the alimentary canal, ceases ; then milk may be gradually and cautiously resumed. • * * Returning to the regimen of the healthy infant, it will be found that after the first year far less change is required in the food from month to month. • » * Children who have cut their milk teeth may be fed for a twelve- month, namely, up to the age of three and a half years, in the fol- lowing way : First meal, 7 a. m. One or two tumblerfuls of milk, a saucer of thoroughly cooked oatmeal or wheaten grits, and a slice of bread and butter. Second meal, 11 a. m. (if hungry). A tumblerful of milk or a teacupful of beef tea with a biscuit. 714 DISEASES OF CHILDREN. Third meal, 2 p. m. A slice of underdone roast beef or mutton, or a bit of roast chicken or turkey, minced as fine as possible ; a baked potato thoroughly mashed with a fork and moistened with gravy ; a slice of bread and butter ; a saucer of junket or rice, and milk pudding. Fourth meal, 7 p. m. A tumblerful of milk and one or two slices of well-moistened milk toast. From three and a half years up the child must take his meals at the table with his parents, or with some reliable attendant who will see that he eats leisurely. The diet, while plain, must be varied. The following list will give an idea of the food to be selected : BREAKFAST. Every day. One dish only each day. Milk, Fresh fish, Eggs, plain omelette. Porridge and cream. Eggs, lightly boiled, Chicken hash, Bread and butter, Eggs, poached, Stewed kidney. Eggs, scrambled. Stewed liver. Sound fruits may be allowed before and after the meal, according to taste, oranges, grapes without pulp (seeds not to be swallowed), peaches, thoroughly ripe pears, cantaloupes and strawberries. DINNER. Every day. Two dishes each day. Qear soup, meat, (roasted Potatoes, baked. Hominy, or boiled, and cut into Potatoes, mashed, Macaroni, plain, small pieces.) Spinach, Peas, Bread and butter. Stewed celery. String beans, young. Cauliflower. Green com, grated. Junket, rice and milk or other light pudding, and occasionally ice cream, may be allowed for dessert. SUPPER. Every day. Milk. Milk toast or bread and butter. Stewed fruit. Fried food, highly seasoned or made-up dishes, are to be excluded, and no condiment but salt is to be used. Eating, however little, between meals, must be absolutely avoided. Keep a young child from knowing the taste of bonbons, or, having learned it, let him feel that they are as unattainable as the thousand other things be- RECTAL ALIMENTATION. 715 yond his reach, and he soon ceases to ask for them. Even a piece of bread between meals should be forbidden. His appetite then remains natural, and he will eat proper food at his regular meal hours. Filtered or spring water should be the only drink, tea, coffee, wine or beer being entirely forbidden. As to quantity, a healthy child may be permitted to satisfy his appetite at each meal, under the one condition that he eats slowly and masticates thoroughly. In cases of illness, the diet must be reduced in quantity and qual- ity, according to the rules that are applicable to adults. RECTAL ALIMENTATION. A. JACOBI, M. D. (Arc. Ped., February, 1888.) Dr. JacoBI says the rectum absorbs, but it does not digest. Whatever, therefore, is to enter the circula- tion through the lower end of the alimentary canal, must be dis- solved before being injected. Suspension alone does not usually suffice. Water can be introduced in quantities of from twenty-five to one hundred grammes (one to 3 ounces),every one, two or three hours, and may thiis save life by adding to the contents of the thirsty lymph ducts and empty blood vessels. Salt in a mild solu- tion will thus be absorbed. Food must be more or less peptonized before being injected. Milk should always be subjected to the same treatment. The white of eggs becomes absorbable through the addition of some chloride of sodium. Kussmaul beats two or three eggs with water, keeps the mixture through twelve hours, and injects it with some starch decoction. The latter is partly changed into dextrin. Fat, when mixed with alcohol, is apt to be partly absorbed. Andrew H. Smith recommends the injection of blood. Its sol- uble albumen, salts and water are readily absorbed ; more we ought not to expect. Still, he has observed that the evacuations the next day contain none of the injected blood. Whatever we do, however, and be the rectum ever so tolerant, not more than one-fourth of the food required for sustaining life can 71 6 DISEASES OF CHILDREN. be obtained by rectal injections, and inanition will follow, though it be greatly delayed. Finally, children are not so favorably situated in regard to nutri- tious enemata as adults. In these, the lengthening of the nozzle of the syringe, by means of an elastic catheter, permits of the introduc- tion of a large quantity of liquid : indeed a pint can be injected and will be retained. But the great normal length of the sigmoid flex- ure, in the infant and child, which results in its being bent upon itself, prevents the introduction of an instrument to any considerable height. It will bend upon itself; besides, a large amount of the contents will be expelled by the resisting young patient. When a solid instrument is used, it is apt to be felt, high up in the abdomen. This is the result of a large portion of the intestine being pushed up with the tube. NATURAL MINERAL WATERS. DR. JOHN M. KEATING, OF PHILADELPHIA. This author, in the Archives of Pediatrics, 1884, calls attention to the advantages to be derived from the use of natural mineral waters in the diseases of children. He has used largely and with success the Buffalo Lithia Water, Spring No. 2, and Farmville Lithia Water, with infants of the tenderest age ; he has found them especially val- uable in the eruptive fevers, where there is much thirst and scanty, high-colored urine. A stone jar of it should be kept on hand, and the water used ad libitum, when the child is thirsty, or it may be used to dilute the food. In those cases where there is constipation, the alkaline saline waters, as Saratoga Seltzer, may be used instead. As alteratives in scrofula, the saline waters are most useful. The best way to administer them to children is by the bath. In chil- dren's practice the most valuable of this class is sea water. The baths should be administered daily, allowing the child to remain in the water ten or fifteen minutes, and it is better for the water to be about blood heat. When the sea shore is inaccessible, or in winter, the prepared salt can be obtained and will answer almost as well. Of this, about one ounce to the quart of water will represent the strength of .sea water. Sulphur waters, when fresh, are most useful as baths, especially in syphilitic cases ; after exposure to the air they can be used internally in rickets with inherited syphilis. As a rule sulphur waters have a tendency to constipate, but the saline sulphur NATURAL MINERAL WATERS. 717 waters are, of course, cathartic. In obstinate constipation an infant may be given a tablespoonful or two of Bedford water several times daily. As an alterative, for constant use, the water of Sharon Springs is probably the best. For the rheumatic diathesis, the water of Richfield Springs, New York, is very good, and probably many of those distressing cases of organic disease of the heart, the result of rheumatism in early life, could be avoided by proper use of this excellent water before it is too late. In syphilis, or rickets, the iodine spring of the Bath Sulphur Springs of West Virginia would be useful. There is no reason why children should not become soon accustomed to the taste of these sulphur waters, and until then the water can be exposed to the air. For infants the baths would be advantageous. The water of the Hot Sulphur Springs, Virginia, is said to be especially useful in allaying irritation of the mucous membrane, especially of the lungs or in chronic bronchitis. These calcic-sulphur waters are probably more valuable in diseases of adults, owing to their special action upon the bladder. The chalybeate sulphur waters, as Minnequa Springs, Pennsylva- nia, are recommended in cases of anaemia following rheumatism, or in mild syphilitic affections of the skin. Of the sahne-sulphur waters, useful in eczema, the rheumatic diathesis, and where there is a syphilitic taint, the author mentions the Blue Lick, of Kentucky ; the Lafayette, the Indian Spring, the West Baden, the French Lick, of Indiana ; the Blount Springs, of Alabama ; and the Green Cove Springs, of Florida. The chalybeate springs are represented by the Rawley Springs, of Virginia, or of Schooley's Mountain, New Jersey. There are those that are saline, most valuable in cases where saline waters are demanded, as in scrofula ; there are those that are alka- line, useful in cases of weak digestion, and dropsy from kidney dis- ease, with anaemia. Of the former, the Ocean Spring, of Missis- sippi, is an example ; of the latter, the Bailey Springs of Alabama, The alum waters, which also contain iron, are valuable in the scrof- ulous and tubercular diathesis. The Oak Orchard Acid Springs of New York contain free sulphuric acid. They are useful in cases of atonic conditions of the bowels, without congestion of the mucous membrane, in relaxation of the mucous membrane in whooping- cough or as a stimulant to that of the stomach, following summer complaints, etc. They can be taken internally in small quantities. They are most useful as baths, especially in bone scrofula, in dis- 71 8 DISEASES OF CHILDREN. charges from the ears or nose, and in chronic eczema. The Rock- bridge Alum Springs of Virginia are a type of this class. The Bath Alum Springs of Virginia are probably the best, as they contain a larger proportion of iron. The Alum Springs of Cresson are said to be valuable. The calcic waters are very useful in the rickety diathesis. They are tasteless, and can be used freely as ordinary drinking-water. He has frequently required pregnant women, who have previously borne children deficient in bone development, to drink these waters. Of this class, Gettysburg water is a type — it is an alkaline calcic water. The Allegheny Springs, of West Virginia, would also be valuable, especially when a slight purgative action is required, as they have an excess of sulphate of lime. The Sweet Springs, of West Virginia, contain 'a large amount of the carbonate of lime. Bethesda water also belongs to this class. To obtain the alterative action, which is the one we most fre- quently require, will necessitate the constant and prolonged use of the water selected, either internally or by bath, as the case demands. For bathing purposes, it may require a sojourn at the spring selected ; and for cutaneous affections, or scrofulous discharges and rheumatic joint troubles, this may be imperative. SCHOOL HYGIENE. Dr. Charles J. Lundy, of Detroit, read .a paper on this subject before the American Public Health Association (1884) in which he dwelt on the evils that accrue to young children from defective school hygiene, and summed up his paper as follows : 1 . Avoid the cramming process in education and the nervous ex- citement due to the spirit of rivalry. 2. Reduce the number of subjects in the curriculum and shorten the periods of study. 3. Ventilate the school-rooms in accordance with the most ap- proved methods. 4. Regulate the temperature of the school-room — an atmosphere which is too warm debilitates the system. 5. Provide properly constructed and arranged seats and desks. 6. Instruct pupils to sit erect and to hold the book or paper at least twelve inches from the eye. 7. Provide highly myopic pupils with proper spectacles, which will enable them to read at the natural distance of twelve inches. SCHOOL HYGIENE. 7IQ 8. Furnish pupils with well-printed books. 9. Furnish abundance of light, without producing glare. Let it come from the left side if the room is narrow, from both sides if the room is wide. 10. Provide for the physical education of school children, and teach them the importance of out-door exercise. The following is quoted from the remarks of E. A. Wood, M. D., in his address before the Medical Society of Pennsylvania, 1886. The popular notion, evidently shared by some educators, is something like the following : The mind of a child is an empty re- ceptacle, into which may be poured all kinds and quantities of knowl- edge, and that intelligence is a unit of constantly invariable power. If this were true, then equal amounts of knowledge could be poured into every young head, and equal value given to every unit. By this pernicious theory, or one akin to it, comes the high-pressure system of schooling, aptly called "cramming." By this system our schools are made brain factories, run by routine, and our teachers, machines, our pupils, raw material, the one to grind and the other to be ground, in the educational mill. • ♦ • The force system now in vogue, the long hours and many branches, the plan of cramming much and varied knowledge without special aim, break down health, destrby individuality, and put manacles on the natural bent of youthful minds. While it smothers the fire of genius and talent, and surfeits medi- ocrity, it makes dunces duller and idiocy more hopeless. The most appalling results of our faculty system of schooling, are yet to be named. Children whose nervous systems are so highly and exclusively developed must sufifer in health and vigor. There is no escape from this doom if we persist in our present course. The results are still more dreadful to contemplate when we remem- ber that heredity is saving every bad impression, and will surely transmit them intensified to the coming generation. These highly strung nervous systems imparted to your children by the schooling now fashionable — nervous systems pitched to the highest key of the living diapason, nervous systems out of tune with bodily har- mony — will be transmitted to their children. That is, if they have offspring, for, as sure as effect follows cause, such faulty develop- ment tends to deterioration and ultimate extinction of the race. It is sad to believe that America is not for Americans. The effect of severe and exclusive mental application is bad 720 DISEASES OF CHILDREN. enough for boys, but it is still worse for girls. There are few girls who can stand severe and continuous mental strain, between the years of twelve and sixteen, without serious detriment to health and vigor, and the loss of time is never made up to them. During that critical period the budding womanhood demands all the very high- est vital energies to fit her for that highest and noblest of all func- tions, maternity. Rob her of her vigor at that time, by diverting the vital processes to the brain, and you rob her of health, and probably the proud honor of becoming a mother. If there is one being in this wide world worthy of man's special homage, that being is the healthy mother of healthy children, and the more children the greater the homage. Chivalry and good taste alike prompt the gentleman to remove his hat in the presence of a woman who is proud to be a mother, and who is able and not ashamed to nurse her child at her own breast. It would be more gallant to tip your hat to her than to the flat-breasted, padded piece of millinery and leader of fashion, cultured to affectation, wise in novels and society scandal, and whose dainty nose turns up in dis- dain at vulgar maternity. Thanks to heredity, she is not likely to become vulgar, for Nature has set her eternal seal of barrenness on her kind. And yet, pity her; she is the product of this age of high brain culture. High schooling, in her case, as in thousands and thousands in this land, spoiled what might otherwise have been a normal woman, a contented wife and a happy mother. FEVERS AND MIASMATIC DISEASES. TYPHOID FEVER. DR. EDWARD HENOCH, OF BERLIN. This author considers that the former notion, with regard to the rarity of typhoid fever in children, is erroneous. He never employs cold baths, unless the temperature at night reaches 40° R. or more, and he confines himself to two baths daily, their average tempera- ture being 25° R. and never below 22°. These baths act favorably in many children by making them feel better generally, and tem- porarily relieving severe nervous symptoms that may be present. The duration of each bath should not exceed from five to eight minutes. Symptoms of collapse (tremor, coldness of the hands and feet, small pulse, pinched expression,) may develop after the bath and constitute a decided contra-indication against their continuance. In milder cases he applies an ice bag to the head and abdomen. When there is great restlessness he uses lukewarm baths of 26-27° R., which not infrequently produce a sedative effect. In milder cases, no active antipyresis, by means of drugs, is requisite. A mild fluid diet (milk, broth) and four to five spoonfuls of wine, ac- cording to age, are amply sufficient ; and when a prescription must be given, as in private practice, we may order hydrochloric acid in minute doses. In more severe cases, he replaces the cold bath by large doses of quinine a few hours before the nocturnal exacerbation, and he not infrequently employs it in combination with the baths. According to the antipyretic effect, the quinine is repeated every day or every other day. When the diarrhoea is profuse enough to call for special treatment, he gives subnitrate of bismuth or tannic acid, with extract of nux vomica or tincture of nux vomica. Constipa- tion may be relieved with castor oil or an enema of water. As a rule, no attention need be paid to the bronchial catarrh. When it is very extensive or terminates in broncho-pneumonia, he orders : 46 (721) 722 DISEASES OF CHILDREN. 1 1 30. R. Camphorae, gf • _8S Acid benzoic, gr. j Sacch. alb., gr. v. M. S. — Give this powder every two hoars. As soon as symptoms of collapse become noticeable, he gives port wine (a tablespoonful every two hours), musk, camphor, or subcu- taneous injections of sulphuric ether. When great restlessness and insomnia are present, he uses hydrate of chloral by the mouth or by the rectum. Above all, we must be careful to continue the fluid diet for a week after the cessation of the fever. M. JULES SIMON, OF PARIS. This author (Medical and Surgical Reporter, 1881,) says that the treatment of typhoid fever in children differs essentially from the treatment instituted for the adult. No dependence can be placed on active medication, or on any special remedy ; a series of indications exists, however, which must receive proper attention. These may be summed up in the phrase, " Sustain the vital forces ; excite or calm the nervdus system according to the state of the pa- tient ; seek to recall the cutaneous functions." During the first days the use, in abundance, of mild emollient drinks, is plainly indicated. Acidulated drinks are to be preferred, as they are refreshing and most agreeable to take. This will suffice at first, but after four or five days the administration of alcoholic preparations may be com- menced. Alcohol acts as an excitant in certain doses, but on the other hand it is a well established fact that in diseases accompanied by high fever, it lowers the temperature and sustains the rapidly- failing vital forces. The form under which alcohol is administered matters little ; brandy, rum, or Madeira wine may be indifferently employed, proper attention being, of course, paid to the dose ad- ministered. During the first period of the malady the child is, as a rule, con- stipated ; but the scene soon changes, intestinal hypersecretion supervenes, and diarrhoea, accompanied in some cases by violent colic. In such cases, emollient fomentations should be applied over the abdomen, and enemata administered, containing two or three drops of laudanum, for a child from five to seven years of age. After two or three days of such treatment, and often sooner, the abdominal pains will become less intense and the meteorism less marked. TYPHOID FEVtR. 723 Every three days a small dose of some mineral purgative water may be given, not with the object of purging the little patient, but in order to clean out, as it were, the digestive tube. Every day enemata of water, containing, if desired, some anti- septic substance, may be administered. In order to excite cutan- eous secretion, the whole body should be sponged with lukewarm water containing a little aromatic vinegar. Cold baths should not be employed in the treatment of infantile diseases ; moderately warm baths give equally good results, without presenting the dangers of immersion in cold water. The patient should, if possible, be moved from one room to another, morning and evening. The object of this practice is to prevent the pro- longed sojourn of the infant in a room where the air is poisoned by the execrations and exhalations engendered during the course of the disease. The most absolute silence, and a darkened room, free from inopportune visitors, will prove of benefit. The diet should be very mild, milk and broths being the staple articles used for the alimentation of the patient. To sum up, the treatment of ordinary typhoid fever, running its course without notable complications, should consist in directly sus- taining the forces by a milk diet, with broths and alcoholic prepara- tions ; and indirectly by diminishing the intestinal secretions and combating the active principle of the disease by washing out the digestive tube, by frequent change of air, etc. TREATMENT OF COMPLICATIONS. 1 . Abdominal Symptoms. — ^When abdominal symptoms are spoken of, super-purgation and intense abdominal pains are generally under- stood. The absorbents and mild astringents should be employed in such cases ; as much as ten grams of creta preparata per diem may be administered in a mucilaginous julep, or four grams of subnitrate of bismuth in sweetened water. Enemata of starch, containing four or five drops of tinct. opii, may be administered ; the dose of opium being gradually but cautiously increased. In conjunction with this treatment, emollient poultices should be applied over the abdomen, but the diarrhoea may possibly not be arrested for four or five days. 2. Thoracic Symptoms. — ^The most frequent are generalized bron- chitis and congestion of both lungs. Emetics should, in general, be avoided. Ipecacuanha, senega, and the preparations of antimony, 724 DISEASES OF CHILDREN. should not be employed, All these medicaments would but depress the vital forces of the patient, if they did not even destroy him. Dry cups may be applied over the chest, morning and evening ; this is a simple, but powerful means of revulsion, always at the dis- posal of the physician. Insist on the alcoholic preparations, which you may prescribe at the dose of from five to seven drachms, adding, if necessary, a small quantity of extract of quinquina. If dyspnoea should become very urgent, a flying blister should, without hesitation, be applied on the chest, and should be left about three or four hours in situ, but never more than five or six. Thus applied, it will suflSce to produce irritation of the skin; after its re- moval a large, warm cataplasm may be applied, to aid in bringing about the serous effusion under the epidermis. We should not de- prive ourselves of an agent of great power, particularly in children, in the dread of producing an eschar; it is true that this accident happens more frequently in typhoid fever and in cachectic condi- tions of the system, but its occurrence may always be prevented by removing sufficiently soon the blistering agent. 3. Cerebral Symptoms. — ^These are the symptoms against which therapeutic agents have least power. If the child presents symptoms of great cerebral excitation, chloral may be administered in the dose of 15 or 20 grains, or an enema, containing 15 grains of chloral, 1 5 grains of camphor, and the yolk of an egg, may be prescribed. Bromide of potassium should be given only as a last resource, and never for more than two days consecutively. 4. Hemorrhage. — Intestinal hemorrhage during the course of ty- phoid fever is rare in children ; epistaxis is of more frequent occur- rence. There is one simple mode of arresting hemorrhage from the nose, which generally proves efficacious. Agaric is cut in long strips, about half an inch in width ; these are introduced as deeply as possible, until the nostril is filled ; then another is applied trans- versely across the external opening, and the whole is kept in place by a roller passed around the head. Sometimes it is necessary to saturate the agaric with tincture of ferri perchloridi. Plugging the posterior nares with the aid of Belloc's instrument should be avoided ; it is very difficult of accomplishment, on account of the restlessness of the child; it induces nausea, and gives no better results than the other method. When hemorrhage from the intestine occurs, administer two drops TYPHOID FEVER. 735 of tr. ferri perchlor., every half hour or every second hour. If this does not suffice, give cold drinks, place compresses wrung out of cold water on the abdomen ; internally give pounded ice, which when mixed with pulverized sugar, is taken without repugnance. 5. Accidents through Compression. — Redness and eschars are in- duced on the parts which support the weight of the body ; they ap- pear oftenest on the sacrum. An attempt should be made to pre- vent these accidents ; the pelvis of the child should be supported on an air pillow about two-thirds filled ; the parts should be sponged with an infusion of oak leaves, or with some other astringent prep- aration. In ataxo-adynamic forms, characterized by delirium with prostra- tion, a blister should be immediately applied to the back of the neck ; and when the first has become dry, a second may be applied in the same place. Finally, in adynamic forms, in those accompanied by much pros- tration, tonics and substances acting as stimulants to the nervous system must be insisted on. If necessary, the patient may be plunged into a cold bath ; a few seconds' immersion produces re- markable excitation ; but this is a means which should be employed only after having in vain tried all the others. DR. COLEMAN, OF VIRGINIA. " Masterly inactivity," according to this za)i!i\or (Virginia Medical Monthly, 1879), is the principle required in treatment. A nervine now and then, mild diuretics and occasional enemata. As the child grows beyond five years of age, the disease more and more resem- bles the fever as it is found in adults ; and by the age of ten years it loses almost entirely its distinctive infantile form. He has seen the disease in children ranging from eighteen months to five years of age. It is marked by a daily double rise of temper- ature and corresponding remissions. Its critical days are the seventh and its multiple. The cutaneous abdominal eruption is much more common and marked than in the typhoid fever of adults. Besides, in the typhoid fever of children diarrhoea is ab- sent ; and it is this absence of a usually prominent symptom in adults that makes the disease more or less obscure in children. This absence of diarrhoea in the typhoid fever of children is due to the fact that in them, up to five or eight years of age, Peyer's glands are rudimentary, and therefore do not suffer from the effects 726 DISEASES OF CHILDREN.. of the typhoid poison, as in the case of adults. It is a peculiar fact that the typhoid fever of old people simulates very much that of children, although it is not so wanting in risk. Dr. COLEMAN regards typhoid fever as contagious, but as less so than scarlet fever. He believes the true cause why typhoid fever is not more frequent among adults is, that they had the disease in childhood. He has never seen a patient under ten years old die with typhoid fever, which favorable result, he thinks, is due to the undeveloped state of Peyer's glands. SULPHATE OF THALINE IN TYPHOID FEVER. Dr. Steffler (Rev. Mens, des Mai. de I'Enf.) speaks very highly of this drug in the treatment of typhoid fever in children. He says, " being tasteless, children will readily take it in a watery solution." It never excites either diarrhoea or vomiting. Its action is usually manifest within an hour after it has been taken, and the resulting defervescence usually lasts three or four hours. The ordinary dose is from three-foui^hs to one and one-half grains, and not more than two doses are required in twenty-four hours. M. LegroUX (Gazette Hebd.) has- modified M. BOUCHARD'S method of treating typhoid fever, so as to adapt it to children : 1. As soon as the disease is diagnosed, give a purgative dose of- calomel (gr. ivss to ix) divided into two portions. 2. Two days after, give naphthol alone, or combined with salicyl- ate of bismuth or magnesia. If there is only a moderate diarrhoea, give every hour one of the following powders : 1131. R. NaphUiol, gr.xxx. In pulv. No. X. div. I. If the diarrhoea is profuse, give every hour one of the follow- ing powders : 1132. R. Naphthol, Bismutbi salicyl., aa gr. xxx. In pulv. No. X. div. 3. If there is constipation, replace the salicylate of bismuth with salicylate of magnesia, and use in the same manner : 1 1 33. R. Naphthol, Magnesii salicyl., 55 gr. xxx. In pulv. No. X. div. SCARLATINA. 727 SCARLATINA (SCARLET FEVER\ The Lancet (September 3d,. 1887) sums up the treatment of scar- latina in England as follows : A large portion of the profession pursue the expectant plan — i. e., watchfulness for untoward symptoms, and treating these as they arise, but without making any attempt to arrest the course of the malady. Antiseptic gargles are frequently used, and many employ topical applications of the same nature to the throat and nose. Compresses of heat and moisture are generally used externally. For the relief of the disagreeable dryness of the throat and the thirst, nothing is found more effective than ice and raspberry vin- egar. Iced water compresses to the shorn scalp, or irrigation through a coil of rubber tubing, is the best means of controlling central nervous symptoms. Aconite, in frequent small doses, is extensively employed, but needs to be used with caution in treating children. Cold bathing is used by a few, cold sponging by almost all. Pretty much all the "specifics" have been abandoned. Bella- donna finds but few adherents, and carbonate of ammonium almost none. Considerable difference of opinion exists with regard to in- unctions, two of the most recent writers taking opposite views. GOODHART recommends general inunction, while Angel MONEY opposes it, although he does not oppose relieving the tension of the palms and soles by the use of vaseline scented with eucalyptol. PROPHYLAXIS OF SCARLET FEVER. Of asserted prophylactics, belladonna easily stands at the head of the list. The testimony regarding it is very conflicting. On the one side. Prof. J. LEWIS Smith believes, from the weight of evi- dence, that it is entirely inert. Dr. Andrew Wood, at Heriot's Hospital, Edinburgh, and Dr. ALLEY, at the. Orphans' Asylum, Bos- ton, experimented with it, administering it to one-half the children in their institutions, and, to use the words of the latter, " there was no manifest difference between the two classes as to susceptibility to the contagion ; " and Thomas, in his exhaustive articles in ZlEMS- SEN'S Cyclopedia, speaks of belladonna as the "much-vaunted pseudo-prophylactic." On the other hand, RiLLlET and Barthez think it worthy a trial. 728 DISEASES OF CHILDREN. Professors MEIGS and PEPPER think favorably of it. Dr. McKee, of South Carolina, thinks he used it with success.- Dr. PORCHER, after a review of four hundred volumes of literature on the subject, ex- presses himself in favor of it ; and Professor StilLE, after review- ing the whole subject, says : " We feel bound to express the convic- tion that the virtues of belladonna, as a protection against scarlatina, are so far proven that it becomes the duty of practitioners to invoke its aid whenever the disease breaks out in a locality where there are persons liable to the contagion — particularly in boarding-schools, orphan asylums and similar institutions, and among the families of the poor ; whenever, in a word, it is difficult to place the healthy at a distance from the sick." Dr. CHARLES W. Earle, of Chicago, from an extended experience in that city, reached the conclusion that although its administration does not prevent children taking the disease, it mitigates the character of the attack. The bisulphites and hyposulphites of soda and magnesia come next in importance. They may be given in solution of syrup and water, gr. ^ to j, for each year of the child's age, four times daily. Re- cent and strong testimony to their efficacy has been added by Dr. G. H. Harman. (Ohio Medical and Surgical Journal, April, 1878.) Tonic doses of tinctura ferri ckloridi during an epidemic have been found by Dr. J. A. Larrabee, of Kentucky, to. exert a protect- ing influence. He believes that the direct action of the iron upon the blood will prevent the scarlatinal poison from involving the sys- tem. (Trans, of the Kentucky State Medical Society, 1865.) The sulpho-carbolate of soda has been urged on theoretical grounds by Drs. Samson and Brackenridge, upon persons exposed to the poison of scarlet fever, and the latter relates several striking in- stances of what he believes to be its protective powers. He gives the salt in doses of gr. v-xxx, three or four times daily. Its use in this country has not answered expectations, and it has rather been found to depress the vital powers and tend to cause the patient to succumb. The value of inunction as a prophylactic, has been prominently set forth by Prof. James B. Walker, M. D., of Philadelphia. (Med. and Surg. Reporter, August 23, 1879). He believes that patients anointed several times daily with fat bacon, warm sweet oil, or sim- ilar fatty preparations, become, in a great degree, unable to propa- gate the infection, as the epidermic scales, which are generally con- ceded to spread the poison, are, by this means, prevented from escaping into the surrounding atmosphere. SCARLATINA. 729 For prophylactic purposes, Dr. John C. Peters, of New York, relies upon sweet spirits of nitre. (Medical Gazette, July, 1869.) It lessens fever, and prevents, by its diuretic action, the occurrence of disease of the kidneys. It may also eliminate the poison so rapidly and completely that the system cannot become affected, nor the disease reach its full development. Complete and continuous isolation is probably the only sure safe- guard against infection. PROF. J. LEWIS SMITH, M. D., NEW YORK. In moderately severe and grave cases, the external treatment should be by cold applications to the head and sponging to the face and arms. This may be frequently repeated. Immersion in cold water or pouring it upon the person is questionable, as such a shock may increase the liability to chronic convulsions. The itching of the skin should be relieved by inunction. The best substance for this purpose is sweet oil or glycerine, to each ounce of which six or eight drops of carbolic acid are added. [Other au- thors commend, as still better, cocoa butter, theobrotna cacao, which has a marked cooling effect.] The inunction should be made with linen or muslin, and the substance should be applied frequently to those parts of the surface which itch. D. ChakoVSKI (Therap. Monatsh., 1889), reports great success in the use of salicylic acid in malignant scarlet fever. The mortality is lowered to 3^ per cent. The remedy was always administered after the following formula : I '34- R- Acidi salicylici i part. Aqiue destil 75 parts. Syr. aurantii cort 3° parts. Sig. — Give a teaspoonful every hour during the day and every two hours during the night. • All traces of fever leave by the tenth day, but the author advises the continuance of the remedy for some time, in decreasing doses, to prevent a relapse. The author believes that all serious complica- tions, such as ursemia, anasarca and diphtheria, are avoided through the use of this treatment. As an internal remedy, carbonate of ariimonia is one of the best : "3S' B- Ammonii carbonatis, Ferri et ammonii citratis, ia 3ss Syrupi, f-SiT- ^^ A tablespoonful every three hours, to a child three years old. 730 DISEASES OF CHILDREN. In the malignant forms of the disease, with the temperature at 105° F., drowsiness, delirium and restlessness, the sulphate of quinine, in full doses, is more useful than any other remedy ; gr. iij-v, thrice daily, to a child of five years. If the stomach will not retain it, give doses of gr. xij by enema. A hot mustard-bath or foot-bath de- velops the rash, and allays nervous excitement ; it is especially in- dicated if the convulsions occur attended by disappearance of the eruption. For the pharyngitis, a slice of salt pork, cut thin, and stitched to a single thickness of muslin, should be applied to the throat. It should pass from ear to ear. This application should be continued throughout the fever, being left off for a day or two, if too much soreness is induced. It is a gentle and effectual counter-irritant. Local applications to the fauces are still more important: "36. R. Acidi carbolici, gtt. xv-xxx Potassii cbloratis, 9iij Glycerinse, Aqiue, aa f. §ii). M. For a gargle. H37- R- Acidi carbolici, gtt. v Liquoris ferri subsulpbatis, ?. 3ij Glycerinse, f.|j. M. To be applied with a camel's-hair pencil, three or four times daily. Yeast is useful in many of these cases, given in doses of f.5ss-f .5j, several times a day. No drink should be allowed for several min- utes after swallowing it. HIRAM CORSON, M. D., NORRISTOWN, PA. This writer has, for several years, been a prominent champion of the ice and cold-water treatment of scarlatina, advocated, early in this century, by Dr, James Currie, of London, and later by Pro- fessor Trousseau, of Paris. He applies the ice in moderate quantities, tied up in two small pieces of bladder, and one placed on each side of the neck, over the parotid gland, and retained by a strip of muslin brought under the jaw and tied on the top of the head, not around the neck. If no bladder nor gutta percha jjag can be procured, fold a strip of old muslin twice, so that, when thus folded, it shall be three inches wide, and long enough to extend from the bottom of one ear, under the jaw, to the bottom of the other. To each end of this, sew a strip of muslin of the same width, and a foot or more in length, by which, SCARLATINA. 73 1 when applied, it may be tied to the top of the head. Have a line of stitches run crosswise through the middle of the fold; there will then be a pocket for ice on each side of the neck. For the first application, wet this with cold water alone, and tie it on ; after wet- ting it a few times, slip into the pouch, on each side of the neck, three or four large lumps of ice, as large as a shellbark, and keep them well stocked with ice. Give the ice freely inside, apply it over the nose, and sponge the body and limbs freely with cool or cold water. STILES KENNEDY, M. D., MICHIGAN. According to this writer, two medicines only have gained much reputation for mitigating or subduing the symptoms of fever in this disease, or the disease itself, and the profession is about equally divided as to their respective merits. One is the chlorine mixture, which, for ready use, may be prepared about as follows : 1 1 38. B. Fotassii chloratis, 3i Acidi muriatici, Aquas, aa f.ij. M. From two to eight drops of this to a tablespoonful of water, may be given every two hours. For children over eight years of age, a solution made of two drachms of the mixture and a pint of water, is strong enough to give, in tablespoonful doses. It is generally pre- pared sweetened with simple syrup, but, at best, it is an unpleasant dose to many children, and often makes them complain of burning in their throats. The other medicine alluded to is the liquor ammonii acetatis of the Pharmacopoeia. Probably no anti-febrile mixture has stood the test of the experience of the profession for so long a time, with so much satisfaction, as this, not in scarlet fever particularly, but in all febrile diseases ; and our author does not remember ever to have heard it complained of when the vital powers begin to flag. An excess of carbonate of ammonia may be added, in the quantity of five to ten grains to the ounce : "39- K- Ammonii carbonatis, ^I'T™ Liquoris amraonise acetatis, f. Si'jss Syrupi, f-Sss. M. Give from half to a whole tablespoonful, in a little water, every one or two hours, according to the age of the patient and the urgency of the symptoms. 732 DISEASES OF CHILDREN. FREDERICK T. ROBERTS, M. D. In reference to the treatment of special symptoms, this author gives the following recommendations : The throat symptoms are best relieved by sucking ice or inhaling steam. A few leeches about the angle of the jaw are occasionally advisable. For ulceration and gangrene, antiseptic gargles are de- manded ; or, if the patient cannot gargle, inhalations or sprays. The antiseptic may be either carbolic acid, creasote, chlorate of potash, permanganate of potash, or sulphurous acid. The nostrils, if blocked up, must be washed out occasionally with a weak disinfectant solution. Ulcerations may be touched with a solution of nitrate of silver. A weak solution of chlorate of potash may be allowed freely as a drink. But in a large number of cases, the only hope of recovery lies in the free support of the patient by food and stimulants. As, often the child cannot or will not swallow, and the necessary materials cannot be introduced into the stomach, they must be administered by enemata. At the same time, tincture of iron, in full doses, •»Lxx— xl, every three or four hours, with qui- nine or mineral acids, is called for. THE ALBUMIlSfURIA AND DROPSY. Dr. W. H. Thompson, of New York, considers that with reference to the nephritic complication, no case is to be despaired of in its acute stage, for recoveries from apparently the most desperate cir- cumstances (as in cases in which urine hcis continued suppressed for seven and nine days) have taken place. The measures to be adopted are, oiling the skin, the hot water pack, dry cupping, counter-irritation by means of spoons heated in hot water and ap- plied momentarily over the kidneys, the free use of the infusion of digitalis, etc., after diaphoresis, large injections of warm water. The injections are preferable to purgatives, because the action of the warm water favors the discharge of water from the bladder. A quart may be perhaps used as many as six times a day, and passing the urine may come only with the last injection. The infusion of digitalis should be given to children in very nearly as large doses as are required for adults. When purgatives are used, the usual one is elaterium: I '40. R. Pulveris elaterii, gr. \ Pulv. scammon, comp., gr. y Potassii bitartratis, 3ss, m. For a child of ten. (E. Ellis.) SCARLATINA. 733 Elaterium is objectionable on account of its tendency to excite vomiting, unless carefully combined. Digitalis is the most approved diuretic. It may be given in the fresh infusion, or as follows : 1141. R. Tinct. digitalis, lUiij Tinct. hyoscyam., Tl^v Syr. aurantii, f.Sss Aquae camphorse, f. Siv. M. This amount for a five-year-old child every six hours. 1142. R. Infusi digitalis, 5ss Potassii acetatis, gr. v Spiritfls juniper, comp., Hlx Decocti scoparii, ad f. § ss. M. For a child live years old every six hours. (Dr. Edward Ellis.") The use of iron in as large doses as the system can bear without producing headache or nausea is recommended by Prof. M. Char- TERIS : 1I43- B- Tinctura: ferri chloridi, f. Sij Infusi digitalis, f. § vij. M, A dessertspoonful thrice daily. The diet should be generous, with plenty of milk, a;id a uniform temperature insisted upon. When convulsions supervene, Dr. S. WiLKS, of Guy's Hospital, and other leading English authorities, do not hesitate to practice venesection to f 5iij— vj. In many instances, where every other means failed, patients have recovered by the judicious employment of the lancet. DR. EDWARD HENOCH, OF BERLIN. This author considers that no drugs are required in normal cases which are free from complications. The child should be isolated as much as possible from his brothers and sisters, or the latter be re- moved from the house. Pure air and cool temperature should be earnestly recommended ; the windows should, therefore, be repeat- edly opened, at least in the adjoining room, the child covered lightly, and the room darkened only when photophobia is present. Cool drinks, milk, soup, pigeon or chicken broth should constitute the diet during fever days. An enema or a mild purgative every other day — for example a teaspoonful of magnesia or a laxative efferves- cent powder ; a wineglassful of bitter water, etc., may be given in con- stipation. If the fever continues, and high and malignant symptoms 734 DISEASES OF CHILDREN. develop, the head should be covered with an ice-bag, a large dose of quinine or salicylate of soda given between four and six o'clock p. m., and the child placed in a lukewarm bath. He decidedly op- poses cooler baths, because in scarlatina, which presents a tendency to heart failure, cold may produce an unexpected rapid collapse more than in any other affection. But he strongly recommends washing the entire body every three hours with a sponge dipped in cool water and vinegar. If something must be prescribed, hydro- chloric acid is the most suitable. 1144. R. Acid, hydrochloric, gtl- H Aq. destil., f. S iij Gum. arab., gr. xv Syrup, f.5v. M. S. — Teaspoonful every two hours. In truly malignant cases, however, antipyretic treatment proves utterly useless. He has never seen any effects from large doses of quinine, and he considers salicylate of soda in such cases a danger- ous remedy. If we can sustain the action of the hfeart by the use of powerful stimulants until the organism has overcome the other severe consequences of the infection, we may still hope for a favor- able termination unless grave complications are present. Among stimulants he gives the first place to alcohol (wine, brandy), coffee in large doses, and camphor. When degultition is impaired by swelling of the pharynx, a nutritive enema of pepton should be given twice a day, or a small cup of bouillon with yolk of egg and a spoonful of wine, and S. hypodermic injection made every three hours of sulphuric ether (a hypodermic-syringeful), or camphor, either in the form of camphorated oil, or better still, as a solution of camphor in alcohol and water. If the malignant form of scarlatina runs its course without any dangerous symptoms of heart failure, as may happen for a number of days, he would advise the constant employment of decoct, cort. chinae (5.0-8.0:120) with aq. chlori (15.0) which may be changed for tincture of valerian if the pulse is sinking. Disinfection of the buccal, pharyngeal and nasal cavities, should be made by injection of these parts every two or three hours with a solution (two per cent.) of carbolic acid, or with perman- ganate of potash (0.5 : 100). He has also had success in injecting the nose with sulphate of zinc ( i.o : loo.o) or brushing it with a five per cent, solution of chloride of zinc. In synovitis the painful or swollen joints should be wrapped in cotton. Lukewarm baths SCARLATINA. 735 should be taken as soon as desquamation begins. Patients should not be allowed in the open air before the fourth week. DR. p. HEUSER, OF GERMANY. This physician writes to the Deutsche Medizinal Zeitung, 16, 1882, that he has nearly always achieved a rapid cure in scarlatina-dropsy, and even when internal remedies could be no longer administered, by the following method : He daily rubs into the skin in the region of the kidneys a mixture of one part of croton oil, with two parts of ol. papaveris. Generally one such inunction suffices to cause within a few hours the appear- ance of a severe eruption of the skin, and simultaneously a great improvement in the condition of the patient and amelioration of all the dangerous symptoms. The change for the better at once sets in with the commencement of the artificial exanthem. If the symp- toms again become aggravated, the procedure is repeated. Inter- nally he administers spirit, mindereri in small doses. ViDAL, Wiener Medicinische Presse, October 5, 1890. In this paper the author speaks very highly of large doses of ammonium acetate in the treatment of scarlatina, and believes that it will also be found very useful in other exanthemata. ViDAL gave from 35 to 90 grains in twenty-four hours. This caused a rapid lowering of the temperature, and desquamation was established within four days. The earlier the remedy is given the better are the results. DR. JOHN W. HAYWOOD, OK LONDON. This author describes (Lancet, 1883) two cases of malignant (hemorrhagic) scarlatina that resisted all treatment and seemed doomed. The cuticle was removed from around the throat by a cantharides blister, and to the exposed cutis a wet compress sprinkled with crotalus was applied, and renewed, at first every half- hour, and then every three hours ; also, a dose, dissolved in a tea- spoonful of water, was dropped on the tongue every half-hour. The symptoms all began to improve at once, and the author thus concludes ; " The above notes of these two interesting cases were written at the time, and have been preserved and withheld from publication, in order to test the drug in similar cases before publish- ing them. This has now been done over and over again, until the writer is thoroughly convinced that the above facts were no mere coincidences." 736 DISEASES OF CHILDREN. DR. KEITH NORMAN MACDONALD, OF SCOTLAND. In the British Medical Journal (1883), Dr. KEITH NORMAN Macdonald, after denying the prevalent opinion that no reliance can be placed on any drug in cases of scarlatina, does not hesitate in affirming that, when properly applied, both locally and internally, sulphurous acid is by far the most efficacious remedy we possess. He continues : " I have had several opportunities of testing its effi- cacy in some of the worst cases I have ever seen, during the epi- demic which has been rife in this town (Cupar Fife) for the last two months, and I am bound to say that, of all remedial measures in this disease, it is, in my opinion, the most reliable. My treatment is as follows : The moment the throat begins to become affected, I ad- minister to a child, say of about six years of age, ten minims of the sulphurous acid, with a small quantity of glycerine in water, every two hours, and I direct the sulphurous acid spray to be applied every three hours to the fauces for a few minutes at a time, using the pure acid in severe cases, or equal parts of the acid and water, according to the severity of the case. Sulphur should also be burned in the sick chamber half a dozen times a day, by placing flour of sulphur upon a red-hot cinder, and diffusing the sulphurous acid vapor through the room, until the atmosphere begins to become unpleasant to breathe. " In the worst cases, where medicine cannot be swallowed, this and the ,spray must be entirely relied upon ; and the dark shades which collect upon the teeth and lips should be frequently laved with a solution of the liquor potass, permanganatis of the strength of about one drachm to six ounces of water, some of which should be swallowed, if possible. " In cases presenting a diphtheritic character, the tincture of per- chloride of iron should be administered in rather large doses in a separjate mixture with chlorate of potash, and equal parts of the same with glycerine should be- applied locally, with a camel's hair brush, several times in a day ; but as in the majority of cases among children it is next to impossible to use a local application more than once, the spray and permanganate solution will then prove of great service. "As to other remedies recommended by various authors, ammo- nia is nasty, and cannot be taken well by children ; carbolic acid has the same fault, and cannot be applied properly. Gargles are SCARLATINA. 737 also useless in children, because they seldom reach the diseased sur- faces, and warm baths and wet sheet packing are dangerous, because they are never carried out properly in private practice. The hypo- dermic injection of pilocarpine is a remedy that may give good results hereafter, but I have had no experience in its use." DR. JOHN W. AYLER, OF WEST VIRGINIA. This physician states in the Medical and Surgical Reporter, 1883, that he has had excellent results from a method of treatment that he fails to find reported in any text-book. When called to a pa- tient, he at once orders chlorate of potash and carbolic acid inter- nally, with inunction of the whole surface of the body. The treat- ment is pushed throughout the whole course of the disease. DR. PAUL GERNE, OF FRANCE. This author says (Le. Concours Medical, 1882) that if you desire to use belladonna, the following is a good formula : I '45- B- Ext. belladonna, gr. iiV Distilled water, f. 5 viiss Alcohol, rectified, tr\_xv. M. Of this mixture, give as many drops, morning and evening, as there are years in the patient's age. In regular and normal forms of .the disease the treatment should be purely hygienic ; the patient must be kept in bed in a room hav- ing a temperature of from 64° to 68° F. The patient should not be surfeited with warm drinks ; he may have reasonable quantities of lemonade, to which wine can be added» when there are symptoms of weakness. Until the period of desquamation is reached, the food should con- sist of broth, unless otherwise specially indicated. The infectious nature of the disease warrants the use, as recom- mended by Scott, of an aqueous solution of sulpho-phenate of soda, in doses of grs. viiss-xv. In irregular forms, the predominating symptoms will, of course, indicate the particular measures that should be adopted. The hyperthermia in those ataxic forms rap- idly accompanied by serious nervous, comatose, convulsive or dyspnoeic symptoms, is successfully checked by cold lotions and affusions, and in very severe cases cold baths may even be given. As an anti-thermic remedy, we use sulphate of quinine ; but sali- 47 738 DISEASES OF CHILDREN. cylate of soda should never be displayed, because it might superin- duce nephritis, which is always imminent, or aggravate it if already present. In syncopal forms, wine, alcohol, cinchona and digitalis, are to be exhibited. In gastro-intestinal forms (complicated from the start by incoer- cible vomiting and profuse and persistent diarrhoea), opiates are to be used, also Seltzer water, and ice in small pieces should be fre- quently given by the mouth. DR. LERVIS, OF FRANCE. Dr. Lervis (Le Progres Medical, 1882,} recommends digitalis to limit the acceleration of the pulse in scarlatina, and also as a pro- phylactic against renal complications. The infusion of digitalis should be given as soon as possible. after the debut of the malady, and continued up to the third week. The whole body should be anointed with oil twice daily, until desquamation is completed. To prevent the development of diphtheritic angina, he recommends the following potion ; 1146. R. Potass, chlorat., 3j Tinct. fern perchloridi, f. 3ij Glycerinae, f, § j Aquadestil., f.lviij. M. S. — A teaspoonful every half hour. DR. JAMES Y. shearer, OF PENNSYLVANIA. This physician has had most excellent results from the cold treat- ment of this disease, which he has practiced for twenty years. He sponges the whole body with cold water and applies ice to the throat, having a piece of muslin between the skin and the ice. He is careful to apply the ice to the inflamed cervical glands. DR. A. WORTHINGTON, OF CANADA. This author (Canada Lancet, 1881,) reports most satisfactory re- sults from the " Cold Water" treatment. His plan is to pour ice-cold water over the patient's head and neck for a couple of hours at a time, to sponge the entire body frequently, and to keep cloths wrung out of cold water constantly around the neck. He uses no medi- cine, except to keep the bowels open. He, of course, always meets with opposition from the parents, but he persists, and his reported success is very great. SCARLATINA. y^g DR. LEICHTENSTERN. The means upon which this author relies (Archivio di Patologia Infantile, 1883) most extensively is the cold bath, administered from the time that the exanthema is well developed. He usually im- merses the child for from ten to fifteen minutes. The contra-indica- tions for its use are : 1 . Cardiac collapse or a tendency thereto, with a cold and cyanotic skin. 2. Laryngeal stenosis, when diphtheria complicates the disease. 3. Inflammatory swelling and infiltration of the cellular tissue of the neck, with venous obstruction. 4. Possible impending pharyngeal or nasal hemorrhages from diphtheritic erosion of the large vessels ; absolute quiet being im- perative. 5. The severe form of poly-articular synoyitis and scarlatinous tendinitis, in which the slightest movements are painful. Less reli- able, in the author's hands, as an antipyretic, is quinine, which is not without danger in children from the possibility of quinine collapse. If given at all, it should be in small and rather frequent doses. Of salicylic acid he speaks with more confidence as an antipyretic. He usually gives it in die form of the soda salt, in seven-grain doses, at intervals of half an hour, until the fever is controlled. In some cases it was effective when the cold bath failed. He thinks its sup- posed unfavorable effect upon the heart is imaginary. For alimenta- tion he prescribes milk, eggs, gelatine and nutritious soups. Stimu- lation is often necessary, and for this purpose red wine, cognac or champagne may be given. Massage and counter-irritation, in the form of blisters, are also beneficial at times. DR. WILLIAM B. ATKINSON, OF PHILADELPHIA. According to this teacher (Medical and Surgical Reporter, 1880), in every case of this disease, whether mild or malignant, much de- pends upon the care and attention of those who are to act as nurses. The efforts of the physician must be directed to the relief of urgent symptoms, as intense febrile action, the prevention of debility and of complications. The patient should be kept in bed in a well-ventilated room, with especial care to avoid the slightest exposure to a draught. In ordi- nary cases the medicinal treatment will be limited to the meeting of 740 DISEASES OF CHILDREN. indications as they arise ; the patient should be allowed cool, acidu- lated drinks, and plain, easily-digested food. Sponging the whole surface with tepid water is in many cases very comforting. The same effect is produced by the process of inunction. The usual domestic remedy is pure lard, or the fat of bacon. Preferable is the unguentum petrolei or " cosmoline," and where the itching is very annoying, it is better to employ the carbolated preparation, which contains three per cent, of carbolic acid. The inunction should be repeated at intervals, as circumstances demand, to relieve the dryness and mitigate the great heat of the skin. The physician must constantly keep in view the tendency to de- pression, and remember that stimulants are to be employed ,at the earliest indication of debility. Preparations containing chlorine in some form have long been favorites with the profession, under the belief that this article acts to destroy the poison of the disease. Watson, in his Principles and Practice of Physic, gives this formula : " Put eight grains of the chlorate of potassa into a pint bottle, and pour upon them one drachm of strong hydrochloric acid. Keep the mouth of the bottle closed until the violent action has ceased ; then add an ounce of water, and shake the mixture well ; then add another ounce of water, and again agitate well ; and so on, until the bottle is full. The chlorate should be pulverized, and in cold weather the bottle should first be warmed. A tablespoonful or two of this mix- ture, according to the age of the patient, may be given for a dose, frequently. An adult may take the whole pint in a day." At present, many practitioners employ a formula containing the chlorate of potassa and the tincture of chloride of iron, regarding this combination as of great value, also, to meet the throat symptoms. When needed, the throat may also be gargled with this combination in' honey and water. For the great restlessness the bromide of po- tassium, or of sodium, will be found valuable in moderate doses, repeated at intervals of an hour or two, until quiet is produced. Many authorities agree that in consideration of the poisoned con- dition of the blood, small doses of carbonate of ammonia should be given every two or three hours. J. Lewis Smith gives the following : >t47- B- Ammon. carb., Ferri et ammon. citrat., iS 5ss Sy™pi. f.gm M. One or two tablespoonfuls every two or three hours. SCARLATINA. 74 1 Some prefer the liquor ammoniae acetatis, and this, in all cases, should be employed with an excess of the ammonia. Should the symptoms indicate exhaustion, with the decline of the eruption, quinine should be employed, as also the carbonate of am- monia. In his own experience, no single remedy has given such good and such constant results as digitalis. About the year 1858 the late Dr. Lewis P. Gebhard read a paper before one of our medical societies, very strongly advocating the use of this article in all the forms of this disease, and claiming for it the character of a specific. His method was to put one drachm of the powdered leaves of digitalis to twelve tablespoonfuls of boiling water, and when the infusion had cooled, to give it in teaspoonful doses every hour or two, according to the age of the child and the gravity of the symptoms. Since that time Dr. Atkinson has used it in a large number of cases and with the best results. He generally orders it prepared in the same way, and directs the nurse to give it in teaspoonful doses every hour or two, until the pulse and temperature are positively reduced ; then to lengthen the interval, so as to maintain the effect thus obtained. He believes that he has almost invariably observed the symptoms to moderate within from twelve to twenty-four hours, and he feels confident that while he has never in a single instance known any of the so-called poison- ous effects of the remedy to follow, he has also failed to see the usual dangerous sequela in many cases, and only slightly in any. He has never seen anything to warrant a belief in its usually dreaded "cumu- lative effect." DR. W. VAWDREY lush, OF ENGLAND. After ten years' experience, added to fifteen of Dr. THOMPSON'S, this author speaks highly, in the Lancet, 1880, of the warm bath treatment of scarlatina. At first, he orders the patient to have three warm baths daily, to be kept in from three to five minutes, rapidly dried, wrapped in a blanket, and returned to bed. As the disease subsides, he reduces the baths to two or only one daily. He finds that it brings out the rash, reduces the temperature, and soothes the patient. DR. J. MURPHY, OF ILLINOIS. Dr. J. Murphy states, in the Peoria Medical Monthly, 1 880, that he has found the following formula of great benefit in the treatment of scarlet fever : 742 DISEASES OF CHILDREN. 1 148. R. Acid, salicylas, 3ij Mucilag. acaciie, Aquae rosae, aa § iss Syr. tolu, Sj. M. Of this mixture one or two teaspoonfuls, according to the age of the child, should be given every two hours until a favorable impress- ion has been made on the throat and on the general symptoms. When this has been accomplished, the intervals of administering the medicine should be extended to four or five hours, varying the periods as the changing symptoms of the disease may indicate the propriety or necessity. During the existence of acute symptoms, the use of the acid should not be permitted to interfere with the sus- taining treatment, which is so essential in this disease. Nor should its continued use after the acute symptoms have subsided, prevent the adoption of the tonic treatment so positively required during the period of convalescence. M. ARCHAMBAULT, OF PARIS. In the Medical Press and Circular, 1880, this great teacher says that there is a certain class of infantile diseases for which it is not at all necessary that the physician should display his skill. Scarlatina is one of these. Put the patient to bed in a well-ventilated chamber, but the windows should not be opened. The temperature of the chamber should not exceed 64°. When the fever falls the tempera- ■ ture may be raised a little, because the patients have tendency to chills. The covering should be no heavier than in health. How long would you leave a patient in bed ? Some say that he might get up as soon as the fever fell; others, on the contrary, exact a month or six weeks. Leave him a long while in bed, about three weeks. The statistics of an English doctor, comprising six or seven hundred cases of scarlatina, show that nephritis appeared oftenest from the fourteenth to the eighteenth or twenty-second day. If, then, nephritis is due to cold, it will be well to oblige the patients to keep their beds. They might sit up in bed, but care should be taken to put a kerchief around the neck, for secondary sore throats are grave. It would be well also to recommend mittens on the wrists, the carpal articulations being the most subject to the rheuma- tism which is frequent after this disease. The patients should not go out before the thirty-fifth or fortieth day ; but that will depend again on the gravity of the disease. Barthez has said that he did SCARLATINA. 74, not know of any case of anasarca after scarlatina since he forced his patients to keep their bed during five or six weeks. Hot drinks should not be given unless the eruption does not come out properly. Refreshing drinks, such as lemonade, gooseberry wine, etc., are pre- ferable. To aid the eruption he has given the acetate of ammonia. If the patient is constipated, a little rhubarb or castor oil will suffice. If the nights are restless, a little bromide of potassium is of great benefit. The mouth must be washed often, but for the throat, caus- tics are seldom necessary. Chlorate of potash, or alum gargles, will be sufficient. If the patient is too young to gargle, one or two grams of chlorate of potash mixed with five or six grams of white powdered sugar may be given. One might order a bath if the fever were very high and the eruption abundant, but in ordinary cases it would be better to dispense with it. This practice is much used in England ; it is thought hazardous in France. Sometimes the itching is very great. Some German doctors conceived the idea of rubbing the children with fresh lard ; but to this procedure, which is not very clean, he prefers the English method, which is a mixture of glycerine and cold cream. As regards nourishment, it is evident when the fever is high, a light diet should be prescribed ; when the fever abates, a stronger nourishment might be administered, but with caution. Such is the treatment that will suffice in scarlatina; it is simple, and will not cover you with glory, but it will cure your patients, and will prevent, in the majority of cases, complications. Do not neg- lect, above all, hygienic precautions, for there is not a case of scar- latina that ought to be neglected. DR. BEDFORD BROWN, OF VIRGINIA. This author enunciated his views before a recent meeting of the American Medical Association, which may be thus summarized : There are two safe and efficient means always at hand to control high temperature. One is the warm bath, either by the immersion of the body in water at a temperature of 80°, or the wet pack at the same degree, repeated every three or four hours until copious per- spiration follows. The patient is permitted to repose in the wet sheet, enveloped in blankets, the entire body being for hours subjected to free perspira- tion, and of course undergoing the combined antipyretic and elimi- native processes. In connection with those measures the sedative treatment is also practiced. For this purpose I have found the fol- lowing formula well adapted : 744 DISEASES OF C^^ILDREN. * '149- R- Infus. digitalis, f-Sij Tinct. anconit. rad., * gtt. xvj Spts. ammon. arom., f- 5 "i Spts. eth.j nit. f-Sj- M. S. — A teaspoonful in water every two hours to a child of five years. This method of treatment in my experience rarely fails to induce a marked change for the better in the temperature and pulse. In this manner we accomplish two leading objects simultaneously. My rule has been, in those cases attended with excessive inflamma- tion and swelling of the structures of the throat and neck, a very high grade of temperature, and frequent pulse, to reduce the pulse rate and temperature by the combined agency of digitalis and aconite, as rapidly and steadily as is consistent with safety, down to a standard perfectly compatible with life. This peculiar combination I regard as particularly effective in this class of cases, and whatever dangerous or ill effect the one may exert is counteracted by the other. In this way many cases of the severe form of what is termed the anginose variety with decided malignant tendencies may be robbed in great measure of malignancy of type, and converted into more simple and manageable forms. With a slow, strong pulse, and a moderately low temperature, the chances for life become at once greatly improved. The combined influence of the sedative and elim- inative treatment over the extensive and dangerous swelling of the structures of the throat, usually diminishes the effusion and inflam- mation permanently, and in proportion to the abatement of fever. Long and continued experience in the use of eliminative measures through the skin and kidneys, principally the former, only tends to increase my high estimation of the great value of this means of treat- ment in all the more severe forms of scarlatina. In all grave forms of the affection the skin is particularly dry, and devoid of perspiration. My custom has been, in all of this class of cases, to maintain a free and continuous action of the skin by means of the tepid bath and the wet pack, throughout the course of the attack. For the purpose of illustrating what may be accomplished in the conversion of a very grave and malignant type of this disease into a very simple and benign form, I will cite the following case: "A little boy of six years, in very robust health, in 24 hours after the first in- dications of scarlatina, became alarmingly ill with malignant symp- toms. The eruption was imperfect in development ; the pulse so frequent that it could not be estimated. There was great stupor. SCARLATINA. 745 The temperature ranged at about io6° ; the general prostration was correspondingly great. The child was first given a general bath at 80°, then enveloped in a wet sheet at the same temperature, and over this a dry blanket ; then put to bed and permitted to luxuriate in a free and delightful perspiration for many hours. When the temperature increased, the same process was resumed. Then he was given a drachm of infusion of digitalis, one drop of the tincture of aconite root and ten drops of sweet spirits of nitre, every two hours, until the pulse and temperature were reduced to near the normal standard. Then the consciousness and vital powers of the little patient returned, and the type of the case in another 24 hours was changed from a very dangerous to a very simple one. Treatment of the True Adynamic Type of Scarlatina. — ^We occa- sionally meet with a class of cases presenting, from the incipiency, symptoms of adynamia. The eruption is always of a dark or ma- hogany color, and not abundant ; the pulse is exceedingly frequent and feeble. The urine is dark, very scanty, and often albuminous. There is excessive stupor and prostration of the yital powers, the tongue a dark red and very dry. We all appreciate the gravity of these cases. The treatment which I have found most efficient in this type of disease, consists of the wet pack saturated in water at 80°, with a considerable proportion of alcohol combined, used sufficiently often to maintain a moderate perspiration. The following formula I have found the most useful of all of which I have made trial : 1 150. K- Sods sulpfa. carbolat., Siss Sodae hyposulphite, 3 j Aqua, S iss Infus. digitalis, § iss Tinct. nux vom., gtts. xij. Of this, two teaspoonfuls are to be given to a child of five years every two hours. Alternately with this, a teaspoonful of brandy and elix. of calisaya are to be administered. In these cases the temperature rarely reaches a very high grade. The temperature and circulation are both unequally distributed. The extremities are usually cool and livid, the body hot. The action of the heart is excessively feeble and frequent, often reaching a rate of 200 per minute in very young children. The poisoned condition of the blood renders the dangers of thrombosis of the heart, lungs and brain imminent. This condition is particularly encouraged because of the inability of the heart to maintain an equable circulation. 746 DISEASES OF CHILDREN. Hence in these cases we need especially a remedy which will both slow and strengthen the action of the organ. The Treatment of the Malignant Type Due to Early Renal Com- plications. — In a certain proportion of cases the malignancy of type seems to be due to early renal complications. We observe in these cases the early development of malignant features very similar to those manifested in cases of serious nephritis from more simple causes. Thus there is always a tendency to coma. The urine is very scanty, high colored, acid in reaction, and albuminous. The temperature is high and the pulse-rate very rapid. There may be but moderate adenitis, yet the case presents all the indications of gravity and danger. In all cases of importance I believe it to be our duty to examine the state of the urine throughout the course daily. Doubtless many cases have assumed the malignant type and ended fatally, solely because of the development of nephritis. In the treatment of these cases all of our appliances, consisting of the warm bath, the wet pack, and, if necessary, the hot air bath, for the purpose of inducing copious elimination through the skin, should be brought to bear on the patient frequently. Prolonged observation of scarlatina convinces me that our atten- tion is directed usually to renal complication at too late a period of the case, and that treatment is often delayed too long. In cases of nephritic complication, with high grade of fever and frequent pulse, I have found a combination of alkaline diuretics with sedativesof infinite service. The alkaline diuretics can not only be given freely in these cases without harm, but with benefit. In my experience it is best to maintain the urine in a perfectly neutral and bland state, so that its acids cannot act as irritants and thereby aggravate the ejfisting inflammation. I have found the following formula a valu- able one under these circumstances : 1 151. £1. Liq. potass, citratis, f.^iss Potass, bicarb., 3 ij Spts. ether nit., 3iij Tinct. aconit. rad., gtt. xij Infus. digitalis, f.§j. M. A dessertspoonful every two or three hours to a child of five years. This combination of therapeutic agents usually exerts a most favorable influence over the engorged and inflamed kidneys. Their functions are always improved, and generally restored. At the same SCARLATINA. 747 time the action of the heart is slowed and strengthened ; the abnor- mal temperature is reduced to a point of safety, and the nervous centres relieved. In connection with this method the patient is fed liberally on skimmed milk. I do not remember having seen a case of orgaiiic renal disease or dropsy following scarlatina in an exclusively nursing infant. Whether this is due to the exclusive milk diet, to the exclusion of animal food, or to the better care or protection from cold, is not known. The Treatment of Protracted Adenitis, followed by Abscesses and Symptoms of Pycemia. — In the severe anginose form of the disease, protracted adenitis, followed by a long line of abscesses in different portions of the system and symptoms of pyaemia, occasionally occurs. The fever is usually hectic in character. The temperature rises and remits at certain periods of the day, followed occasionally, but not always, by exhausting perspirations. The tongue is usually red and dry. There is complete anorexia ; symptoms of adynamia are always present. The process of emaciation is progressive. These morbid processes may continue in operation for many weeks, and end either in death or restoration. I have found in this particular affection no combination of reme- dies so effective as the tinct. of the chloride of iron, arsenic, and digitalis. I usually give to a child of five years, five drops of the iron, one-third of a drop of Fowler's solution of arsenic, and three drops of the tinct. of digitalis every four hours. This method of therapeusis should be maintained until the pyaemic tendency has been arrested. In this place I regard the arsenic as an important ingredient. When the tendency to exhausting perspiration is decided, I usu- ally combine the tinct. of belladonna. Treatment of the Convulsions of Malignant Scarlatina. — A history of the treatment of scarlatina would be very incomplete without allusion to the subject of convulsions. Usually in these cases renal complications are present, and must receive a share of our treatment. The pulse in these cases is usually very frequent and the temperature high. .The entire voluntary, reflex, and ganglionic nervous centres are all profoundly affected by the infectious poison. To relieve the circulation of uraemic poisoning, which is generally present, and to prevent that irreparable damage to the brain which results from the 748 DISEASES OF CHILDREN. capillary thrombosis and extravasation of blood that may arise from the violent and unequal action of the heart, our remedial agents should be addressed to the eliminative organs, the reflex nervous system, and the general circulation. Elimination through the skin and kidneys, as heretofore advised, should be assiduously practised. Chloral hydrate, to control the over-excited reflex centres, and ver- atrum viride combined, have been more efficient in my experience as a means of reducing cardiac action and regulating the unbalanced circulation, than any other agents. Five grains of the chloral and one or two drops of the tinct. veratrum act well after the functions of the skin have been restored. These remedies should be repeated every two hours to a child of five or six years until the object has been attained. In dangerous cases of this kind I regard the use of the veratrum as an important addition to the treatment. In my own hands, when combined with chloral, it has been more prompt, ener- getic, and decided in repressing the convulsive tendency than any other therapeutic agent. Treatment of Scarlatinous Pharyngitis. — ^After a trial of the various local remedies devised by myself and recommended by others, I have reached the conclusion that a combination of astringent and antisep- tic agents, composed of bromo-chloralum 5j, the antiseptic vegeta- ble compound known as listerine Sij, pulverized alum 3ij, carbolic acid gtt. X, diluted with rose water Siv, either used by means of gargling, the atomizer, or brush to the inflamed surface, constitutes the most valuable of all the local applications. I feel sure that the absorption of the antiseptic properties through the mucous surface is in such quantities as to exert decided effect. Two or three drops of carbolic acid, when applied to the cervix of the uterus, will be tasted by the patient almost instantaneously. I have faith, also, in the value of antiseptic agents applied to the cutaneous surface. When carbolic acid, salicylic acid and ointment of rose water in combination are applied to the skin, they act not only as an emollient, allaying inflammation and irritation, but the antiseptic agents, being spread over a vast extent of surface, are largely absorbed, and exert their peculiar influence in correcting the septic processes going on within the system, thus saving the digest- ive organs the ill effects of their influence. In the selection of nourishment, we should be influenced both by the condition of the digestive organs and the renal functions. In cases of seriously impaired digestion, irritable stomach, scanty, albu- SCARLATINA. 749 minous, and acid urine, the best method of administering nourish- ment, in my experience, is in the form of skimmed milk, containing a small amount of bicarbonate of soda in solution, and combined with one-third lithia water. This may be continued so long as these symptoms exist. In all serious cases preference is given to the alkaline lithiated milk as a constant diet. The milk is evidently better digested and assimilated than any other form of nourishment. It is in this form exceedingly bland and non-irritating to the renal passages, and affords relief to the engorged and inflamed kidneys. It is given abundantly and almost exclusively. This form of diet not only serves a good purpose during the acute stages of the disease, but acts well as a prevention of renal sequelae. NOTES ON REMEDIES. Acidutn Carbolicum, gr. j-ij to aquae f.gj, has been used as a gargle for the sore throat. Acidum Salicyttcum has been experimented with by Dr. David J. Bracken- ridge, of Edinburgh, (Medical Times and Gazette, December, 1876,) but his results were not satisfactory. Dr. Pownall, on the other hand, (Brit. Med. Jour., December 21st, 1878,) claims that it is one of the most reliable remedies. He uses : 1 152. R. Acidi salicylici, 3j-ij Syrupi, 5iv Mucilag. tragacanth., §j Tinct. aurantii, 3 >v Aquse, ad S vj. M. A tablespoonful every second hour. Aconite. Bartholow tells us that there are two conditions of this disease especially requiring the use of aconite — the eruptive stage, and the period of desquamation, if, as is usual, a marked rise of temperature takes place at this period of the disease. Several important purposes are subserved by the use of this remedy ; it lowers the fever heat, favors the action of the skin and kidneys, and checks the nasal, faucial and aural inflammations, which constitute such troublesome complica- tions and sequelae. Alcohol. Dr. Giues Mitchell reported to the Cincinnati Academy of Medi- cine (1883) forty-three consecutive cases of scarlatina, treated with large doses of alcohol, without a single death. A half ounce of whisky every hour was given to a child two years old, without the slightest symptom of intoxication. When the kidneys became implicated, the alcohol was still used. It always produced a fall of temperature. Dr. John M. Keating, of Philadelphia, endorses this treatment. 750 DISEASES OF CHILDREN. Ammonii Spiritus Aromaiicus has recently been recommended in the follow- ing form by Dr. Sweeting : "53- R- Spiritfls ammoniae aromatici, f. 3iij Sodii et potassii tartratis, 3j Tinct. lavandube comp., f. 3 i Aquse, ad f. 3iss. M. A teaspoonful every third hour for a child five years old. With this he orders as a diet, undiluted sweetened milk, and uses no external treatment whatever. Ammonii Carbonatis is highly esteemed by many authorities. Mr. G. J. S. Camden, (Medical Times and Gazette, February i, 1873,) gives it at the very onset of the disease, in distilled or cold boiled rain-water filtered. He never gives emetics or aperients, nor does he bleed, or do anything to lower the vital powers. Mr. Erasmus Wilson (Diseases of the Skin) confesses to a strong leaning in favor of ammonia treat- ment, and, instead of salines, begins, from the first, with a solution of the carbonate of ammonia, 2 or 3 grains for a child under seven years of age, and 4 or 5 grains for a child above this age, dissolved in from 2 to 4 drachms of water, and administered every one, two, three or four hours, according to the degree of severity of the fever. Antipyrin. Friedlander, of Russia, (Medical News,) reports a large num- ber of cases of scarlatina, all of which recovered under the use of anti- pyrin in doses of nine grains one to three times in twenty-four hours. Profuse perspiration, fall of temperature, and refreshing sleep followed the use of the drug. Aqua Chlorini is very highly praised by nearly all writers. One formula for chlorine mixture is given above. Another is : HS4' R- Potassii chloratis, gr. bocx Acidi muriatici diluti, f. 3 ij Aquae, ' Oij. M. This amount to be taken in small doses, in twenty-four hours. Mr. Erasmus Wilson's formula is : ('55- .R- Potassii chloratis, 5j Acidi nitrici diluti, f.5j Aquae, f. | viij. M. For a gargle. Argenti Nitras. Dr. Edward Copeman remarks, in the St. George's Hospital Reports, 1870, that for the relief of those severe cases in which there is a profuse ichorous discharge from the throat and nostrils, with dis- position to sloughing ulcers in the pharynx, he has seen no local remedy so successful as a free application of a solution of nitrate of silver (from 4 to 8 grains to an ounce), by means of a brush or syringe. Dr. Niemeyer also recommends the nitrate. He says that, in anginose cases, as soon as the sloughs have been detached, we may SCARLATINA. 75 j touch the ulcers in the throat daily, with a solution of nitrate of silver (3J to |ij water), appHed by means of a probang; and for the coryza, we may inject a weak solution of nitrate of silver (gr. v-x to gij water) into the nostrils. Croup compHcating angina maligna indicates the administration of an emetic and the appHcation of a solution of nitrate of silver to the glottis. Baptisia Tinctoria. The eclectic physicians assert that a gargle prepared from the wild indigo weed acts specifically in the sore throat of scarlet fever. (Scudder.) Belladonna is said by Bartholow to be useful when the eruption is imperfect or bluish, the peripheral circulation feeble and the heart's action de- pressed. It is also highly recommended by Dr. Henry Beates, Jr., of Philadelphia, in the Medical and Surgical Reporter, 1883, and Dr. Owen Pritchard (Lancet, 1881,) thinks that when given to those who are exposed to the disease it will act as a prophylactic. Bromitiium. Dr. W. H. Thompson, (New York,) has met with far fewer throat complications since he has used this agent. He employs it as follows : 1 156. R. Fotassii bromidi, q- s. ad saturandum Aquae, f.SiJ To this add very slowly, and with frequent shaking; Brominise, f-Sj Aquae, ad f.Siv. Of this solution, i drachm is added to r ounce of water, and a tea- spoonful is given in a tablespoonful of sweetened water, as required, the solution being kept in a dark place. As a local application, equal parts of the solution and of glycerine are used, or, in bad cases, the solution alone. Occasional purges of calomel and jalap may be given, until the action of which the antiseptic may be suspended. Copaiba. Mr. A. RowAnn (Medical Times and Gazette, February r;, 1871) gives balsam of copaiba in 4- or 5 -drop doses, mixed in sij syrup, and 3ij mucilage of gum arable, three or four times a day, with most satis- factory results. Under its use, the tongue and sore throat grow rapidly clean and well, and the usual sequete do not appear. Digitalis. Prof. Bartholow declares that, in a considerable experience in the treatment of scarlatina, he has found digitalis uniformly success- fiil, and, taking in a group the ordinary cases of scarlatina simplex and scarlatina anginosa, it is the most efficient remedy we possess. The particular effect of digitalis, in preventing nephritis and other glandu- lar inflammations, has been mentioned in the Lancet, January 23, r869, by Dr. Sydney Fennel. He has used it largely in scarlatina, and says that, when administered early in the fever, the inflammatory ac- 752 DISEASES OF CHILDREN. tion in the glands of the neck subsides gradually. The fever leaves the patient in the usual time, desquamation is very slight, and the chances of chronic nephritis are reduced to a minimum. He also confidently asserts that the infectious character of the disease is less- ened by the remedy, if not destroyed. Ferrutn. Dr. R. Aldridge (British Medical Journal, August, 1871) speaks favorably of the use of iron in scarlatina. He has found if it be given as soon as the disease makes its appearance, that not only does it shorten and lessen the severity of the attack, but it also fortifies the patient against the after consequences — dropsy, etc. The form which be has mostly used has been the liquor of pemitrate of iron, in syrup of glycerine, in doses of 10 minims every three hours. Hydrogen Peroxide. This substance has been warmly urged in scarlatina, by Dr. John Day, of Australia. His formula is : "S7' B- Hydrogen peroxide (ozonic ether), 3iv Pure lard, S iv Benzoic acid, 9j Otto of roses, gtt. iv. M. To be carefully mixed without the aid of heat. With this the body of each patient is rubbed, over the whole surface, three times a day. He also prescribes, throughout the whole course of the disease, a mixture composed of 2 or 3 drachms of ozonic ether in Yi pint of \vater : the dose ranging from a teaspoonfiil for a child twelve months old, to a tablespoonful for an adult, to be .taken every second hour. This is used for the double purpose of benefitting the throat symptoms and disinfecting the breath. Pilocarpine in doses of rV of a grain, hypodermically administered, is highly recommended by Dr. Frank Shearer, of Edinburgh. ( Glasgow Med. your., 1884.) Potassii Chloras is perhaps the most widely used of all drugs in scarlet fever. Large doses may be given to the youngest infants, especially in the adynamic type of the fever. It has been amply shown by Dr. Drys- DALE, of Philadelphia, that this salt can and ought to be given far more freely than is usually done. Quinice Sulphas. In malignant cases some have advocated large doses of quinine to obtain decided antipyretic effects. The result of this meas- ure is questionable. Sodii Benzoatis is highly recommended by Dr. Demme (AUgemeine Wiener Medizinische Zeitung, 1880.) Internally, he gives from five to twenty grams daily, dissolved in from one hundred to one hundred and twenty-five grafns of water, with the addition of from one to one and a half grams of liquorice juice. SCARLATINA. 7-3 Sodii Sulpho-carbolas. This has been administered by Dr. Brackenridge in doses of gr. v-xxx three or four times a day, and he asserts that it has proved very beneficial. American experience is against it. Dr. C. S. Earle, of Chicago, says that not only has it failed to mitigate a single symptom, after the development of the disease, or to diminish the sus- ceptibility of those liable to contract it, but it has seemed to diminish the vis medicatrix natures, to lessen absolutely the chances of recovery, by its impoverishment of the system. (Trans, of the Illinois State Medical Society, 1878.) Sulphur. The use of this old remedy has been very highly lauded of late. Mr. Henry Pigeon writes to the Lancet, November 25th, 1876, in these words : " The marvellous success which has attended my treatment of scarlet fever by sulphur, induces me to let my medical brethren know of my plan, so that they may be able to apply the same remedy without delay. All the cases in which I used it were very well marked, and the epidermis on the arms in each case came away like the skin of a snake. The following was the exact treatment followed in each case : Thoroughly anoint the patient twice daily with sulphur ointment ; give 5 to 10 grains of sulphur in a little jam three times a day. Sufficient sulphur was burned twice daily (on coals on a shovel) to fill the room with the fumes, and, of course, was thoroughly, inhaled by the patient. Under this mode of treatment, each case improved imme- diately, and none were over eight days in making a complete recovery, and I firmly believe in each it was prevented from spreading by the treatment adopted." Dr. F. L. Sim, of Tennessee, (Medical and Sur- gical Reporter, Dec, 1877,) has had remarkable success by thoroughly fumigating the child under a blanket, with the fumes of burning sulphur. Veratrum Viride has been employed to reduce the pyrexia. EXTERNAL MEASURES. Baths, of all temperatures, are used. Dr. Hiram Corson is earnest in favor of the cold bath. (P. 730.) Dr. Eddison, and others, prefer baths commencing at 90°-ioo° cooled down slowly or rapidly to 70°. Danger from " driving in the rash " is asserted to be imaginary. Dr. G. Johnson prefers the warm bath only. Tepid and cold sponging will often be found sufficient. In adynamic cases, with low pulse, pallid skin, and cerebral symptoms threatening, a hot mustard-bath will often have the best effect: or the child may be stripped and wrapped in a sheet well wrung out with mustard water, and then packed in between two blankets. When the temperature reaches 104°, the cold wet padk may be used, and is never followed by any harm. Wring from a wet sheet the water at the ordinary temperature, wrap the child in it, and over that lay one wrung out of iced water. The . 48 754 DISEASES OF CHILDREN. prompt manner in which the symptoms improve shows the wet pack to be one of the great therapeutic resources in this class of cases. Inunction with olive oil, fresh butter, bacon rind, cacao butter, warm ben- zoated lard, and such preparations, repeated three or four times a day, should be employed. The value of this is that it is the most effectual means of relieving the itching of the skin and the excessive restlessness which is due to the irritation of the peripheral nerves, caused by the heat of the skin. This is relieved more rapidly by oiling than by sponging with tepid water. Oiling, too, is truly antipyretic, reducing the temperature. Another reason for its use is found in the close sympathy existing between the skin and the kidneys. It is also recom- mended for its prophylactic properties. Dr. L. C. Johnson {Cinn. Lancet and Clinic, Sept., 1879,) prefers the following ointment: 1 158. R. Glycerinse, i ij Acidi carbolici, gr. viij Olei rosae, gtt. ij. M. Anoint with the palm of the hand after the patient has been bathed and dried. RUBEOLA (MEASLES). (EYE AND EAR COMPLI- CATIONS Ob"). Graucher (Le Concours Med., July 9, 1887). "Of the ear affec- tions which complicate measles, otitis media is of very common occurrence, being present most frequently during convalescence. The treatment should consist of irrigation of the ear, from two to six times daily, according to the extent of the suppuration, with warm carbolized or borated water, the stream being projected with great gentleness. Then the ear having been carefully dried, a fine astringent powder, either alum, borax or iodoform, should "be in- sufflated. Complications of the eye are not apt to be of so serious a character as those of the ear, the lids, cornea and conjunctiva alone being implicated. The inflammations are rarely very deep in extent, phlyctenular conjunctivitis and kerato-conjunctivitis being the forms of disease most commonly seen. Serious results to the cornea from ulceration are not frequent. For acute blepharitis, with swelling of the lids, compresses moistened in a warm solution of boric acid should be used permanently, while. morning and evening a small portion of ointment containing 1 159- R- Vaseline, 3ij Hydr. ox. flav., gr. v RUBEOLA. 755 should be applied to the borders of the lids. Should the blepharitis develop into chronic eczema, warm poultices, made antiseptic with boric acid, should be used, and for an application : 1160. R. Vaseline, 3ij Zinci ox., gr. v. Should the conjunctivitis be simple, cold applications of a solution of boric acid may be used, but if accompanied with keratitis, the applications should be warm. Should the conjunctivitis be very purulent, a mild solution of nitrate of silver (two to five per cent.) should be used. If keratitis predominates, the yellow precipitate ointment should be applied. If perforation of the cornea should appear imminent, use the follow- ing collyrium : 1 161. K. Eserine salicyl., gr. 1 Aq. destil., 3ij. DR. W. B. POWELL, OF LOUISIANA. This author's treatment for ordinary cases of measles is g follows (Medical and Surgical Reporter, 1881 ) : 1 162. B. Morpfaise sulph , gr. j Liq. calcis. Aquae menth., aa f. § j. M. . S. — One to two teaspoonfuls, according to age, every hour, until relieved. When dysenteric symptoms are present, he orders : "63. R. Pulv. opii, g'. i] Bismuthi subnit., Bj Salicin., gr. vj. M. Excipienti q. s. ut ft. pil. No. iv. S. — One pill every two hours until bowels are quiet. DR. WILLIAM M. POLK, OF NEW YORK. This clinician (Med. and Surg. Reporter, 1880,) confines himself, as a rule, to meeting symptoms as they arise. It is a self-limiting disease, and one which, under ordinary circumstances, will get well. Of course, if the child have a laryngitis or a bronchitis, or a pneu- monia, there is danger of a fatal termination, or at any rate, the prognosis is not so good. When such complications arise, the in- dications for treatment are such as belong to them respectively. In 756 DISEASES OF CHILDREN. a case of simple measles, put the child to bed, to insure warmth and protection ; keep the bowels open by some mild laxative, as castor oil, if the child will take it ; then support it by nutritive food, such as is easily digested. Stimulants are indicated only by the condi- tion of the pulse. Where the pulse indicates heart failure, stimulants are to be used, otherwise not. Cough is very frequently an obstinate and a trouble- some symptom, particularly in earlier stages, and the cough has something characteristic about it. It is a dry, hacking, constant cough. The best treatment is local applications to the throat, be- cause the cough is due entirely to the condition of the pharynx. The local application which insures the best results is some astrin- gent wash, as tannin and glycerine or lime and glycerine. It is im- portant to protect the child from exposure for some time after the eruption has subsided, because as long as there is that scurfiness of the skin which indicates desquamation, we may be sure that the mu- cous membrane is in a condition in which it will readily take on in- flammation. He would keep the child indoors for at least four weeks from the time that the symptom made its appearance. As soon as the redness of the skin has subsided, and before desquama- tion is complete, there is no objection to the child taking a bath, in order to hasten desquamation as much as possible. If there be ex- cessive irritation of the skin, as there often is, the local application of vaseline will have a tendency to check it. Oil the child from head to foot with ordinary vaseline. DR. EDWARD HENOCH, OF BERLIN. According to this author the disease merely requires, in the way of treatment, that the patient be kept in bed (the room being kept warm), with light covering and a diet consisting of milk soup and cool drinks as long as the high fever lasts. The room should merely be darkened to an extent agreeable to the child. He does not consider it advisable to isolate the patient from his brothers and sisters, on account of the slight danger and the certainty that the children will become affected sooner or later; he would only endeavor to secure very young or sick children against infec- tion. No medicinal treatment is required in simple cases. If the cough is violent, we may order infusion of ipecac root, and per- haps a fly blister about an inch long over the trachea. If diarrhoea becomes profuse and the passages occur four to six times a day, RUBEOLA. 757 or even more frequently, we may relieve it with inf. rad. ipecac and opium : 1164. R. Inf. rad. ipecac, f. §iij Mucil. gum arab., Syr. simpl., £5 f.Sijss Tinct. opii, gtt. ij-iv. M. S. — Dose, a dessertspoonful. DR. Q. S. SMITH, OF TEXAS. The treatment recommended by this practitioner in the Nashville Journal of Medicine and Surgery, 1 881, is as follows: He reduces the temperature by tepid ammoniated baths — a tablespoonful of strong aqua ammonia to each gallon of water — repeated as often as necessary to keep the temperature quite normal. The patient should remain, in the bath from five to fifteen minutes, being well rubbed during the time. Just before being removed from the bath, one or two gallons — according to the intensity of the fever — of drinking-cold water is poured over the patient's head in a full stream, the patient quickly removed from the bath and wrapped in a dry blanket, and allowed to rest quietly for twenty or thirty minutes. Then, without removing the coverings, the patient is gently but thoroughly embro- cated over the whole body with camphorated vaseline, repeating the embrocation after each bath. Should the case be so light that bath- ing is not deemed necessary, the camphorated vaseline embrocation is repeated three or four times a day. For internal medication, he uses: 1 165. g. Ammonise carb., Lithii bromid., aa 3ss Liq. ammonii acetat., q. s. ad f. % j. M. S. — ^Teaspoonful in a little sweetened water, every one to three hours. For the throat trouble, put a few grains of pure dry .bisulphite of soda in the patient's mouth every few minutes ; let it slowly dfssolve and pass down the throat. When the patients are too large to han- dle in a bathing tub, he substitutes the sponge bath. He allows all the cold water, lemonade, milk and fruits (in small quantities at a time), that are desired. PROFESSOR M. CHARTERIS, M. D., GLASGOW. Measles is an essentially dangerous disease in infancy and in old age, though the danger is not in the disease so much as the sequelae it leaves behind it. 758 DISEASES OK CHILDREN. All exposure to cold must be avoided. The room should be darkened and the patient kept in bed. Mild diet is advisable, and a light diaphoretic mixture, as : 1 1 66. R. Vini ipecac, f.Stss Synipi, f- S ss Tinct. camphorse comp., f. 5iij Liquoris ammonise citratis, f. § ss Aquam, adf.§ij. M. A teaspoonfiil every two bouis. When the cough is troublesome, an emetic often gives relief; and for the diarrhoea, cold compresses may be applied to the ab- domen. In "black measles," which is the hemorrhagic form of the disease, and a very fatal complaint, the system must be actively supported by wine' or brandy, and the bronchi kept clean by stimulating ex- pectorants. HIRAM CORSON, M. D., PENNA. This practitioner has practiced and advocated for many years the cooling treatment of measles. (Medical and Surgical Reporter, vol. xxvi.) He allows the child abundance of cool or cold water to drink, opens the windows to allow free ventilation, keeps the tem- perature of the apartment low, and if the heat of the skin be ex- cessive, sponges the body frequently with cool or tepid water. Internally, small doses of neutral salts to move the bowels are all that is generally required. Ice is given ad libitum, to allay thirst. By this method he believes the dangerous complications are pre- vented, and a light eruption of the skin is secured. DR. DAVIS, NEW YORK. This writer (Medical Record, July, 1871,) considers the following formula one of the best preparations in the first stage of severe cases of measles : 1 167. £t. Synipi scills comp., f.§iss Vini antimonii, f. § ss Tinct. opii camphoratse, f. § ij Tinct. veratri viridis, f. 3ij. M- One teaspoonful every three hours in water. If the bowels are costive, they should be moved by a mild laxa- tive. RUBEOLA. ^CQ When symptoms of pneumonia arise, they may be met with the following : 1168. R. Liq. ammon. acetatis, f. §iss Syrupi ipecac, f. | ss Tinct. opii campborat., f. § j Tinct. veratri viridis, f. 5j. ji_ Ten drops every three or four hoars, for a child a year old. The chest should be covered with fomentations. NOTES ON REMEDIES. Acidum Nitricum, and other mineral acids, are useful in the hemorrhagic variety ; gtt. xv to water Oij, may be given as a drink. Aconite, according to Bartholow, possesses the power of arresting the catarrhal pneumonia, which is one of the most serious complications of this dis- ease. Ammonii Acetatis Liquor. An excellent diaphoretic. Dr. Aitken pre- scribes : 1169. R. Liq. ammon. acetatis, f. 3j Spiritfls setheris nitrici, 1H.x-xx Misturae campborx, f. § ss. M. For a child six years old every four or six hours. Ammonii Carbonas. Mr. Erasmus Wilson recommends that as soon as an attack of measles is suspected, the patient should have a mild purge, followed promptly by gr. v of carbonate of ammonia every two or three hours, in water, broth or milk. Aqua. Cold water is given to any extent by recent practitioners. For the laryngitis which often develops, a sponge may be wrung out in very hot water and applied to the throat. For the rather common and some- times very perilous epistaxis, water, as hot as it is possible to bear, con- taining a few grains of sulphate of zinc to the ounce, is used by Dr. Jaccoud, of Paris. Potassii Bromidum is called for when there is sleeplessness and nervous ex- citability. Potassii Chloras, in large doses, with stimulants, is recommended by Dr. Ellis, when the fever is of low type with brown tongue and failing powers. Quinine, according to Bartholow, is highly useful for the ad)mamia, and in large doses when catarrhal pneumonia comes on. Veratrum Viride is used by Dr. Davis to reduce the febrile symptoms in severe cases (F. 1167). Warm Bath in Measles is spoken of in the highest terms by Cohn, Z' Union 76o DISEASES OF CHILDREN. Med. des Can. As soon as the temperature reaches 100.5" or iot° Fahr., the children receive as many as six baths, at 95° to 99.5° Fahr., in the twenty-four hours, the duration of each bath being from eight to ten minutes. The patient is immersed up to the neck, and, in cases of somnolence and prostration, cold water was poured upon the head during the immersion. This treatment greatly decreases the bodily temperature, increases perspiration, and gives an easy, regular respiration. MALARIA. Dodge: Malarial fever in children (Pkil.Med.Reg.,M.ay26, 1888). The author, after a long experience, advises the following treatment : A small dose of calomel virith a few grains of soda, followed by castor oil or rhubarb and magnesia. After the gastric symptoms are re- lieved, he gives quinine, proportioning the dose to the: age — for a child two years old, one grain of the sulphate three or four times a day. Other symptoms are treated as they arise, restlessness or in- somnia with bromide of sodium or small doses of Dover's powder. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. According to these authors, children, even at a very early age, bear full doses of quinia very well. The amount which they have usually found necessary to arrest an attack of intermittent fever is three grains daily for children of one year of age or under, and one grain additional for each succeeding year, though they have given as much as five grains by the mouth in the course of a day to chil- dren of ten months, and without the slightest ill effect. It may be administered in the form of powders, containing one-half grain, mixed with an equal amount of sugar and powdered extract of liquorice, repeated as necessary, and given at such times as to bring the system thoroughly under the influence of the drug, before the hour at which the accession of the fever has been noticed. Some children, however, will not take the powders without difficulty or nausea, and the quinia may then be given simply suspended in syrup of liquorice or in the following combination : 1 1 70. K. Quiniae sulpK, gr. xxiv Acid, sulph. diluti., gtt. xxx Syr. zingiberis, Syrupi, Aquje, aa f.gj. M. Ft. sol. S. — Teaspoonful three or four times a day, according to age. MALARIA. 761 If, however, the stomach rejects it in all of these forms, the ad- ministration by enema of two grains of quinia in a tablespoonful of starch water, three times a day, will be equally successful. We may also resort to the use of suppositories, which, when neatly made with the butter of cacao, and of small size, are perfectly well tolerated, as a rule, even by very young infants. A small amount of dilute sul- phuric acid, about one-half of a drop to each grain, should be added to the quinia in either of these modes of administration to favor its solubility and absorption. In ordinary acute cases, no other treatment is required. It may be well to give a few doses of some saline febrifuge each day, until the fever is entirely subdued, and, of course, any special disturbance of function must be relieved by appropriate remedies. The treat- ment of pulmonary complication must be subordinate to that of the general disease. All depleting or perturbing treatment must be avoided, and it will generally be found that with the aid of mild counter-irritation, the localsymptoms will begin to improve, after the malarial fever has been subdued by quinia. It is necessary to keep up the action of quinia for some time after the paroxysms are broken, because the tendency for the disease to recur is fully as great in children as in adults. Our authors are in the habit of continuing it for three or four weeks, in diminished doses, giving, however, on each septenary period, dating from the arrest of the paroxysms, the full antiperiodic dose, suited to the age of the patient. At the same time the child should take suitable doses of iron and arsenic, which may be conveniently given in the following form : 1171. R. Liq. potassii arsenitis, f.5) Vin. ferri amari, f. § iij. M. S. — From a half to a whole teaspoonful thrice daily, in water, after meals. In chronic malaria, we must persist in the use of quinia, iron and arsenic for a considerable period. At the same time careful attention must be paid to securing the best possible hygienic influences for the child. When practicable, a change of climate should be secured by a journey to the mountains or the sea-shore. The patient should be warmly dressed and carefully guarded against all exposure to damp or cold. The diet should be carefully" selected, and every error of digestion promptly corrected. Even after the child is apparently re- stored to health, it should not be allowed to return to the locality where it contracted the disease, and for several successive springs and 762 DISEASES OF CHILDREN. autumns should take a short course of quinia and arsenic. In the treatment of enlargement of the spleen, which frequently occurs in chronic malaria, our authors have obtained excellent results from the use of hypodermic injections of ergotin into the subcutaneous tissue of the abdominal wall. DR. HOLT. In the American Journal of Obstetrics, for 1884, this author tells us that malaria in early life presents symptoms peculiar to that pe- riod, and differs from the same disease in adults as widely as does pneumonia. In any acute febrile disease, presenting an unusual course, the spleen should always be examined. It may be the cause of obstinate cases of diarrhcea or bronchitis, not affected by ordinary remedies, especially if these symptoms show a tendency to periodi- city. Spells of drowsiness and frequent attacks of epigastric pains should always excite suspicion. PAROTITIS (MUMPS). A. Jacobi (Arc. Ped., February, 1889). According to Dr. JACOBI the infection must be presumed to take place through the Stenonian duct. Thus a careful hygiene of the mouth must be considered the best preventive. In many cases the patients do not take to their beds, and simply covering the swelling with cotton is sufficient to give comfort. Where there is a great deal of pain, narcotic appli- cations may be made, or ice applied. > The latter certainly reduces the amount of swelling, although it may not shorten the course of the disease. The application of iodoform collodion (one to eight or ten) has been found efficacious when made twice a day over the " entire surface. When there is a tendency to suppuration, warm ap- plications will favor it. Free incisions must be made in time, and treated antiseptically. The diet must be that of all fevers, liquid. A consecutive anaemia, which is more frequent than the apparent mildness of the affection would seem to explain, requires generous feeding, iron, nux vomica, and a change of climate. EDWARD ELLIS, M. D., LONDON. The swelling of the parotid gland should be fomented several times a day with a flannel wrung out in a hot lotion containing an PAROTITIS. 763 opiate, and a linseed-meal poultice applied occasionally. The bowels must be kept open by laxatives. Should there be metastasis to the brain, a few leeches may be ap- plied to the temples, the feet should be immersed in hot mustard water, and a brisk aperient given every three or four hours. Meta- stasis to the testicles or mammae requires fomentations and the same general treatment in the way of purgatives and derivatives. When the parotitis occurs in the course of measles or scarlatina, it is usually significant of an adynamic condition, and requires sup- porting and stimulant medication. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. As mumps almost invariably runs a favorable course, the treat- ment should be of a mild and expectant character. The child should be strictly confined to bed ; the diet should be fluid, partly on ac- count of the great difficulty in mastication, light and digestible, consisting chiefly of preparations of milk and light animal broths. The only internal remedies required are febrifuges, such as spirits of nitrous ether and solution of acetate of ammonia, with a free supply of water and acidulated drinks; occasional laxatives; and, if there is sleeplessness, small doses of Dover's powder or some other ano- dyne. Local applications appear to have little or no influence upon the course of the swelling. The only ones to be recommended are warm, light poultices, or light water dressings, covered with oiled silk, which do not annoy the child, but tend to favor resolution. If the induration be marked and extensive, so as to threaten suppura- tion, it has been advised to apply a few leeches behind the angle of the jaw. If it should become evident that suppuration has occurred, the abscess should be opened immediately, and the discharge fav- ored by the application of poultices, in order to prevent further destruction of the gland or perforation of the external auditory meatus. In cases where induration and enlargement of the gland persist, absorbent applications, such as inunctions of iodine or mer- cury, should be made over the tumor. In cases where alarming symptoms of depression, and cerebral disturbance, make their ap- pearance after the sudden subsidence of the parotid swelling, the effort may be made to redevelop the external inflammation by stimulating applications to the surface, and by the internal adminis- tration of nervous and diffusible stimulants, such as ammonia, musk or brandy. 764 DISEASES OF CHILDREN. After the acute symptoms of the attack have subsided, and the child has fully entered upon convalescence, we would caution against allowing it to leave bed too soon, since we have occasionally ob- served such premature exposure to be followed by marked febrile sequelae. Thus, in one case, occurring in an adult, there was marked fever lasting for a week ; in another case, in a child, there was high fever for ten days ; and in a third case, also in a child, there was most obstinate and violent vomiting for four days. ERYSIPELAS. A. Jacobi, M. D. (Arc. Ped., February, 1889). According to this author, every case of erysipelas should be isolated ; the diet and general treatment should be regulated on general principles. The local treatment may be quite simple in some cases. The ery- sipelatous surface may simply be covered with soft cotton, or a powder of talc, or of starch, or one part of salicylic acid with ten parts of oxide of zinc and twenty-five of starch. Applications of lead water and laudanum or of sulphate of zinc have been success- fully used for a long time. Where the extent of the erysipelas is limited, cold applications and ice have been applied to great advantage. Incisions outside the inflamed portion have been ad- vised. They are useless and brutal, because the lymphatics are as a rule infected a good while before the inflammation shows on the surface. This is the reason why neither saturated solution of nitrate of silver nor the solid caustic has been of advantage. Heuter re- commended, many years ago, the subcutaneous injection of a two per cent, solution of carbolic acid around the inflamed surface, and claims to have confined every case within its original limits. The author himself has used for many years a mixture of one part of carbolic acid in eight, ten or fifteen parts of oleic acid. This treat- ment has proved very successful. The application is to be rubbed into the surface around the diseased part, at frequent intervals, or, when the erysipelas is confined to one of the extremities, a band or compress soaked in the mixture should be applied above or below the diseased part, not infrequently with the result of stopping the pro- cess. Carbolic acid thus applied is usually rapidly absorbed, and its first appearance in the urine must be carefully watched for and the ERYSIPELAS. 765 use of it discontinued. The internal administration of the tincture of the chloride of iron has been considered a specific by many ; its merits, however, have probably been very much exaggerated. Abscesses complicating erysipelas require large incisions and anti- septic treatment. Erysipelas of the neck is very often complicated with oedema of the larynx, and may require scarification, tracheot- omy, or intubation. DRS. MEIGS AND PEPPER, 6f PHILADELPHIA. Our authors prefer the use of cooling emollient applications dur- ing the first part of the attack, whilst the skin is of a bright red color, hot and shining. When the circulation becomes languid, and the color of the eruption is disposed to deepen from red to purple, we should suspend the use of the emollient applications, and employ instead the lotion of camphorated spirit, recommended by UNDER- WOOD; the camphorated tincture of soap, applied three or four times a day with a soft sponge, or Kentish's ointment, prepared by rendering basilicon ointment soft (not fluid) with spirit of turpen- tine. It is rubbed upon the inflamed part with the fingers, the anointing being "repeated often enough to keep the part always very thinly covered." The internal treatment should consist in at- tention to the bowels, which are to be kept soluble by the mildest laxatives, without being purged, and in a resort to tonic and stimu- lating remedies upon the very first approach of symptoms indicating exhaustion. The best remedies of this class are proper diet, wine whey, small quantities of brandy and bark, in connection with minute doses of carbonate of ammonia. In addition to these, the tincture of the chloride of iron should be given in large doses. For an in- fant of a month old we may use : 1 1 72. R. 1 inct. ferri chlor., f. 3s3 Acid, acetici dil., f.Sss Liq. ammonise acetat., f- 5 j Syrupi, (• S ss Aqiue, q. s. ad f. | iij. M. S. — Teaspoonful every three hours. When the inflammation has gone on to the production of subcu- taneous suppuration, it becomes still more important to sustain the forces of the constitution, by giving the baby a healthy and abun- dant breast of milk, and by the internal use of brandy in small quantities, of bark, or better still, of quinia in combination with small doses of carbonate of ammonia. At the same time, the suppurating ^66 DISEASES OF CHILDREN. surfaces must be well fomented, and dressed with warm poultices, and when necessary laid open by careful incisions, observing the precaution to cause as small a loss of blood as possible. DR. EDWARD HENOCH, OF BERLIN. Treatment is almost entirely unavailing in this affection. In the beginning, we may attempt to ameliorate the inflammatory process by large fomentations of lead water. Internal remedies, aside from mild purgatives, are entirely useless. If the erysipelas begins to ex- tend, there is no remedy that will check its spread. Nothing re- mains but the use of tonic remedies, wine and infusion of bark. Complications must be treated according to their character. Ab- scesses must be poulticed, opened when distinct fluctuation is felt, and antiseptic dressings employed. NEW METHODS OF TREATMENT. 1 . Rosenbach's Method. — Wash affected and surrounding portions of skin with soap, then apply 5 per cent, solution of phenic acid in absolute alcohol. 2. Nolte's Method. — Mucilage of acacia, containing 3 per cent, to 5 per cent, of phenic acid, applied to affected and surrounding parts twice daily. 3. Koch's Method. — ^With a soft camel's-hair pencil apply a thin layer of the following ointment; Creoline, i part; iodoform, 4 parts ; lanolin, 10 parts. Cover with rubber tissue. 4. Hallopeau's Method. — Solution of sodium salicylate (5 per cent.) applied on compresses, covered with rubber tissue to prevent evaporation. 5. Wolff e/s Method. — Mechanical compression, with strips of ad- hesive plaster applied at the borders of the affected skin, on the healthy surface, completely circumscribing the diseased portion. DIPHTHERIA. W. C. Caldwell, M. D. (Arc. Ped., February, 1889). The au- thor firmly believes that diphtheria is, primarily, a local disease, and that the pseudo-membrane forms a covering for the point of inva- sion of the bacteria. He therefore directs his treatment first to the DIPHTHERIA. 7^7 removal of the pseudo-membrane, so that the bacteria can be reached, and then directs his attention to arresting the growth of the bacteria. For the sake of convenience he prescribes agents to meet these two indications in combination, being careful that they do not neutraHze each other's action, or that they are in no way incompatible. Papain acts in an acid, neutral or alkaline menstruum, and hence is very available for combination. He objects to bichloride of mer- cury because of its poisonous properties, but speaks highly of hy- dronaphthol as a powerful antiseptic, acting in either a neutral or acid menstruum and not being poisonous. His method of treatment in detail is as follows : The bowels must be kept open ; two to six ounces of milk should be ingested every two hours ; the throat should be sprayed every half-hour till tem- perature is reduced and breathing is easy, and then every hour un- less asleep. Where the spray is used thoroughly, temperature usually falls in from four to eight hours. To make this application thorough, it requires that the child shall be firmly held in a semi- prone position, and that the posterior portion of the tongue shall be depressed, so as to render accessible all the structures involved while the hand atomizer is used rapidly for a few seconds. The child is then given a little rest, and this procedure is repeated several times. It is absolutely necessary that the tongue be forcibly depressed in order to reach all of the infected tissues. If success in treatment is to be obtained, this must be done, even against the struggles of the child, although it may appear harsh and brutal to those inter- ested. No untoward results have been noticed from the struggles of the child until after the infection becomes general, when there might be danger of heart failure, and also too great exhaustion of the other vital functions. The following is the prescription, used in the form of a spray : 1173. R. Papain, 5ij Hydronaphthol, gr. iij Acidi hydrochlorici dil., gtt. xv Aq. destil., ad | iv. M. The papain is not very soluble in water, hence it sometimes ob- structs the atomizer. Its solubility can be very much increased by adding four drachms of glycerin to the mixture ; this will also help to preserve the solution, which usually undergoes a change in a few hours. Dr.. LichtERMANN, (El progreso GinecoL y Pediatra, November 768 DISEASES OF CHILDREN. loth, 1888.) The following method of treatment has been used by the author in more than three hundred cases of diphtheria, in a lo- cality in which diphtheria seems endemic. When called to see a patient, he at once has the largest room in the house disinfected with chlorine. After keeping it closed for an hour, submitted to the in- fluence of the gas, it is opened and ventilated, and the patient re- moved to it. Then a mustard foot-bath, at a temperature of 30° C, is given for fifteen minutes, after which the patient is wrapped in a woolen covering and allowed to sweat for two or three hours. This bath is repeated every afternoon. The local treatment consists in applying a solution of fifteen grains of salicylate of sodium, in a half drachm of glycerine, to the posterior portion of the pharynx four times daily, and gargling the throat every half hour with a solution containing a drachm and a half of chlorate of potassium to four ounces of water. For internal treatment two mixtures are used — one containing forty-five grains of chlorate of potash, one ounce of simple syrup, and four ounces of water, to be taken in teaspoonful doses every hour ; and the other, containing half a drachm of hydrochloric acid, one ounce of fruit syrup and four ounces of distilled water, also to be taken in teaspoonful doses every hour, immediately after the first medicine has been taken. Children under two years of age should take only half teaspoonful doses of each mixture every hour, and to those of more than two years two teaspoonfuls may be given. A three per cent, solution of carbolic acid should be atomized in the room. After twenty-four hours of this treatment the temperature will usually be normal, and after forty-eight hours the false mem- brane will have entirely disappeared. The author says that after being accustomed to a mortality of forty-five per cent., under the ordinary treatment for diphtheria, he only lost four out of two hun- dred and thirty-seven cases (sixty-eight of which were gangrenous) when the above treatment was employed. Dr. Lax (Jour, de Med. de Paris, February, 1887). In this arti- cle the author speaks of the great success he has had in treating diphtheria with pilocarpine. The following formula was used in a series of cases : »I74- R. Pilocarpini hydf ochl., gf-Jtol Pepsin, gr. x Aquae destil., f.Sxviiss Acidi hydrochl., gtt. ij-iij. The dose was a teaspoonful or dessertspoonful, according to the age of the chUd, three or four times a day. DIPHTHERIA. 769 . Tokay wine was also given, and warm fomentations were applied to the neck. After three days of this treatment all traces of false membrane had disappeared from the tonsils and pillars of the pharynx. Under the influence of the author's method, the secretion of mucus and saliva was increased, and quantities of false membrane were expelled from the mouth and nostrils. The respiration became easier, the fever disappeared, the appetite returned, and the children were cured after three to five days' treatment. In all of the cases a herpes labialis followed the disease. GUTTMAN reports eighty-one cases of diphtheria treated with pilo- carpine within a year and a half, without a death. He believes that this agent is certain in its action, and superior to all medicaments which have been used in this disease up to the present time. In most of his cases the pilocarpine treatment was used. A cure was effected in from one to three days, in benign cases, and in from nine to eleven days in severe ones. The combination of pepsin was used both on account of its useful effect upon intestinal catarrh and its solvent action upon false membranes. DR. KNAGGS. This author {Ther. Gaz., March 15, 1888,) believes in the effi- ciency of sulphur in treating this disease, and recommends the fol- lowing formula: 1 1 75- R- Precipitated sulphur (pure), 3iss Chocolate powder, 3j Cinnamon water, f. S j Glycerine to make f. § iij. The cinnamon water should be gradually added after the. powders have been well rubbed with the glycerine. Sig.T— Half to one teaspoonful to be taken every hour or oftener. While he seems to prefer insufflations where the posterior nares or nasal cavities are involved, he thinks that suspension in a viscid liquid such as glycerin will answer every purpose, with the least possible amount of distress to the patient. PAIRMAN T. WYLD. This author {^Edinburgh Med. Jour., February, 1889,) mentions a number of cases which were successfully treated by continuous inhalation of steam, combined with antiseptic fumes, obtained by burning sulphur in the apartment. The patient is surrounded by an 49 770 DISEASES OF CHILDREN. atmosphere of steam, retained by fixing to the bed an open umbrella, and throwing over this a large sheet. A pipe conveys the steam from a kettle of boiling water into this tent. A teaspoonful of sul- phur is burned in the room every night. Among the advantages in favor of this plan the author gives the following : constitutional and local rest are obtained during the whole course of the disease ; the method is applicable in all forms of the malady, even in cases where the air-passages are much involved ; the method is simple, and little apparatus is required ; paralysis never seems to occur as a sequela, and convalescence is rapid ; no bad effects have followed where children have breathed steam four days and nights succes- sively. DR. HUBBARD. This author (^Medical Record, 1888,) has found the following remedy extremely satisfactory. He uses a clear solution prepared as follows: 1 1 76. R. Lime, 1 part. Sulphur, 2 parts. Water, 20 parts. Slake the lime with sQme of the water, then add the remainder and the solpbor; boil to twelve parts and filter. This solution is used undiluted in the form of a spray, every hour until the disease is under control, and then at longer intervals. In cases of very young children it is well to add a little water to the solution at first, to prevent it from irritating the tender mucous membrane. Under the use of this spray, even sparingly applied, the diphtheritic patches undergo a change in a few hours. The temperature soon subsides and a general improvement in the condi- tion takes place almost from the first application. In some cases the patches disappear entirely in a day. The solution is supposed to do much toward preventing constitutional infection, as it is taken into the patient's stomach. Its stimulant, laxative, and somewhat diaphoretic and diuretic actions are quite marked. KUSURCOW. This author {Rev. Hebd. de Tkeraf.) has, in a series of observations on the treatment of diphtheria of the pharynx, had unsatisfactory results with resorcin, tannin and the sulphate of copper. He thinks DIPHTHERIA. 771 the best topical application is oil of Mars, in combination with borax in glycerine and the following mixture : 1 177. R. Menthol, grs. Ixvi Alcohol, sufficient to dissolve. And add Naphthaline } e i. Spirits of turpentine / °^ =^'='' 6"- <=•• Glycerine. With this solution the aCfected parts are painted over every two or three hours. The mixture must be shaken before using. As a cleansing gargle, lime-water is employed. Internally, anti- pyrine with sulphate of copper, suspended in peppermint water, is used. A purgative should precede all treatment. — La Pratique Medicate, January 6, 1891. PROF. E. N. CHAPMAN, M. D., OF BROOKLYN. It is the opinion of this author that a decided stimulant, especially alcohol, taken regularly, will protect persons from the diphtheritic poison. He prescribes for those in health, who are exposed to it, the following: 1 1 78. R. Quinoidine, Cinchoniae sulphatis, aa gr. xxv Acidi sulpburici aromatici, f.3>j Spiritils frumenti, f-Sviij. M. Fifteen drops to a tablespoonful, according to age, four or five times a day. PROF. KLEBS, OF GERMANY. This author from experiments to ascertain what drugs have a destructive influence on the diphtheritic process, believes that he has shown that the most potent in this direction is the benzoate of soda, and is inclined to think that the administration of this substance will strongly tend to prevent the establishment of the disease. He also uses it when the attack begins, 5j-ij, to a child of five years. In all cases of illness, when diphtheria is prevalent, it is expedient to look into the throat, as, occasionally, when there is not even ground for suspicion, the characteristic spot or layer of moldiness, like an irregular patch of white kid, will be discerned. Now is the time when one single painting with a strong solution of nitrate of silver may effectually destroy the parasite and rescue the patient. Twenty-four hours later, and the attempt will be vain. In a paper read at the Medical Society of Victoria, and published in ^e^ Australian Medical Journal, 1880, "On the free Use of Salt 772 DISEASES OF CHILDREN. as a Prophylactic Against Diphtheria^ Dr. Day stated that, having for many years past looked upon diphtheria in its early stage as a purely local affection, characterized by a marked tendency to take on putrefactive decomposition, he has trusted most to the free and constant application of antiseptics ; and when their employment has been adopted from the first, and has been combined with judicious alimentation, he has seldom seen blood-poisoning ensue. In conse- quence of the great power which salt possesses in preventing the putrefactive decomposition of meat and other organic matter, Dr. Day has often prescribed for diphtheritic patients living far away from medical aid, the frequent use of a gargle composed of a table- spoonful or more of salt, dissolved in a tumbler of water; giving children who cannot gargle a teaspoonful or two to drink occasion- ally. During the prevalence of diphtheria, he recommends its use instead of sugar in the food of children, adults using the gargle as a prophylactic, three or four times a day. M. HAGER, of GERMANY. In the Pharm. Centralblatt, 1882, M. Hager recommends lozenges composed after the following formula, to persons who are exposed •to the contagion of diphtheria : M. M. M. 'After the mass has cooled, divide into 100 pastilles. One of these lozenges. should be very slowly masticated four or five times daily. PROF. J. LEWIS SMITH, M. D., NEW YORK. The internal treatment of this author is as follows, for a child of five years : 1 181. S^. Quinise sulphatis, 5s3 Elixir taraxaci comp., f. § ij, J^f, A teaspoonful every two to four hours. 1 1 79- Ji. Cera: alb., 3v Colophon, 5iss Melt together, and then add Balsam, tolutan., 3iis3 Pulv. aromat.. 5iss ^acch. alb., 3v Ac. benzoic. 3iss-iiss. Reduce to fine powder and aromatize with 1 1 80. S. 01. cinnamomi. mx Creasoti, 3j. 1182. R. Tincturse ferri chloridi, f.5ii Potassii chloratis, 5ii Syrupi, f.^iy_ To be given hourly, alternating with the previous mixture. M. DIPHTHERIA. 773 The tonic effect of the iron is not impaired by the chlorate of potassium, which is added to the mixture on account of its local action on the inflamed surface. The citrate of iron and ammonia, alone or in combination with carbonate of ammonia, may be given in 2-grain doses, dissolved in simple syrup, in place of the above mixture, when the inflammation of the fauces has considerably abated, or is moderate. If the pa- tient improve, and the disease begins to abate, the doses may be given at greater intervals, but not discontinued. Local Treatment. — Forcible removal of the pseudo-membrane, irri- tating applications, the use of a sponge or other rough instrument for making the applications, should be avoided as likely to do harm. The applications should be made either with a large camel's-hair pencil, or better, for most of the mixtures employed, with the atom- izer. The hand atomizer, which is cheap and of simple construc- tion, while it carries a heavy spray from the curved tube, which is introduced over the tongue, is very useful ; but the constant spray of the steam atomizer is more effectual, and is preferable in severe cases. The following mixtures he is in the habit of using with the atom- izer : 1 183. K. Acidi salicylic!, 3ss Glycerinse, f. § ij Liquor calcis, f. § viij. M. 1184. R. Acidi carbolici, gtt. xxxij GlycerinoB, f- S ij Liquor calcis, f. S vj. M. ' 1185. R. Acidi carbolici, gtt. xxxij Potassii chloratis, 3"! Glycerine, f.§ijj Aqu2e, f-Sv. M. In many cases of diphtheritic inflammation of the fauces, the spray suffices for local treatment, but the following mixture, applied by a large camel's-hair pencil, is also very effectual, immediately con- verting the pseudo-membrane into an inert mass, and putting a stop to all movements of the bacteria which swarm in it, as Dr. S. has observed under the microscope. 1186. R. Acidi carbolici, 8"-.y'iJ. Liquoiis ferri subsulphatis, f- 3 ij-"j Glycerinse, f-3J- M. 774 DISEASES OF CHILDREN. This may be used two or three times daily, between the spraying or oftener without the spraying. It is not irritating (such an effect would condemn it,) but it is dreaded by most children on account of the unpleasant "puckering" which it produces. If there is discharge from the nostrils indicating diphtheritic in- flammation of the Schneiderian membrane, a little of the same mix- ture, diluted with an equal quantity of warm water, is injected into each nostril every three to six hours. To do this, the child is placed upon its back, with the head thrown backward and the eyes covered with a towel to prevent the liquid from entering them. A small glass syringe (ear or nostril), with a knob or button at the end of the noz- zle, is the best form of instrument for these injections. One-third to one-half of a teaspoonful of the diluted mixture is a sufficient quantity to employ for each nostril. This application, properly made, prevents decomposition, removes the offensive odor, and that which is of the greatest importance, prevents blood- poisoning. In three or four days, if the case progress favorably, these reme- dies are employed less frequently, but they are continued until not only the pseudo-membrane has disappeared, but the inflammation also has in great part abated. ^When the inflammation has begun to abate, and there is no re-appearance of the exudation, a gargle or drink of chlorate of potash, or the following mixture, is given. 1 187. R. Sodii bisulphitis, 3j-ij Tinctune aurantii, f. 5 ij Aquae, f.5x. M. One teaspoonful every two hours. Sometimes, in place of water, a bitter infusion, like that of quassia, has been employed. The sulphites have not been found so valuable in this disease as was expected at their introduction. Dr. James Tyson (in the Philadelphia Medical Times, February 15 th, 1879,) speaks strongly in favor of Dr. BiLLiNGTON's treatment of diphtheria. This is the frequently-repeated small dose of tinct. ferri chloridi, and sol. potassii chloratis, alternately, every half hour, following each, for two or three minutes, with a spray, from a hand atomizer, of liq. calcis and carboHc acid. The formulae are : 1 188. R. Tinct. ferri chloridi, f.3j-iss Glycerinae, Aquae, aa f.|j. M. DIPHTHERIA. 775 1189. R. Potassii chloratis, 5ss-i Glycerinse, f 5 53 Liquoris calcis, f!|iss. M. 1 1 90. R. Acidi carbolici, TUxv Liquoris calcis, f. | vj. M. For spray. DR. ROBERT BELL, GLASGOW, SCOTLAND. 1 191. R. Acidi carbolici, f. 3ij Acidi sulpburosi, f. 3 vj Tincturae ferri chloridi, Glycerinse, ii f.§j. m. Apply to the throat with a large camel's-hair pencil, or by means of the spray ap paratus, every two hours. 1192. R. Potassii chloratis, 3iij Acidi sulphuTosi, f. 3 iijss Tincturse ferri chloridi, f. 3 iij Glycerinae, f. § j Aquae, adf.fvj. M. A dessertspoonful every two hours. From the very outset of the disease, with this medication must be combined free stimulation and plenty of nourishment, in the shape of soups, jellies, and milk. DR. CARLO PAVESI, ITALY. This writer (in the Annali di Medicina, August, 1876,) gives a formula which he recommends in the treatment of diphtheria. It is founded on the antizymotic properties of chloral, salicylic acid, and the sulphites. It is as follows : 1 193- R- Chloralis, Acidi salicylici, Glycerinae, Sodii sulpnitis, aa 3 iij Alcoholis, f. 3 ij Aquae, f.Svij. M. The whole is put into a strong glass vessel, which is closed, and exposed to a heat of 100° to 120° Fahr. for a few minutes, until the sulphite, salicylic acid and chloral are completely dissolved. A homogeneous solution is produced, which is filtered through bib- ulous paper, and preserved in a well-closed vessel. It is an oily, limpid, colorless liquid, having the odor of its constituent parts. It is insoluble with water. On the application of proper tests, the chloral, salicylic acid, sulphite of soda, and glycerine, are found to be unchanged. "]•](> DISEASES OF CHILDREN. Used both internally and externally, it is an energetic antiseptic, antifermentative, disinfectant, haemostatic and preservative, as well as a destroyer of parasitic organisms. Dr. PavesI says that it may be used as an antiseptic, and also as a sedative, in a large number of diseases. DR. EDWARD HENOCH, OF BERLIN. The views of this great authority are not very encouraging, for he repeats now what he said in 1874, namely, that in his experience all remedies hitherto recommended, and he has tried almost all, with the exception of sulphur preparations, are entirely useless in severe cases of the disease, and these alone should be considered, since the mild cases recover spontaneously. He therefore limits himself to describing what he considers the most rational treatment, though he does not ascribe to it any specific action on the disease. Locally, he uses gargles alone, or in small children, injections of the pharyngeal and nasal cavities with a solution of the chlorate of pot- ash (10:500), alumen aceticum (25:500), carbolic acid (j^ per cent.), or equal parts of lime-water and distilled water. These rem- edies are employed most satisfactorily with a spray apparatus, as it can readily be forced between the teeth if the children resist. The object of this method is to remove decomposed masses as thoroughly as possible, to abolish the fcetor and to gradually loosen and dis- solve firmly adherent exudations. For this reason he recommends the method suggested by RiGAUER, of pouring four or five teaspoon- fuls of cool water into the nose daily. He does not approve of pen- ciling the affected surfaces with anything, as this only tends to excite the patient, and, if done with force, may injure the mucous mem- brane. Such .injuries must be avoided at any cost, on account of the almost unavoidable diphtheritic infection of all lesions of the mucous membrane. If the pharynx shows marked inflammatory redness and swelling, he applies an ice-bag to the throat, and allows small pieces of ice to be frequently swallowed. Internally, he recom- mends from the beginning, decoct, chinae (5 or 10: 120) with aq. chlori. (10.0-15.0), in addition to nutritious diet (milk, broths, wine), though this is often rendered impossible by the complete anorexia of many children. If no food will be taken, he resorts to nutritious enemata (meat solution, peptone, bouillon with egg, and wine). He strongly warns against all methods which increase the tendency to collapse already present, especially large doses of chlo- DIPHTHERIA. -j-j- rate of potash (small doses are harmless, but useless), which may also give rise to dangerous intoxication and haemoglobinuria ; large doses of quinine and salicylate of soda are equally harmful. Sub- sulphite of soda and inhalations of bromine have proved absolutely useless in his hands, as also has carbolic acid internally and subcu- taneously along the hyoid bone. He considers that we are equally powerless against diphtheritic collapse. In diphtheritic croup, he considers tracheotomy the sole measure from which we can expect any results, and he therefore advises its performance in all cases that are not moribund, or do not present severe symptoms of in- fection. It is of great importance not to perform the operation too late. — after cyanosis, coolness of the extremities, and extreme orthopnoea are present. It is advisable to operate on the appearance of the local signs of stenosis (continuous stridor in breathing, croupy cough, retraction of the lower part of the neck and the lower ribs). There is nothing to be lost by the operation, and everything to be gained. Even the presence of pneumonia is not a contra-indication. If the progress is favorable the canula may be removed, as a rule, on the sixth day after the operation. There may be considerable swelling of the mucous membrane which interferes with the removal of the canula, and under such circumstances there is always danger that a canula, which has been in the trachea for an unusually long time, may even cause ulceration, and finally give rise to polypoid proliferation. If this has occurred, the canula may not be removed, and the child must retain it for a very long time, until we succeed in removing the proliferation of the mucous membrane, and thus the danger of stenosis. Children upon whom tracheotomy has been performed, exhibit a special tendency to infection with scarlet fever. For diphtheritic paralysis Dr. HENOCH recommends strychnia, sub- cutaneously, combined with electricity. DR. J. N. COONS, OF MISSOURI. In the Medical and Surgical Reporter, 1 884, this practitioner says that, given a typical case of diphtheria of average malignity, in a child of eight or ten years of age, at an early stage of the disease — for then only is treatment of most avail — he would give, if the nerv- ous chill has not passed, a teaspoonful of tinct. opii camph. to calm the nervous shock and quiet the aching limbs, after which he would 778 DISEASES OF CHILDREN. clear the alimentary canal by a mild laxative, and at once give the following : 1194. 51. Potassii chloridi (not chloratis), 3i Tinct. ferri chloridi, f. 3«i Syrupi scillse, f. § ss Syrupi, q. s. ad f. | iv. Misce. Sig. — One teaspoonful in a little syrup or water every three hours; to be continued throughout the disease, but at lengthened intervals, after all diph- theritic membrane shall have disappeared. With each dose of this alterative syrup he would give (according to frequency and hardness of pulse) from two to six drops of tinct. veratri viridis, till the pulse has been reduced to normal frequency and softness, and then in lessened doses every six or eight hours, till cessation of all tendency to febrile excitation. Should an expectorant seem called for, he would direct : IZ95- B- Tinct. sanguinarise canad., Tinct. ipecacuanhas, aa f. 3s$ Tinct. opii camphoratse, f. § ss Syrupi tolutani, q. s ad f. § ij. Misce. — ^Teaspoonful as needed to loosen or quiet cough. From the first, food of some kind, preferably milk, soup, or other liquid or soft animal food, should be given at least as often as every three hours — say after each dose of medicine. Fruits, most vege- tables, and acid syrups, are forbidden. As the vital powers weaken, cream, toddy, egg-nog, and occasional two-grain doses of quinine or salicine (the last preferably in capsule, to avoid faucial irritation) serve to bridge over the period of weakness, whilst possibly neutral- izing the poison of the disease. Local Treatment. — Believing that the systemic infection largely springs from the constant inhalation and ingestion of the putrid pro- ducts of the local disease, coupled with the retention of effete matters produced by the irritative fever, he considers the local treatment quite as important as the systemic. He adds to hot water as much acetic acid as may be borne without irritation of the external surface (from i in 8 to i in 16 parts), trust- ing that the inhalation of the vapors ever rising from the hot foment- ing cloths will stimulate secretion and prevent deposit, if the vapor do not also dissolve membrane already formed in the fauces and air passages. The fomentation may be by flannel cloths or sacks of linseed meal reaching across the front of the neck from ear to ear, and kept frequently wetted in the hot diluted acetic acid (or, in its DIPHTHERIA. 779 absence, vinegar), and well covered with dry flannels to preserve the heat. Should the skin become irritated, the proportion of acetic acid must be lessened, or it must be omitted altogether from the fomenting liquid, lest we have a raw surface, forming a new nidus for the further extension of the disease. For direct application to diseased fauces, nares, etc., he has found nothing so good as a satu- rated solution of chemically pure acetate of lead, to which may be added, when necessary (which is rare) a non-irritant antiseptic. This solution may be best applied in spray by means of an atomizer, but a gargle is of service, and the following powder dusted upon the parts will materially assist in causing the removal of any diphtheritic deposit formed in the fauces : 1 196. R. Pluinbi acetatis (C. P.) pulv., Pulv. gum. acacise, aa 5j. Misce. Sig. — A small quantity to be blown upon the diseased parts two or three times a day. This may be done through a roll of letter sheet. When the larynx becomes involved, the inhalation of hot steam from a saturated solution of acetate of lead in dilute acetic acid fur- nishes probably as hopeful treatment as any with which we are ac- quainted. Summing up. — Relieve nervous shock, clear the alimentary canal, give veratrum viride till its constitutional effect is felt in a softening and slowing of the pulse, give the iron and chloride of potassa altera- tive steadily throughout the disease, adding an expectorant when needed; and most important, foment assiduously for the first few days, applying the acetate of lead freely and often to the diseased fauces. Lastly, forget not to feed liberally throughout the disease, and to stimulate and support freely by alcoholics and tonics, as the exigencies of the case call for, in the wane of the disease. DR. A. WORTHINGTON, OF CANADA. Dr. A. WORTHINGTON was led to use cold water in diphtheria, be- cause he had successfully used it for twenty-seven years in all forms of scarlatina, and he says that he has not been disappointed. A cold wet cloth, large enough to cover the entire body, is wrapped around the patient, and it is covered with dry flannel ; it is changed every half hour for a fresh one. In the Canada Lancet for June, 1883, he thus concludes his article : I. To secure any safety to the patient, the treatment of diphtheria 78o DISEASES OF CHILDREN. must be begun with the invasion of the disease — not a moment's time should be lost. 2. The cold water application should be made on the first appear- ance of a rise in temperature, and its continuance governed by the tendency of the extremities to become cool. 3. The most careful attention should be given to the nourishment of the patient from the first. 4. Adynamic symptoms should be anticipated by the free use of stimulants and tonics, and the application of artificial heat if neces- sary. DRS. J. BENZON, OF BUCCARI, AND S. KORACH, OF COLOGNE. These gentlemen have both been using iodoform locally in diph- theria with success {Deutsck. Med. Woch., 1882). The former treated one man, two women and two girls, (respectively aged eigh- teen and twenty-two), and a four- year-old child ; and notwithstanding the cases were all of a grave type, under the local .treatment men- tioned they all ran a favorable and rapid course. BUCCARI treated his cases as follows : He took a painter's brush, one ctm. wide, and dipped it into finely-powdered iodoform until the points were all colored yellow. He then depressed the back of the tongue and ap- plied the iodoform to the diphtheritic membrane. This procedure was repeated, in the beginning of the disease, about eight times dur- ing the day and six times during the night. With the exception of ice applications to the neck, this constituted the whole of the treat- ment. For nearly a year all the diphtheria patients in the Cologne City Hospital were treated in this way, cleansing injections with unmedicated water being the only local or internal medication used besides. The results were very satisfactory, for in 213 cases there was only one death. DR. DEUKER, OF RUSSIA. This physician {Medical Press, 1882), who, during twenty-four years of very extensive practice in the Children's Hospital, St. Pe- tersburg, has treated upwards of two thousand cases of diphtheria, and tried all the remedies, both external and internal, recommended in this affection, has obtained the best results from the following method, which he has employed for the last ten years. As soon as the white spots appear on the tonsils, he gives a laxative, mainly composed of senna, which produces an abundant watery evacuation. DIPHTHERIA. 781 When the purgative effect has ceased, he gives cold drinks, acidu- lated with hydrochloric acid, and every tw^o hours a gargle com- posed of lime-water and hot milk in equal parts. DR. H. L. GETZ, OF IOWA. This author {Medical and Surgical Reporter, 1882), relies upon the following plan of treatment : Locally, tincture of iron with glycerine, in the proportion of two parts of the former to one of the latter, and this mixture satu- rated with chlorate of potash ; this should be carefully and thor- oughly applied, every six hours, to the fauces, tonsils, etc., by the physician, and never entrusted to inexperienced persons. A gargle consisting of one part of the above mixture and three parts of water should be used every two or three hours. Small pieces of ice may also be allowed to dissolve in the mouth to good advantage when not annoying the patient. Externally, nothing, except where there is swelling of the lymphatics; then the application of liniment of ammonia. DR. MORELL MACKENZIE, OF LONDON. This distinguished author says (^Medical and Surgical Reporter, 1 88 1 ) that so far as local treatment is concerned, he places his sole reliance on varnishes, i. e., remedies which exclude the air from the false membrane, tolu dissolved in ether being the most useful. Dr. DiX, a Danish medical practitioner, scrapes away the false mem- brane and cauterizes the scraped surface with solid nitrate of silver. DR. JOHN A. LARRABEE, OF KENTUCKY. This author {Philadelphia Medical Times, 1881) lays down the following rules : Muriated tincture of iron, persistently and freely given, should form the basis of treatment ; its astringent property tends to prevent the formation of the membrane, while its effects upon the constitution tend to sustain the life of the patient, and thus enable him to throw off the membrane. He also recommends the free use of alcohol. DR. JOSEPH H. WARREN, OF BOSTON, This author ( Virginia Medical Monthly, 1880) has been using the 782 DISEASES OF CHILDREN. following with greater success than he ever achieved with any other form of medication : I197' R- Glycerinae, f.S_>i Acid, thymic, gr. iv-vj Potass, chlorat., 3ijss Quinice bisulph., 3ss-j Brandy (very old), f-S^j. M. S. — ^To a child from one year old up to five, a teaspoonful every hour or two, ac- cording to the urgency of the disease. Increase the dose from this age upward, to f. 3iv. Let the patient take it without any water, if possible, as by so doing he will get the stimulating effect on the throat and thus avoid the use of anything for a gargle. For atomizing the throat, he uses the following : 1 198. R. Glycerine, f.Sj Acid thymic, gr. vi-x Sodii borat., 3'^ A qux camphors, f. § iv Aquae picis liquidse, f. § v. M. Filter, S. — ^Atomize freely every two or three hours. DR. J. R. BLACK, OF OHIO. This physician considers that he has a very potent local applica- tion in the following (^Medical and Surgical Reporter, 1 880) : 1199- B- Glycerins, f. §S3 Tr. iodinii, f.3ss Acid salicylic, gr, xx. M. It should be applied freely, with a large camel's-hair brush, morn- ing and evening, carefully covering the whole of the diphtheritic surface with it. When the disease extends up into the nasal cavities, the use of the camel's-hair brush is impracticable, and he usually relies upon the use of an injection of a liquid containing one fluid drachm of the solution of carbolic acid to seven fluid drachms of a saturated solution of chlorate of potassium. DR. J. W. MOORE, OF COHOES, N. Y. Dr. J. W. Moore says that in his hands the following line of treat- ment, which he publishes in the Med. Atma/s, 1884, has been almost uniformly successful in the cases that he has treated during the past six months, the rate of mortality being two out of thirty, these two dying from fibrinous tracheo-bronchitis. After attending to the hy- gienic necessities as far as possible, such as putting the patient in a well-ventilated room, the air of which is both warm and moist, with the temperature between 60° and 65° (assuming that we are able to put DIPHTHERIA. 783 our patient in a comfortable room, as we often have to treat them as we find them), and thin patches of false membrane presenting them- selves, with other concomitant symptoms, he gently sprays the throat with a weak solution of chlorine gas, made by the action of tr. chlor. iron on potassium chlorate, slowly adding water as the chlorine is given off. He then gives, according to age, from ten to fifteen drops of the tr. of iron every three hours in a little glycerine and water ; good nourishing diet, such as milk, eggs, etc. On the second day, if the disease is not checked, he gives one drop of Lugol's solution of iodine, and a half drop of carbolic acid, in a little water and gly- cerine, every two hours, and increases the intervals of the iron to four or five hours ; he also discards the spray, using a direct appli- cation of a mixture of iodine, glycerine, and carbolic acid. DR. ROBERT J. CULLEN, OF NEW YORK. This author states, in the Medical and Surgical Reporter, 1880, that he has treated about eleven hundred cases of diphtheria, and has cured about ninety-eight per cent. His treatment consists in adding one drop of dilute nitro-tnuriatic acid to every teaspoonful of the following mixture : 1200. B- Fotassii cfalorat., 3"] Tinct. ferri chlor., f. 5 iv Aquae, Glycerinae, aa f.Sij. M. S. — ^Teaspoonful every fifteen minntes. DR. THOMAS GURNEY, OF ENGLAND. Nutritious support and the arrest of the disease, our author claims, in the Lancet, 1879, are our great aims. For this purpose he has adopted a respirator, made of the ordinary shape and size, the front being minutely perforated. Inside of the respirator he has two or three perforated plates inserted, between which he places common tow, (not cotton wool). He then drops on each of the layers of tow ten to twenty drops of a solution of carbolic acid, creasote, and glycerine. Should the patient tire of these, he uses turpentine or iodine. He places the respirator over the mouth and keeps it con- tinually applied. He keeps two kettles of water boiling on the fire. Attached to the spouts of the kettles he has an elastic tube- of an inch calibre, at the end of which is a spray-like nozzle, which he puts immediately under the mouth of the patient By this means the disinfectant remedies are carried moist to the throat. Previous 784 DISEASES OF CHILDREN. to this, he gives an active purge, which usually removes offensive stools, of effete, poisonous matter. Internally he gives aconite, in frequent small doses. At the same time, the strength is supported with milk, cream and eggs, with or without brandy, and beef tea ad libitum. As a drink, he recommends patients to take as much chlorate of potash in solution as they can, without vomiting. If this is objected to, he orders lemon juice. If the system is very weak, he gives belladonna in lieu of aconite. As soon as the urgent syrnp- toms have subsided, he orders strychnia, with or without nitro-muri- atic acid. He never forgets bicarbonate of potash, on account of the tendency to rheumatism after this disease. DR. RUDOLPH SIEFFERT Writes to the Chicago Medical Journal and Examiner, 1880, that his main remedy in the treatment of this disease is the inhalation, through a sponge, of dilute carbolic acid. The sponge is saturated with a solution of carbolic acid (the strength ranging from I part in 200 to I part in 100 of water), and then placed in a wire holder, formed so as to fit over mouth and nose. This inhaling apparatus is fastened to the patient's mouth and nostrils, so that respiration must take place through the carbolated sponge. These inhalations are repeated every two hours, each lasting about half an hour. Within twenty-four hours, the membranes become loose, and are gradually either swallowed or expectorated, and they do not re- appear with the same severity. In the cases of larger children, he orders the throat to be gargled with warm chamomile (German) tea. After every application, the sponge ought to be well washed in hot water, and if there be several patients in the same family, each one ought to have his own apparatus, or at least his own sponge. To prevent the carbolic acid solution from affecting the lips, it is well to oil the lips well before applying the inhaling apparatus. Besides the inhalation, he uses quinine, and, in order to keep the bowels open, the fluid extract of rhamnus frangula. For older children, he occasionally orders gargling with a weak solution of carbolic acid. DR. S. MURDOCH, OF MISSOURI. This author states, in the St. Louis Courier of Medicine, that he has long since abandoned all swabs, and the use of tincture of iron, or iron in any of its forms, believing it to be one of the most mis- DIPHTHERIA. 785 chievous remedies ever given in this disease, and he depends prin- cipally upon chlorine mixtures and supportive treatment. DR. GASPARINI, OF ITALY. Dr. Gasparini {Gazz. Med, Ital. Lomb., February 16, 1884,) ac- cepts Morell Mackenzie's definition of diphtheria, and looks upon it as an acute infectious general disease, with a tendency to the produc- tion of certain local manifestations. His treatment consists in wrap- ping the patient in a cold, wet sheet, repeating the packing three or four times a day, according to the height of the fever. Cold com- presses are to be kept continually to the throat. He also uses gargles of the alkaline sulphites, carbolic acid, etc., as disinfectants, never caustics. In 1875, six cases were thus treated; all recovered, the disease lasting 'from five to eleven days. In 1879, seven cases recovered under the same treatment, the average duration of the dis- ease being ten days. This treatment is well borne, and the patients like it ; its antipyretic action is marked, though transitory. Stimu- lants are at the same time to be freely administered. The duration of the disease is not influenced ; but convalescence is shortened, and the strength is more quickly recovered. M. DELTHIL, OF FRANCE, Bums in the sick-room (^Deutsch. Med. Zeit., 1884,) an equal mix- ture of coal-tar and ol. terebinthinae, causing the formation of thick, black vapor. The air of the room becomes impregnated with carbon in various combinations, and the latter are said to dissolve the fatty substances which unite the constituent parts of the diphtheritic membranes. In consequence of this chemical action it is believed the membranes lose their tenacity and their adherence to the tissues, and their expectoration is easier. He tried this method on four children, on whom, on account of laryngeal diphtheria, tracheotomy had been performed. Three of the patients died. But remembering the fatality usually attending cases of this kind, the result is, if anything, favorable. Dr. FfeRfiOL employed the same treatment on an adult suffering from a mild type of the same disease. After each fumigation, which was very well borne by the patient, free expectoration ensued, and on the second day the membrane had become soft and was much less adherent. SO 786 DISEASES OK CHILDREN. DR. GEORGE A. LYNN, OF PENNSYLVANIA. This author, in a paper read before the American Medical Asso- ciation, 1884, set forth the proper mode of administering corrosive sublimate in diphtheria. In order to make it thoroughly reliable and valuable, he says : 1. It must be used in the first stage of the disease. 2. It must be used in large doses frequently repeated. The first rule is apparent, he thinks, from the fact that the great- est value of the medicine is in the prevention of the formation of the poison in the membrane, and it should not be put off until, all other remedies have been tried and failed. The effect of the remedy, given early, is to reduce the temperature, relieve pain in the head, back and limbs, unlock the secretions, and lessen the soreness in the throat, in time to relieve the nausea and vomiting. He advises as the best mode of administering it that a solution be made of one grain of the bichloride to one drachm of alcohol. He recommends as a vehicle for the bichloride, an elixir of pepsin or of pepsin and bismuth. To a child of three years, he gives from t's to t't grain ac- cording as the disease is mild or malignant, repeating the dose every three hours. To an adult, A to t grain may be given at the same inter- vals. He states that in mild cases convalescence is generally estab- lished by the end of the third day, when the treatment is commenced early, and that it is seldom necessary to continue it more than five days. When this treatment is instituted early, nothing else is found necessary. In cases where it is not commenced until late in the course of the disease, it may be necessary to give tonics and stimu- lants, as tincture of iron and brandy. In some cases membrane has already formed before the physician is called to see the case or be- fore the remedy has had time to take effect ; and then, if it affect the larynx or trachea, a new danger arises from the mechanical obstruc- tion, for which the corrosive chloride gives no relief. In many cases of croup, simple or diphtheritic, dyspnoea is due not to the mechan- ical obstruction produced by the membrane, but to a spasmodic condition of the glottis. Dr. Lynn thinks that a remedy which will relieve this spasm will obviate the necessity of resorting to tracheo- tomy in nearly all cases. He believes that we have such a remedy in the chloride of gold. He directs the druggist to dissolve the con- tents of a fifteen-grain bottle, as it comes from the manufacturer, in fifteen drachms of distilled water, and to dispense from that solution. DIPHTHERIA. 787 The *dose may be i^-^ grain, and may be administered easily in watet, as it is almost tasteless. It should be given from a glass or a teactip, as the preparation acts readily upon metals, especially upon silver. DR. W. B. POWELL, OF LOUISIANA, Uses the treatment recommended by Dr. Maynard, and in addition {Medical and Surgical Reporter, 1881), uses the muriated tincture of iron and chlorate of potassium, both externally and internally, as follows : 120I. R. Tinct. ferri mtir.. f.3ij Potassii cblorat., 5; Aquxpnne, f.giy. S. — One teaspoonful according to age of patient every three hours. M. Many little ones are unable to gargle or rinse their throats, hence, when the preparation is swallowed, it comes directly into contact with the diseased membrane, both in the front as well as in the back of the throat. Before using the solution, he orders th'e inhalation of equal parts of good vinegar and hot water (a common vessel, with a spout, where a good inhaler cannot be had, will do) ; this vapor softens the membrane. He also gives quinine, in appropriate doses. MERCY HOSPITAL, CHICAGO. In this institution {Medical and Surgical Reporter,) diphtheria is treated as a general disease, with more or less intense local manifes- tations. The indications are for supporting measures for the general constitution, with treatment for such local symptoms as may arise. Good alimentation by soft articles of food is directed. The blood poisoning is treated with an antiseptic solution containing the chlor- ate of potash and hydrochloric acid, which latter also increases the plasticil^y of the blood. It also, in the act of swallowing it, produces a local astringent and antiseptic effect upon the mucous membrane of .the fauces. To this solution the tincture of belladonna is added, because of its known power to produce contraction of the arterioles of the nouth and pharynx, and so possibly lessien the amount of exudation. This is administered in frequent small doses, to obtain its maximum local effect. After the exfoliation of the membrane begins, it is discontinued, and a combination of the tincture of iron 788 DISEASES OF CHILDREN. and chlorate of potash is substituted. When the cervical glands become swollen, the following infusion is made : Cms. or C.C. I2C2. R. Aconiti foliorum, 32.00 Ammonii chloridi, 16.00 Aqua bullientis, 256.00 M. Flannel cloths are wet with this hot solution and applied to the neck. This is covered with another dry cloth, so as to retain the heat as long as possible. This has also been very efficacious in re- lieving acute tonsillitis and other similar inflammations in the cervi- cal region. A stimulating liniment is sometimes used in its stead. DIPHTHERITIC PARALYSIS. DR. ARCHAMBAULT, OF PARIS. This distinguished authority tells us that attention must first be paid to the general health, for such patients are usually in a state of profound anaemia when convalescent from a more or less intense attack of diphtheria. They are pale and feeble, and you will gener- ally find a blowing murmur in the cervical vessels. And this anaemic condition is generally more marked in cases where paralysis follows diphtheria, so that he is in the habit of giving the muriated tincture of iron to such patients, in doses of from five to fifteen drops. In conjunction with iron, he has found the arsenical preparations of great advantage. The preparation most frequently employed in the Hopital des Enfants Malades, is the liquor potassii arsenitis, or Fowler's solution, of which the dose may be gradually increased, without difficulty, to ten or twelve drops per diem, for a child of from five to eight years of age. The two medicaments may be given conjointly at meal times, in a little wine. The syrup of the iodide of iron and the ferruginous elixir of M. Rabuteau also answer all the indications for treatment. He also ad- ministers during the day, by dessertspoonfuls, a branjdy mixture con- taining thirty grains of extract of quinquina (Fr. codex), and eight or ten minims of tincture of nux vomica. If the tincture induces vomiting, it may be necessary to omit it, or it may be advantageously replaced by some preparation containing sulphate of strychnia, such as thie syrup of the French codex, which contains xb of a grain in one teaspoonful, and is easily taken and well supported by the stomach. At the same time the more generous wines may be allowed. DIPHTHERIA. 789 When the paralysis is generalized, he makes use of the continuous electric current, placing the positive pole over the cervical region and the negative at the lower part of the vertebral column or on one of the limbs. M. TROUVfe has constructed small electric machines of six ele- ments, which are not above the means of most families, and nothing is more simple than to instruct some one about the patient in the use of this little apparatus. These continuous currents may be maintained for hours if but four elements are used ; when six are employed the machine should not be left so long in action. When he considers that the diaphragm is enfeebled, he makes use of electricity, so that the current will traverse that muscle ; and in the same way when there is paralysis of the intrinsic muscles of the larynx. In order to act on the nerve extremities, and, consequently, on the paralysis, dry friction or massage should be made over the entire body, with the hand simply covered with a glove, or with a soft woolen brush ; frictions with a horse-hair glove are much too rude. The woolen glove used for the frictions may often, with ad- vantage, be first wetted in some alcoholic solution ; in such case the massage produces a sensation of cold, which is soon followed by general reaction which much invigorates the patient. Or a large flannel gown may be made so as to fasten about the child's neck, and he may then be subjected to a species of vapor bath, gum benzoin or juniper berries being burned on a small brazier placed so that the fumes mount under the gown ; while this is going on the little patient can be vigorously rubbed through the flannel. When recovery is slow and the season permits, nothing is more apt to hasten it than a sojourn at the seaside, with sea bathing. When paralysis of the pharynx induces pronounced dysphagia, it should receive most careful attention from the physician, particularly if tracheotomy has been performed and the wound in the throat is still open. Remembering that compact substances are most easily swallowed, thick soups and macaroni cooked in milk may be given, and drinks may be administered slowly with a spoon. If the wound in the trachea is still open, it will be necessary to occlude the orifice while the child drinks, for deglutition is easier where this is done. But the children are often completely spent by fruitless endeavors to satisfy their thirst, and also fatigued by the constant fits of coughing at each attempt to swallow, so that they finally refuse all species of 790 DISEASES OF CHILDREN. liquid, and there is great difficulty to introduce sufficient food to keep them alive. In such cases very thick soups may be given, which are at the same time an aliment and a drink. These may be thickened with the different lichens, Irish moss, etc., or with gelatine. When the patient can swallow nothing, it becomes necessary to in- troduce food by means of the oesophageal tube, which is not always easy to pass, in the case of children. The soft rubber oesophageal tube, such as is made at present, should be used, so as to avoid all chances of injuring the soft parts. Concurrently with these means of sustaining the system, analeptic enemata, particularly those com- pounded with the different peptones, are of very great benefit. Such an enema may be made up as follows : 1203. R. Salep, gr. xxx Thin beef soup, without salt, § ivss Yolk of egg, No. j or ij. M. By means of an electric current passing by the larynx, deglutition has been facilitated, and the contractility of the intrinsic muscles of the larynx awakened. The paralysis of the diaphragm should be combatted with perseverance, by means of the electric current, and this paralysis shcfuld receive special attention, as it is one of the di- rect causes of death. . Strabismus and blepharoptosis should also be treated by elec- tricity; but here there is less urgency, as these are of little import- ance, and always finally disappear. The visual troubles induced by the default in accommodation, are corrected by a coUyrium containing eserine : 1204. K- Sulphate of eserine, gr. v Aquse destil., f.§j. M. A few drops in the eye, morning and evening. Here again there is little need of therapeutic intervention, for the visual troubles are always fugacious, and disappear completely after *a certain length of time. SIR JOHN ROSE CORMAC, M. D., PARIS. In an article on this form of paralysis, in the Edinburgh Medical Journal, August, 1876, this writer observes that iron is particularly indicated, as the patients are always anaemic. There are few cases in which its administration does not prove itself in an obvious man- ner to be useful in a high degree. Sometimes it is only borne in very small doses. DIPHTHERIA. 79 1 Nux vomica, either in the form of extract or strychnia, taken daily, with some ordinary combination of laxatives, such as the com- pound rhubarb pill, ought to constitute a part of the treatment in nearly every case. The dose ought to be moderate, for large doses prove too exciting to the nervous system, and so tend to exhaust rather than invigorate its flagging powers. From 5^ grain to 2 grains of the extract once a day, with or without the occasional or constant addition of from 5 to 10 drops of the liquor strychnije (B. Ph.), two or three times a day, are suitable doses. Local treatment with a view to direct toward the wasted and wasting muscles a greater supply of blood, and thereby improve their nutrition, is of the most importance. Occasionally blisters act very beneficially in this way; but they must not be relied on to the ex- clusion of the constant use of stimulating pastes or liniments. No local stimulant is more efficacious, or better adapted for continuous use, than a ginger and mustard paste. The object of using the paste is to maintain a warm glow in the skin without vesicating it. The potency of the paste must, therefore, be proportioned to the sus- ceptibility of the skin. In some excitable patients who cannot bear long-continued counter-irritation of the skin, gentle kneading or massage of the paralyzed muscles, three or four times in the twenty- four hours, will be found useful as a means of directing a supply of blood to them. In such cases, after each kneading, a moderately stimulating liniment containing a small quantity of laudanum may be applied with great benefit. The laudanum prevents an uneasy, bruised feeling, which is often complained of after the kneading, and in irritable subjects is apt to induce restlessness and insomnia. Galvanic excitement of contraction in the paralyzed muscles is often decidedly useful ; but it is a measure which requires to be eni- ployed with moderation, and at intervals of about twenty-four hours. If resorted to too early, or too freely, it exhausts the nervous power of the affected muscles. For the paralysis following diphtheria, the following formula ( re- commended by Prof. Metcalfe, of New York,) is useful: 1205. B. Strychnise, gr-j Acidi nitrici dilud, f.3i Aquae, f-Svij. M- From three to five drops, in a dessertspoonful of water, are to be given three times daily to a child of three years. The anaemic state which succeeds diphtheria is to be remedied by the administration of iron, for several weeks. 792 DISEASES OF CHILDREN. NOTES ON REMEDIES. INTERNAL REMEDIES. Acid Sulphurous is highly praised by Dr. W. W. Carpenter, of California {Medical Herald, 1880). 1206. B- Acidi sulphurosi. Aquae purse, aa % i Glycerinse, f-Syj- M- S. — From one-balf teaspoonful to a dessertspoonful, according to age, every half hour. Seldom is anything beyond this required. But, if the case is very malignant, the acid can be combined with sulphur, or a saturated solu- tion of chlorate of potash can take the place of the water in the above formula. Alcohol, according to Dr. E. N. Chapman, of Brooklyn, "neutralizes the diph- theritic poison, sets free the nerves of animal life, subdues the fever and inflammation, destroys the pabulum that sustains the membrane, cuts short the disease, conquers its sequelae, and shields the other members of the family from an attack." It is also highly recom- mended by Dr. F. C. Roberts, of Fort Madison, Iowa, {Gaillards Medical Journal, 1881,) who orders 1207. £1. Fotassii cbloratis, §ss Alcohol, Aquse rosse, aa f. § ij. M. S. — ^To be used as a gargle every half hour. Acidum Carbolicum, gtt. j, in solution every hour, with steam inhalations, is a plan advocated by Dr. F. A. McEwen. (Practitioner, December, 1878.) Ammonii Murias. Dr. W. W. Oglesby, of Oregon, has had very favorable results with this agent. He gives : 1208. K. Ammonii muriat., Pulv. acaciae, Sacch. alb., S5 5H Aquae font., _ f.giv. M. A teaspoonful every two hours. When the depression is marked, he adds alcoholic stimulants ; and for a gargle, uses chlorine water. Apomorphia, in the dose of gr. ^, by the mouth, or gr. j',, hypodermically, is a certain, rapid, and useful emetic in diphtheria. Aqua Chlorinii has been found a valuable internal remedy, by Dr. J. S. Ben- son. (Canada Zancet, ]an\ia.Ty, 1876.) He gives it in doses of a teaspoonful or a dessertspoonful, to children, every three hours. In all cases, it should be given without any addition of water. DIPHTHERIA. 793 Bromine is strongly recommended by Dr. Schiltz, (Pharm. Central., 1884), in the treatment of diphtheria. One form in which he uses it, is as a solution, prepared thus : Chlorine water, 30 parts : distilled water, 150 parts ; and bromide of potassium, 3 parts. The bromine, separated by the chlorine from the bromide of potassium, remains dissolved in an excess of the latter, like iodine in potassium iodide. The chlorine water of the German Pharmacopoeia is not so strong as that of the British Pharmacopoeia. Chloralis. Dr. Farrini, in Tunis, as well as several Italian physicians, have used with much success, in diphtheria, a solution of chloral in glycerine. 1209. R. Chloralis, gr. xxx-xl Glycerinae, 3iv-v. M. The dose is varied according to the age, and may be given in water, to the taste. Dr. RoKiTANSKY paints the throat with a fifty per cent, solution. Cubeba. In the early stages of the affection, M. Trideau recommends cubebs in enormous doses — gij to a child of one year, .^iss to an adult, daily. Other observers have spoken well of this treatment. {^London Med. Record, '^xAy, 1877.) Cupri Sulphas ranks, according to Dr. W. Squire, with alum as one of the best and most effectual emetics in diphtheria. He directs : 1210. R. Cupri sulphatis, gr. v Aquae, f § j. M. A teaspoonful at a time, to young children. Ferri Chloridi Tinctura is much employed in diphtheria. It shoiild be com- menced on the first day of the illness, or as soon as the patient is seen, and continued until the tongue becomes red and the throat improves. When deposit has already taken place, the good effects of the treat- ment will be shown, not by any alteration in the size of the patch, but by a diminution in the accompanying secretion, and by improvement of the general symptoms. The iron treatment, as carried out by Dr. Wm. Yeats {Edinburgh Medical J^oumal, July, 1876), is as follows : As soon as a case came under his notice, he prescribed, for adults, lo-drop doses of the strong liq. ferri perchloridi, with 10 to n; -grain doses of chlorate of potash, to be taken in a wineglassful of water, every two hours, until decided improvement was evident, when the interval was prolonged. The dose was modified for children, of course. Vomiting was usually set up by the first two or three doses, but the patient, being warned of this, was instructed to persevere, and after- ward there was no trouble in this way. Constipation was rarely com- plained of, and when it did happen, a little glycerine added to each dose, obviated the difficulty. The local treatment was in the following 794 DISEASES OF CHILDREN. form : Liq. ferri perchloridi and glycerine, in equal parts, which was brushed over the exudations daily. The glycerine helps to dissolve the slough, and the iron hardens the subjacent surface, and consider- ably modifies further exudation. Guaicuum. The following formula has been recommended : I2II. R. Tincturae guaiaci ammoniatse. f.5ss-v Tlncturae cinchonae composite, f.gss Potassii chloratis, 9iv Mellis, q.^. Aquae, adf.Sviij. M. From a teaspoonful to a tablespoonfal, from one to five hours, or thrice daily, accord- ing to the severity of the case. Guaiacum, as a gargle, in all varieties of sore throat, hoarseness, etc., is a remedy of ancient and acknowledged repute. Hydrargyrum Chloridum Mite, Dr. DuER, of Philadelphia (^American Supple- ment to Obstetrical Journal of Great Britain and Ireland, I^Ay, 1873), highly extols the efficacy of small doses of calomel and large doses of the bicarbonate of soda, and the free use of nutritious food and brandy. He states that he has treated a large number of cases, of all grades of severity, by this plan, with satisfactory results. Dr. P. F. WnrrEHEAD combines the calomel with quinine and iron : 1212. R. Hydrargyri chloridi mitis, gr. vj Sodii bicarbonatis, 5j Ferri redacti, Quinix sulphatis, aa gr. xxiv. Enclose in twelve capsules. One every two hours. Under this treatment he has repeatedly seen the pseudo-membrane disappear, and upon the cessation of the mercury and soda, return, and again disappear when the mercury and soda were resumed. The mer- cury and soda should be continued until after all signs of the pseudo- membrane have disappeared. There need be no apprehension of ptyalism. The excess of the alkali prevents it. {Trans. Mississippi Med. Soc., 1878.) Hydrargyrum Chloridum Corrosivum is highly lauded by Dr. Madison Reece, in the Journal of the American Medical Association, 1S83. He dis- solves one grain of bichloride in four ounces of rain-water ; if the patient is old enough to gargle and rinse the mouth and throat, he is to do so every two hours, and immediately afterwards to take a tea- spoonful internally. If the disease be severe, it should be given this way every hour. The above dose is calculated for a child five years of age. It should be continued in smaller and less frequent doses for a week or longer. (See also Dr. Pepper's remarks under the head of croup.) Dr. Hanks reports to the New York Obstetrical Society, 1884, that he has for two years been employing minute doses of corrosive DIPHTHERIA. 795 sublimate internally in the treatment of diphtheria in children, and be- lieves that he has obtained better results thereby than by the use of any other medicine. Hydrargyrum Cyanuretum. Dr. A. Erichsen (St. Petersburg Med. Woch., April 14th, 1877), on the strength of twenty-five cases in which he tried it, strongly recommends minute doses of cyanide of mercury (gr. h-ii) in diphtheria. He believes in the efficacy of mercury abridg- ing the duration of the diphtheric process, while he knows of no other preparation except this which does not quickly disturb digfestion and nutrition. Given in small doses, it scarcely disturbs the alimentary canal at all, even when continued for a long time. It is highly praised' by Dr. Sellden (Jahrb. f. Kindhlkde, 1884.) He uses a solution of in grain in three ounces of water, of which he gives two teaspoonfuls hourly, day and night. Pilocarpine. Dr. Lax {jFournal de Medicine) has successfully treated a number of cases with pilocarpine. Under the influence of this drug the mucus and salivary secretions are greatly increased, large quanti- ties of diphtheritic membrane are expelled from the throat and nose, respiration becomes more free, fever disappears, appetite returns, and convalescence is established in from three to five days. At the close of the attack, every case manifested a characteristic- attack of herpes labialis. The following formula was employed : 1213. R. Pilocarpin. hydrochlor., gr. \ to f. Fepsinise, gr. x to xij. Acid, muriat. dil., niij to iij. AquKdest., f.Sxvijss. M. Sig. — From one to four teaspoonfuls in wine, three or four times a day. Warm fo- mentations were applied to the throat. Papayotin. Schaeffer {Berlin. Klin. Woch., 1883,) has treated forty-seven cases of diphtheria with applications of a five per cent, solution of papayotin, and in almost all of them there was a rapid disappearance of the false membrane, and simultaneous decline of the fever. The applications should be carefully made, every ten or fifteen minutes. It is very expensive. Potassium Bichromas is highly spoken of, gr. tV-J being given in water every half hour till vomiting is caused, when it is to be continued every two hours. Potassii Chloras is the old and tried stand-by in diphtheria. It must be given in large and frequent doses. PotasscB Liquor has proved itself of the utmost value in many severe cases. It may be given, gtt. xx every two or three hours, as long as any membrane is present. 796 DISEASES OF CHILDREN. Quint ce Sulphas has been advocated. Sodii Benzoas. Prof. Klebs, of Prague, (Der. Prak. Arzt., Jan., 1879,) praises this as the best of antiseptics and an antidote to the diphther- itic poison. He gives to adults as much as ,^ss daily, dissolved with an equal amount of sugar in mint-water. Others have also spoken well of it in smaller doses, gj-ij daily. Sodium Chloridum has been used by Dr. G. F. Stewart, of Tennessee, in three well-marked cases, with the happiest results. Sodii Salicylas is recommended by Dr. C. R. Illingworth {Lancet, 1884). To an adult he gives from five to ten grains with twenty minims of the aromatic spirits of ammonia every two hours. If the pulse should be feeble and rapid he adds five minim doses of digitalis, and if there should be any delirium, ten-grain doses of bromide of potassium. Sulphites and Sulpho-Carbolates of Sodium, etc.. have been at times extrava- gantly praised, and again wholly condemned. In some epidemics they certainly have been efficacious. Stimulants. Dr. W. Squire, of London, lays down the rule, the less the quantity of nourishment the patient is able to take, the greater must be the dependence on the stimulant. The youngest children may re- quire a teaspoonful of brandy every two hours ; a child of three years of age, two teaspoonfiils. It may be given diluted in any way, very small quantities at a time, frequently repeated. Other children take it well, mixed with ice or soda water. Champagne is often a good substitute for brandy. Thymol. The following formula has proved very efficacious in the hands of Dr. Warren {Le Frogres Medicate, 1882). 1214. R. Thymol, gr. ivss^vjss Potass, rhlorat., 3ijss Quiniae bisulph., 3ss-j Spts. vini gaUici, f. § viijss Glycerinse, f. % ij. M. For children from two to five years of age, a dessertspoonful may be given every hour, or every second hour. Turpentine is highly recommended by German clinicians, ( journal de Med- ecine de Paris, 1884.) The dose for children is a coffee-spoonful morning and evening. It may be given to children directly after a drink of warm milk, or it may be mixed with the milk and then taken. It has been found to act with great rapidity, since within half an hour a bright red rim can be observed around the diphtheritic exudate, which is soon cast off. LOCAL applications. Acidum Boracicum has been highly praised, when used as a- gargle, and painted over the throat and membrane in saturated solutions. DIPHTHERIA. 757 Acidum Carbclicum. Dr. C. Sedgwick recommends highly {Medical Times Febnaary 27th, 1867,) the following formula: 1215. R. Acidi carbolici, Hlxx Acidi acetici, T^xxx Mix and add gradually, Mellis, Tincturae myrrhse, aa f. 3 i) Aq»2e, ad. f.|j. M. Use as a gargle for adults; apply by means of a sponge to the throats of children. Dr. F. C. HoRTZ, of New York, {Medical Record, August 1871,) uses : 1216. R. Acidi carbolici cryst., Alcobolb, aa 3 j Aquse, f.3v Tincturx iod.i, f. 3is3. M. This makes a perfectly clear, transparent mixture, of a brown-red color, which soon, however, becomes pale yellow. This should be ap- plied to the diphtheritic exudation three or four times in twenty-four hours, by means of a camel's-hair brush. In adults it should be used in a diluted form (fifteen to thirty drops to a cup of water) as a fre- quent gargle, and for injections into the nostrils if the nose is imph- cated. Acid Hydrofluoric by inhalation is recommended by Henri Bergeron, of France. He uses J^ of a drachm for every i J/^ cubic yard which the apartment contains, evaporated in the space of three hours. He claims that they never do harm, that all whom he submitted to this treatment for forty-eight hours were cured, and that it acts as a pro- phylactic for the attendants. The acid is allowed to slowly evaporate from a leaden vessel. ' Alcohol hy inhalation is recommended by Dr. C. T. Melsheimer, of Indiana, in what he calls croupal diphtheria. Argenti Miras. Dr. W. Squire, of London, recommends in diphtheria, when the whole of the false membrane is visible, and its margins within reach, to apply to the patch, and to the surrounding turgid mucous membrane, a solution of the nitrate (one part to three of distilled water) . When there is much redness and pain, a weaker solution (one part to eight or twelve of distilled water), pencilled over the whole surface, tends to prevent further exudation, and affords relief. The solid nitrate is objectionable. Blistering. Dr. F. W. Bartlett, of Buffalo, N. Y., reports, in the Therapeutic Gazette, 1883, one case, wherein the throat exudation markedly di- minished and the general symptoms greatly improved, after the acci- dental blistering most severely of the abdomen, with hot turpentine. The raw belly was covered with an exudation, identical, to ordinary 798 DISEASES OF CHILDREN. inspection, with that in the throat ; and Dr. E. M. Reid reported to the Baltimore Academy of Medicine, 1884, several cases in which marked benefit and improvement in the throat symptoms followed the application of blisters to the chest. As soon as the membrane made its appearance on the blistered surface, the relief was observed. In some cases as the blister healed the throat symptoms reappeared ; but on the application of another blister and the metastasis of the mem- brane, the same relief ensued as before. Brominium. The inahalation of the vapor of bromine has been found of service. Chinoline. The journal of Laryngology speaks favorably of swabbing the throat with chinoline, or irrigating the diseased surfaces with the same. The former method is employed every two hours in the following solution : 1217. IJ. Pure chinoline, gr. cHv Distilled water, SiijSiij Alcohol, S"j 3iij. M. For irrigation the following is used : 1218. R. Pure chinoline, gr. xxxj Distilled water, § xxxij Alcohol, §iij 3iij- M. Chloral is considered by Dr. R. Carney (Canada Lancet, 1880), as a specific in diphtheria. 1219. K. Chloralis, 3) Aquse, § ). M, S. — Use as a gargle every hour or two. With infants it may be applied by a sponge swab. Eucalypti Oleum. This has been introduced as a remedy in diphtheria by Prof. MoSLER. He adds a teaspoonful of a mixture of equal parts of the oil with alcohol, to the water used in a steam atomizer, and directs the inhalation to be kept up twenty minutes in each hour. It causes no irritation of the bronchi, and acts as a powerful disinfectant. Ferri Chloridi Tinctura, applied alone or diluted with equal parts of glycerine. Ferri Sulphas. The following gargle is highly recommended by Dr. De Sabbata, of Venice : 1220. K. Ferri sulphatis puri, 5j Acidi sulphurici diluti, TIlxxv Aqua, f. g iij. M. Use as a gargle. For a topical application, aqux f. % ij should be used in the above. (DoBELL's Reports, 1876.) Dr. Fera uses the finely powdered dried sulphate. He applies it DIPHTHERIA. 799 with a horse-hair brush to the diphtheric patches, and repeats it twice a day. The benefit is prompt and visible. Liq. Ferri Subsulphatis (Monsel's solution) is highly extolled as a local appli- cation by Dr. W. M. Hepburn, of Pennsylvania, in the Medical and Surgical Reporter, 1884. Galvano Cautery. Dr. Bloebaum, of Coblens {Edinburgh Medical Journal), has found in the treatment of diphtheria, that the application of the red-hot platinum wire, even without the use of cocaine, causes very little pain ; that the cauterized sores were totally sterilized, the fever disappeared, the membrane did not re-form, and that no local inflam- mation followed the burning. These results were obtained without the aid of anticeptic or antithermic medicines, and confidence is expressed that " the number of deaths must be reduced to a minimum if the patients are treated in the proper manner without loss of time." Hydrargyrum Chloridum Corrosivum. Dr. Tomasso Billotti has tried in a number of severe cases : 1221. Bt. Hydrarg. chlor. corrosivi, gr. j Alcoholis, Ttlxv Aquae, TIlxx. M. Apply with a fine camel's-hair brush to the diphtheritic patches, two to five times a day. The application must be performed with care, though he never bad any bad results firom it. All his patients recovered in one or two days. (Dobeix's Re- ports, 1877.) lodum. Dr. Waring-Curran obtains excellent results from iodine inhala- tions : 1222. R. Fotassii iodidi, lodi, aa gr. iv Alcoholis, f. 3>v Aquae, f. § iv. M. A teaspoonful (gradually increased to a tablespoonful) of the solution is to be placed, with a handful of dried garden sage, in a pint of boiling vinegar, in a common in- haling jar, for inhalation. The inhalations are to be repeated about twelve times daily. Iodoform is very highly praised by a number of authorities. lodol as a local application has been tried by Dr. Stembo, of Vilna. The drug was applied in the following solution : 1223. R. lodoli, P- " Liq. vini, 3 ss Glycerinse, 5i"SS' The patients all recovered in from four to six days. The advantages claimed for iodol are, its complete harmlessness, its freedom from unpleasant taste or odor, the painlessness of its applica- tions, and the absence of any secondary effect. Lacticum Acidum. Lactic acid inhalations, by means of a spray producer 800 DISEASES OF CHILDREN. (15 to 20 gtt., aquae f.gss), are said to act as a powerful solvent of the false membrane. Limonus Succus is strongly recommended as a gargle. Muriaticum Acidum. Dr. Hillier prefers this caustic to nitrate of silver. In very dilute solution it is an excellent gargle. Potassii Chloras in strong solution is an excellent gargle. Potassii Permanganas. Dr. Watson Campbell recommends {^Edinburgh Medical Journal, February, 1867) the following : 1224. UL. Potassii permanganatis, gr. x Aquse, f. § xx. M. To be used as a gargle, together with the internal administration of iron . and port wine. Pepsin. Acid glycerine of pepsin is recommended by Dr. W. Hale White {^Lancet, 1882), as a solvent for diphtheritic membrane, used as a spray. Salicylicum Acidum. For those who can gargle. Dr. Wagner, of Fribourg, recommends the following formula : 1225. Jt. Salicylic acid, 150 parts. Alcohol, 15 " Distilled water, 150 " M. To be used every two hours. He reports fifteen serious cases as being cured by this method. For children too young to gargle, he gives the acid in water or wine, in doses of i^ to 4^ grains every two hours. Sassafras (oil of) is praised as a local application, by Dr. Kennard, of St. Louis. Soda Chlorinaice Liquor, used as a disinfectant gargle. Sodii Hyposulphis. Dr. Maynard recommends {^Medical Times and Gazette, December 30th, 1865,) the local application of the hyposulphite of soda. In the very early stages he employs, two or three times a day, the following lotion : 1226. B- Sodii hyposulphitis, Si] Glycerinse, f.3ij Aquas, f.Svj. M. This, he finds, generally removes the incipient exudation in forty eight hours, or less. In advanced stages he washes the throat out well with warm water by means of a flexible syringe, and then dresses the affected part with the above solution, using at the same time the following gargle : 1227. B. Sodii hyposulphitis, 5) GlycerinsB, gj Aquae, Qj. M. r The effect of this solution he asserts to be most marked ; it appears to solidify and dry up the false membrane, and when the syringe is DIPHTHERIA. 8oi again used, which it should be frequently, the force of the water will wholly or partially wash it away. The exudation rarely re-forms, and the patient makes a comparatively rapid recovery. It is also highly recommended by Dr. J. M. Armstrong, of Lisbon, Iowa, who uses it in connection with quinine and whisky, and insufflations of sulphur, {Medical and Surgical Reporter, i88i). Dr. M. Meredith, of Vin- ton, Iowa, {Ibid.) has also used the hyposulphite of soda in diph- theria, and thinks it a valuable remedy, but he prefers : 1228. R. Potass, chloratis, 5j Acidi hydrochloric!, nixv Ext. beUadonnse fl., TIlxv Aquae, f-fiv. M. S. — F. § ss to an adult every two hours. Vinegar. F. Frederick Engelman has used vinegar internally in the propor- tion of I tp 4 ; as a gargle, from i to 2, to full strength ; as a spray, I to 2-3 ; or, as a local application, with brush or mop, the pure vine- gar. It has the advantages of being pleasant to the taste and not harmful to the mucous membranes. According to Engelman, it is only exceeded as an antiseptic by corrosive sublimate. (Quoted in Archiv.fiir Kinderheilkunde.) Medicinische-Chirurgische Rundschau recommends the following application in the treatment of diphtheria : 1229. R. Carbolic acid, ij^ to 2>^ drachms. Camphor, S to7M Tartaric acid, 4 to 1° grains. Olive oil, 9 to 12 drachms. Alcohol, 23^ " To be applied with a soft brush. LoFFLER recommends the following gargle in the treatment of diphtheria : 1230. R. Carbolic acid, iS drops. Alcohol, 2 ounces. Distilled water, 5 This should be used as a gargle. In Other cases a solution of i to 2000 of corrosive sublimate may be used in the same manner ; or the following, which is not poisonous, may be employed : 1231. R. Thymol, »5 g^ins. Alcohol, 3 ounces. Water, « SI 8o2 DISEASES OF CHILDREN. PSEUDO-MEMBRANOUS LARYNGITIS (CROUP). LARYNGEAL DIPHTHERIA. M. JULES SIMON, OF PARIS. This distinguished teacher, who has had great experience in the Hopital des Enfants Malades, treats croup as follows : (^Medical Press, 1883). As soon as the malady is diagnosed, he touches the throat with lemon juice or a solution of muriate of iron every two hours, Every three hours he washes the part affected with a solution of borax (two drachms to the ten ounces). The atmosphere of the room is charged with atomized phenic solution, a stimulant nourish- ment is given, and three to five drops of tincture of iron administered every three hotirs. When dyspnoea becomes apparent, an emetic is given ; but if the symptoms are not relieved, tracheotomy must be performed without delay. The after-treatment consists in placing a piece of tarlatan over the canula, warming the room and administer- ing beef tea and tincture of iron. The removing and cleansing of the canula should be done by an experienced person ; it might be definitely removed after the eighth or tenth day. M. Simon con- siders that chlorate of potash is of little use in croup. DR. CHARLES J. FAHIE, OF ENGLAND. This writer states, in the British Medical Journal, 1883, that out of ten cases of croup treated as follows, he did not lose one. He pro- vides that the case must be seen early. A hot bath, a hot poultice of burnt salt to the throat externally, a mustard emetic, and a dose (to be regulated according to the age of the child) of the following mixture every two hours : Tartar emetic, liquor ammonias acetatis, and mistura potassse citratis. The citrate of potash mixture can be made by saturating bicarbonate of potash with citric acid. DR. WILLIAM L. MARTIN, OF NEW JERSEY. This author (^Medical and Surgical Reporter, 1883,) says that since adopting the lime inhalation treatment his success has been almost uniform. But the lime inhalations will only answer where the de- posit is that of true croup. He is satisfied from numerous trials that it has no effect in the croupous form of diphtheria, or diphtheritic croup. When seen early, he places much reliance upon small and repeated doses of calomel, but the cases must be seen early. PSEUDO-MEMBRANOUS LARYNGITIS. 803 DR. E. R. DUVAL, OF ARKANSAS. This author ( Transactions of the Medical Society of the State of Arkansas, 1882,) states that for twelve years, after the manner of Dr. FORDYCE Barker, of New York, he has been using the turpeth mineral in the treatment of this disease, and he has, since the adop- tion of this plan, lost no case of croup. His treatment has been, immediately upon being called to a case, (without stopping to interrogate very closely as to whether he had a croup reflex, catarrhal, or true croup,) to administer at once a dose of the agent (from two to five grains, according to age) in honey, syrup, or sugar of milk, and if there is no decided emesis within fif- teen minutes, to repeat the dose ; and he has never known it to fail to produce vomiting at the second dose ; almost immediately a satis- factory response is secured by the first administration. The vomit- ing is usually free, without effort and without depression. The pow- der is tasteless, small in bulk, prompt in action, and thorough in effect. The virtues claimed for it are sedative and revulsive. " It depletes the mucous membrane by an abundant secretion of mucus, which is thrown up ; it removes from the larynx, by the forced expiration which it causes, any albuminous or fibrinous exudation which may be there in a diffluent state, and which by remaining may become, subsequently, pseudo-membrane ; it acts as a powerful revulsive, and thus diminishes the capillary circulation in the trachea and larynx ; and thus it becomes a most effective agent in arresting the inflamma- tory forces." If the croup persists after removing the causes of reflex action, then, of course, other therapeutic agencies will need to be essayed ; but, throughout the attack, be it short or long, whenever the breath- * ing becomes suffocative, from the accumulation of mucus in trachea or larynx, he gives the turpeth mineral in the manner and according to the conditions and plan above designated. M. THIBON, OF BELGIUM. In the Lancette Beige this author becomes quite enthusiastic over the therapeutic effects of sulphate of copper. He considers it to be not only a very efficient emetic, but also a powerful parasiticide, and therefore of especial value in croup, first causing the expulsion of the false membranes and then preventing their reproduction, through its destructive action on the vegetable organisms. Practically, he asserts 804 DISEASES OF CHILDREN. that this medicament has given him very satisfactory results in very desperate cases ; it should be given in sufficient doses. Children of two years of age have taken over fifteen grains in twenty-four hours without any toxic effects. He employs the following potion : 1232. R. Cupri sulph., RT. viij Aquae, i ij. M. A teaspoonful should be given every ten minutes, until vomiting is induced ; afterwards the same dose may be repeated every hour, and later, every second hour. DR. A. JACOBI, OF NEW YORK. Dr. A. Jacobi reaches the following conclusions in relation to this subject (^Medical Record, 1884): 1. The mercurial treatment of pseudo-membranous affections of the respiratory organs, is promising of great results. 2. The corrosive sublimate is the preparation best adapted for in- ternal medication. 3. The system must be brought under its influence speedily, by frequent doses. 4. It must be given in dilutions of i to at least 3,000-5 ,ocxd. 5. Babies of tender age bear one-half grain and more a day, and many days in succession. 6. Salivation and stomatitis are rarely observed, and appear to heal kindly. Gastro-intestinal disturbances are not frequent; they are -moderate, can be avoided by the administration of mucilaginous and farinaceous food, or of mild doses of opium. 7. If not well tolerated, the inunction of sufficient and frequent doses of hydrargyrum oleate takes the place of the corrosive chlor- ide, either together, or alternately with the internal administration. 8. The treatment of croup may be preventive to a great extent. Most of the cases are complicated with, or descend from, diphtheria of the fauces. Here the preventive treatment of croup must begin. Without desiring to encourage mere local treatment, which, in un- willing patients, has to resort to force or violence, and thereby does great harm, he points to the peculiar local effect of mercury on the pharynx, both in the healthy and sick, as a means to influence the threatened invasion of the larynx. PSEUDO-MEMBRANOUS LARYNGITIS. 805 DR. W. H. DAY, OF ENGLAND. This authority on diseases of children, as the result of long ex- perience, lays down the following rules : The temperature of the room should not be lower than 65°. 1 . The vapor bath is indispensable in the treatment of croup, and should be used at the commencement in every case, and continued unremittingly until all fear of a relapse has departed. 2. All cases of croup are invariably relieved by the vapor bath, especially if the tracheal membrane is dry ; when it is moist there might be fear of causing too much depression. 3. The earlier that a case comes under treatment, the greater the probability of a successful termination, because it is then possible to prevent the tracheal secretion from becoming organized. 4. The most trying difficulty we have to contend with, in the man- agement of croup in the catarrhal form, is a relapse, because, with it, comes exhaustion ; and the weaker the patient, the less will be the chance of recovery. 5. Tartarized antimony is our sheet-anchor as a medicinal agent; not so much from any specific effect it exerts on the tracheal mem- brane, as from its certainty in effecting free and speedy vomiting. 6. Tartarized antimony should, however, be mainly given for the purpose of producing vomiting; that failing, it is comparatively use- less, because, if continued in small doses at intervals, its depressing effect is too great. 7. When the emetic has fully operated, if there be much febrile excitement and disordered primae vise, which aggravates the laryn- geal symptoms, a grain of calomel every four hours, or one full dose for the purpose of emptying the bowels and controlling the fever, will be found necessary. In the fibrinous form, when there is violent and acute inflammation, with a firm, hard pulse and a full reserve of strength, two or three leeches may be applied over the thyroid carti- lage, and bleeding can easily be arrested by pressure with the finger, and if need be, with cotton wool ; then mercury may prove a valu- able addition to the antimonial treatment. Some cases improve from the moment the mercury affects the bowels, the fever diminish- ishing, and the expectoration of the false membrane being promoted. When employed in small doses at regular intervals it would appear to diminish the cohesive attachment to the mucous membrane, and to render the lymph less fibrinous and more readily absorbed. 8. When in a case of croup, seen at an early stage, and satisfac- 8o6 DISEASES OF CHILDREN. torily progressing, forty-eight hours have elapsed, we may generally augur a favorable termination ; and we should then begin, if not be- fore, to support our patients with good beef-tea, milk, and arrow- root, and (it may be) a little wine and water. If after vomiting, the temperature remains high, and especially when the bowels have acted freely, minim doses of aconite every two or three hours, are of great service in inflammatory croup. This keeps up a gentle diaphoretic action on the skin, diminishes tension of the pulse, and controls vascular excitement in a very striking manner. At this stage it comes in well, because antimony should not be long continued in any of the diseases of children, and it cer- tainly ought not to be in this disorder. DR. C. R. ILLINGWORTH, OF ENGLAND. This practitioner {British Medical Journal, 1884,) has had very satisfactory results from the internal use of strong astringent reme- dies, and powerful counter-irritants, in the shape of blisters exter- nally. He applies the blisters under each angle of the lower jaw, and gives minim doses of the perchloride of iron, grain doses of the sulphate of alumina and two-minim doses of the tincture of bella- donna every two hours, sweetening the mixture with glycerine. PROF. FORDYCE BARKER, M. D., NEW YORK CITY. This teacher always commences treatment by the following emetic o{ turpeth mineral: '233. R. Hydrargyri solphatis flavae, gr. iij-^v. For obe dose. If it does not act in Efteen minutes, give a second dose of three to five grains, according to the age of the child. This, however, is rarely necessary. If, on the next visit, he finds the child with a quick pulse, hot skin, somewhat hurried breathing, and an occasional ringing cough, but with no thoracic rales, he directs that it shall be kept quiet in bed, comfortably covered, but not with too many clothes, and pre- scribes the veratrum viride, in one or two-drop doses, according to the age of the child, as, for example, in the following formula : 1234. Jt. Tincturse veratri viridis, gtt. xvj-xxx Spiritfls aetheris nitrosi, f.3ij Sympi, f.|j AquK, f.§vj. M. A teaspoonful every second hour. He visits the child at least as often as every eighth hour, and in- PSEUDO-MEMBRANOUS LARYNGms. 807 creases or diminishes the dose, according to the effect of the medi- cine on the pulse. He is not satisfied until the pulse is below eighty per minute, and then continues the veratrum in half thtf dose that was necessary to bring it down to that point. If thoracic rales, hur- ried and labored respiration, and other symptoms, indicate that the disease is extending downward, then substitute for the above pre- scription something like the following formula, of course varied ac- cording to the special indications of the case : 1235. R. Tincturae veratri viridis, gtt. xvj-xxx Ammonix carbonatis, 5ss Synipi tolutani, Synipi acacise, aa f.§j. M. A teaspoonful every second hour. Sometimes, on account of increasing laryngeal and bronchial ob- struction, the emetic of turpeth mineral should be repeated on the second or third day, but it is not necessary or well to repeat it a third time. Quinine is a remedy of great value, and well tolerated in large doses in some of the diseases of the respiratory organs of children. It is of great service in some cases of croup in the advanced stages, when the respiration is hurried and irregular, and paroxysms of cough are becoming less marked, the intermissions less distinct, and the cough is husky instead of ringing. Our author then substitutes for the last formula the following : 1236. R. Quinise sulpbatis, Ammonise carbonatis, aa 3ss Syrupi senegae, __ Syrupi acacise, aa '•Sj- M. To be well shaken. A teaspoonful every fourth hour. When the croup is complicated with lobular pneumonia, give the quinine separately, 4 or 5 graing three times a day, while the little patient takes the last of the prescriptions containing veratrum viride. (F. 1235.) HERMAN BEIGEL, M. D., ETC., LONDON. Dr. B. recommends in a case of croup the use of the following medicated sprays, given in the order of their value. They are ap- plied by means of the atomizer : 1237. R. Liquor calcis, f-SJ- "*• For one inhalation, lasting about a quarter of an hour, and to be repeated every two hours as long as bad symptoms are present. 8o8 DISEASES OF CHILDREN. A convenient method is to pour hot water on unslaked lime in a, pitcher, and to have the patient inhale the vapor as it arises. 1238. R. Acidi tannici, gr. ij-xx Aquae, f. S j. M. For one inhalation, to last fifteen or twenty minutes. 1239- R- Potassii bromidi, gr. v-x Aquae, f.§j. M. This inhalation, at the early stage of the disease, will often be found to arrest the symptoms. With these inhalations the administration of the emetics or other remedies may be combined. DR. FELIX VON NIEMEYER, PROFESSOR UNIVERSITY OF TUBINGEN. 1240. R. Cupri sulphatis, gr. x-xv Aquae, f. § ij. M. A large teaspoonful to be taken every five minutes until vomiting sets in. In regard to the employment of emetics in croup. Prof. N. thinks that they are only indicated when obstructing croup-membrane plays a part in producing the dyspnoea, and when the child's efforts at coughing are insufficient to expel it. Impeded expiration is an indication for their employment. Sulphate of copper is preferable to tartar emetic or ipecacuanha. It should be given in full doses ; in small ones it is uncertain, and more apt to operate as a poison. If the bowels be confined, administer a clyster,, so that the dia- phragm may have roam to act. The best is a cold one, as follows : 1241. R. Acidi acetic! diluti, f. § ij Aquae, f-fv). M. If, however, there is no remission, notwithstanding the employ- ment of the emetic and the cold application, apply the following con- centrated solution, at intervals of several hours, to the entrance of the glottis : 1243. R. Argenti nitras, 5ss Aquae destillatae, f. 3 ij. M. Dip a curved rod of whalebone, with a small sponge made fast to its lower end, into this solution, press down the tongue of the child, and endeavor to reach the en- trance of the glottis with the sponge. There the sponge is immediately compressed by the muscular contraction which takes place, whereby certainly a portion of the liquid, if only a small one, reaches the larynx. Administer also half a grain of calomel every two hours. PSEUDO-MEMBRANOUS LARYNGITIS. S09 Should this treatment remain without effect, proceed at once to tracheotomy. Besides treating the dyspnoea upon the principles given above, it may be necessary to relieve the paralytic symptoms due to blood- poisoning by carbonic acid. For this purpose the powerful stimulus obtained by pouring cold water upon the child while in a warm bath is of great service. Lose no time in making use of it the moment the child begins to grow drowsy, the skin to cool, the sensorium to be benumbed, or as soon as emetics fail to act. A few gallons of cold water, poured from a moderate height, over the head, nape and back of the child, almost always cause it to revive for a while and to cough vigorously. Thus, sometimes, after the bath, masses of exu- dation are expelled. Other stimulants, such as cainphor or musk, are much less effective, and ought not to be employed, save when in- superable objections are opposed to the cold affusion. They should be given in large doses, immediately prior to the emetic. The fol- lowing formula may be used : 1243. R. Campborse, gr. x iEtheris acetici, f.S")- M. Ten to fifteen drops to be given every quarter of an hour. PROFESSOR J.. LEWIS SMITH, M. D., ETC., NEW YORK. 1244.. £^. Potassii cbloratis, 3j Ammonii muriatis, 9\i Syrupi, f-|j. Aquae, f-SiJ- M. One teaspoonfui every twenty minutes to half an hour, or in cases not severe, every two hours. This should be continued regularly, night and day, until the cough becomes looser, or until it is evident, if the case be unfavorable, that it can be of no service. The atmosphere the child breathes should be constantly loaded with moisture, without, however, that degree of heat which would add materially to the discomfort of the patient or attendants. The temperature should be of 75° or 80°. Besides the nitrate of silver, three other substances have been used of late years, for the topical treatment of the throat, which appear to be more effectual in removing the pseudo-membrane, and control- ling the inflammation. One is liquor ferri subsulphatis ; the second, carbolic acid, and the third, bromine. The following formulae may be used : 1 24s. R- Liquoris ferri subsulphatis, f-3i Glycerine, ^-S^^- ^- 8lO DISEASES OF CHILDREN. 1246. R. Acidi carbolici fluidi, f- 3j Aquae, f-S-vj. M. 1247. g. Brominii, 3>j Potassii bromidi, gr. xlv Aquse, f-lj- M. This is called the bromine solution ; but it must be considerably- diluted for use. Twenty-four to forty drops should be added to an ounce of water, for application to the fauces or larynx. Our author most highly recommends the sulphate of iron solution. DR. J. J. HIGGINS, NEW YORK. The special indications in croup are laid down by this writer {The Practitioner, May, 1877,) as follows: 1. The relief of spasm. For this purpose, emetics are demanded. The best is turpeth mineral (hydrargyri sulphas flava), gr. iij, for children from one to three years of age, repeated once in six or eight hours, if necessary. 2. The relief of congestion and inflammation. To accomplish this, aconite is the most efficient remedy, in small, oft-repeated doses, gtt. ^ to a child of four years. 1248. R, Tinct. aconiti, • gtt. vj Sympi ipecacuanbse, Spiritfls setheris nitiici, ia f. 3ij Aquae cari (vel anisi), f. S ij. M. A teaspoonful for a child of two years. A sinapism to the upper part of the thorax, aids the remedy. 3. The dissolution and expulsion of the membrane. This may partially be done by emetics ; but the real reliance must be on calo- mel, in full doses, gr. x-xx. These large doses are absolutely neces- sary to check the disease. The administration of mercury in small doses does not do this ; it simply effects an augmentation of the secretions ; and, again, neither does the disease last for such a length of time that the constitutional effects of mercury could be got, nor, as a rule, could such effect in the infant be obtained. In larger doses of from 5 to 10 or 20 grains, mercury acts in a totally different way ; and, when so given, exerts a powerful influence upon the dis- ease, of a sedative and salutary character. Dr. ElliotsoN also strongly and earnestly advocates this course, and says, "There is extreme danger here, and, therefore, mercury should be given with the greatest freedom." PSEUDO-MEMBRANOUS LARYNGITIS. 8X1 NOTES ON REMEDIES. Acetum. The fumes of vinegar are highly extolled by Dr. Lesdorf. (Doctor, November, 1875.) He directs that when, after emetic doses of sul- phate of copper, the dyspnoea seems not to yield, a vapor-bath is to be given, as follows : A wooden vessel, containing eight to ten quarts of hot water, half to three-quarters of a pint of vinegar, and a handful of meal, is to be placed at the foot of a child's bed ; a quilt is then to be suspended over the bed, so that one end is to cover the vessel, and the other so arranged that the vapor, in escaping, must pass over the child's head. A red-hot iron is then to be placed in the vessel, and left there so long as it develops the hot acid vapor. This bath is to be repeated every two hours, night and day, while there is any danger. The very best results may be anticipated from this method of treat- ment, and operative interference, even in acute cases, may often be prevented by energetically carrying it out. Acidum Lacticum, as a solvent of false membrane in croup, is highly esteemed. The following is the formula of the London Throat Hospital : 1249. £^. Acidi lactici, § ss Aquae destillatse, f. § x. M. Use with an atomizer. Alumen was the favorite emetic in this disease with the late Prof. Charles D. Meigs. He gave 3J in molasses or honey, as required. Antimonii et Poiassii Tartras is still preferred as an emetic by some. Dr. Ellis prescribes : 1250. Q. Antimon..et potassii tartratis, gr. ij Oxymellis scillse, Aquie, £5 f.ij. M. Two or three teaspoonfuls every quarter of an hour, in the early stages of croup, to a child four years old. Apomorphine is effective, but highly dangerous, as it exerts a paralyzing action on the respiratory organs. Prof. Dujardin-Beaumetz recommends its use as an emetic, the dose being from -^^ to ^^ of a grain. Argenti NUras, dried and pulverized, and mixed with sugar, has been used for an insufHation in membranous croup by Dr. Guillon, of Algiers. Belladonna has considerable value in spasmodic croup. Atropia, hypoder- mically, gtt. iij of a one per cent, solution, has been used successfully by Dr. DePontives {Union Medicate, 1878). Brominium is recommended by Dr. Redenbacher, {Med. Cent. Zeit., 1879) : 1251. R. Brominii, _ g*.'" ^ Potassii bromidi, ^j Decocti altbese, | ?* , , Syrupi. SJ- ^' A dessertspoonful to a child of seven years. 8l2 DISEASES OF CHILDREN. Calx. The odor from slaking lime, and lime-water as a gargle, are both valu- able remedies. (See above.) Chloral has been highly extolled by Dr. Wiluam Stewart in spasmodic croup. {^Lancet, May 2Sth, 1878.) He claims it to be the remedy par excellence. Collodium Cantharidatum. In severe croup of diphtheria, when emetics give no relief, Dr. Musicautoff, of Warsaw, has found repeated out- ward applications of cantharidal collodion to the throat to yield very successful results. (Dobell, Reports on Diseases of the Chest, 1876.) Cupri Sulphas is one of the best emetics in croup. To a child a year old, gr. j5^ , in some sweetened water, till emesis is produced. Ferrutn, in almost any of its preparations, is useful in strengthening the sys- tem and diminishing the excessive nervous sensibility which is so con- stantly a cause of laryngismus stridulus. Hydrargyri Chloridum Mite, in large doses, is recommended on good authority. Hyoscyatnus is an excellent sedative. Dr. Da Costa recommends : 1252. R. Extract! hyoscyami fluidi, IHiij-x AqiuE destillatse, f. § j. M. Used as an inhalation in speismodic croup. Oxygen inhalations are highly lauded by Dr. Joseph B. Potsdamer in the Medical and Surgical Reporter, 1880. Petroleum Rectificatum, or kerosene, in doses of f.gj-iv, is a popular and suc- cessful remedy in croup. {^t& Medical and Surgical Reporter, ^xA 14th, 1877.) Potassii Chloras. Dr. J. F. Meigs speaks highly of this drug, which he com- bines with ferric chloride. Potassii lodidum. Dr. Taylor, of Baltimore, speaks highly of this drug, in large doses (fifteen grains every two hours). Potassii Chloras. 1253. R. Potassii chloratis, gr. v-x Tinct. ferri chloridi, lUiij-v Syrupi, f.5ss AquK, f.5ij. M. This quantity every three or four hours. QuinitB Sulphas, given in the largest doses the child can bear, and during the intervals of the paroxysms, is a very satisfactory remedy, especially in weak and obviously nervous infants. VaUrian is highly recommended by Dr. G. Hill {British Medical yournal. INTUBATION OF THE LARYNX. 813 April nth, 1868,) who, however, neglects to mention the preparation and dose he employed. Dr. Ellis recommends in spasmodic croup : 1254. R. Tinct. valerian, ammon., Dlv-x Tinct. camph. comp., Hlv Spiritfls chloroformi, I^iij Aquae anethi, f. 3ij. ^ For one dose. M. Lewentauer {DOrgane de la Confratemite) describes a num- ber of cases in which recovery seemed doubtful, but which entirely recoverd after the employment of the following : 1255. R. Olei terebinthinse, 3j Olei amygdalae dulc, 5 iiss Syrupi, 3v Mucil. acacise, 5" Vitelli ovi No. j, 5 iv Aquee cinnamomi, 3 xijss. Sig. — ^Take a teaspoonful every two hours. INTUBATION OF THE LARYNX. The following remarks have been carefully collected from the most recent current literature : Denhard {N. Y. Med. Presse, September, 1887). The author looks upon intubation as a great advance in therapeutics when com- pared with tracheotomy. He considers the latter a very difficult and dangerous operation, and thinks that intubation is almost entirely free from the many dangers which beset the more formidable ope- ration. In performing tracheotomy, we also have to contend with the the parents' dread of having any operation performed, the dangers of anaesthesia, the disadvantages of operating at night, shock, and the care which must be devoted to the tube, and atmospheric sur- roundings. On the other hand, intubation is bloodless, and after a little practice can be performed very easily. Its principal advantages are to be found in the facts that the parents will readily consent, there is no need of an anaesthetic, the irritation of the tube is much less than that of a canula, the air in- haled through the tube is warm and moist, and the danger from lung complications is much less. In addition to these, the time required for the operation is insignificant, and if the patient recovers no un- sightly scar will be left. The after-treatment is simple, and does not tax the physician; it can be performed on very young children, 8 14 DISEASES OF CHILDREN. often in cases where tracheotomy would be almost, or quite impossi- ble. The chief disadvantages of the tube are that its introduction may cause portions of the membrane to be forced into the trachea with the result of occluding the lumen ; the tube may be obstructed . by mucus, but this would excite coughing and be readily expelled ; the difficulty in swallowing interferes with nutrition, and in some cases it may be found necessary to feed the patient through an oesophageal tube or per rectum ; the tube may be coughed up, in such cases a larger one should be used. The author thinks that the percentage of recoveries after intuba- tion is but little greater than after tracheotomy, but at the same time he is of the opinion that the time is not far distant when the former will entirely supplant the latter. In his own practice, he has performed tracheotomy thirty-four times with fifteen recoveries, and intubation twenty-seven times with thirteen recoveries. The age of the patients who recovered after intubation, ranged from thirteen months to five years. Bernard Pitts {Lancet, December 24, 1887), thinks that laryn- geal intubation and tracheotomy are about equally efficacious. He says, " laryngeal intubation is to be preferred because it does not compromise the patient's life as an operation ; because it does not give pain ; because it can be performed without danger to life ; be- cause it does not require the subsequent constant attention of a trained assistant, and because convalescence after its use is more rapid than after tracheotomy. " The operation is simple and easily performed. Without doubt, it can be more readily performed by one who has manual dexterity and who has had suitable practice upon the cadaver or some artificial apparatus." Gay {Boston Med. and Surg. Journal, October, 1888), gives a large number of statistics, showing the percentages of recovery from tracheotomy and intubation to be respectively: In tracheotomy, from twenty-two to thirty-three per cent. ; in intubation, from twelve to forty per cent. The author at the same time remarks, that statistics are proverb- ially unsatisfactory, and that at times they are positively misleading. His conclusions are, that in a majority of cases of membranous laryngitis, intubation may be done with a fair prospect that it will effectually relieve the dyspnoea. That it is to be preferred in young children and in all cases where the patient lives at a distance from INTUBATION OF THE LARYNX. 815 skilled aid. That it may be resorted to, preliminary to tracheotomy. That it may be done for euthanasia, provided the operator is expert and can do it quickly, without producing collapse. Tracheotomy is indicated in those cases in which intubation cannot be done, or in which it fails to relieve the dyspnoea. It is also to be preferred in those cases of intubation which can- not be fairly nourished, either in the natural way or by enemata, etc. It may be resorted to when the O'Dwyer tube is frequently ejected, or when it requires frequent removal to prevent obstruction. Francis Huber, M. D. (Arc. Fed., January, 1889), reports ninety- four cases of intubation, with thirty-seven recoveries — about forty per cent. The author considers this a very favorable showing, and especially so because of the fact that the larger portion of the cases occurred in thickly populated districts under the poor hygienic and sanitary conditions existing in tenements. " Intubation was resorted to," he says, " no matter what complications existed, where the ste- nosis became sufficiently grave to warrant operative interference." CATHETERIZATION OF THE TRACHEA. Since it is not always possible to secure the consent of the parents to perform tracheotomy, it will be well to bear in mind that a cor- respondent of the British Medical Journal, when placed in such a position where tracheotomy seemed imperatively demanded, yet where consent was refused, resorted to the following procedure : He introduced a large (No. 12) gum-elastic catheter into the trachea, with less difficulty than he had anticipated — having first gagged the child's mouth with a cork. After a severe paroxysm, the patient suc- ceeded in getting a good breath, and the next expiration was fol- lowed by the ejection of muco-purulent debris and sticky phlegm through the tube. In about ten minutes these convulsive effisrts ceased — the child, in the meantime, getting a good amount of air iuto her lungs. In half an hour her face was flushed, but had lost its lividity, and the breathing was fairly comfortable. The tube was re- tained by tape tied around the child's neck, and was removed twenty- four hours after its insertion, when the temperature had fallen to 100° F., and the pulse from 150 to 100. Five days later she had entirely recovered. 8l6 DISEASES OF CHILDREN. TRACHEOTOMY IN DIPHTHERIA. PROFESSOR BUCHANAN, OF GLASGOW. This author considers {^Proceedings International Medical Congress, 1881), that tracheotomy is justifiable in diphtheria as well as in croup, but only in the sthenic or simply suffocative form. The type and stage of the disease demanding tracheotomy was best recognized by observation of the naked chest. The operation should be per- formed with the utmost deliberation, and the higher up the trachea the better. In the after-treatment all medicine should be abandoned, and reliance placed solely on nourishing food, with a copious supply of fresh air, at a proper temperature, the moisture being secured by a porous sponge, kept moist and hot, or a little loose gauze placed over the mouth of the tube, which should be kept scrupulously clean and clear. DR. E. E. MONTGOMERY, OF PHILADELPHIA. In operating, this author (^Med. and Surg. Reporter, 1884,) gives chloroform, and avoids hemorrhage by transfixing a fold of the skin, held by himself and assistant, making an incision one inch long, com- pleting the dissection to the trachea by the forceps and grooved director. After opening the trachea, care is observed to remove all membrane previous to insertion of canula. After-treatment consists in attention to tube, keeping several thicknesses of tarlatan wet with hot carbolized water over it. The temperature of the room is main- tained at between 75° and 80° F., and stimulants and good food given, together with quinia, tincturse ferri chlorid. and corrosive sub- limate — the latter in frequently repeated doses. The attempt is made to dispense with the tube from the fifth to the eighth day, but it should not be removed until respiration per vias naturales is fully established. He formulates the following conclusions : 1. That tracheotomy is justifiable in diphtheria as well as in croup. 2. That it should be performed in croup when it is evident that drugs do not control the progress of the disease, particularly when there is depression of the lower end of the sternum during inspira- tion ; in diphtheria, with the advent of suffocating symptoms. 3. That in the performance of the operation, the knife should only be used to incise the skin and trachea, the intervening tissue being torn by director and forceps. 4. That the subsequent use of proper drugs will promote a favor- able result. PERTUSSIS. 817 PHRTUSSIS (WHOOPING COUGH). Dr. Jacobi {Arc. Ped., July, 1889). The following conclusions are the result of this author's wide experience : The air must be kept pure, uniform and moderately warm ; no wind or draught must be permitted. Utensils must be kept clean and disinfected, and the masses brought up by vomiting disinfected, destroyed or removed. The mucous membrane of the mouth and pharynx should be kept clean and healthy. Careful measures in this direction will aid in preventing complications that are so apt to occur. This end can usually be attained by the use of the chlorate of potassium in the dose of half a grain to a grain in a teaspoonful of water every hour. Many of our expectorants also find application in such cases. All expectorants which cause depressing effects, must be carefully avoided, particularly antimonials. Even ipecac must be given in very small doses. The muriate of ammonia in doses of from half a grain to two grains every hour or two hours will liquefy the viscid secretions of the bronchial mucous membrane. The vapors of benzol and carbolic acid give relief, and offer explanation of the fact of benefit derived from the inhalation of the vapors from gas-houses. Cases exhibiting a severe degree of pharyngitis and laryngitis, par- ticularly in children who have suffered a long time from chronic in- flammatory affections of the parts, will do well, as far as the local symptoms are concerned, under the use of the tincture of pimpinella saxifraga ; a drachm distributed over the twenty-four hours, will be the proper dose for a child of from two to three years. Almost all the drugs of the pharmacopeia have been used for the cure of this disease, with varying success. Antipyrin has been recommended by eminent authorities since 1886. It is claimed that it can be given with the same beneficial result in the beginning of the disease and in its most severe stage, and that the affection will terminate favor- able in from four to five weeks. The dose is from a grain and a half to two grains, three or four times a day, for every year of the patient's life, with an occasional large dose for the night. Dr. Jacobi thinks that the remedy, par excellence, is belladonna. He says : " I scarcely remember a single case, for years past, in which its administration has proved unsuccessful in shortening the dura- 52 8l8 DISEASES OF CHILDREN. tion of the process. The result obtained by me has generally been this : that a well-developed case of whooping cough, after the diag- nosis was made certain without a doubt, would last for only three or five weeks longer instead of running through its full course of months and quarters of a year. The effect is generally not a sudden one. Many cases in which belladonna is given from the commence- ment will become worse for a short while, then remain at their height for some days, and then gradually improve, in both the character and frequency of the attacks. In others the effect is per- ceptible from the first, the cases soon assuming a favorable aspect. Such has been my uniform experience during the last five years, in each of which the children of this city have been suffering from a more or less severe epidemic. Infants of six or eight months of age require a sixth of a grain of either the root or the alcoholic ex- tract, three times a day; children of three or four years tolerate three doses of half a grain each." He finds that children can stand a much larger dose proportionately than adults, and that large doses are necessary to get the full beneficial effect. The tincture of bella- donna is a convenient form for administration, in as much as the dose can be readily regulated. A baby of two years may take three daily doses, the first of which may be six drops. If the char- acteristic flush be perceptible within twenty or thirty minutes, the dose is sufficient ; if not, the dose must be increased until this effect is obtained. After a few days larger doses will be required. Every case will demand at least twice the amount of the original dose, within ten or twelve days. For the purpose of giving the child quiet nights Dr. Jacobi recommends small doses of opium, but does not advise it for anything like a regular administration. A grain of Dover's powder, given at bedtime to a child of two years, will, at all events, have the effect of producing sleep. In a number of cases the combination of opium and belladonna hag a favorable action. Dr. Rachel {New York Med. Press, K\x%Vi%t, 1888). Formerly this physician has always used belladonna in whooping-cough, with good results. He was induced, however, by favorable reports, to try the use of chloride of gold and sodium. For the past two or three years he has continued to use it with great satisfaction, either alone or in combination with tincture of opium. A two per cent, solution of the chloride is used, and five to eight drops in water are given every two hours. The nuinber of paroxysms will soon be reduced, and also the du- PERTUSSIS. 819 ration of each. If, after two or three days, the improvement should be only slight, the dose can be cautiously increased. The resulting improvement will be especially marked by the freedom from parox- ysms at night. The author has used as large doses as fifteen drops of the two per cent, solution every two hours. It is claimed that this treatment will shorten the disease, and make the patient much more comfortable during its course. It is also claimed that it will lessen the danger of complications. Dr. Stepp {Deutsche Med. Wock., 1889), publishes a valuable article on the treatment of whooping cough with bromoform. In 100 cases treated, there was not a single failure. He gives the bromoform pure in one drop doses, in a teaspoonful of water. On account of its high specific gravity, the bromoform sinks to the bottom of the spoon, and there forms an isolated drop. The spoon should then be carried well back into the mouth, and its con- tents rapidly swallowed ; by this means all taste is avoided. The dose, given 3 or 4 times a day, varies as follows : For children 3 to 4 weeks old, i drop ; in older nursing children, 3 drops, ac- cording to the intensity of the attack ; in children of 2 to 4 years of age, 4 to 5 drops. Dr. Stepp claims diminution of vomiting, shortening of attacks and increased appetite, with a perfect cure in from two to three weeks. But a small quantity of the drug should be ordered at once, as it is very volatile. Protect it from the light. Dr. Geo. Hollow ay, {British Medical Journal^ 1887, adopts the following treatment : The patient is confined to one room for a week or ten days, each nostril is insufflated every three hours during the day, and once dur- ing the night, with from two to three grains of finely-powdered boric acid. No difference should be made in the diet, unless some special circumstance calls for it. At the end of ten days, allow the child to go out in favorable weather. An ordinary insufflator of small size may be used. Twenty cases reported by the author, were cured in three weeks without other treatment. MORPHINE AND APOMORPHINE IN WHOOPING-COUGH. Dr. FedoROFF {British Medical yournal) states that he has ob- served good results from the administration, four times a day, of a tablespoonful of a mixture containing two grains of morphine hydrochlorate, one grain of apomorphine hydrochlorate, one-half drachm of hydrochloric acid, and eight ounces of distilled water. The paroxysms are lessened after the first few doses. 820 DISEASES OF CHILDREN. SULPHATE OF QUININE IN WHOOPING-COUGH. Dr. G. A. Mueller, Chicago, (^Chicago Medical Times, 1887,) has treated a great number of cases, without one failure, with the follow- ing remedy : 1256. R. Quininse sulpb., gr. xv. Ft. chart., No. x. Sig.— One powder at 7, 9 and 1 1 o'clock a. m., respectively, every alternate day until all have been taken. The spasmodic or paroxysmal element is positively subdued after the first day's treatment, which simply leaves the bronchial catarrh to treat. The above dose is for a child three years of age, and can be modified to suit any age. coceine in whooping-cough. Bianche, (^Medical News, 1887,) claims good results from the use of cocoaine. He gives from one and one-half grains to twelve grains in twenty-four hours. He uses a solution in small frequently re- peated doses. PURE BENZOL IN WHOOPING-COUGH. Dr. Jno. Lowe, {British Medical Journal, 1887,) recommends the use of benzol in whooping-cough after the acute stage. Its most marked effects are the diminution of the expectoration and a de- crease in the spasmodic nature of the cough. The following will be found a convenient and not unpleasant formula : 1 25 7- K- Benzol, Tllxxxij Glycerinaj, § iss 01. menthse pip,, Dlx Syrupi, § ss. M. Sig. — A teaspoonful every two or three hoars. PEROXIDE OF HYDROGEN IN WHOOPING-COUGH. Dr. Benjamin Ward Richardson, in The Asclepiad, states that he has had excellent results from the use of peroxide of hydrogen in whooping-cough. It subdues the spasmodic paroxysms, checks the secretions in the throat, and shortens the duration of the mal- ady, thereby lessening the danger of sequelae. His favorite pre- scription is as follows : 1258. R. Hydrogen peroxide (lo vols, strength), 5yj Glycerine, 3iv Distilled water, to make § iij, M. One teaspoonful in a wine-glass of water, to be taken at one dose. Where, there is stridulous spasm with the cough, Dr. RICHARDSON either substitutes two drachms of ozonic ether for the solution of the peroxide of hydrogen, or adds it to the above solution. PERTUSSIS. 821 Von Geuser is said to use the following prescription in the treat- ment of whooping-cough : 1259. R. Carbolic acid, • ij grains. Rectified spirit, 2 drops. Tincture of iodine, j drops. Tincture of belladonna, 10 drops. Peppermint water, 2 ounces. Syrup, 1 drachm. To a child of two years a teaspoonful of the mixture may be given every two hours. DR. ARMAND SEMPLE, OF LONDON. This author very truly says that the treatment of whooping-cough cannot be considered as satisfactory. After enumerating the various classes of remedies that have been recommended, he says that it may be stated in general terms that in uncomplicated cases of whooping- cough it will be useful to administer in the first place some mild al- teratives and antacids, as hydrargyrum cum creta, soda, potash, and rhubarb, together with ipecacuanha in moderate and long-continued doses (5—10 minims according to the age). In general the disease lasts, in spite of all remedies, from a month to six weeks ; but it may last much longer, in which case change of air will be found the most efficacious remedy, and not merely from an unhealthy to a healthy locality, but vice versa. It has been proposed and successfully car- ried out, to take sufferers from whooping-cough to the neighborhood of gas works, the effluvia from which, appear to exercise a beneficial influence over the disease. When pertussis is complicated, as it often is, with other affections, the appropriate remedies must be employed. Thus in the strumous diathesis, cod-liver oil and iron will be indicated. DR. EDWARD HENOCH, OF BERLIN, Tells us that he has come to rely upon one drug alone, viz. morphine, which will at least moderate the violent paroxysms, especially the nocturnal ones, and diminish their frequency, although it does not influence the course of the disease on the whole. 1260. R. Morphiae acet. vel. muriat., gr- \-\ Aquse destil., (•!•!.. ,, Syrupi, f-3"). M. S. — ^Teaspoonful two or three times daily. We should be careful to warn the mothers, that as soon as unusual drowsiness develops, the remedy should be at once discontinued. When carefully administered Dr. H. has never seen any bad results 822 DISEASES OF CHILDREN. follow, even when one or two teaspoonfuls of the mixture were given daily for weeks ; he therefore prefers it to all other narcotics, espe- cially to the dangerous atropine. But he would recommend mor- phine only in severe cases, where at least twenty paroxysms occur in the twenty-four hours. He sometimes uses inhalations of carbolic acid, combined with the morphine. From them he has sometimes had good results, sometimes none at all, but he hjis never observed any bad effects. He uses either a one or a two per cent, solution, by means of a spray apparatus ; if this is difficult of performance, the air of the room may be impregnated with its vapor, and a sponge, dipped in the solution, hung at the head of the bed, with a similar one held in front of the child's nose several times a day, so that its vapor can be inhaled for several minutes. In fine weather the fresh air should be enjoyed as much as possible ; but in rough, windy weather, or when severe bronchial catarrh is present, this should be strictly prohibited. His experience does not teach him that a change of air has any beneficial influence. DR. V. H. MOORE, OF ONTARIO. This author has been using croton-chloral hydrate for some years with great success {^Medical and Surgical Reporter, 1884). In ninety-five per cent, of the cases in which he used it, the disease was cured in from six to twelve days. During the past five years he has attended two epidemics of pertussis, which gave him ample opportunity for testing the merits of croton-chloral in persons of almost all ages, from infants under eight months to persons of the age of fifty-five years. He found it to act equally well, no matter what the age was. It must be given in full doses, every three hours, properly dissolved. His method of prescribing it is as follows. For a child from eight to ten years of age : 1261. R. Cioton-chloral byd., Biiss Aqiue bulUentis, ad. f, § viij. M. Sig. — § ss every three hours, night and day. The above dose, of course, should be increased or lessened, ac- cording to the strength and age of the patient. He does not use anything to cover the taste of the remedy, nor does he use any- thing to render it more soluble, experience having taught him that the best results were obtained when the remedy was given as above described. Croton-chloral has proved as sure a specific in his PERTUSSIS. . g23 hands, in whooping-cough, as quinine has in intermittents. Let it be constantly borne in mind, that to get the beneficial effects of this drug, it must be given in full doses, every three hours, properly dissolved. DR. ^CONCORVO, OF RIO DE JANEIRO. This author tells us, in the Allg. Med. Centr. Zeitung, 1884, that he has come to the following conclusions after careful study and much experience: 1. Whooping-cough, the nature of which, until recently, was the subject of the greatest dispute, seems, to judge from the latest clin- ical observations and microscopical examinations, to belong to the zymotic diseases. 2. The disease seems to be due to the presence of micrococci, which develop themselves to an alarming degree in the mucous membrane of that part of the larynx situated below the glottis, and infiltrate the epithelial cells. 3. Resorcin, applied directly to the mucous membrane of the larynx, has not only diminished in a very short time, the number of the attacks of coughing in cases in which it was employed, but it has also decidedly cut short the course of the malady. The best method of applying resorcin in these cases is its admin- istration by an atomizer. If this cannot be had, it should be blown in the usual manner into the larynx by the aid of a quill. The only trouble is that whooping-cough is apt to attack your children, and that in them all direct applications to the larynx are difficult to ac- complish. The internal administration of resorcin is, however, utterly useless. DR. W. C. WEBB. This author has also had excellent results from the use of croton- chloral, (see Dr. V. H. MoORE, previously) which he mentions in the American Practitioner, 1883. The lesson taught him by his experi- ence, is to the effect that croton-chloral is, with very rare exceptions, singularly well borne by children. Next, that to get the full value of the drug, it must be given in decided doses — doses large enough to produce quick and marked effect. A child twelve months old will bear a grain of the medicine every four hours, day and night, or six grains in the twenty-four hours ; and to get its curative effects, not less than this should be given. This during the first week. After that time the cough is usually so much relieved that the number of 824 • DISEASES OF CHILDREN. doses may be lessened, the drug being given during the day only. Used in this way, that is, pushed to its full effect, he has very seldom seen a case in which the cough was not under entire control within a fortnight. And he includes in this statement several excessively severe cases, complicated by convulsions and marked catarrhal difficulty. Children from ten to twelve years years old will require two grains of croton-chloral at a dose, while an adult will not often bear more than four grains repeated, every four hours, as with the young child. The drug does not disorder the digestive organs, and by lessening the frequency and severity of the paroxysms, it puts an end to trou- blesome hemorrhage and vomiting. Occasionally the first few doses produce some irritation about the throat and fauces, but this soon passes off. The toxic effects of the medicine do not seem to affect the organic centres. He has more than once seen patients fall asleep under its influence while in their chairs, the respiration and move- ments of the heart remaining unchanged. Croton-chloral is readily dissolved in. comp. tr. cardamom, if first the drug be thoroughly pulverized. An eligible mixture is' formed by dissolving one drachm in two ounces each of tr. card, and gly- cerine. He has met with several cases in which the paroxysms of cough were so severe, and accompanied by such extreme gastric irritability, that it was necessary to give the patient a few whiffs of chloroform before attempting to administer the croton-chloral. He has seldom found it necessary to repeat the chloroform more than two or three times. In such cases as have used the anaesthetic, the very happiest effects have followed. Of the mixture mentioned, one drachm of croton-chloral and two ounces each of tr. card, and glycerine, the dose is a half-teaspoonful every four hours for a child two years old and under. Croton-chloral is so expensive a medicine that he has, owing to the known efficacy of belladonna in whooping-cough, sometimes used the following recipe, and with very good results : 1262. R. Croton-chloral, 5j Tr. cardam., § ij Tr. belladon., 5ij Glycerin., § iij. M. Dose, same as of other. He sometimes combines the several bromides with the croton- chloral, but never felt sure that they added in any degree to its effi- PERTUSSIS. 825 cacy. If one bromide is better than another, it is the bromide of quinia. But he relies now exclusively on the croton-chloral in the management of pertussis. While he has never seen any unpleasant effects from this drug, he adds that in its exhibition, a watchful care should be exercised lest, for some reason, its toxic effects should manifest themselves. DR. DOLAN, OF ENGLAND. This author reviews all the remedies usually recommended for whooping-cough, in the Midland Medical Miscellany, 1884. Bella- donna for general results, and salicylic acid, in the form of spray (^ to y^ per cent.), for immediate relief, are credited with the best average of efficacy. Dr. DOLAN deduces, with some force, from this conclusion (the salicylic acid having, in his belief, merely a germici- dal action) a support to the theory advanced in his previous essay of the fungoid origin of pertussis. The special form of microbe, rejoicing in the name of the bacillus pertussis, and believed to be pathognomonic of the disease, has been described and shown by Professor Berger. Dr. DOLAN observes, however, that we must " recognize, as in phthisis, that the finding of the bacillus is only the first link ; experiments must determine the connection between the organism and the disease." So obviously and readily contagious is pertussis, that such experiments, when performed, ought soon to fur- nish a definite conclusion. PROF. JOHANN STEINER, M. D., PRAGUE. This judicious author remarks that we have no specific remedy for whooping-cough, and of all those which have been recommended, belladonna, in doses of the extract of ^ or ^ a grain three or four times a day, either alone or in combination with quinine or the oxide of zinc, seems of greatest service. The dose of belladonna is to be gradually increased until symptoms of intoxication appear. When there is abundant mucous secretion and no vomiting, an occasional emetic is useful. Prof. BarthOLOW and others consider the best form for adminis- tering belladonna is a solution of the sulphate of atropia : 1263. R. AtropisE sulphatis, gr- j Aquae destillatae, - f-SJ- M. Two to four drops at a dose. He believes it most effective in the spasmodic stage, when there is profuse bronchial secretion. 826 DISEASES OF CHILDREN. MR. JOHN REYNOLDS, LONDON. 1264. R. Quiniae sulphatis, gr. xv] Acidi sulphuric! diluti,. q. s. Tincturse aurantii, f. 3 ) Aquas, adf-gij. M. Two teaspoonfuls every three hours. Mr. Reynolds claims for quinine a specific abortive power over whooping-cough. With the above formula he cures his cases in two days. Other physicians report favorably of the method. To do good, it must be pushed to a quantity equal to a full antiperiodic dose. To a child under three years, ten grains should be given in twenty-four hours ; to a child twelve years old, from sixteen to twenty grains should be given in the same time. Dr. F. FORCHEIMER, of Cincinnati, prefers to give quinine by in- sufHation. For this purpose a laryngeal insufflator is used — it mat- ters not what kind ; this is introduced, and three or four of the powders, the formula for which follows, are blown daily into the larynx, but especially upon the epiglottis and surrounding mucous membrane. 1265. H- Quinise sulphatis, 9j Sodii bicarbonat., Pulv. acaciap, ia gr. xx. M. For ten powders. When this method is used as described, according to his experi- ence, no cases withstand it. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. 1266. K. Aluminis, 3ijss Syrupi zingiberis, Syrupi acadse, Aquae, aa f.§j. M. A tablespoonful thrice daily, every five or six hours. This recipe, when prepared with good syrups, tastes very much like lemonade, rendering it acceptable to children. Our authors more generally employ alum in combination with belladonna. They have obtained better results from the following formula than any other ever employed : 1267. R. Extract! belladonnse, gr. j Aluminis, 5 ss Syrupi zingiberis, Syrupi acacise, Aquse, aa f.Sj. M. A teaspoonful morning, noon and night; also once in the night, if the cough be troublesome. PERTUSSIS. 827 1268. g. Potassii carbonatis, ^j Cocci., 9ss Sacchari albi, 5j Aqua, f.|iv. M. Dessertspoonful thrice da3y, to a child a year old. This mixture has long enjoyed a high reputation in this country and abroad. Our authors, believing its efficacy to be due to the carbonate of potash, ordinarily omit the cochineal. This recipe, to- gether with the alum and belladonna mixture given above, present the most useful agents we have to keep down the violence of the disease. DR. GOLDING BIRD, LONDON. 1269. li- Aluminis, gr. xxv Extract! conii, gr. xij Syrupi rhoeados, f. 3 ij Aqvue anetbi, f. § iij. M. A medium sized spoonful every three hours in the second or nervous period of the disease, after the subsidence of inflammatory symptoms, and when the patient is harassed and exhausted by the attempts to get rid of the copious bronchial secre- tion. Under these circumstances, this author considers alum, which he administers according to the above formula, the most satisfactory of all remedies, affording the speediest and most marked relief: PROF. FELIX VON NIEMEYER, M. D., TUBINGEN. This author attaches considerable value to a well-managed treat- ment by sweating, especially at the commencement of the disease. When there is much mucus in the throat and a paroxysm of cough- ing is threatened, he gives : 1270. R. Coccinellae, gr. xij Potassii carbonatis, 9j Syrupi simplicis, f. i j Aquse, f. S iij- M. A teaspoonful at a dose. Dr. NiEMEYER cannot admit that any narcotic whatever (bella- donna not excepted) has any specific action against this disease. Should the treatment given above prove ineffective, should the child empty its stomach with every paroxysm, should his nutritive condition begin to suffer from constant vomiting and sleepless nights, should convulsions or signs of actual suffocation occur during the seizures, the administration of narcotics is indicated. Belladonna enjoys the advantage over opium, that, in the condition of the pupil, we have an index for regulation of the dose. To children between the ages 828 DISEASES OF CHILDREN. of two and four years, we may give the ^ of a grain of the drug, night and morning, gradually increasing the dose up to ^ a grain, or until the pupil begins to dilate. For older children small doses of morphia (gr. A-jr, in die). If, immediately after the cough, there still remain audible rales in the chest, it the child grow short of breath, or the respiration become enfeebled throughout a part of the thorax, an emetic should be given forthwith, and repeated when- ever the symptoms recur. In the third stage, when impoverishment of the blood and general exhaustion furnish the most urgent symp- toms, the free administration of meat diets, eggs, wine, and the fer- ruginous preparations, is indicated. NOTES ON REMEDIES. Acidum Carbolicum is highly recommended. Acidum Hydrocyanicum, useful after the catarrhal symptoms have diminished. Dr. West was accustomed to prescribe a dose of J^ a minim of dilute hydrocyanic acid every six hours for a child nine months old, gradu- ally increasing the dose to i minim every four hours for a child of that age, and so in proportion for older children. It is also recommended for the cough kept up by habit after the subsidence of the disease, and the cough by imitation. Acidum Nitricum sometimes benefits exceedingly, but is uncertain. It should be given well diluted in sweetened water. Alumen. Dr. Ringer is of opinion that in complicated cases few remedies give better results than alum ; he gives gr. ij-vj every three hours. Ammonii Picras. Dr. Z. T. Dellenbaugh (^Medical Times, September, 1878,) reports a number of cures with this agent in from twenty-four to sev- enty-two hours, and claims it as a specific. The dose to babies is gr. y'j ; to children, gr. \, every three hours. 1 27 1. R. Anunon. picratis, gr. ij-iij AmmoD. muriat., Ex. glycyrrhyz., aa 3j Aqua ad., f. § iij. S. — FL 3 j every three hours. Amy/ Nitrite. This is one of the late cures for whooping-cough. Dr. Sawa- ROSKY directs the patient to breathe, several times a day, a mixture of a few drops of nitrite of amyl in a drachm of chloroform ; at the same time administers, internally, for three days, every two hours, ^ of a grain of silver cyanide and three grains of pure clay. . Hot food and drinks must be avoided. A cure is effected in a few days. Dr. George Bayles has also reported on its use very favorably. (Va, Medical Monthly, August, 1877.) PERTUSSIS. 829 Antipyrine {Phila. Med. Times). It is claimed for this drug that it greatly ameliorates all troublesome symptoms at once, and finally effects a cure without producing any bad effects whatever. Antipyrine may be given to children in doses of from one-quarter of a grain to three or five grains, according to the age. It is best given in the form of powder, in sweetened water. It may be con- tinued for several weeks without bad effect. Argenti lodidum, gr. J/^, to a child three years old, is recommended by Dr. Bartlett as a most effective and pleasant remedy. Argenti Nifras. Drs. McNinr and Maxwell ( Boston Medical and Surgical jTournal, August i6th, 1871,) use a solution of nitrate of silver, gr. xv to the ounce, applied by the spray atomizer, which seldom fails to ef- fect a cure. Argenti Oxidum. Dr. W. Macfarlane {Australian Medical Gazette, De- cember 15th, 1869,) has every reason to believe that oxide of silver shortens the disease ; dose, J^ of a grain, three or four times daily, in any simple powder, up to one year of age. Asafoetida is a disagreeable but useful remedy, and may be given freely to infants and young children. Belladonna. Prof. J. Lewis SinrrH, of New York, commonly employs the ex- tract of belladonna in I- grain pills. For an infant one year old, one pill is dissolved in eight teaspoonfiils of water ; three years old, four teaspoonfiils. A teaspoonfiil to be given once daily, or, if there be no appreciable effect, three or four times. If there be no modification of symptoms, an additional half-spoonful should be given on the third day. If atropia is used, gr. tth, twice daily, is sufficient. Benzine, in doses of gtt. xx-xxx in sweetened mucilage, is praised by Drs. Bottare and Lochner. It has also been inhaled. Bryonia. In a communication to the Journal de Therapeutique, May 25th, 1878, Dr. Louvet-Lamar stated that he had derived great advantage from treating the catarrhal stage of pertussis by the tincture of bryony and the paroxysmal stage by the tincture of drosera. Of the former, he gives one gramme per diem to a child seven years old, and although it may not abridge this first stage of the disease, it diminishes the tracheo-bronchitis very sensibly, and, therefore, the violence of the cough. When the bronchial tubes are overloaded with mucosites, he also administers an emetic. As soon as the paroxysmal character be- comes well established, he gives the tincture of drosera, (one gramme daily for a child seven years old,) and as long as there are any rales heard in the chest he associates the bryony with it. It soon lessens the violence of the paroxysms, but may have to be continued two or three weeks before convalescence is established. These agents were intro- duced by American "eclectic" physicians. 830 DISEASES OF CHILDREN. Calx. The carbolate of lime is recommended by Dr. Ed. M. Snow. The gas from the hme used in gas-works has been shown by Dr. W. S. King to be a remarkable alleviant in whooping-cough. {Med. and Surg. Reporter, May, 1867). Camphorce Monobromas is a useful sedative. Castance, chestnut leaves, recommended by Dr. Ludlow, of Cincinnati : 1272. R. Castanese vescse, Sss Aquae bulUentis, Oj. M. Add to this a pint of cold water; sweeten with white sugar, to make it palatable, and administer cold. As much should be given during the day and evening as the pa- tient can be induced to take. Dr. J. CoopREiDER, of Taylorsville, Ind., writes to the Canada Med. Record, (1883,) that he has used iht fluid extract of chestnut leaves for whooping-cough, with great success. The dose employed is from fifteen to sixty drops, according to age. If the child is large enough, he gives it in hot water as an infusion, sweetened ; to a small child, in syrup or elixir of orange. It not only relieves and lightens the paroxysms, but will actually cure, in from four to five days. He gives four to six doses per day, according to the severity of the case. If good fresh leaves can be procured, he makes the infusion as a tea, say two drachms of the leaves to half a pint of boiling water, and gives two ounces at a dose, sweetened with white sugar. Cerii Oxalas. This salt is given in doses of gr. ss-ij, before breakfast, once daily. Dr. T. Clark has recommended it in the Practitioner, 1879 ; and a New York physician. Dr. Morje, has reported favorably of its use. Chloral, in small doses, allays the cough. Dr. P. B. Porter, of New York, after extensive trials, says he has found it, on the whole, the most re- liable and satisfactory agent that he has employed. It has the great advantage over quinine in solution, (which he has also used with suc- cess), of not being unpleasant to the taste when given in syrup. Croton Chloral has been highly praised by recent writers. A child a year old can take i grain every four hours. It should be specially impressed on parents and nurses, that to do good it should at first be given every four hours, night and day, even should the patient require waking up. At the end of the week, it need only be every four hours during the day, and at night when the patient is awake. The worst cases usually completely jield in a fortnight. The drug does not upset the digestive organs, and, by lessening the frequency and duration of the paroxysms, it puts an end to troublesome epistaxis and vomiting. Sometimes the first few doses produce a feeling of irri- tation about the throat and fauces, but this soon passes off. It may be PERTUSSIS. 83 1 given, gr. j-ij dissolved in compound tincture of cardamom, and sweet- ened with glycerine. (See Drs. Webb and Moore, pp. gai, 823.) Dr. Farquhar, of Zanesville, Ohio, confirms all that Dr. Webb says about croton chloral, and speaks highly of the following : 1273. R. Croton chloral, gr. xv Etheris., gtts. xx Potass, bromid., 5j Tr. belladonnas, gtts. xv Tr. hyoscyami, gtts. xxiv Syr. tolu., ad f. | iv. M. S. — One teaspoonful every four hours until better, then only three times a day. Drosera. See Bryonia. Ferri Carbonas administered in cakes, (one grain for each year up to six years old, every three or four hours) is highly praised by Dr. W. H. O. Sankey, in the Birmingham Medical Review, 1884. Hydrargyri Sulphuretum Nigrum, in doses of gr. vij daily, is strongly recom- mended by Dr. Chiricozzi. (Dobell's Reports, 1877.) Hydrobromate of Cicuiin. This salt of the alkaloid of hemlock has been em- ployed in whooping-cough, asthma, and phthisical cough, by M. Lan- DUR, with satisfactory results ; ij to rV may be given an adult every hour or two. {Bull. Gen. de Therapeutique, May, 1876.) In pertus- sis, it is given in doses of I'l of a grain, if necessary, every hour, for a child three years of age, or t j of a grain for a child of one year, and B of a grain for adults. Lactucarium. The syrup of lactucarium is a useful vehicle for the exhibition of other medicines. Lobelia has been used successfully, especially after the cessation of the ca- tarrhal stage. It is adapted to cases in which the cough is dry, reso- nant and spasmodic. It succeeds best in those who have attacks of cough with spasmodic difficulty of breathing, and who get up a little tough mucus after long and painful paroxysms of coughing. (Bar- THOLOW.) Morphia, especially the bimeconate, in small doses, is an excellent sedative for the cough. Oleum MorrhucR. Mr. Prestwich {Lancet, December 9th, 1871,) reports a few cases, selected from more than thirty in his own practice, in order to show the value of cod-liver oil, which he looks upon as a specific in this complaint. Petroleum. Dr. Lesser recommends rubbing the chest twice a day with a teaspoonful of this substance. Potassii Bromidum and Ammonii Bromidum are popular and efScient seda- 832 DISEASES OF CHILDREN. lives. They may be combined with belladonna or syrup of wild cherry : 1274. R. Potassii bromidi, gr-J-v Extracti belladonnse, gr- ^^-i Syrupi papaveris. lUxv Aquae, f-3ij. For one dose every two or three hours. (Dr. E. Ellis.) M. Potassium Chloridum. Jacques Munk, in Pester Med. Chir. Presse, 1880, reports favorably on the use of chloride of potassium in from one-half to two-grain doses, given with one-sixth of a drop of laudanum, every two hours. Potassii Nitras. The inhalation of nitrous fumes has been recommended. Potassii Sulphuretum, commended by Dr. MacKklkan, of Canada, in doses of gr. iij-vj in sweetened water. Its beneficial effects are not perceived for five days, when the intervals between the paroxysms of cough be- come longer, and, after that, their violence diminishes from day to day. until, at the end of ten to fourteen days, it is seldom necessary to pur- sue the treatment further. As the drug easily spoils by keeping, it is important to have it fresh. QuinicE Sulphas is regarded as an almost certain abortant by many. Dr. C. F. Swan, of Chicago (Med. jFour. and Examiner, 1877), recom- mends Prof. C. Bdjz's formula : 1275. R. Quiniae solphatis, 3j Acidi tannici, gr. xv, M. This aborts one-third to one-half the cases in three or four days. Dr. Lasinsky treats his patients by insufflations of a powder composed of 15 grains of hydrochlorate of quinine, 30 grains of salicylic acid, and 7 grains of bicarbonate of soda and white sugar. A small quan- tity of this powder is blown into the larynx twice a day. He states that in the course of eight days, the attacks become greatiy reduced in violence and fi:equency. (Dobell's Reports, 1877.) It is also recom- mended by Dr. W. Thornton Parker, U. S. A., who gives every two hours a teaspoonful of a solution of sulphate of quinine, four, six, eight, or even ten grains, to the ounce (Medical and Surgical- Reporter, 1883). The following is recommended by a British authority as almost a specific in this disease : 1276. R. Quinise sulphatis, g| Sol. acid, bydrobromic (Fothergill), 3iss Syrupi althese, f. | igg AqusB, adtivj. M. S. — A dessertspoonful four times a day. The dose to be increased according to age. PERTUSSIS. 833 SotUi Benzoas. Tordens has used it successfully in whooping-cough, using the prescription of Letzerich : 1277- R. Sodii benzoat, ^iv Aq. destil., Aq. menth. pip., i£ 3x Syr. aurantii, 3 ij. m. S. — ^Two drachms every hour or two. (Bartholow.) But, on the contrary, Dr. J. Shelton Hill, of Maryland, has found that it has no influence on the frequency of the paroxysms and but little on their intensity, though it did check the woTKA\ng\{Medual and Surgical Reporter, 1 880) . Turpentine, in pertussis complicated with irritative fever, bronchitis, or convulsions, is praised by Dr. Bedford Brown, of Alexandria, Va. It is also highly recommended by M. Barety. of Nice. {L Union Medicate, i88i). He places deep plates containing this liquid, under the head of the bed and in the corner of the room. The paroxysms of coughing soon become less marked, and the malady, taking on a benign character, generally lasts about one month. Tonka Bean has been employed with success by Dr. John Cooper, of Phila- delphia ; gtt. v-viij of the fluid extract every three hours, to a child five years old. INHALATIONS. The inhalation of many different substances has been tried in whooping-cough. Referring for the complete list to the works of Dr. J. Sous Cohen and others, we mention as most promising of success : Acidum Carbolicum, in a solution of one and a half to two per cent., boiled in a Siegle apparatus and inhaled three times a day into the widely- opened mouth. The violent paroxysms of cough disappear in two or three days. (Burchard.) Alumen. 3J to water |vj, to be used twice daily, ten minutes at a time. (SlEGLE.) Amyl Nitrite, gtt. ij-iij, on a handkerchief, when a paroxysm is impending. Argenti Nitras, gr. ss-j to water f.gj. Inhale by a nebulizer f.gss twice daily. Protect the face with a mask, or by smearing with salt and butter. Belladonna. Make an infusion and inhale the vapor ; or, better, throw about 3ij of the leaves on burning coals, and let the patient inhale the smoke. (SCHROEDER.) Benzine. Place small quantities in a number of shallow vessels about the room. Benzole. A writer in the Lancet, 1881, recommends benzole vapor as pre- pared by an atomizer. Brominium. Dr. Vogelsang, of Switzerland, finds that one or two scruples S3 834 DISEASES OF CHILDREN, oi bromine, and as much bromide of potassium, to a tumblerful of hot water, placed in the room of a child suffering from whooping-cough, affords it great relief. The mixture should be renewed three or four times a day. Dr. J. J. Caldwell recommends : 1278. R. Potassii bromidi, 9j Ammonii bromidi, 9ij Extracti belladonnse fluidi, gtt. x Aqiue destiU., f. § ij. M A tablespoonful once or twice daily with a nebulizer. Dr. WiMTREBEN {La France Midicale, t88o,) habitually uses a solu- tion of bromide of potassium, one in twenty, and repeats the applica- tion of the spray for one minute after each fit of coughing, when the mucous membrane of the air-passages, free from the mucus which usually covers it, is accessible to the action of the remedy. Calcis Carbolas. Dr. E. M. Snow, of Providence, R. I., has often recom- mended carbolate of lime as a remedy to relieve the spasmodic fits of coughing in this disease, and the evidence is abundant that it is of real value for this purpose. It is used by exposing it to the air in the rooms where the children live and sleep, so that the odor will be plainly perceptible at all times. Liquor Ammonia, f.gj to a gallon of boiling water. Place in an open pan by the bed-side, and evolve steam by introducing a red-hot brick. Sulphurous Acid fumigation is recommended by Dr. Mohn (London Medical Record') . His plan is to have the patient put into clean clothing in the morning, and removed from the chamber to be used as a sick room. All the clothes and toys to be subsequently used are brought into this room, and then sulphur is burnt upon live coals in the centre of the room. In the evening the child is brought back. About one ounce of sulphur to every cubic metre (394- inches) of room space is the proper amount for the fumigation. CONSTITUTIONAL DISEASES AND DIS- EASES OF NUTRITION. SCROFULA. DR. EBWARU HENOCH, OF BERLIN. Among the drugs that are usually termed " anti-scrofulous," this author prefers iodine, given in combination with iron, as syrup ferri iodidi, (S-I2 drops three times a day), or with iodide of potassium. If no disturbances of digestion are produced, the remedy must be continued for months, but is contraindicated by the presence or sus- picion of pulmonary tuberculosis. He has never observed symp- toms of so-called iodism, such as are sometimes described ; at the most, there may be severe coryza or erythema in the face or other parts of the body. When circumstances prevent the use of natural mineral baths, we can give salt baths at home, putting from one to five pounds of common salt in the bath. It seems doubtful to our author whether the traces of iodine contained in cod-liver oil, possess any specific effect. This much-lauded remedy probably acts rather as an article of nutrition, in the same manner as fatty articles of diet in general, and it is therefore said by some" that it may be entirely replaced by olive oil. In his experience it is far inferior to iodine, and he warns against too large doses, as it frequently interferes with digestion. Two or three tablespoonfuls daily are amply sufficient. The inunction of cod-liver oil on the skin, so highly recommended by many authors, he considers objectionable on account of the dis- agreeable odor and uncleanliness. Nor does he observe any good effects from other lauded remedies, such as Plummer's powders, walnut leaves, etc., and he considers that we only lose time by trifling with these remedies. In addition to this general plan of treatment, the various local affections, such as inflammation of the eye, diseases of the bones, joints, skin and mucous membranes, pre- sent a number of indications for special treatment. (835) 836 DISEASES OF CHILDREN. DR. FORSTER, OF GERMANY. According, to this writer in Jahrbuch fur Kinderheilkimde, Band, xxi, Heft 3, scrofulosis is exceedingly common in children, and evi- dences of it are found in more than half the children dying within the first six months, whose bodies are examined. The two objects of prophylaxis are, firstly, to combat the disposition to disease ; and, secondly, to ward off infection. The first indication is fulfilled by providing good food, warm clothing, fresh air, a country life and sea bathing. To save the child from infection we should instil into those who have charge of it, the danger that may arise from sleep- ing with, kissing, living in a small, confined room with parents or relatives already diseased, and insist upon the necessity of efficient ventilation. Infection by food is not so common, but it may be caused by the milk of a diseased cow — boiling the milk removes this danger ; and tubercular mothers should not nurse their children. The author evidently considers tuberculosis and scrofulosis as iden- tical, at least so far as their prophylaxis is concerned. DR. JOHN M. KEATING, OF PHILADELPHIA. In the Medical and Surgical Reporter, 1882, this teacher says that the treatment of the scrofulous diathesis should be both prophylactic and curative. We should see that our little patients who present this diathesis have plenty of warm clothing, fresh air and sunlight, occasional trips to the sea-side, with salt baths, etc. We should also see that their diet is carefully regulated and nutritious ; an import- ant article of the dietary is good, rich milk. The digestive organs should receive a large share of your attention. See that they are in perfect condition, and maintain them so if possible. You should order a proper amount of physical exercise, with little mental labor. For the curative treatment our sheet-anchor is cod-liver oil, iron and iodine ; the two latter may be combined as the syrup of the iodide of iron, or you may use the tr. ferri chlor. An important re- inforcement to the cod-liver oil is the lacto-phosphate of lime. Tonics should not be given until you have corrected all evidences of marked intestinal derangement. Alcoholic stimulants must be used in moderation. He prefers the light wines or malt liquors to the stronger stimulants. Local ailments should be especially attended to. For glandular swelling you may use iodide of pot. 3j, ung. stra- mon. 5j, or the ointment of the red iodide of mercury. SYPHILIS. 837 For the conjunctivitis he uses atropia sulph. gr. ij-5j ; when phlyc- tenulae occur, you may dust with calomel. The various skin eruptions, bone afifcctions, etc., attendant upon this diathesis, need but little modification of your general plan of treatment. Le Bulletin Medical, 1890, says that iodine and iodoform give better results than the alkaline iodides. To young children, tincture of iodine may be given, one drop daily, in a little thin porridge made of farina and milk. Besnier prefers the use of iodoform, which may be given continuously for a long time. He prescribes it after the following formula : 1279- R- lodofonn, gr. iss Mellis, I iv. M. Sig. — One or two teaspoonfuls at a dose. SYPHILIS (INHERITED). F. R. SturgIS {Arc. Ped., May, 1888). The author says that the treatment of syphilis may be divided into two broad groups — indi- rect and direct treatment. The former consists of the introduction of remedies into the child's stomach through the medium of the milk of the mother or nurse, and the second, where the drug is given to the child directly by the mouth or through the medium of the skin. In using the direct method, the mother or nurse is put upon an act- ive mercurial treatment under the belief that a certain portion of the drug will reach the child through the milk. The author believes that ■ ■ 1 the amount of medicine eliminated in this way is but infinitesimal, and he, therefore, condemns this treatment as being practically use- less. The direct method is the only one which offers a fair chance for the child's recovery. The author gives preference to the admin- istration of medicines through the medium of the skin. The method he employs is to spread from one to two drachms of mercurial oint- ment upon a cloth, which should be bound around the child's body, extending from the axillae to the hips, directly in contact with the skin, care being taken that the axillary and genito-crural folds shall not be irritated by the mercurial ointment. This should be worn by the child for two or three days, when it should be removed and the skin gently washed with warm water and soap. A fresh supply of" 838 DISEASES OF CHILDREN. ointment should be applied to the cloth and again bound to the child's body. This is better than making inunctions upon the child's trunk or limbs, as it is less likely to produce irritation or eczema ; the warmth of the child's body causes a rapid absorption of the drug ; it does not interfere with the child's nursing, nor is it apt to derange the stomach and intestines — a thing which so frequently happens when the medicine is given internally. If it is considered advisable to give the mercury by the mouth, it may be administered either in the form of the ordinary pulvis hydrargyri cum creta, or else it may be given in the form of the bichloride, in doses of from one one-hundredth to a fiftieth of a grain rubbed up with sugar or milk, or administered in sweetened water or milk. The powdered preparations are by far the best. Sublimate baths are not highly spoken of. In the earlier months of treatmerft, iodide of potassium is seldom, if ever, called for, and should be reserved for lesions of a later type, more especially those of the ulcerative variety. Under this method of treatment the child will usually recover from its ear- lier symptoms, especially if they have been of a mild type, and even in cases where the lesions are tolerably severe, a proper and thdr- ough course of mercurials, directly administered, offers the child the best chance for recovery. In the lesions of the late type, iodide of potassium may be given either alone or conjointly with mercury, in the same manner as it is used for acquired syphilis, and it is in these cases that the iodide of potassium will oftentimes produce the most brilliant and satisfactory results. To be of any service, however, the drug must be given with quite a free hand, for these later lesions of syphilis are oftentimes extremely rebellious, and will not yield to mild medication. From ten to thirty grains at a dose, large as the amount may seem, is of more service than two, three or five grain- doses ; and the surgeon should be prepared to increase his dose if circumstances require it, or to suspend its dse if toxical symptoms ensue. In addition to this, mercury may be administered either in the form of the protiodide, which is the one best borne, or of the bichloride. In addition to the constitutional treatment, local treat- ment will often be required for the relief of some of the symptoms. Where the mouth and tongue are attacked with mucous patches, a weak solution of nitrate of silver, from one to five grains to the ounce, may be applied daily in the case of infants. As gargles and mouth-washes cannot be used in these cases, in addition to the em- ployment of nitrate of silver, the lesions may be lightly penciled SYPHILIS. 839 over with a preparation of ten grains of tannin to the ounce of gly- cerine, or with a solution of the sulphate of zinc — one to three grains to the ounce of water. In cases where ulcerations are present on the body, the crust should not be removed unless there are signs of extension underneath ; but if there be signs of extension, the crusts should be gently detached by poulticing or soaking in water, and the ulcerations themselves touched with a weak solution of nitrate of silver, of the strength previously advised, and then dressed with mer- curial ointment diluted with an equal proportion of vaseline. In cases of pemphigus, the bullae should be emptied of their con- tents, and if the epidermis covering them has become detached, they should also be dressed with a diluted mercurial ointment. Lesions about the genito-crural fold and the anus should be kept clean and dry. Aftet the parts have been washed and thoroughly dry, they should be freely powdered over with calomel and bismuth, in the proportion of one part of calomel to two or three of bismuth. After each change of diaper, the powder should be gently removed by washing, and again applied. In the later stages of the disease, the local treatment often plays an important part. When ulceration of the soft palate or throat is present, the best application is that of nitrate of silver, of the strength of twenty or thirty grains to the ounce, applied every second or third day. With this may be used a mouth-wash or gargle of alum, sulphate of zinc or myrrh. When necrosis occurs and there is abundant suppura- tion, the best method of treatment is by the application of mercurial ointment, spread upon kid or cloth and applied directly to the part. A child born of syphilitic parents should not be treated until after the symptoms of the disease have made their appearance, for two reasons : first, in order to judge of the severity of the disease, and second, in order not to delay the appearance of the symptoms. As soon, however, as the symptoms have made their appearance, treat- ment should be instituted at once, and should be continued until all manifestations of the attack have passed away. Treatment should then be stopped and the child placed on tonics for a year or two, and watched carefully for a return of any of the symptoms. This plan enables the physician to determine whether his treatment is curative or only palliative. Feeding becomes of great importance. If the mother cannot nurse the child, the wet nurse becomes an im- portant factor. Usually hand-feeding is resorted to, and in this case, cow's milk prepared so as to resemble mother's niilk is by far the best food. 840 DISEASES OF CHILDREN. ADMINISTRATION OF MERCURY. In speaking of the administration of mercury to syphilitic infants, the following from the Revue General de Clinique et de Therapeutique is of interest : When the child is from five to six weeks of age, Eloy recommends that from five to twenty drops of Van Swieten's liquid shall be given each day, in milk. (Van Swieten's liquid consists of a solution made by the addition of I part of bichloride of mercury to 100 parts of alcohol and 900 parts of distilled water.) At the same time that this liquid is being given internally, it is advisable to use inunctions of mercurial ointment, or, better still, to employ mercurial ointment diluted by lanolin, equal parts. After this oint- ment has been used for two or three days, a hot bath should be given. When the child is older, that is, six or seven months of age, the following prescription may be administered with advantage : 1280. R, Biniodide of mercury, Ingrains. Iodide of sodium, "1 «■ 1. . j v Distilled water, '1°^^==^ I drachm Syrup of oranges, 6 ounces. Of this give a half coffeespoonful to a child of a year, and five cofieespoonfuls to a child of eight years. EDWARD ELLIS, M. D., LONDON. This author remarks that mercury is the sheet anchor. In treat- ing children, he prefers the use of gray powder, in doses of from a J^ grain to 2 grains, twice to thrice daily, with a few grains of com- pound cinnamon powder to prevent the mercury running off by way of the bowels. This treatment should be persevered in, from six to twelve weeks, occasionally substituting corrosive sublimate with bark. Vomiting and diarrhoea are indications for temporarily stopping the mercurial course, or at least for changing its form. Sometimes a little chalk or carbonate of potash added to the gray powder enables it to be well borne. Black-wash is the best local application ; anal condylomata should be dusted over with calomel, and kept scrupu- lously clean. Occasionally they may require a touch with nitrate of silver. Caustic is also useful in ulcerations of the mouth and tongue. Iodide of potassium, bark, sarsaparilla, and the syr. ferri iodidi are of value, after the mercurial course, for improving the general health. Baths of corrosive sublimate are recommended in the skin complica- tions. SYPHILIS. As examples of prescriptions he gives : 841 1281. g. Potassii iodidi, „. ss_v) Spiritfls ammonite aromatici, Hlj-v Syrupi sarsaparilbe, ITlx-f. 3j Aqu*. f.5iH.§j. M. For syphilitic cachexia in infants, /. r. n. Where the iodide of potassium does not agree, he prescribes the sodium iodide : 1282. R. Sodii iodidi, gr. iv Syrupi sarsaparillx, f. 5 ss Decocti sarsapariCse Comp., f. 3 iv. M. R. W. TAYLOR, M. D., NEW YORK. In the monograph by this author {Syphilitic Lesions of the Osseous System in Infants and Young Children, N. Y., 1875,) he prefers, for the treatment of these lesions, a mixed plan, combining mercury and iodine. His usual prescription is : 1283. R. Hydrargyri bichloridi, pr. j Potassii iodidi, 3 iv Syrupi aurantii, Aquae, aa f. § ij. M. Five drops for a child about two months old, increased to fifteen or twenty drops, if the disease does not yield. There need be no apprehension of salivation, nor other noxious effects of the mercury, even if, as is generally the case, the medicine has to be continued for a long period of time ; for the iodide, in this combination, corrects any such hurtful tendency. It is an important point in the treatment to suspend the medicine altogether, from time to time, as, otherwise, the system will become habituated to its use, and it will fail of its remedial effect. A well-regulated and sufficient diet must be maintained while the child is under treatment. As a nurse is liable to contract syphilis from such an infant, cow's milk is the best resource, if the mother is not able to suckle it. Dr. Taylor advises strongly against both hypodermic injections and endermic inunctions of mercurials as uselessly severe and of doubtful results. Locally, for ulcerations, he applies iodoform in the cavities, with a covering, to the other parts, of balsam of Peru oint- ment. Nodes on the scalp may receive daily frictions with mercurial ointment. When they degenerate into abscesses, a free crucial inci- sion should be made, the detritus carefully removed, and the whole 842 DISEASES OF CHILDREN. thoroughly mopped out with strong carbolic acid ; the cavity then to be stuffed with charpie, and a cold-water dressing applied. The next day this should be removed, and the cavity dusted with iodo- form. Cold lotions should be continued as long as any inflamma- tory symptoms remain. DR. P. BRYNSBERG PORTER, NEW YORK. This practitioner states {American Journal of Obstetrics, July, 1878,) that he has found, as a general rule, the treatment by mercu- rial inunction to be the most serviceable, usually in conjunction with such tonic or alterant remedies as seemed indicated. It has the great advantage of not interfering with digestion, as is sometimes the case with agents given by the mouth ; though he has almost always found minute and somewhat frequently-repeated doses of calomel to be well borne, especially when their administration was intermitted from time to time. He generally combines the calomel with soda. DR. EDWARD HENOCH, OF BERLIN. According to this author, mercury is the only sure remedy for infantile syphilis. Its effects are often astonishing, and neither iodide of potassium nor iodide of iron can be compared to it. He prefers to use calomel and the black oxide of mercury in doses of from ^ to 2 )^ grains, given morning and evening. The latter sometimes causes emesis, especially at the begining of the treatment. He regards every other form of administration of mercury improper, including mercurialization of the nurse. Inunction with gray ointment, or the subcutaneous injection of corrosive sublimate, should only be considered when extensive syphilitic eruptions are not present, or when intestinal complications prohibit the internal use of mercury. When there is marked atrophy, and the internal use of mercury is prohibited by vomiting and diarrhoea, he resorts to baths of corro- sive sublimate (15 grains to the bath). Condylomatous growths, he powders with calomel, or brushes daily with a solution of nitrate of silver (one grain to four drachms of water) if they have ulcerated. He also uses this solution for the nasal mucous membrane, if the coryza resists internal treatment. If the mother is syphilitic, she may, of course, nurse her affected child ; but if she presents no evidence of the disease, she should only be allowed to nurse the child if the lips and buccal cavity of the latter present no abnormal appearances. Even the secretion of SYPHILIS. 843 coryza must be regarded as a not altogether safe factor in nursing from the breast. DR. ARMAND SEMPLE, OF LONDON. According to this author, if the mother has previously given birth to syphilitic children, it is advisable to subject her to a mild course of mercury during her subsequent pregnancies. For the infant, the most nutritious diet must be afforded ; no wet-nurse should be em- ployed, in consequence of the risk of her becoming infected. Dur- ing the presence of marked symptoms, some mercurial must be exhibited, such as hydrargyrum cum creta or calomel; or this alterative may be conveyed to the system by inunction of mercurial ointment. A flannel roller may be smeared with ointment and bound round the child, by whose movements rapid absorption is occasioned. Small doses of the mercurial should be used, and they should be steadily continued in order to affect the system ; but this remedy should be stopped short of salivation, which occurrence is, however, rare in children, and it should be discontinued temporarily if any gastric symptoms arise. The mercurial may be followed by iodide of iron or iodide of potassium, either separately or together. Lie- big's extract of meat and raw beef, finely scraped, are often valuable in supporting the strength of the patient. If any sores are present, they may be treated with black wash, and if condylomata are pres- ent, they may be touched from time to time with solid nitrate of silver, or dusted with calomel. DR. ARCHAMBAULT, OF PARIS. This distinguisTied authority says (^Gazette Des Hopitaux, 1882,) "when the child is suckled by its mother or nurse, you have two modes of treatment, the one complementary to the other — the direct treatment of the child, and the indirect treatment through the mother or nurse, to whom you give the suitable medicinal substan- ces. But this latter mode of treatment is only an adjuvant, and em- ployed alone, it would prove absolutely insufficient. How is the in- fant to be treated directly by mercury ? The preferable mode is to administer the sublimate dissolved in water or in milk, with which it will form without any inconvenience (notwithstanding what has been said about it) an albuminate of mercury. Baumes commences with one, one and a half, or two milligrams, progressively increasing the 844 DISEASES OF CHILDREN. dose to six milligrams in the twenty-four hours ; Bertin commences with two milligrams, reaching four, as his maximum dose ; CuUerier begins with five milligrams ; and Bassereau prescribes the dose for an adult reduced to a fourth or a third, which comes to pretty much the same. A milligram and a half seems a very small affair ; but if you compare the weight of a child with that of an adult Cthe mean weight of an infant being five kilograms, while that of an adult is seventy), you will find that the dose advised for infants is compara- tively a large one. He ordinarily commences with a milligram and a half per diem, and, according to the condition of the little patient, gradually reaches the maximum of five or six milligrams. All de- pends upon whether we have to do with a slight syphilis or with grave symptoms. In certain cases, when he has found a true cachexia with gastro-intestinal disturbance, he has begun with four milligrams from the first day. We may employ the liquor of Van Swieten, which is a solution of the sublimate in the proportion of a thousandth part, and which allows the quantity of mercury you wish to give to be very easily dosed. Thirty drops of this liquor cor- responds to one milligram and a half of the sublimate, and he pre- scribes them to be taken in milk, in three doses, morning, afternoon and evening, increasing by two drops every other day, until the maximum is attained. In the infant you do not find, as in an adult, any positive sign of the mercurial saturation of the organism, and the sole rule you have to guide you is the local and general condition of the child. Thus you will no longer continue to increase the dose when you find vegetations subsiding, ulcerations filling up, and spots disappearing, etc. " Mercurial treatment has been accused of inducing intestinal dis- turbances and provoking diarrhoea ; but it is exactly the contrary of this which takes place, and, save in some exceptional cases, the diarrhoea, which existed prior to any treatment, disappears almost always under the influence of mercury. Still, should the diarrhoea persist, or should it appear under the influence of a peculiar dispo- sition, you may add, according to its intensity, a half or a whole drop, or even two drops, of laudanum to the liquor ; or still better, you may prescribe five centigrams of hydrarg. cum creta twice a day, to which you may add, if required, half a drop of laudanum. External treatment may be employed either alone, or concurrently with in- ternal treatment ; but he only has recourse to it when mercury is not tolerated internally, and on the condition that it is very efiec- SYPHILIS. 845 tually administered. A gram and a half of mercurial ointment may be rubbed in night and morning, continuing it for a considerable time, and varying the part on which the friction is made, in order to avoid producing eczematous eruptions. For the same reason the frictioned parts should be washed, from time to time, with mild soap. The curative efifects of these frictions do not admit of doubt, and in cases of slight manifestation of the disease, they may suffice. Never- theless, whenever it is possible, he associates the internal with the external treatment. Sublimate baths also may be employed as ad- juvants to general treatment in cutaneous manifestations of the disease. The dose for an infant is from two to six grams per bath. This may be used even in any metallic bath, on condition of adding ten to fifteen grams of the chlorhydrate of ammonia, or even of simple chloride of sodium, in order to obviate the effects of the de- composition of the mercurial salt in presence of a metal. "Such is the mode of treating the general accidents of hereditary syphilis in infants, a treatment to which we must add a good hygiene. Thus, alimentation should be severely watched, and especially if the child is brought up on the bottle, which is the case when the mother will not suckle her infant, and under the difficulty there is of finding a nurse who will consent to suckle a syphilitic infant, in the face of the risk she runs, unless she herself has been syphilized. Great care also must be taken to preserve the infant from the impression of cold, which may induce severe intestinal disturbances. It is well known, in fact, that if syphilis is of more frequent occurrence in warm climates, it is also there cured more easily." DR. THOMAS. As a means of treatment, this author {Arch f. Kinderh., B. v., H. 3 and 4,) gives the preference in all cases to mercury over iodine. Mercurialization need not be dreaded, for it very rarely occurs. He prefers- calomel in doses of from one to three hundredths of a grain, three or four times a day. If there is severe diarrhoea, a little opium may be given with the calomel. For condylomata and other skin af- fections, calomel is also recommended. Sublimate baths (one to three grains to a bath) are also very useful. Care must be taken to pre- vent the water from getting into the mouth. For children from one to two years of age, inunctions are quite proper and efficient ; they are not advisable for younger children, because they may produce an eczema. In lieu of calomel, the yellow iodide of mercury may 846 DISEASES OF CHILDREN. be given two or three times a day, in doses of one-hundredth of a grain. Later, if the symptoms of the disease have not disappeared, a solution of the iodide of iron may be given with advantage. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. If the previous children of a mother have proved syphilitic, it is well to subject her to a mild mercurial course during her pregnancy. In the treatment of the infant, every care must be paid to support its strength by the most nutritious diet, if its mother is unable to suckle it. It is, however, improper to employ a wet-nurse, on ac- count of the danger of her being infected by the child. In regard to medicinal treatment, the use of mercury is universally recom- mended during the presence of marked symptoms. The mercurial may either be given in the form of hydrg. cum creta, calomel, or bichloride of mercury, in solution in some aromatic water or syrup ; or finally, it may be introduced into the system in the form of mer- curial ointment by inunction. The most convenient mode of intro- ducing it in the latter form is by smearing a flannel roller with mer- curial ointment and binding it around the child, whose movements cause its speedy absorption. The dose of the mercurial should be small, and it is to be continued steadily, though with caution, so as to avoid producing salivation, until a decided improvement in the symptoms manifests itself. During its administration, it will fre- quently have to be discontinued temporarily, on account of gastro- intestinal irritation. So soon as the mercury is stopped, we should order the iodide of potassium or iodide of iron, either one or both together being employed according to the toleration of the stomach. We should also recommend the use of cod-liver oil, and some prep- aration of cinchona, from an early period in the case ; and even when the child is nursed, a certain amount of Liebig's cold extract of meat or of raw beef scraped finely should be given. The best application to the sores is black-wash, though the con- dylomata usually require to be touched occasionally with solid nitrate of silver. PROF. J. STEINER, M. D., PRAGUE. As the result of his extensive experience in the Francis Joseph Hospital of Prague, this writer advises the mercurial treatment in infantile syphilis. The preparation he prefers is calomel, which he gives in doses of gr. y^-y^-i/^, three, or four times a day. If there RACHITIS. 847 is anaemia, he combines it with sacchafated carbonate of iron ; if colic and sleeplessness, with Dover's powder. He also uses calomel, locally for condylomata, fissures, ulcers, etc. He believes the calomel acts best on lesions of the skin ; but when the bones and viscera are involved, he prefers iodine, giving it either as iodide of potassium, or as a syrup of the iodide of iron. The long-continued use of any form of the drug, he considers prejudicial ; but he has observed a wide difference in the tolerance of the drug in infants. He uses tincture of iodine for a local application to syphilides. NOTES ON REMEDIES. Hydrargyrum Tannicum Oxydulatum. Professor Monti, of Vienna, is much pleased with this preparation in cases of hereditary infantile syphilis. The tannin prevents the diarrhoea, which so often occurs in the exhi- bition of calomel and other salts. His formula for infants is : 1284. K- Hydrarg. tannic oxyd., gr. iss-iij Sacch. alb., gr. xlv. M. Div. in pulv. No. x. S. — A powder every two or three boars. (^Archives of Pediatrics, 1884.) RACHITIS (RICKETS\ EDWARD ELLIS, M. D., LONDON. Fresh air, abundant and nutritious food, and frequent bathing, are measures always demanded in this disease. Tepid salt-baths, fol- lowed by friction over the whole body with a towel, are most useful. Bleeding, blisters, or mercury, are never to be thought of. Of medi- cines, none is more valuable than cod-liver oil combined with an equal portion of lime water, and the compound syrup of the phos-. phate of iron, f.5j every day. To check the extreme perspirations which often occur, tannin, gr. >i-j, thrice daily, or belladonna, may be given. For the diarrhoea, a gentle purge, as rhubarb and soda, with some carminative, or a dose of castor oil, will be useful. P. BRYNSBERG PORTER, M. D., NEW YORK. In the treatment, aside from the regulation of the diet and the im- provement of the hygienic conditions of the child (which are, of 848 DISEASES OF CHILDREN. course, matters of vital importance), there are no remedies which, in the opinion of this physician, are to be compared to cod-liver oil and the syrup of the iodide of iron. They should be intermitted from time to time, and especially if diarrhoea occurs, as it not infre- quently does in rachitis. Where they are not well borne (and such cases are, according to his experience, very rare exceptions), an emulsion of cod-liver oil with bitter almonds, to which the hypo- phosphites of lime and soda are added, will often be found an excel- lent substitute ; and it has the advantage of usually not affecting the bowels unfavorably when diarrhoea is present. It is a mistake to be too sparing of the oil, and teaspoonful doses several times a day can be borne by quite young children. C. CURRIE RITCHIE, M, D., MANCHESTER. The treatment of rickets requires as its essential condition the restoration of a healthy nutrition — hence diet and hygienic measures are of the utmost importance. Regular feeding at stated intervals ; abundance of milk with a fourth part of lime water, and the addition of a teaspoonful or two of cream to the half pint ; as the child gets older, a little beef tea with bread, eggs, or light puddings ; if pota- toes be given, they must be finely mashed with a little meat gravy ; after eighteen or twenty months, meat twice a day, or strong soup in small quantities — these are the chief dietetic indications. Daily tepid chalybeate or salt-water baths, plenty of warm woolen clothing, warm but well-ventilated rooms, and as much dry open air, (the bracing sea-air to be preferred,) as practicable, are points which will at once suggest themselves. As to strictly medicinal treatment, it has for some time been the stereotyped phrase in our text-books — "There is no specific remedy for rickets." Cod-liver oil is one of our most important remedies. Its efficacy is greatly enhanced by a combination with iron. The phosphate of iron is the preparation from which Dr. R. has found most benefit ; it may be given either as the simple syrup, or in the form of Par- rish's compound syrup of the phosphates ; in private practice, he has found children take it remarkably well with the cod-liver oil. Of course, before administering cod-liver and iron, we must see that the movements have become healthy and the tongue clean. Dr. R. usually employs Sir Wm. Jenner's plan for this purpose, viz., to give a single dose of an aperient, such as a teaspoonful of castor oil, RACHITIS. 849 or a little gray powder with jalap, even though the bowels should be rather loose — as the stools are frequently most offensive, from the acidity which is always present in these cases, and which is relieved by an occasional dose of rhubarb, with soda or magnesia. DR. ARMAND SEMPLE, OF LONDON. This author agrees with all other writers on this subject, in stating that the greatest attention must be paid to hygienic conditions, and to the feeding of the infant. A wet-nurse should be substituted if the mother's milk is deficient either in quantity or quality, or, care- fully selected cow's milk may be provided. The most nutritious and digestible diet must be given after the child is weaned, and es- pecially a diet containing a large amount of animal food. In rickety children, the teeth are generally defective, and as complete mastica- tion is often impossible, their meat should be finely chopped and bruised in a mortar. The child should be taken out daily in the air and sunlight, and it should be suitably and warmly clad. Salt-water baths may be given with benefit. Impaired digestion and diarrhoea may call for vegetable tonics, iron preparations, antacids, and mild astringents. Cod-liver oil should always be given, either alone or in combination with vege- table tonics and iron preparations. The cod-liver oil may be rubbed into the axillae, or the groins, if its internal administration is attended with difficulty. The oil will sometimes be better tolerated when given in the form of emulsion, or when combined with lime-water. To prevent deformities, the child should lie upon a smooth, firm mattress ; no high pillows should be allowed, and, until the bones have become inflexible and firm, no sitting up for any length of time, or attempts at walking, should be permitted. During the earlier stages of the disease mechanical contrivances are not advisable, but during convalescence attempts should be made, by means of paste- board or leather splints, to control the deformities. DR. EDWARD HENOCH, OF BERLIN. This author maintains that we are unable to furnish a scientific basis for treatment, and must be satisfied that we almost always prove successful with empirical remedies. After insisting on the necessity of good hygienic surroundings, he says that to him it ap- pears absurd to forbid the use of milk (as some do), since this inter- diction is founded on some unreliable experiments concerning the 54 850 DISEASES OF CHILDREN. injurious influence of lactic acid. In the large majority of cases of rachitis, recovery ensues despite untoward external circumstances, unless tuberculosis or some other complication occurs, or the gen- eral cachexia has reached too high a grade. He begins treatment with the milder preparations of iron, especially tincture of the chlor- ide, eight or ten drops three times a day; if this (as he has some- times observed) produces diarrhoea, he substitutes ferri lacticum or reductum (gr. ss— j twice daily). As a matter of course, the diges- tive organs must be in good condition in order to tolerate the iron. If anorexia, coated tongue, constipation or diarrhoea is present, he gives first hydrochloric acid, then mild bitters, especially tinct. rhei vinosa (10-12 drops three times a day), and the latter may be com- bined with iron. On alternate days, a lukewarm bath should be given, with the addition of salt or infusion of malt or aromatic herbs (about a handful of chamomile or calamus) and the lower limbs should be rubbed and kneaded with flannel while in the bath, as well as several times during the day. We should persistently wash the occiput in order to relieve the profuse perspiration, and if there are softened spots in the occipital bone, the head should be rested on a hair pillow, with a hole in it, in order to protect the part in question from pressure. Cod-liver oil, he only gives in cool weather, chiefly in emaciated children, and never more than two tableepoonfuls daily, either alone, or in combination with preparations of iron. He has never seen any good results from the administration of lime salts, and has long since discontinued their use. DR. JOHN M. KEATING, OF PHILADELPHIA. This authority on diseases of children says (^Medical and Surgical Reporter, 1883), that in the treatment of these cases, your first thought should be as to their hygienic condition and surroundings ; and see to it that these are as perfect as circumstances will permit. Food next calls your attention. If the child is still nursing, exper- ience will tell you that there is no food so well adapted to its use as the maternal milk, provided, of course, that the supply is sufficient and of proper quality, and that the mother is healthy. As the child grows older, its diet must still be uppermost in your plan of treatment. We have no medicinal agent which acts as a specific in this disease (as iodine and mercury do in the syphilitic diathesis), but we must exhibit our drugs in order to meet special indications. Lime-water meets the condition of the gastro-intestinal tract, and also supplies RACHITIS. 851 the bones with the needed material. A good plan is to give it with the milk. Cod-liver oil should be your sheet-anchor to prevent emaciation. Give it either internally or by inunctions; the latter method acts marvelously in these cases. Iron, as the tinct. of the chloride, must also be supplied as an haematic, and for its restraining property on the bowels. Salt sea baths, when possible, are good adjuvants to general treatment. PROFESSOR F. FORCHHEIMER, OF CINCINNATI. This author tells us that we must regulate the diet (^Archives of Pediatrics, 1884.) As food, give milk and broth principally. Add salt to all the food you give the patient. Regulate the bowels. If you find that the child is constipated, you can often secure daily evacua- tions by some change in diet." If diarrhoea be present, treat it as you would any other catarrhal affection of the bowels. Every patient with rickets ought to receive a tepid or cool salt-water bath every day. The bath ought to be made by adding a handful of ordinary fish- salt to the bath. When the child comes out of it he is to be rubbed thoroughly with a towel, rough, if the child be old enough. Have the patient sent out into the fresh air every day ; you can protect them against the inclemencies of the weather, but give them fresh air. Here, however, you must take precaution, or you may cause de- formity. In order to prevent deformity, you will teach the child's at- tendants how to handle it — one hand under the nape of the neck and the other under the buttocks. If there is any danger of deformity of the spine, you must send the child out, resting on a pillow in a perambulator, or upon the arms of a nurse. Do not permit any at- tempt at walking until you are positive that the disease has run its course in the legs. His indications for the use of cod-liver oil are as follows : If a child is very thin, and over six months of age, you can begin carefully with small doses. Never give this until you are positive that your patient has digestive organs that will bear the remedy. The oil sometimes acts very well, not only in caus- ing an increase in the child's weight, but also in regulating the bowels. The great objections to this remedy are, that it produces dyspepsia or intestinal catarrhs. You must not, however, think that because a child increases in weight it is improving ; fat children fre- quently suffer with rickets. Neither must you prescribe cod-liver oil in every case of rickets, because it was once looked upon as a spe^ 852 DISEASES OF CHILDREN. cific. The lime water also, in some cases, acts very well, but he believes with Baginsky, that its action is due, not to any specific properties, but simply because of its efifect upon the milk. You will find it necessary in some cases to give iron preparations ; and, in children over one year of age, when there is an appreciable tumor of the spleen, very small doses of arsenic are not only well borne, but seem to act beneficially both upon digestion and blood-making. Of the complications, it is necessary to speak, in detail, only of one — laryngospasmus, or laryngismus stridulus. Against this much-to-be- dreaded complication, you may use the bromides, chloral, or, if ne- cessary, hypodermic injections of morphia. The parents and attend- ants are to be impressed with the physical and psychical treatment of their children ; they must be told that a scolding or fright, or anything that may act suddenly upon the child, can produce an at- tack the determination of which is always a matter of doubt. All other complications will be treated as indications may call for; never, however, neglect the anti-rachitic measures. (^Journal de Medecine de Paris.) The following prescription is recommended for the treatment of rhachitis : 1285. B. Phosphorus, I grain Absolute alcohol, 5 drachms Spirits of peppermint, 30 drops Glycerine, 2 ounces. Six drops of this mixture may be given in water three times a day, and after the lapse of one week, another drop may be added. NOTES ON REMEDIES. Cakii Lacto-phosphas. M. Dusart finds that in every case in which the diet, though sufficient in quantity, was unsuited to the digestive organs, the addition of lacto-phosphate of lime caused rapid improvement. Very interesting observations upon this subject have been collected in the large hospitals of Paris. ( Gazette Medical de Paris, March, 1879.) Calcii Stilpho-carbolas. Dr. Ernest Sansom says he has used this "calcium salt, (which is one of the most soluble known,) in rickets . . . with uniformly good results, in doses of three to five grains, or more." Others who have tried it have been disappointed with it. Ferrum, either as the phosphate or the iodide, is esteemed by all writers. Dr. AiTKEN recommends : 1286. R. Viniferri, f.3j-ii Quinise sulphatis, gr. j •Acidi sulphurici diluti, "Ij-ij. M, Liquor Calcis, widi milk, or cod-liver oil, is useful to prevent acidity and diar- rhoea. RACHITIS. 853 Oleum Morrhux is almost indispensable. Dr. William Goodell recom- mends it in small doses (gtt. xx, to an infant ; but Dr. P. B. Porter believes much larger amounts may be taken with advantage. If any of the oil is passed by stool, the quantity should be diminished. Phosphorus. Baktholow says that since phosphorus induces an hypertrophy of bone tissue, it should be carefully tried in this disease. It may be advantageously given in cod-liver oil. Do^s Milk has been found by Dr. Bernard, of Monttrum, France, to be the best of aliments in rickets. (^Gazette Hebdomadaire, 1877.) DISEASES OF THE RESPIRATORY TRACT. ACUTE CORYZA. CARL SEILER, M. D. (^Cyc. Dis. Child., Vol. II.) In a very excellent article on this sub- ject, this author outlines the following course of treatment: In most varieties the cure depends upon the removal of the cause, and upon the good judgment of the attending, physician. The febrile symp- toms should be combated in the usual way, with aconite and spiritiis aetheris nitrosi in small oft-repeated doses, graduated to the age of the child, and a small dose of calomel and soda, as a mild purge. The patient should be kept as quiet as possible, in a warm but well-ventilated room ; and if it is an infant at the breast, feeding with a spoon should be at once commenced, so as to supply the nourishment which it cannot obtain in the usual manner. In the case of older children, the nostrils should be cleansed three or four times a day with a spray from an atomizer, containing a solution made from the following formula : 1287. R. Sodii bicarb., 3'''iij Sodii bibor., S^iij Sodii benzoat., Sodii salicylat., aa gr. zx Eucalyptol, Thymol, aa gr. x Menthol, gr, y OL gaaltberix, gtt. -vj Glycerini, § viiiss Alcoholis, § jj Aquae, q. s. ad O xvj. With infants and young children, this cannot easily be done, but a swab of absorbent cotton dipped in the solution can be used to cleanse the nasal mucous membrane. This gives great relief to the little sufferer, and amply pays for the trouble which it occasions to the nurse. The external rim of the nostrils, as well as the skin of the upper (854) ACUTE CORYZA. 855 lip, should be well anointed with cacao butter or vaseline, and even the skin covering the nose itself should be kept well greased. If the cause of the disease is of an infectious nature, change of air, if such be possible, is of great benefit, and if the coryza is the result of the infectious pharyngitis lately observed, small doses of benzoate of sodium (one-fifth of a grain) every hour, will speedily break it up. Plenty of cold water should be allowed, and in older children the diet should be chiefly milk and bread. Powders of an astringent nature, such as tannic acid, nitrate ot silver, sulphate of zinc and others, should never be used as local ap- plications, in the anterior or posterior nasal cavities of children ; nor should astringent solutions, in the form of washes or sprays, as they invariably give rise to increased swelling of the turbinated tissues, and thus make the little patient worse, rather than diminish the dis- comfort. As a local disinfectant in those cases in which the disease is due to the presence of micro-organisms, a spray of Labarraque's solution, diluted in the proportion of one part to four of water, or a spray of peroxide of hydrogen, diluted (i to 5) thrown into the anterior nares, after they have been cleansed with the antiseptic solution for which the formula is given above, will aid materially in checking the flow of mucus, and diminish the swelHng of the turbinated tissue. If the coryza is merely a symptom of one of the zymotic diseases of childhood, the cleansing of the anterior nares gives great relief, aids materially in keeping the fever down, and in many cases prevents the distress and suffering occasioned by dry tongue and throat, be- cause these latter conditions are largely due to enforced mouth- breathing. In those cases in which a careful inspection of the nasal cavities reveals ulceration, which in children Is invariably due to congenital syphilis, it is best not to wait for the slow action of internal or even local medication, but surgical measures should at once be instituted to remove all dead bone and necrosed tissue with a small nasal curette. Very little if any hemorrhage will follow such an operation, and much permanent damage and disfigurement of the face can be prevented by such timely surgical interference. If foreign bodies are detected they should be removed at once ; and one of the best instruments for the purpose is Gross' ear-spoon and hook. Polypi or other neoplasms should also be removed at once, by 856 DISEASES OF CHILDREN. means of the Jarvis Snare, an instrument which, if properly used, gives rise to little bleeding and pain, and is far superior to the now- old-fashioned and barbarous polypus-forceps, formerly used for the purpose. Although these surgical procedures can readily be carried out, with little or no pain, by anaesthetizing the parts with cocaine solu- tion, yet it is better to administer a general anesthetic to the little sufferer, for only when unconscious, will a young child submit to a lengthy operation in the nasal cavities. After all obstructions by foreign bodies, or neoplasms, have been removed, the after-treatment should consist simply of frequent cleansing of the nasal cavities with the alkaline antiseptic solution, and in a short time the normal nasal respiration and secretion will return, and the troublesome disease will have disappeared. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. Simple coryza requires no treatment in children over two years of age, except attention to hygienic conditions. In young infants, even the mildest coryza gives trouble, by obstructing the full freedom of the respiratory act, by interfering with the suckling, and by the. rest- less and broken sleep which it induces. In such cases, all the treat- ment required is to keep the child warm, and to clear the nasal passages, at the same time lubricating them, by the occasional in- troduction of a camel's-hair pencil, charged with diluted glycerine, cosmoline, or sweet oil. When the coryza is more severe, quinia even in young infants will prove useful ; the dose should be half a grain, twice or thrice daily for a child under a year old, and double that amount for a child of two or three years. . In purulent or pseudo-membranous coryza, the indications of treat- ment are to remove the secrefions as they collect and to subdue the inflammation of the mucous membrane by which they are produced. The first indication may be fulfilled by means of a brush made of long camel's hair, by throwing water or lime-water from a small syringe into the nasal passages, or when the discharges are thin and fluid, by blowing strongly into the nostrils, whilst the tongue is depressed by a finger introduced into the mouth, so as to allow the secretion to pass out of the posterior nares into the fauces. The second in- dication is to be fulfilled chiefly by the application of solutions of alum, nitrate of silver, sulphate of zinc or copper, and by insufflations of different substances in powder. The best application is probably ACUTE CORYZA. 857 the solution of nitrate of silver, which may be made of the strength of five or ten grains to the ounce, or stronger, to be made use of several times a day, with a brush. In chronic coryza the treatment must be general and local. The general treatment will consist in care as to the clothing, suitable diet, and the administration of altera- tives and tonics. Our authors prefer the syrup of the iodide of iron, from three to five drops, at four or five years of age, three times a day, in half to one teaspoonful of syrup of sarsaparilla. When the appetite is poor and the digestive process seems slow and feeble, one grain of quinine, three times a day, should also be given. When the attack is particularly obstinate, and when, also, it occurs in a subject who either inherits or exhibits signs of the tuberculous or scrofulous diathesis, the best remedy is cod-liver oil, which should be given in doses of from half a teaspoonful to a teaspoonful two hours after each meal. In cases of a syphilitic nature, we should give the iodide of potassium, associated, in obstinate cases, with minute doses of bichloride of mercury. The local treatment must consist in the use of means intended to keep the passage clean and free from scabs and incrustations, and in the employment of astrin- gent and alterative applications. When the patient will submit, the nasal passages should be cleansed by means of a syringe once or twice a day, with tepid water or milk and water, or with a weak so- lution of alum in water, (two or four grains to the ounce). If the discharges are offensive, we may use chlorinated soda, one, two, or three drachms in two ounces of water. The surfaces should be fre- quently lubricated with glycerine and cold cream, (oj of the former to 5j of the latter). Amongst the astringent applications, the best are weak solutions of the nitrate of silver, (gr. ij to v, to water f Sj) which sliould be used only once a day, or solutions of the sulphate or the acetate of zinc with wine of opium. From two to five grains of either preparation, with a drachm of wine of opium, to an ounce of water, make a proper application. This may be applied twice a day. After the use of the alum injection during the day, (see above) Drs. Meigs and Pepper strongly urge the application of the follow- ing ointment at night : 1288. R. Unguent, hydrarg. nitrat., 3ss Ext. belladonnse, ^- " It should be applied, after being completely softened by a gentle 858 DISEASES OF CHILDREN. heat, with a camel's hair pencil, care being taken to apply it thoroughly to the mucous membrane itself, and not merely to the outside of the hardened scabs. EDWARD ELLIS, M. D., LONDON. For the ordinary colds and snuffles in children, this writer has found no treatment, at the outset, so useful as small doses of spirits of camphor, frequently repeated, say every half hour or hour. If the cold be more advanced, and what is called " feverish," with hot skin and frequent sneezing, tincture of aconite, gtt. ^, in water every half hour, will sp'eedily cause diaphoresis and a general feeling of relief. The lassitude left after a cold, or a cold showing a tendency to be- come chronic, is best met by tinctura nucis vomiccB, gtt. ij— v, to a child, according to age, three times a day, in a little water. He has frequently and thoroughly tested these plans of treatment, and can recommend them with confidence. PROF. J. LEWIS, M. D., NEW YORK. In children, ordinary attacks of this affection require little treat- ment beyond keeping the bowels opeUj soaking the feet in mustard water, and having the body warmly clothed. Frictio'n with cam- phorated oil, over the nose, is of some benefit. In attacks which commence with greater severity, an emetic of syrup of ipecacuanha, given early, will moderate the inflammation, and may prevent the occurrence of bronchitis. Afterward, a simple diaphoretic mixture should be administered, such as the following : 1289. R. Syrupi ipecacuanhae, f. 3ij Spiritfis xtheris nitrosi, f. 3 j Syrupi,. f.gij. M. One teaspoonful every three hours, to a child of six months. In place of sweet spirits of nitre, acetate of potash may be em- ployed, in the dose of i to 2 grains, for infants. If there is febrile reaction, from ^ minim to 2 minims, according to the age, of tinc- ture of digitalis, may be given in each dose. In pseudo-membranous coryza, the laryngitis which usually ac- companies this affection, demands the first attention. The injection of a solution of chlorate of potash, in water, several times a day, sub- dues the inflammation and removes the collection of mucus and pus. Or, the following may be employed : 1290. B. Aluminis, gr. xvj-xx Aquae, f. § iv. M. PHARYNGITIS. 859 This bromide solution, diluted as directed, will also be found useful when injected into the nostrils. Chronic coryza should be treated by tonics and by alteratives, di- rected to the cachexia which may be present. Together with such constitutional treatment, a solution of nitrate of silver (gr. iij-v to f.5j) may be injected into the nostrils. An excellent formula for ap- plication to parts which can be reached by a camel's-hair pencil, is : 1 29 1. R. Pulveris zinci oxidi, 5j Glycerinse, f.gj. m. To be applied three or four times a day. 1292. R. Liquoris ammonise acetatis, f. 3j Vini ipecacuanhae, ITlxvj Potassii nitratis, gr. viij Misturae amygdalae, f.Svij. M. A teaspoonful every four hours, for a child of six months. PHARYNGITIS (SORE THROAT). CAPART. This author {^Journal de Medecine de Paris) recommends the fol- lowing prescription for the cure of this condition : For a simple catarrhal sore throat he advises a gargle, such as the following, to be used every hour : 1293. R. Borax, grs. xv Salicylate of soda, grs. xxx Decoction of althea, § vij Honey of roses, 5 j- If, after using this for twelve or twenty-four hours, the affection continues, an astringent gargle is of value, made up as follows : 1294. R. Alum, 3j clytnt. V^^ 3"j Distilled water, § x. In cases in which there is sore throat, with herpetic spots upon the pharynx, it is ordered that the patient shall go to bed, and shall keep pieces of ice in the mouth, while poultices are applied exter- nally, and lemonade, strongly acid, is administered. In these cases the following prescription should be used : 1295. R. Chlorate of potash, grs. xlv Syrup, 3ij Distilled water, % j. A teaspooliful to a tablespoonful may be given every hour. 860 DISEASES OF CHILDREN. Where there is much swelling of the throat with tonsillitis of the phlegmonous form, accompanied by great pain, five or six leeches should be applied back of the angle of the jaw, and ice kept in the mouth. The following powders should also be given internally : Divide into three powders, and take one every hour. Or, a gargle may be employed as follows : '297- R. Salicylic acid, IJ grains Acetate of sodium, 7 grains Syrup of roses, i ounce Distilled water, 10 ounces. In cases in which there is a tendency to a return of the sore throat, a gargle composed as follows is useful as a prophylactic : 1298. R. Crystallized carbolic acid, i drachm Alcohol, 5 drachms Essence of peppermint, 15 drops. Ten drops of this mixture should be placed in a half glass of water, morning and eve- ning, and used as a gargle. Or the following may be employed : 1299- B- Salol, I drachm Alcohol, 5 drachms Essence of peppermint, 5 drops. A teaspoonful in a tumblerful of water three or four times a day as a gargle. TONSILLITIS. W. E. GREEN. Dr. Green {British Medical Journal, 1887) hsis found that aconite combined with guaiacum was very efficacious in the treatment of tonsillitis in children. He believes that nine out of ten cases can be aborted by the use of the following prescription, provided the cases are seen within the first forty-eight hours : 1300. R. Tr. aconiti, 3ij Tr. guaiaci, § ss Glycerinse, ad |j. Twenty drops in sweetened water every hour till easier, then every four hours till well. The patient experiences relief at the first dose. LARYNGITIS. 86 1 W. J. BAKER. Dr. Baker {British Medical Journal, 1887,) speaks very highly of the local application of bicarbonate of soda before the appear- ance of dysphagia in the course of the disease. He found that it not only gave relief in the early stages, but also when suppuration seemed inevitable. Many patients who were quite unable to swallow even liquids without acute suffering, were, in the course of an hour almost entirely free from pain, and cured in the course of four or five days. The patient, after having moistened the tip of the index finger, dips it into the powder, and then rubs it gently all over the tonsil. This should be repeated every five minutes for half an then once every hour for the rest of the day. Journal de Medecine de Paris : 1301. R. AmmoniateH tincture of guaiac, \ t x, >r • Compound tincture of cinchona, J ^ ^^J Chlorate of potassium, 3j Honey, Powdered gum arabic, q. s. Distilled water enough to make 5 iv. From one-half to one teaspoonful of this should be used as a gargle in a little water every two or three hours. LARYNGITIS (ACUTE). DR. E. FLETCHER INGALLS, OF CHICAGO. According to this author, ( Chicago Medical Journal and Exam- iner, 1880), acute laryngitis in young children requires more vigor- ous treatment than in adults, because of the small size of the larynx, and the greater liability to spasm of the glottis. In treating these cases the warm bath should be used at first, to relieve the engorge- ment of the mucous membrane and tendency to spasm. The atmos- phere of the room should be kept moist by steam, and the tempera- ture kept up to 80° F. or 85° F., and when possible, the little patient should be induced to inhale steam from the atomizer. Frequently, young children become very much alarmed by the atomizer, when brought close to their faces, but they will get some benefit from it though it is placed three or four feet away. A great deal of benefit will frequently be derived from warm applications, care being taken to keep the parts constantly warm and moist. For this purpose, 862 DISEASES OF CHILDREN. poultices of flaxseed are as good as anything ; or you may use cloths wrung out of hot water, or spongio-pilin with warm water, which latter is a more elegant application. Whichever of these is employed, it must be kept constantly hot, for if allowed to cool it will do more harm than good. If these cannot be kept warm, it is much better to apply dry cloths. Turpentine stupes to the neck have also been found beneficial. If there is much tendency to spasm, the compound syrup of squills may be given, or small doses of belladonna, which not only reUeves the spasmodic tendency, but possibly has some specific curative effect on the mucous membrane of the throat. If oedema comes on, you should make an effort to scarify the part, but generally this cannot be effected in young children ; failing in this, by passing the finger over the base of the tongue you will some- times be able to tear the mucous membrane with the nail, and thus allow the serum to escape. If you cannot relieve the oedema, and the dyspnoea continues to increase, do not hesitate to resort to trach- eotomy, which holds out very good chances for recovery. In a few rare instances of acute laryngitis in young children, the dyspnoea seems to be due to inflammation of the posterior crico- arytenoid muscles, which are the abductors of the vocal cords. The glottis, during respiration in health, is a triangular chink ; but with •paralysis of these muscles, the cords are drawn together during in- spiration, so as to greatly interfere with the ingress of air. In one case of this sort, reported by Dr. J. SOLIS COHEN, it was found that the application of ice-bags to the neck every minute, for about eight hours, succeeded in inducing reflex respiratory movements, which carried the child over the critical period. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. The most useful internal treatment that these authors have found, has been the exhibition, three times a day, of a fluid-drachm of one of the following mixtures, diluted with a little water : 1302. B. Potass, carbonat., 3j Tinct. opii, gtt. xxiv-xlviij Syr. senegae, f.3ij Syr. tolutani, f.Syj Aq. fluvial, f. 5 iij. Ft. sol. 1303. R. Ammonii bromidi, gr. Ix-xcv Ammonii muriatis vel potassii chloratis, gr. xlviij Tinct. opii deodoratas, gtt. xxiv-xlviij Syr. scillae, f.5iij Elix. calisayx, f. § j Aquae, q. s. ad f. | iij. Ft. sol. LARYNGISMUS STRIDULUS. 863 LARYNGISMUS STRIDULUS. DR. PERCIVAL. This author {Lancet, November 17, 1888) tabulates twenty-four cases which occurred in his practice, almost as an epidemic. Treat- ment by ipecacuanha, sedatives and hot applications proving of no avail, antipyrin was given in two-grain doses every hour. The dys- pnoea soon ceased, and the child fell asleep. The same dose was then continued every hour. The same good result was obtained in all cases. It was necessary to increase the dose in some instances, according to the age of the child or the severity of the paroxysm, five grains being the maximum. PROFESSOR WIDERHOFER, OF AUSTRIA. In a clinical lecture {Allgetneine Wiener Medicinishe Zeitung, 1884), Professor WiDERHOFER, to prevent closure of the glottis, recommends traction of the tongue during the attack, or sprinkling water in the face. In the intervals, he gives bromide of potassium, and regards this as almost a specific for these spasmodic attacks. The remedy must be given in rather large doses, four grains morn- ing and evening, gradually increased to eight grains. In one or two days, he claims, the attacks will have wholly ceased to occur. DR. W. H. DAY, OF ENGLAND. According to this author's teaching, found in the Medical Press and Circular, 1880, the first indications are to remove all exciting causes. If the bowels are disordered they should be set right as soon as possible by proper aperients, and healthy digestion pro- moted. If the child has taken a heavy meal, or indigestible food, an emetic may be advisable ; and should the gums be swollen, and dentition appear to invite the complaint, they ought to be scarified. The child should occupy an airy apartment, and noise and excite- ment be precluded. If seen during the paroxysm, it should be kept in an upright position, and the windows opened, so that it may be encouraged to breathe. In severe cases, especially if a convulsion threaten, it may be immersed in a warm bath, while cold water is sprinkled at the same time over the face. Dr. MORLEY ROOKE re- corded a case of laryngismus stridulus in a child nine months old, where occlusion of the larynx during the fit produced symptoms 864 DISEASES OF CHILDREN. like those of " a recently drowned person." The little patient " showed no sign of life," when first seen in the seizure ; the lips were blue and swollen, the face a livid gray, and the eyes half closed and glassy. Dr. ROOKE thrust his finger between the teeth to the fauces, when the child gave a short heave and a gasp ; on repeating the movement inspiration took place, and in a few more seconds breathing ensued. On two more occasions, when occlusion of the larynx was equally severe, a similar manoeuvre brought the child round. This is a mode of treatment well worth bearing in mind when the child threatens to die from spasm of the glottis. The cure was completed by bromide of potassium, which was taken for eleven months. Dr. Wardell also points out the beneficial effect of " rotating the finger in the throat " in these cases ; it induces an attempt to vomit, when the laryngeal muscles become relaxed, and air is admitted into the trachea. He says it is the first thing to be done, and he has seen it succeed when death seemed imminent. In extreme cases, where death threatens from asphyxia, the operation of tracheotomy should be employed. The inhalation of chloroform has been recommended in some cases, but then its influence soon passes off, and it cannot be said to have any curative effect. When there is much restlessness, and the child can obtain no sleep, the excitability of the nervous centres must be calmed, and for this pur- pose, small doses of morphia may be cautiously employed. In the intervals of the seizures the bowels must be kept freely open, so as to remove all sources of irritation that might sympathetically excite spasm. Among the chief drugs are belladonna, in the form of extract or tincture, which sometimes has the effect of diminishing the glottic spasm, but in most cases it fails altogether. Bromide of potassiuni is very serviceable given with citrate of potassium, sal volatile, or quinine, according to the peculiarities of each case. Carbonate of ammonia, henbane, bark, and mild preparations of iron, as the am- monio-citrate, or the syrup of the iodide, are remedies to be selected. If the child is strumous and rickety, or in any way delicate, cod-liver oil is invaluable. It is a remedywhich ought to be persevered with, as by improving the general health we may keep off the disease. Diet is of great importance, and, when carefully selected, the dis- ease may disappear without drugs. If the child is fed at the breast, it is sometimes advisable to change the nurse or to give milk from the cow or ass. If older, the food must be light and nutritious, and LARYNGISMUS STRIDULUS. 865 given frequently, in small quantities. The clothing should be warm, and if the child is not too ill, it should be taken out in the open air daily. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. When the disease seems to immediately depend upon difficult d^tition, the gums ought to be carefully watched, and freely scar- ified, so soon as there is the least heat or swelling over the advanc- ing teeth. When the disease depends on gastric irritation, the result of an unhealthy milk or of artificial diet, our attention must be directed chiefly to removing these conditions. When the child is thin and pale, and the stomach evidently weak and dyspeptic, it is well to resort to small quantities of stimulants, and to tonics in proper doses. The best stimulant is fine old brandy, of which, from ten to twenty drops may be given three or four times a day, or every two or three hours. Or we may administer the aromatic spirits of hartshorn, with or without brandy ; of this, about ten or fifteen drops should be given four or five times a day. Of tonics, the most suitable are quinine, in the dose of a quarter to half of a grain, three or four times a day, or the citrate of iron and quinine, in the dose of half a grain, given in the same way. Another very excellent stimulant and tonic is Huxham's tincture of bark, of which about five to fifteen drops may be prescribed in the place of brandy. When the disease is associated with marked intestinal irritation, we must inquire carefully into its nature and cause. It may be connected with constipation, diarrhoea, or with an unhealthy state of the contents of the bowels. It is often dependent upon the presence of crude or imperfectly-digested articles of food in the ali- mentary canal, and when this is the case, the only proper method of treatment is to attend to the state of the digestive functions, and to discover and employ a proper diet. The bowels are frequently very torpid, and the stools, when obtained by medicine, are often found to be very offensive, light-colored, and pasty, conditions generally resulting from imperfect action of the liver. Under these circum- stances, small doses of mercurials, or taraxacum, should be resorted to, in combination with, or followed by, light aperients, as castor oil or rhubarb. One of the very best cathartic remedies, when this combination of symptoms is present, is Chaussier's mixture of cas- tor oil and aromatic syrup of rhubarb, consisting of three parts of the former rubbed up with five parts of the latter. The dose is a 55 866 DISEASES OF CHILDREN. teaspoonful every two or three hours, until the bowels are well evac- uated. It is gentle in its actioh, and yet very efficient, gives no pain, and is easily taken. If a mercurial be desired, about two or three grains of blue mass, one or two grains of calomel, or four grains of the mercury with chalk, may be incorporated into the mixture. When diarrhoea is present, it must be treated according to its causes. When, on the contrary, constipation is a marked symptom, this is to be treated by regulation of the diet, by the daily use of warm water enemata, or, if these do not answer, by the exhibition of small doses of the mildest aperients. In cases apparently connected with en- largement of the bronchial or cervical glands, the treatment should be directed to the invigoration of the general health by attention to diet, by the use of tonics, and by proper exposure to fresh air, whilst we should employ internally cod-liver oil, iron, iodide of po- tassium, the preparations of iodine and anti-spasmodics. When the disease persists, in spite of the means recommended, and especially when it depends on dentition or digestive irritation, change of air will often produce a wonderful effect, and should always be tried. PNEUMONIA. C. W. TOWNSEND, M. D. This authority {Arch. Ped., April, 1889), thinks that all active de- bilitating measures are harmful because of the fact that the natural tendency of pneumonia is towards recovery. Dr. MiNOT, in an ar- ticle on the treatment of pneumonia, says, " I would plead for little children, who like nothing so well as to be left undisturbed by offi- cious ministrations." Nourishment can only be taken in the liquid form, and milk in small quantities, frequently repeated, is the best form. It is not necessary to force feeding, as the course of the disease is short, as compared with such debilitating diseases as typhoid fever. Cireat care is given to the condition of the air of the room, and it is always considered well to give some medicine, even if only as a placebo to the mother's mind. He says that he does not believe the administration of chloride of ammonium, nitre and bromide of potassium do any good in this PNEUMONIA. 867 trouble. Antifebrin has had the effect of reducing the temperature, but had no good effect on the disease itself. Morphia, in small doses, was beneficial in quieting the pain and restlessness, and the author thinks it good practice to employ it with discretion. The use of the jacket poultice is to be decried on account of its being heavy and making the child uncomfortable, although a small poultice, applied directly over the seat of pain, is advised. A poul- tice to the stomach, when the pain is in that region, is also found beneficial. His parting advice is, to avoid active debilitating treat- ment, as the natural tendency of the disease is toward recovery. BARTHEL AND MORITZ, ST. PETERSBURG. These authors {Arch. f. K., viii. 4) do not claim to have origi- nated the mercurial treatment, as it was employed by WiTTICH as early as 1850. It was employed by this latter authority in the form of the bichloride in very small doses, but the authors of this article found that it produced very marked disturbances of the gastro-intes- tinal tract, and they substituted for the bichloride, mercurial oint- ment in the form of inunctions. They began the treatment in adults, and found it so satisfactory that its use was extended to chil- dren. Over 1 50 cases have been treated by these gentlemen with a mortality of only 6.2 per cent., while all other methods of treat- ment employed at the same time and at the same institutions gave a mortality of 31.4 per cent. The inunctions were practiced as soon as the diagnosis was made clear, the extremities, the abdomen and the sacrum being the seat of the applications. The quantity used was four grammes (one drachm approximately) morning and evening, and in the severest cases, six grammes (one drachm and a half). The inunctions were continued, as a rule, only half a day after the crisis occurred. A mouth-wash of chlorate of potash was used from the beginning of the treatment, but in spite of this, gums and salivary glands became inflamed in some cases. After the crisis occurred, the inunctions were only practiced once a day. DR. EDWARD HENOCH, OF BERLIN. According to this author, the expectant treatment, usually recom- mended in the pneumonia of adults, will also hold good during the period of childhood. He only uses wet cups when there is intense dyspnoea and great extension of the pneumonia, and in a complica- 868 DISEASES OF CHILDREN. tion with severe pleurisy, when required on account of violent pains in breathing and coughing. When the pneumonia is restricted in extent and the pleuritic complication is absent, or at least does not occupy the foreground, bleeding should not be employed, and it is best to resort to cold applications or fomentations to the chest (see Bronchitis) which, so long as the high temperature continues, are re- newed every half hour, later every hour or two. The application of an ice-bag to the head or abdomen, is also advisable. He has ceased the use of quinine and other antipyretics, and confines himself to the local application of cold. Internally he gives digitalis and nitrate of potash. I304- B- Inf. digitalis, f-Siij Potass, nitrat., gr. xxx-xlv Syrupi, f. 3v. M. S. — ^Teaspoonful every two hours. This, however, is contra-indicated by any gastric complication (re- peated bilious vomiting, thickly-coated tongue, nausea). In this event he orders : 1305. R. Acid. hydrochloT., gtt. j-xv Aq. destil., f. § iij Gum. arab., gr. xv Syrupi, f. 3v. M. S. — ^Teaspoonful every two hours. In very rare cases, he has given tartar emetic, when bilious, gastric symptoms, (constant frontal headache, vomiting, fcetor of the breath,) were prominent, and it was always very successful in such cases. DR. ARMAND SEMPLE, OF LONDON. This author recognizes two types of pneumonia, which demand very different handling — the one sthenic or plethoric, the other asthenic. The former is, at the present day, comparatively rare, the large majority of cases being of the latter kind. The sthenic form may re- quire blistering and leeches, with depletory remedies, such as mercu- rials and antimonial preparations. The asthenic form will derive ben- efit by the application of jacket poultices of linseed-meal, i. e., encirc- ling both the back and chest of the patient ; the linseed-meal should have the oil crushed in it, and a little oil should be smeared over the surface of the poultice. These poultices should be tolerably thick, moist, thoroughly warmed and frequently changed. Decoction of poppies may be used in place of water for forming the poultices, if PNEUMONIA. 869 severe pain is present. Internally aconite preparations, ipecacuanha, citrate of potash, acetate of ammonia, spiritus aetheris nitrosi, and senega, may be administered. The strength should be supported by strong beef tea, eggs, and milk, and if the exhaustion be very great, carbonate of- ammonia, brandy, or port wine may be given. If the sputa be viscid, and urine cloudy, alkalies are indicated. For want of sleep, hydrate of chloral may be used, and it is advisable to combine this drug with belladonna, by which the enfeeblement of the vaso-motor system, and the diminished activity of the respira- tory centres, caused by the chloral hydrate, are obviated. The above-named drugs, especially aconite and hydrate of chloral, must be very cautiously administered. Bromide of potassium is a safer remedy than chloral, since it exerts a sedative action on the nervous system by depressing the action of the heart. During convalescence, cod-liver oil and iron preparations are the appropriate remedies. DR. SILBERMANN, OF GERMANY. This author describes in the Deutsch. Arch, fur Klin. Med., 1883, a form of septic pneumonia in children, which, from his remarks, it would seem is always fatal. He thus describes it: 1. The septic pneumonia of infants and nursing children, which begins as a tracheo-bronchitis, is a catarrhal and, very often, a "foreign-body," pneumonia. 2. It is caused by the aspiration of decomposing amniotic fluid and genital secretions, or by the inspiration of strongly-infected air from some septic disease of the mother. 3. Septic pneumonia of infants, frequently accompanies diseases of the pleura, but seldom of other organs. The alveoli and bronchi of the lungs of children dead of septic pneumonia, are filled with bacteria.. 5. The blood shows an increased amount of white globules, and a broken-down condition of the red. 6. Icterus is not a constant accompaniment of the disease. 7. The time at which the disease occurs is from one to two days after birth, and death usually takes place in about two days. DR. JOHN M. KEATING, OF PHILADELPHIA. In the first stage of croupous pneumonia this author uses (^Med teal and Surgical Reporter, 1882,) large, thinly-spread poultices of mush or flax-seed meal as hot as the child can bear them, (to be 870 DISEASES OF CHILDREN. tested by the hand), changed every three hours and covered with oiled silk, which he prefers to hot baths, though hot foot-baths, with a tablespoonful of mustard added, can be used twice or thrice daily. He also gives the bisulphate of quinia, gr. iij, twice daily, by sup- pository, to keep down high temperature, with instructions to use one of gr. v should the temperature register 105°. He also uses whisky or brandy in 3j doses, to aid the suppository in reducing temperature, if required ; the desire being to keep the temperature below 105°. He insists strongly on the importance of making out for the mother or attendant, a register of diet and medicine, to be strictly adhered to, so that you can readily see what your patient is getting. If the patient is fretful or sleepless, you can give two grains of Dover's powder, using the bromide, instead of the sulphate of potassium, at night. When mucous rales are heard over the entire consolidated lung, you can replace the poultices by a thick layer of . cotton wadding, changing it twice daily, and rubbing the surface of the chest with the following liniment : 1306. R. 01. succini, f.3ij Linimenti saponis, f. § yj. M. You may use cod-liver oil, in place of sweet oil, in the liniment. In a few days, he uses an external application of the following : 1307. R. Tinct. iodi, f.3j 01. myrrbffi; ol. olivx, ia §vj. M. Sig. — Well rubbed in. If you wish now to give tonic doses of quinia and iron in some form, you can order: 1308. R. Quinise et ferri citratis, gr. xij Syr. limonis, f. § ss Aquae, q. s. ad f. | iij. M. S. — Dessertspoonful three times daily. Or: •309- B- Ferri ammon. citrat., gr. xij Syr. amyg. amar., f. § ss Aquae, q. s. ad f. g iij. M. S. — Dose 3ij-iv. And still give the quinine by suppository. If the cough is loose, but annoying, he gives : 1310. R. Ammon. muriat., gr. viij Syr. scillae, niclv Tinct. opii camph., IUxxir Syr. tolut, q. s. ad f. § ij. M. S. — Teaspoonful three times a day. PNEUMONIA. 871 And if the secretion is free and you think it advisable to act gently on the intestine to carry ofif the accumulated mucus, you can use : 1^ 131 1. R. Liq. potass, citratis, f. §j Syr. pruni virg., f. § ss Glycerinae, f. % ij. M. S. — Dose Sij-iv. In the third stage, the greatest danger is from weakness. Here the child needs supportive treatment — iron in particular, quinine, milk- punch or wine-whey, cod-liver oil, with the phosphates and the hypo- phosphites. He orders, especially if the children are run down : 1312. R. Syr. ferri. iodidi, f.3j Emul. ol. morrhvue (fifty per cent.), f.§iij. M. S. — Dessertspoonful t. d. M. JULES SIMON, OF PARIS. According to the Medical Press and Circular, 1882, M. SiMON recommends, at the beginning, dry cupping and poultices. The next day or the following, small blisters, left on for three or four hours, and when taken off, another poultice applied and left on for an hour, when the blisters will have arisen and can be dressed. This revulsive treatment should be continued throughout the whole course of the disease. Internally, he gives : I3I3- R- Tinct. scillse, Tinct. digitalis, aa gtt. x Syrupi, *•§] . Aquse acacix, f. § iij. M. S. — A teaspoonful every two hours. The digitalis and the squills should be suppressed after four or five days. Milk should be freely given, as it acts as a good diuretic. THOMAS HILLIER, M. D., LONDON, F. R. C. P., ETC. Usually the best treatment in the lobular pneumonia of children, is to keep the patient in bed in a room of about 60°, well ventilated without a draught, milk diet during the height of the fever, and when the temperature falls, some good beef tea, and a simple saline mixture, such as : '3 '4- R- Potassii citratis, 9i Syrupi aurantii, f. 3 ij •Aquae, q. s. adf.iij. M. Two teaspoonfuls as required. The tendency of the disease in children, is to recovery. The great 872 DISEASES OF CHILDREN. point is to do nothing which will interfere with rapid convalescence. Antimony is seldom desirable or necessary ; if given at all, it should be confined to those cases in which the pulse is full and strong, the temperature very high, and the skin and mucous membranes very dry and injected, and it should be given only for a short time, at an early stage of the disease. Counter-irritation is not much to be relied upon. When there is severe pain in the side, a mustard plas- ter is of service. Blisters are seldom or never to be recommended, certainly not in the acute stage. If resolution comes on very slowly, andthere is persistent pleuritic pain, an occasional flying blister will be of service. Calomel is not to be recommended except as an occa- sional aperient. If the pneumonia is complicated with bronchitis, and the bronchi contain much mucus, a stimulant expectorant is in- dicated, such as: I3I5- B- Ammonii carbonatis, gr. viij-xij Tincturae sciUse, IIlxx Syrupi, f.3ij Decocti senegse, q. s. ad f. § ij. M. Two teaspoonfuls for a child three years old. During convalescence, the use of iron, in a mild form, is of ser- vice, as : 1316. R. Ferri et quinise citratis, 9j Syrupi limonis, f. 3 ij Aquae, q. s. adf.Sij. M. Two teaspoonfuls thrice daily. EUSTACE SMITH, M. D., M. R. C. P., ETC., LONDON. '31 7- B- Liquoris ammonii acetatis, f. Si^ Potassii nitratis, 5j Potassii bicarbonatis, 3 iss Spiritiis jetheris nitrosi, f.3iss Aquse cari, q. s. ad f. § yj. M. A tablespoonful every third hour for a child Six or seven years old, in cases of " pul- monary phthisis." At the same time, the chest should be kept covered with hot linseed-meal poultices, frequently renewed, and the child confined to his nursery or bedroom. After the cough has become loosened, and the oppression of the chest has subsided, expectorants should be given with an alkali : 1 31 8. B- Spirit&s ammonise aromatici, Spirittls setheris nitrosi, Vini ipecaciianhse, ga t. 3j Potassii bicarbonatis, 3j Infiisi calumbse, q. ». ad f. § vj. M. A tablespoonful every sixth hour. PNEUMONIi^. 873 Afterward, when the secretion is free and easily brought up, and the fever has disappeared, an astringent is useful, combined with expectorants and a little opium. '3'9' R- Liquoris ferri pernitratis, Acidi nitrici dilnti, aa f. 5i Tincturae opii camphoratse, f. 5 ij Oxytnellis scillae, f. § j Infusi calumbae, q. s. ad f. § vj. M. A tablespoonful thrice daily. When unabsorbed pneumonic deposits continue, alkalies are ex- tremely useful. The inhalation of sprays of weak solutions of bicar- bonate, nitrate, or chlorate of potash, promotes expectoration. In chronic pneumonic consolidation, irritants are sometimes useful : 1320. g. Olei tiglii. f. 3j Linimenti saponis, f. § j. M. To be rubbed into a limited spot on the chest twice a day till pustulation, and then once a day for a week. So long as there is much heat of the skin, counter-irritants should not be employed. PROF. J. LEWIS SMITH, M. D., NEW YORK. In the earlier stages, the following is a useful formula for a child of five years : 1321. R- Tincturje ipecacuanhae compositse, gtt. xvj-xxiv Tincturae aconiti radicis, gtt. xvj Syrupi tolutani, f. Sj Aquae, adf.§j. M. One teaspoonful every three hours. In the second stage — that is, when there are signs of lung hepati- zation, such as bronchial respiration and dullness on percussion — aconite and veratrum viride do harm. The following may then be employed : 1322- R- Morphise sulphatis, gr. j Syrupi ipecacuanhae, f.§j Syrupi tolutani, f. S iij. M. Teaspoonful every three hours. In feeble children, and in secondary pneumonitis, quinine is prefer- able to any other agent, for reducing the temperature and pulse, as it does so without causing depression. 874 DISEASES OF CHILDREN. LEONARD WEBER, M. D., NEW YORK. In simple pneumonia, whether of children or adults, this prac- titioner states {American Journal of Obstetrics, April, 1878,) that he has been accustomed to prescribe : '323. R. Infusi digitalis, (3 ss of the leaves), f-S^i Sodii nitratis, Sj- St. A teaspoonful every two or three hours, to a child of ten, when the pulse and tem- perature are high. When there are signs of the heart giving out, camphor, carbonate of ammonia and wine, are required. Protraction of resolution in the lung is often caused by a state of acute anaemia, and demands a liberal diet, the discreet use of stimulants, and iron. In severe and extensive broncho or catarrhal pneumonia, a most valuable resource is the hot mustard bath. As soon as pneumonia develops, in cases of capillary bronchitis, the temperature rises to 103°, or more, in a few hours, the pulse beats fast, the face becomes flushed, the child is exceeding restless, wears an anxious expression of countenance, but soon becomes apathetic and somnolent. The course of the disease is rapid, and ends fatally, by cyanosis. He immerses the patient in a hot mus- tard bath (105°), prepared by diffusing a pound of mustard in a baby-tub full of hot water, keeping the child in ten minutes, making thorough friction all over the surface, until the skin becomes pink- ish. Then the patient is put in a warmed bed. If necessary, repeat in four hours. Its modus of action is " ubi irritatio, ibi affluxus " — it relieves the congested lung and overburdened heart, by increas- ing the amount of blood in the peripheral circulation ; also by stim- ulating, reflexly, the vaso-motor centres. It may be claimed for the use of the bath, that it is easily pre- pared ; that the materials for it can be procured in the household of the poor as well as the rich ; that its action is prompt ; that there is no danger whatever in applying it as often as the urgency of the case may require it, and that it is a valuable means of fulfilling the vital indication in severe cases of pneumonia in children. Q. C. SMITH, M. D., CALIFORNIA. In all acute pulmonic inflammations in small children, this prac- titioner states {Pacific Med. and Sur. Journal, January, 1878,) that he has for several years used, with very satisfactory results, the PLEURITIS. 875 moist girdle, as directed by VOGEL, of Dorpat; and he has found the measure to greatly promote relief He manages it thus: A piece of white woolen flannel, two yards long, wide enough to cover the patient's body from the hips to close up under the arm-pits, after being wrung out of warm water, so that it will not drip, is closely^ but not oppressively so, wrapped around the body, and the terminal end secured by two small pins. This moist wrapper is snugly cov- ered by a dry one, which outer wrapper must be changed as often as it gets wet. The inner wrapper should not, ordinarily, be re- moved for several days, but is to be kept moist by applying, as often as necessary, warm water, with a small, soft cloth or sponge. In from four to seven days, when the more urgent symptoms have been subdued, the moist girdle may be supplanted by a dry one, which should be applied for a few days longer. Of course, the at- tendant will not neglect to make use of such other remedies and measures as may be deemed necessary in any given case. PLEURITIS (PLEURISY). SIMON. After speaking of the great difficulty of making a diagnosis at times because of the obscurity of the classical symptoms, the author (^Le Progres Med., January 31, 1891) divides the treatment into two parts: First, the period of development where the indications are entirely medical ; at this time he uses calomel in doses of three-twentieths to three-fourths of a grain, for two or three days, for its intestinal action. Digitalis is also given as a diuretic and antiphlogistic, together with hot milk, diuretic drinks, etc. Local treatment consists in the appli- cation of sinapisms. Effusion constitutes the second period of treatment, being the same as for adults ; thoracentesis for excessive effusion, and the in- sertion of drainage tubes and lavage for the empyema. In lavage of the pleural cavity, the use of a syphon is preferred, as is also boric acid solution and iodoform gauze dressing. Attention is given to hygiene and the administration of tonics. DR. LOUIS STARR, OF PHILADELPHIA. According to this author (^Archives of Pediatrics, 1884,) the child 876 DISEASES OF CHILDREN. must be kept at perfect rest in bed. Over the affected side he ap- plies a poultice to act as a counter-irritant, drawing the blood to the surface and relieving the congestion of the pleura. As there is an inflammatory fever, a light and nutritious diet must be selected, since fevers of this kind are accompanied by gastric catarrh, and strong food cannot be digested. The only medicines indicated are diaphor- etics, as : 13^- K- Spts. aetfaeris nitrosi, f-Sij Liq . potassii citratis, q. s. ad f. § iij. M. S. — A dessertspoonful every two hours. Sometimes after fever has subsided, you will hear a friction sound on auscultation, especially when the breathing is forced, as it is after running or coughing, showing that plastic exudation has taken place, and that there may, perhaps, be a tendency to adhesion between the two pleural surfaces. Under these circumstances, an alterative is called for, to favor the absorption of the effused lymph. For this purpose iodide of potassium is most useful ; beginning with doses of one or two grains in half a fluid-drachm each, of compound syrup of sarsaparilla and water, three times a day ; or, if there be anaemia, ten drops of the syrup of the iodide of iron three times a day may be substituted. An ointment consisting of equal parts of the compound iodine ointment and lard, may be applied twice a day, locally. If the tincture of iodine is used, inflammation of the skin is likely to be produced, and after this has occurred, no more of the iodine is ab- sorbed. The ointment, when properly diluted, causes no such result. The iodine is absorbed, and thus we get an alterative effect, in addi- tion to a counter-irritant action. DR. ARMAND SEMPLE, OF LONDON. In acute pleuritis the child may be enveloped in a large jacket poultice. With a strong, healthy child a few leeches may be placed on the side, and a saline diaphoretic administered, such as acetate of ammonia or nitrate of potash combined with a little antimonial wine ; a grain of calomel combined with the compound ipecacuanha pow- der is useful. The regimen should be antiphlogistic. In chronic pleuritis, the diet must be liberal ; good food and wine should be given. Blisters may be applied from time to time. The chest may be painted with iodine. Iodide of potassium, bark, squills, digitalis, and acetate of potash may be given internally. In anasmic children. PLEURITIS. 877 tonics, such as quinine, strychnia, the various preparations of iron and cod-liver oil, may be given. When the process of absorption fails, the lung becoming seriously compressed, giving rise to urgent dyspnoea, the pulse being irregular, the heart feeble or the fluid be- coming foetid, and great constitutional disturbance occasioned, the patient being in danger from hectic fever and septicaemia, the oper- ation ol paracenthesis thoracis is demanded, and care should be taken that this operation is not delayed too long. The following are the cases calling for paracentesis : I.' Those cases in which the fluid is so abundant as to fill one pleura and induce compression of the lung of the opposite side. 2. Cases of double pleuritis, in which the whole amount of fluid may possibly occupy a space equal to the capacity of the two pleural cavities. 3. Cases in which the amount of effusion has given rise to one or two attacks of orthopncea. 4. Cases in which a large effusion has existed for a long time (a month or so) , and in which there has been no indication of progres- sive absorption. 5. In every case in which the contained fluid is suspected to be purulent, an exploratory puncture should be made and the fluid evacuated. DR. EDWARD HENOCH, OF BERLIN. At the onset, when severe pain is present, he considers the appli- cation of a number, (corresponding to the age,) of wet cups, (dry cups in feeble children,) as necessary. Hydropathic applications should also be made constantly, while infusion of digitalis, combined with nitrate of potash, is given internally. 1325. B. Inf. digitalis, f-§iij Potass, nit., gr. xxx-xlv Syrupi, f. 3v. M- S. — Teaspoonful every two hours. Calomel and digitalis also do good service, especially when con- stipation is present. 1326. B. Hyd. chlor. mitis, gr. \ Pulv. digital., gr. \ Saccb. alb., gr. j. M. S. — Give this powder every two hours. With the increase of exudation, diuretic treatment comes to the 878 DISEASES OF CHILDREN. foreground, viz. : infusion of digitalis and acetate of potash. In sub-acute cases he recommends infusion of bark, with acetate of potash, cod-liver oil, whey, and country or mountain air. S. HENRY DESSAU, M. D., NEW YORK CITY. It is observed by this writer {Medical Record, September, 1878,) that pelurisy is frequently overlooked when it occurs in infants. For its detection, as well as an aid to treatment, he recommends that whenever a doubt exists in the mind of the physician, in regard to the diagnosis of even the simplest case of pleurisy, it should at once be cleared up by an exploratory puncture of the chest-wall with an ordinary hypodermic syringe, as recommended by EUSTACE SMITH, and later by Dr. THOMAS Barlow and Mr. R. W. PARKER, of Lon- don. The operation is perfectly harmless, does not give much pain, and may be repeated several times if necessary. The puncture is best made in the intercostal space, immediately below and on a line with the angle of the scapula. When the effusion is localized or circumscribed, as is sometimes the case, the puncture is advised, by the last-mentioned writers, to be made over the centre of maximum dullness. Dr. Dessau has frequently found the withdrawal of a syringeful of fluid, obtained on exploratory puncture, to rapidly hasten the ab- sorption of the effused fluid. This has been explained as due to the relief of pressure, stimulating the absorbents of the pleura. For internal treatment, he prefers small doses of infusion of digi- talis, together with syrup of the iodide of iron. Moderate counter- irritation over the back, is occasionally useful, and as a tonic to has- ten convalescence, sulphate of cinchonidia. EDWARD ELLIS, M. D., LONDON. This writer is satisfied of the relief which calomel and opium often give in the acute pleurisy of childhood, and sees no objection to their employment. The best form is : 1327. R. Hydrargyri chloridi mitis, gr. ss ] Pulveris ipecac, et opii, gr. j-iij. M. He can speak well of both aconite and veratrum viride in- the ear- liest stages, but both of these, especially the latter, must be discon- tinued as soon as a decline in the pyrexia is established. For the relief of the pain, we may prevent the movement of the PLEURITIS. 879 side by fixing it in place by strips of adhesive plaster several inches wide, and long enough to reach from the middle of the spine to the middle of the sternum. They should be applied at the close of an expiration, while the lung is emptied of its air. Another means is a lotion of aconite or opium applied immediately over the painful spot, and covered with a poultice. Later in the disease, when the pyrexia has disappeared, a combi- nation of iodide and citrate of potash with digitalis will be found very useful, e, g. : 1328. R. Fotassii iodidi, gr. viij Potassii nitratis vel citratis, gr. xxxij Infusi digitalis, l.^j Syrupi, f.3ij AquK, adf.Siv. M. A tablespoonful for a child six years of age. Care should be taken that the infusion of digitalis be freshly made. For the treatment of the effusion, painting the side with tincture of iodine, or a succession of flying blisters, or finally, paracentesis thoracis, are our resources. The last-mentioned operation is grow- ing more into favor the more extensively it is adopted. It should not be postponed until the patient is in extremis, and the powers of nature are exhausted. DR. THOMAS BARLOW AND MR. R. W. PARKER. In regard to the treatment of pleuritic effusions in children, these writers (^British Medical jfournal, August 25, 1877,) strongly re- commend an exploratory puncture, and the removal of a small quantity of serum. When the history is recent, and the effusion serous and small, they abstain from further operative interference. When three weeks elapse without improvement, they recommend the additional removal of a small quantity, either by the hypodermic syringe or the aspirator. If the effusion be considerable, it is right to perform paracentesis at once ; not only to relieve dyspnoea, but to give the lung a chance of re-expansion before adhesions bind it down. Paracentesis should be performed quite irrespectively of pyrexia. As to drugs, they have seen no benefit whatever from their use in pleuritic effusion. No harm results from the external application of iodine; indeed, it has seemed that its use, combined with the inter- 880 DISEASES OF CHILDREN. iial administration of iodide of potassium, has produced benefit. In this, as in every other wasting disease of childhood, cod-liver oil is invaluable. If the exploratory puncture reveals the presence of pus, it is re- commended to withdraw as much as possible with the hypodermic syringe. It is quite marvelous to observe the rapid improvement which frequently follows the emptying of a very small collection of pus. If the quantity of pus removed be incommensurate with the extent and intensity of the dulness, subsequent punctures must be made. If the pus does not become foetid, and if at each successive operation the quantity notably diminish, there seems no reason to limit the number of attempts to cure the empyema by repeated aspiration. If the pus should become foetid, or rapidly re-accumu- late in larger quantity, permanent drainage is recommended. In all cases, it is contended that this should be by a double opening. If possible, the first opening should be made in the front of the thorax, and the second below and internal to the angle of the scapula. A long probe, threaded with a piece of drainage-tube, may be passed downward and backward from the first opening, and the second in- cision made over the point of the probe when it is felt through the integuments. The drainage-tube should then be drawn through and secured by tying the two ends together. Most of the cases with which they have been concerned, have been dressed with oakum. They have seldom had need to use stim- ulant injections ;, but in one case, they saw marked and rapid im- provement from the use of a solution of quinine, 5 grains to the ounce. One of the strongest arguments in favor of the method of double openings, is that in a large proportion of cases, it dispenses with the need of washing out the erripyema cavity. It is well known that washing out the chest has been followed, in a certain number of cases, by sudden death. EMPYEMA. DRS. EWART AND BENHAM. In the special case reported by the above authorities, (^Brit. Med. yournal, March i2, 1887,) an opening was made in the fifth inter- space in the axillary line, and a counter-opening in the scapular EMPYEMA. 88 1 line in the ninth interspace. Free discharge of fetid pus took place for four days, but the cavity was not washed out. Perflation was then employed in the following manner: with a hand-bellows air was forced through a strong carbolic acid solution, and then into the anterior opening. This was followed by a large amount of fetid discharge and shreds of false membrane, which escaped from the posterior opening. From this time the fetor ceased, and both wounds closed in a month. Following are the opinions of a num- ber of eminent authorities on perflation. Dr. D. G. POLLOCK does not see what advantage perflation possesses over washing out through a free opening. This latter procedure has given excellent results in his hands, in some long-standing cases. He is unquali- fiedly in favor of early incision. Dr. Dyce Duckworth thinks well of the new operation. His treatment heretofore has been to make a free opening and counter- opening under antiseptic precautions, but not to wash out the cavity. Mr. R. J. Godlee thinks the case would have recovered under almost any treatment. Where some suppurating residue is left be- hind, he prefers to blow iodoform into the cavity. He believes that the cases are few in which washing out is called for. Dr. SansONE suggests that it would be better to pass the air used for perflation through cotton, wool or blotting paper, soaked in car- bolic acid, than through an aqueous solution. Dr. EWART thinks that perflation is especially advisable in cases where loose or loosely-attached substances are in the chest, keeping up irritation and suppuration. In five out of seven cases he has operated on the left side without danger, and without embarrassing the heart's action. DR. BLACHEZ. Dr. Blachez {L'Union Med. du Can., September, 1886,) gives it as his opinion that pleurisy sometimes gets well spontaneously, but says that as a rule it is best not to expect spontaneous recovery, but to perform thoracentesis. Many cases are on record in which abso- lute cure has resulted from a single operation of this kind. As a rule, however, repeated punctures will be required, the quantity of pus obtained being less with each succeeding operation. If after five or six operations of this kind the patient is not cured, thoraco- tomy should be performed. The operation is not particulary dan- gerous, and should be followed by irrigations of antiseptic solutions. 56 882 DISEASES OF CHILDREN. The author prefers for this purpose a one to one thousand solution of sublimate, or a two to one hundred solution of boracic acid. As the fever declines, the irrigations are made with diminished fre- quency, until at length from two to three times per week will suffice. The wound should be kept covered with several folds of carbolized gauze. The drainage-tubes must not be too long, and should be removed when the development of pus has reached its minimum. Alimentation should be as strengthening as the condition of the di- gestive organs will allow;. Many authors have objected to the ad- ministration of chloroform during the performance of this operation, but Blachez does not share this feeling. He considers local anaes- thesia very excellent for such cases, and advises a stream of ether to be directed upon the field of the incision, in order that the patient may not suffer pain, and that the physician may operate with the necessary deliberation. CADET DE GASSICOURT. {Jour, de Med., April, 1888). " There are two methods of treat- ing and curing purulent pleurisy — simple punctures, and the cutting operation. The punctures are not infrequently preliminary to the cutting operation, the latter being required if there has been no cure as the result of a number of punctures." According to the author, the most favorable conditions for success from simple punctures are that the patient should be not more than six or seven years of age, that the thoracic walls should be very supple, that the lungs should be very sound and expand readily, and that the false membranes should not be very strong. His advice is that the punctures should be made systematically, at regular inter- vals of four or five days, that one may judge of the quantity of pus produced in a given number of days. The author is thoroughly opposed to the indefinite repetition of punctures, and his rule con- cerning this method is that the quantity of pus withdrawn at each successive puncture must diminish. If, after two punctures, the quan- tity increases, no further time should be lost before performing the more formidable operation. This operation has nothing peculiar about it in the author's hands, but it is done with antiseptic precau- tions, and has usually been followed by cure in from twenty to thirty days. BRONCHITIS. 883 BRONCHITIS. HARE, PHILADELPHIA, Uses the following in the acute stage of bronchitis in children : «3*9. R. Tr.aconiti, gtts. zij Syr. ipecac, f.^sa-j Liq. potassii citiatis, q. s. ad f. $ iij. ■ Sig. — One teaspoonfnl every three hours. For the later stages : I330' B- Ammonii chloridi, 5i Ext glycyrrhizse fld., f. Jiv Aquae dest., q. s. ad f. 5 nj. Sig. — One teaspoonful three times a day. FRIEDLANDER, OF RUSSIA, {Medical News, 1887,) says that in acute bronchitis, nine grains of ant^yrine sufficed to'influence children under two years of age, for twenty-four hoiirs. Profuse perspiration, lessened cough, sleep, and general improvement followed. During convalescence, half this dos^ was used. In addition, the following was found useful : 1331. B. Caffeine, gr. iij Sodii bicarb., gr. xx to xl Aquae foeniculi, 3xT Syr. ipecac, Sviiss. M. Sig. — One-half to one teaspoonful every half hour to every two hours. DR. EDWARD HENOCH, OF BERLIN. According to this author, simple catarrh recovers spontaneously if the child is kept in its room, but two or three weeks almost always elapse before the disease has been completely cured. The use of inf. rad. ipecacuanhae is recommended by some writers, but our author does not think it will shorten the attack, though it may have a sedative effect on the cough. When constipation and fever are present, he uses ipecacuanha in combination with calomel. 1332. B- Calomel, gr. iss Pulv. ipecac, gr. iss Sacch. alb., gr. viiss. M. S. — Give this powder every two hours. But if the disease is attended with great dyspnoea and high fever, more energetic treatment is necessary, and he uses cups (dry or wet), four or eight, according to the age of patient. He strongly 884 DISEASES OF CHILDREN. recommends hydropathic applications to the chest, from the neck to the umbilicus. . A napkin or diaper is dipped in water at the tem- perature of the room, well wrung out and then placed around the chest, without exercising any compression, so that the arms are free ; this is surrounded by a roll of batting, and then covered with a layer of oil-silk. When the fever is high, these applications should be renewed at least every half hour ; later, they may be kept for one or two hours, and this should be continued for several days and nights. These applications will be aided, by allowing steam to escape from a tea-pot near the bed, thus rendering the atmosphere moist. The applications often produce favorable perspiration, which should not, however, be allowed to become too profuse, as it may cause symptoms of collapse. During the entire course of the disease, it is not well to keep the child constantly on his back, but to change him from one side to the other, or carry him on the arm, in order to prevent hypostatic congestion as much as possible. Our author co- incides with the view that emetics are useful. When the patient is strong and healthy and can be carefully nursed, he uses tartar emetic. '333- R- Antimonii ct potassu tart., gr. iss Aq. destil., f. % iij Syrupi, f. 3v. M. Of this he gives a teaspoonful every hour until vomiting occurs, and then every two hours. If vomiting or perhaps diarrhoea occurs after each dose, the drug must be Stopped at once. Even though vomiting is not produced after the first three doses, still he increases the intervals to two hours, in order to prevent cumulative effect. This plan is unsuitable for weakly children, when diarrhoea is pres- ent or in advanced stage of the disease. In such cases it is better to use ipecacuanha. 1 1 34. B- Pul'"- ipecac, gr. xv-xxx Aq. destill., . f.Sviiss Oxymel scillae, tSiij. M. S. — One dessertspoonful every ten minntes until the effect is produced. In vigorous nurslings, he has often found the following useful in the beginning of the disease : '335- B- ^''^ antimonii, Oxymel scillae, 5a tjiiss, M. S. — A teaspoonful every ten minutes until the effect is produced. BRONCHITIS. 885 As soon as numerous rales indicate the presence of profuse secre- tion in the bronchi, and the sinking of the powers prohibits the use of emetics, he recommends a strong infusion of ipecac root, decoction of senega root or polygala amarae. '336- R- Decoct, rad. senegas or polygala amarse, f. | iij Liq. ammon. anisat., f. 5ss Syrupi, f.3v. M. S. — ^Dessertspoonful every two hours. Mustard poultices to the sternum or back, and small flying blisters to the thorax, he also uses at this time. Milk, broth and wine must be given alternately to sustain the strength. If these articles are of no avail, and the loss of strength progresses, he resorts to camphor and benzoic acid. I337- R- Camphorae tritae, gr. ^ Acid, benzoic, gr. ^ Sacch. alb., gr. iss. M. S. — Give this powder every two hours. PROF. J. LEWIS SMITH, M. D., NEVST YORK. At the outset of acute bronchitis in children, it is often of great service to exhibit small and repeated doses of veratrum viride, as the following, for a child five years old, in the first stage of the disease : '338. R. Tinct. veratri viridis, Illxij Syrupi scillae compos., f- 3 ij Syrupi tolutani, f. 3kv. M. One teaspoonful every two or three hours. When the pulse lowers, the temperature falls, and moisture appears upon the skin, the medicine should be omitted. The re- maining treatment is by expectorant mixtures, etc. The chronic laryngitis occurring in children in general good health, sometimes resulting from an acute attack, is an obstinate affection. The patient should be warmly clad, and every effort made to guard against tak- ing cold. The most satisfactory treatment is the application of tincture of iodine upon the neck, directly over the larynx, and in some cases, of a solution of nitrate of silver — 10 or 20 grains to the ounce — to the fauces, so that, if possible, some of it may enter the larynx. Little benefit is derived from stimulating expectorants. The following recipe has proved beneficial in a number of cases: 1339. R. Extract! cubebae fluidi, tUxl-f. 3j Syrupi, f- S ijss. M. A teaspoonful three or four times daily. 886 DISEASES OF CHILDREN. Chronic laryngitis, dependent on syphilis or tuberculosis, requires specific treatment ; local measures have but little effect. DR. R. FOWLER, MISSISSIPPI. This physician reports (^Transactions of the Mississippi State Medi- cal Association, 1876,) his treatment of capillary bronchitis in chil- dren, which is, in some respects, peculiar, and from which he has had the best results. He commences with an emetic, turpeth mineral, gr. iij, or alum, oj. If there is tympanites, he avoids purgatives, but gives an enema of milk of assafcetida. For the fever : 1340- B- Quinix sulphatis, gr. iij Potassii bromidi, gr. v. M. For one dose, every three or four hours, until the fever abates. When the temperature is above 103°, he places the child in a warm bath, to which cold water is rapidly added until the child's tempera- ture falls, to 99°. He also uses : 1341. R. Tinct. aconiti (Fleming^, gtt. j Ammonii muriatis, gr. iij. M. This amount every two or three hours to reduce the circulation and thin the mucus. The local treatipent is important. He directs a mustard cata- plasm every six hours, to the posterior portion of the thorax ; and in the intervals, has a constant relay of warm mush poultices com- pletely enveloping the chest, preceded by thoroughly anointing the surface with camphorated oil, before the changing of each poultice. For the cough, he uses chloral ; sometimes chloroform by inhala- tion — and always gr. viij iodide of iron — the latter most frequently as an enema, in conjunction with brandy, and chicken or beef essence* and in convalescence, tonics. When all these measures fail, when the mucus collects rapidly in the tubes, the dyspnoea becomes more and more urgent, the breathing ceases and the pulse is not to be felt, he has recourse to artificial respiration. As a dernier ressort, he would especially recommend this measure. J. M. DA COSTA, M. D., PHILADELPHIA. 1342. R. Ammonii carbonatis, gr. xyj Spiritfls setheris compositi, f. 5 iss Syrupi tolutani, Aqu2B, 55 f.gj. M. A teaspoonful every two hours; a stimulating expectorant for a child a year old, affected with bronchitis of two weeds' standing. BRONCHITIS. 887 Counter-irritation to be applied to the chest by means of weak mustard plasters, (one part of mustard to four of Indian meal; . Also, if the child be much debilitated, 1 5 drops of brandy every four hours. When the child is seen frequently, so that the effect may be watched, there is no better treatment than relieving the lung mechanically by emetics. Hoffman's anodyne, in the above recipe, acts as a diaphor- etic and quieting agent, which latter influence would not be obtained from sweet spirits of nitre. I343- B- Syrupi ipecacuanhse, f. §S3 Liquoris potassiE citratis, f. 5 ijss Misturae glycyrrhizae composite, f. § j. M. A teaspoonful every three hours, for a child two years of age. Afterward, when the disease passes into second stage, to be changed to : ' 344- R- Syrupi scilbe, f. 5 ij Tincturse opii camphoratce, f. 3 ij- M. Thirty drops four times a day. 1345- R- Syrupi ipecacuanhae, f.§j. M. A teaspoonful every ten minutes until vomiting is produced; to be repeated every second day. For ordinary acute bronchitis in a child a year old. Together with : 1346. R. Ammonii carbonatis, 3ss Syrupi senegx, f. § ss Syrupi tolutani, f. § j Aquae, f. § ijss. M. A teaspoonful thrice daily. J. M. JULIAN, M. D., HOBOKEN, N. J. In the suffocative capillary bronchitis of children, says this writer, _ {Medical Record, October 2d, 1871,) the indications are to get rid of the excessive mucous secretion as speedily as possible. For twenty-five years he has used for this purpose, with eminent success, the following: 1 347- B- Zinci sulphatis, gr. xij Tincturae sanguinarise, f.Sij Aquae, ( f.iiss. M. A teaspoonful in mild cases to a child one year old, every three hours; in severe cases, treble the dose, and give it every half hour or hour, regardless of vomiting. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. According to these authors, the acute simple form of bronchitis is frequently so mild as to need no other treatment than careful atten- tion to the hygienic condition of the patient, and the administration of some simple febrifuge and expectorant. The child ought to be confined to one room, in a mild and uniform temperature, and 888 DISEASES OF CHILDREN. should be kept quiet until the development of the symptoms shows what is to be the type of the attack. Our authors believe that the practice of keeping the body quiet in all febrile di.sorders, is one of the most important therapeutic means we have, and they strongly recommend that in bronchitis, children should be kept in bed. The clothing ought to be warm, and yet not sufficient to produce free perspiration, cis this, by sudden exposure and evaporation, often in- duces chilliness. The diet must be simple, and may consist of any of the milk preparations, with or without bread, or bread and butter. Light soups in the middle of the day, or roast potatoes or apples, with bread, may generally be allowed. When fever sets in, our authors order: 1348- B- Potass, citrat., 5) Syr. ipecac, f. 3j-ij Tinct. opii camph., f. 3 j-Jj Syrupi, f. § ss Aquae, q. s. ad f. § iij. M. S. — Teaspoonful every two or three hoars, for a child of from two to four years. This should be given until the child sleeps, and occasionally in the night, if there be cough and restlessness. At six months of age, the following may be used in the same manner : 1 349- R- Syr. ipecac, Tinct. opii camph., aa f. 3ss Spts. seth. nitrosi. vel, Liq. ammonii acetat., f. 3 ij , Syrupi. f. 3v Aquae, f. § ij. M. S. — ^Teaspoonful every two hours. If the fever is very slight, and the cough only moderately severe, it is often well to use no drug through the day, but, to give in the evening, two hours before bed-time, and again at bed-time, some simple expectorant and anodyne. Thus at two or three months of age, three to five drops of syrup of ipecacuanha with five of pare- goric or half a drop to a drop of laudanum ; at one or two years of age, ten drops of the syrup, with ten to twenty of paregoric or two of laudanum ; at five to ten years, ten to twenty drops of the syrup, with twenty to thirty of paregoric or four or five of laudanum. The laudanum is often better than paregoric, as it produces a more de- cided and lasting impression on the nervous system, and appears to extend its useful control over the symptoms, further into the follow- ing day. In this very mild form there is no necessity for giving BRONCHITIS. 889 active purgatives. If the bowels are moved once in the day, or once in two days, it is best not to interfere with them. If, however, the patient be constipated, a little simple syrup of rhubarb, a teaspoon- ful of castor-oil, or an enema, will be quite sufficient. A warm foot- bath, in the evening, containing salt, or better, mustard, will often assist in moderating the cough and promoting quiet sleep. If, as the case progresses, the bronchial secretions become very abundant and the dyspnoea severe, the proper remedy is an emetic. This may be ipecacuanha, either in powder or syrup, or a teaspoonful of powdered alum, to be repeated, if necessary, in ten or fifteen min- utes. Great benefit may be obtained in all forms of bronchitis, from the more or less frequent application of mustard poultices to the front or back of the thorax, and from mustard foot-baths. The oc- currence of gastric disturbance, with coated tongue, anorexia, and a torpid state of the bowels, may, in some cases, call for the adminis- tration of a single dose of blue mass, followed by a mild saline laxa- tive. When the patient is over two years of age, and the oppression very great, the right heart laboring, as shown by a congested surface and a throbbing cardiac impulse at the base and left edge of the sternum, and the strength not too much reduced, the abstraction of from two to four ounces of blood from the interscapular space, by cups or leeches, would be a useful, legitimate practice. If the tem- perature is very high and the pulse full and strong, small doses of sul- phurated antimony, (gr. tt,) in combination with Dover's powder every two or three hours, will be very useful in moderating the in- flammatory symptoms. Should nausea or vomiting, with exhaus- tion, follow, they must be suspended at once. Counter-irritation is a very important part of the treatment. It may be obtained by the application of dry cups to the back of the - chest, or if this be inconvenient, or be objected to for any cause, by the use of mustard poultices, which should be applied first to the dorsum of the chest, and after having reddened at that point, should be shifted to the front of the thorax. Soak the feet in mustard water, and give a few grains of Dover's powder at night to promote the action of the skin and check the annoying cough. Small doses of aconite, in conjunction with sweet spirits of nitre, are useful in reducing feverishness, and by dilating the small vessels arterial tension is lowered in the bronchi. In very young infants ipecacuanha is much safer than antimony, and it is quite sufficiently active. When the child presents a pale 890 DISEASES OF CHILDREN. surface and a languid expression, and particularly when the surface is very slightly warmer than usual, or cool, the following prescription has proved most useful : I350- B- Liq. ammon. acetat, f.§ss Syrupi ipecac, f. 5 j Liq. morpb. sulphat., gtt. xl Syrupi acaciae, f §j Aquse, f. § iss. M. S. — ^Teaspoonful for a child two years old, to be repeated every two hours. If there is any nausea, the ipecac should be reduced to half the quantity ; and if there be any drowsiness, the morphia should be left out. It often becomes proper and necessary to make use of stimulants. In the suffocative form, when the symptoms become urgent, small doses of brandy or wine-whey may be administered alternately with the spirit of mindererus. In milder cases, when the symptoms indi- cate that collapse of certain portions of the lung has taken place, it is best to abandon for the time all nauseating remedies, and to make use simply of brandy in doses of from five to twenty drops every half hour or hour, or wine-whey in dessert or tablespoonful doses, and of counter-irritants, with very light fluid nourishment. In cases where there is marked debility, our authors have used, with advantage, small doses of quinine, as follows : '35'- R- Quiniae sulphat., gr. vj Acid, sulph. dil., gtt. xij Syrupi, f. § ss Aquae, f. | iiss. M. S. — ^Teaspoonful every two hours, to children two or three years old. If this should sicken, as it sometimes will, by the disgust its bitterness produces, and the conse- quent resistance to the doses, it is best to lay it aside after two or three trials and to use the following : 1352. R. Elix. cinchon. flav., f5ij Curagoa, f 3 .ij Acid, snlph. dil., TUxij Aquae, f. § iiss. M. S. — ^Teaspoonful every two hours. In chronic bronchitis, our author recommends daily friction with J3S3- R- 01. tiglii, f.3j Ether sulph., f.3j Tinct. iodi, Alcoholis, aa f.Siij. M. S. — Use locally. CHRONIC BRONCHITIS. 89 1 FRIEDLANDER. In speaking of antipyrine, this author {Rev. Mens, de V Enf., Oc- tober, 1887,) says: " In the treatment of acute bronchitis with this agent, the results have been very favorable, the duration of the disease being shortened from the usual period of two or three weeks to about eight days. " In those cases in which there is decided elevation of temperature, the drug was found especially useful. Antipyrine acts more ener- getically in robust and well-nourished children, than in those who are weak and debilitated, and the former also show less debility during the period of reaction from its effects. " Even in poorly-nourished children, the use of this remedy has reduced the mortality from acute bronchitis, in the author's practice, from fifty per cent, to ten per cent., or less. The dose should vary between six and twelve grains for children from two to five years of age. Its action continues for twenty or twenty-four hours. It pro- duces profuse perspiration, and causes the cough to be less dry. In connection with antipyrine, the author is in the habit of using wine, tonics, laxatives and caffeine." CHRONIC BRONCHITIS. Mays {Med. News, March 17, 1888). Quite an extended expe- rience in the treatment of these cases, leads the writer to the conclu- sion that persistent counter-irritation is of the first consideration. He uses croton oil and sweet oil, one or two parts of the former to six of the latter, well rubbed into the skin of the chest. The inter- nal treatment is directed towards a stimulation of the bronchial mu- cous membrane, and towards a recovery of the appetite. He thinks the former will be attained by the following combination : 1354. K- Ammon. muriat., 3j Ex. euphorbix pil. fld.. Tr. digitalis. aa f.Siij Atropix sulph., gr.T^ Chloroformi, gtt. XIJ Syr. tolu, Syr. picis liquid.. aa q. s. f.|j Aqua, adq.s. f.Siv. Sig. — ^A teaspoonful every three hours. 892 DISEASES OF CHILDREN. To aid digestion, and as a general tonic, the following will be found useful: 1 355- R- Acid phosph. dil., Acid nitro-muriatici dil,. Acid sulph. aromat., Tr. ferri chloridi, aa f. § ss. Sig. — ^Thirty drops in sweetened water after each meaU NOTES ON REMEDIES. Aconitum, in half or quarter-drop doses of the tincture in the first stage of acute bronchitis, is very efficient. Ariimonii Carbonas. Dr. Stierlin, of SchaflFhausen, recommends carbonate of ammonia rather than emetic or other treatment in the broncho- pneumonia of young children and in the catarrhal attacks of infants. His doses range from gr. v-xx. Ammonii Murias. Dr. H. C. Wood (^New Remedies) hsis obtained, in ob- stinate acute bronchitis, after the first intense stage, more apparent good from the use of muriate of ammonia than any other remedy. The best formula is as follows : 135^- R- Ammonii muriatis, 5ij Extract, glycyrrhizse, 3j Mucilag. acaciee, AquxE, aa f.§iij. M. One teaspoonful every three hours for a child a year old. Ipecacuanha. Dr. Bedford Brown {American 'journal of Medical Sciences, October, 1870,) has found the early use of an emetic of ipecacuanha very serviceable in a number of cases in children ; a combination of ipecacuanha and quinine being continued afterwards. Hydrargyrum. Dr. J. C. Thorowgood (Practitioner) has found frictions with oleate of mercury to disperse threatening pulmonic dullness in bron- chitis. Particularly in catarrhal bronchitis tending to pneumonia, with blocking up of air-cells and consolidation of lung, he believes we may employ mercury without fear. Nitrate of Silver Fumes. M. Storch {Jlospitalstidende) , following the sug- gestions of several Norwegian physicians, employed the vapors ob- tained by dissolving nitrate of silver in nitric acid in diseases of the upper and pulmonary air passages. He speaks of this remedy especi- ally in connection with chronic bronchitis. QuinicB Sulphas is called for to reduce the fever in pyrexial cases, and also as a tonic in convalescence. BRONCHO-PNEUMONIA. BRONCHOPNEUMONIA. 893 Simon {L' Union Medkale) recommends the following prescrip- tion : '357- R- Acetate of ammonia, -j grains. Tincture of aconite, ic drops. Codein, 2 grains. Synip, _ \ ounce. Water enough to make 3 ounces. A teaspoonful may be given every hour until five or six doses are taken. At the be- ginning of the attack, a mustard plaster or other counter-irritant should be applied over the thorax, and after it has acted for one or two hours, should be followed by an emollient poultice. Keep the air of the room moist by allowing steam to enter it. Dr. ZOUNIS, {Maladies de l' Enfance, A\ig\is\., 1887,) highly recom- mends the iodide of potassium in cases of broncho-pneumonia in children from six months to five years of age. The drug has seemed in most cases, to be useful, but its action is more satisfactory when it is given from the beginning of the disease, than if it is com- menced at a later period. The following shows the result and action of the drug : 1. The iodide of potassium is more efficacious in the acute stage than when the disease has advanced. 2. It is particularly useful with feeble and strumous children. Its usefulness is very much greater in children from one to five years of age than in younger children. 3. In doses of from eight to twenty grains, the temperature is often lowered one or two degrees in two or three days ; it greatly diminishes the frequency of respiration, softens the cough, and makes expectoration easier. The percussion shows at the same time that all of the physical signs are diminishing. If any improve- ment is to be obtained, it will be noticeable after taking the salt for a few days. The cure of broncho-pneumonia, is obtained much more quickly by the use of iodide of potassium than by any other drug, especially when it is given in the beginning. The best way of administering the drug, so that it will neither be tasted nor suspected, is to make a plain solution with water, and give it in milk. Dose from 3 to 5 grains, according to the age of the child. Dr. Steffen, {Rev. Mens, des Mai. de I' En/.), iji speaking of sul- 894 DISEASES OF CHILDREN. phate of thaline, says that it is a valuable agent in the treatment of broncho-pneumonia in children. Being tasteless, it can be taken in watery solution. It never excites either vomiting or diarrhoea. Its action is usually manifest within an hour after it is taken, and lasts three or four hours. The ordinary dose is from three-fourths to one and one-half grains once or twice daily. DR. SIMON. This author, {Gaz. Med. di Roma^ May i, 1887,) considers that in the treatment of broncho-pneumonia in children, the patient should be kept in bed, unless under one year of age, in which case the ver- tical position is preferable to the dorsal decubitus. It is also con- sidered quite important that the head and shoulders should be higher than the rest of the body, if the child is treated in bed. At the be- ginning of the fever, an emetic may be given, but during the subse- quent stage of depression, such treatment must not be thought of. Such excitants should also be given as will stimulate the pneumo- gastric nerves ; for example, a few drops of acetate of ammonium, or, for a child one year of age, fifteen to twenty grammes of Malaga wine. If the wine should seem too sweet for the child, port or brandy, in suitable quantities, may be given. Sulphate of quinine should also be administered, morning and evening — two to three grains for children four years of age, one-half to one grain for chil- dren one year of age. When tympanites is present, magnesia or senna may be given, but not in sufficient quantities to excite diar- rhoea. In the early stages of the disease, sinapisms should be applied upon the chest, and by the third day a series of small flying-blisters may be used. The latter should not be allowed to remain more than three hours, after which the wound should be dressed with vaseline, or some other suitable emollient. Two days after the ap- plication of the first vesicant, another may be applied in another place, and two days later, a third in another place, according to the development of the morbid process. The sick-room must be kept well-ventilated but warm, the diet must be light but nutritious, and if there is decided mental or physical restlessness, an enema, con- taining eight grains of chloral, should be given. DISEASES OF THE ALIMENTARY TRACT. CATARRHAL STOMATITIS. DR. FORCHHEIMER. This author says the treatment of this affection, once the cause is removed, is a very simple matter. All food must be given cold — it causes less pain to the patient, and reduces the swelling of the mucous membrane. If the child should be at the breast, it is better to make no change in the medicine for the sake of having the food cool. The mouth must be gently washed as often as possible with pure cold water. Solutions of carbolic acid, boric acid, etc., are useless, as is also the use of chlorate of potassium. The most reliable of all medicines is silver nitrate (one-half to one per cent.). The mouth should be washed out with cold water before making this application. Pencil the surface carefully once a day, and touch any ulcer or abrasion with nitrate of silver stick. PARASITIC STOMATITIS. DR. EDWARD HENOCH, OF BERLIN. According to this author the local treatment of sprue only prom- ises success in the milder cases. Mechanical rubbing is usually sufficient. The attendant should vigorously rub the patches off with his finger, which has been surrounded with fine linen and dipped in water, even if this gives rise to a slight hemorrhage. Whenever a new eruption becomes visible, this operation is repeated. In cases of more severity, the case is different. The fungus can be removed by the above method still better if the finger is dipped in an alka- line solution (5 parts of chlorate of potash, borax or benzoate of soda to lOO parts of water) ; but the general disease is the chief (89S) 896 DISEASES OF CHILDREN. factor, and relapses will therefore occur continually. Under these circumstances, he has with advantage, repeatedly brushed the entire mucous membrane of the mouth with a solution of nitrate of silver (i or 2 parts to 100 of water), after the sprue had been rubbed off. APHTHOUS OR FOLLICULAR STOMATITIS. DR. FORCHHEIMER. Dr. F. says the object of treatment is to give relief from pain and prevent infection. The former, and possibly the latter, is accom- plished by touching each ulcer with nitrate of silver. The treat- ment is identical with that recommended for catarrhal ulcers, and gives as much relief. He has never had good results from cocaine, recommended by some authors in troubles of the mouth, and would hesitate to employ the very strong solutions (ten to twenty per cent.) recommended. Baginsky speaks very highly of permanganate of potassium (o.io to 15.00), and considers it almost a specific, curing the affection in a short time {wenigen Tagen). Chlorate of potassium is unneces- sary, as much so as the great number of external remedies that have been vaunted and applied. The fact must never be lost sight of, that a pure, uncomplicated case of stomatitis gets well of its own accord, and all the physician need do, is to watch, give relief, and prevent any complications, by hygienic measures. GANGRENOUS STOMATITIS (NOMA). DR. FORCHHEIMER. According to the above authors (Arc. Ped., May, 1889,) but little can be done in the way of prophylaxis for the following reasons : Firstly ; It may develop in persons whose mouths are apparently healthy. Secondly ; On account of the rarity of the affection. The physi- cian does not suspect noma until it is already developed. The treat- ment of a case which has developed resolves itself into two principal GANGRENOUS STOMATITIS. 897 divisions ; first, the general ; second, the local treatment. Of the general treatment, little need be said. As the disease is usually found in reduced subjects, steps have probably already been taken for the improvement of the general health. The indications in every case are to keep up the strength of the patient until it has become possible to make the attempt to cure the local process. Tonics and stimulants come fully into play, always being careful not to disturb the digestion. The patient must be fed with condensed, nutritious foods. The local treatment resolves itself into an artificial limitation of the gangrenous process by substituting an artificial destruction of tissue. For this purpose a great many substances have been em- ployed. It is essential that the remedies be used early, before the deep tissues of the cheek are invaded. The caustics which seem to enjoy the greatest reputation are hydrochloric acid, then nitric acid (West). Ev ANSON and Maunsell report good results from the local application of sulphate of copper in six per cent, solution. The author himself thinks that it is best to have recourse at once to those remedies which act quickly, deeply, and thoroughly. Of this class of remedies, we have both chemical and thermal caustics. Of the latter class we have the white-hot iron, the galvano-caustic wire, and the Paquelin cautery. Of the chemical caustics nearly every- thing has been used in both the fluid and solid forms which has caustic properties. The author doubts whether the action of nitrate of silver upon the healthy tissue is sufficiently energetic to produce any benefit. While some authorities claim that they have better re- sults without the use of caustic agents,this author says he would not like to take the risk of such a method of treatment, believing firmly in the necessity for a caustic of some sort. If circumstances permit, the patient should be anaesthetized before the caustic is applied. This is frequently inexpedient on account of the great weakness of the patient. Before the application is made all the necrotic tissue should be removed with forceps and scissors, and then the operator is ready. The galvano-caustic wire or Paquelin's thermo-cautery seems to offer advantages that are not afforded by any other means. Their action can be limited, and they can be made to act as deeply or as superficially as the operator may choose. In regard to the frequency of the applications, no hard and fast rule can be laid down, as every case is a law unto itself. With cauterization the ordinary antiseptic method of treating wounds will be sufficient local treat- ment for most cases of noma. The surgical treatment of the cica- 57 898 DISEASES OF CHILDREN. trices ought to be delayed as long £is possible, as it has been found that plastic operations do not succeed very well when performed early upon patients who have had noma, and also that noma may recur as the result of these operations. The prognosis is very un- favorable, no matter what the treatment. "THERAPEUTIQUE CONTEMPORAINE." This journal (1882) gives various formulae that have proved use- ful in these obstinate diseases of the mouth. The antiseptic gargle of the Brompton Hospital has often proved useful ; it consists of 1358. R. Aluminis, gr- xvj Tinct. myrrhse, 3iss Aq. destU., S iv. M. This may be used for touching the aphthae, and also as a gargle. If the disease prove obstinate, and no beneficial effect is obtained from the above mixture, TOMMASI recommends the following powder : '359- R- Calomel, 3ss Amyli pur., 3ss. M. Apply a small quantity of this over the surface of the aphthae. Thompson recommends, in the same conditions, the following com- position : 1360. R. Tinct. opii, lUxlv Tinct. catechu, 3ijss Ac. sulphuric dil., Illxlv Aquse ros^, ad. 3 vss. M. The points affected should be touched with a camel's-hair pencil saturated with this mixture. NOTES ON REMEDIES. Alcohol, in the form of lotions of brandy and water, is recommended. Acidum Hydrochloricum. This is a useful application, applied in a dilute form, combined with honey. It may be used locally, and also swal- lowed in moderate doses, with benefit. Nitric acid is employed in the same manner, and with equal advantage. Alumen may be used either in solution as a wash, powdered and mixed with honey, or by being applied as a powder to the ulcerated spots, several times a day. Acidum Gallicum, on account of its astringent qualities, is of considerable service in many cases. tytsmmiA. 899' Bisukuth in powder is recommended to be applied freely. Li^W Cakis. In infantile aphthae, with greenish discharges from the bowels, Dr. Dewb^, of Philadelphia, found great advantage from the use of this alkali, in small quantities, with milk. Mel Boracis is an excellent preparation, and is usually readily given to infants. Mel Rosa has slightly stimulant and astringent qualities, and may be* used in light cases, either alone, as an addition to a mouth-wash, or undiluted; or combined with borax or chlorate of potash. Oleum Thymi, or Thymol, has proved advantageous in some severe cases. A solution of i : 3000 was used as a lotion, with which the parts were sjrringed. Potatsii Chloras is probably the most generally useful of all applications in infantile stomatitis. It may be used in a simple solution, powdered and rubbed up with honey, or in an atomized solution. Most writers speak of it as quite sufficient to check the disease in nearly every case. • Sodii Boras is, next to the above, the most popular remedy for sore mouth, and is very efficient. A favorite form is the honey of borax. The glycerole of borax, sj of borax to 3j of glycerine, is a convenieiit sub- stitute. Sodii Chloras has been found quite as useful as the potash chlorate, and is somewhat more soluble. DYSPEPSIA. DR. A. JACOBI. Dr. Jacobi says {Arch. Ped., Feb., 1888,) some abnormal condi- tion*of the food is spoken of as the most frequent cause of this dis-^ order. The treatment consists chiefly in abstinence, or in the use of- the greatest care in the preparation of meals. Milk requires boilingi peptonizing, or treating with muriatic acid. In every cas^ the ad- mixture of farinaceous decoctrons (barley water) and a little sak, im- proves the digestibility of milk. In many cases the latter alOne, with or without a meat soup, will be the only food which is tolerated. The gastric secretions of infants, who have been hand fed, are liable to be too acid. Alkalies should be given at once. .The addition of a fe* grains of plain baking soda to the food may suffice. If there should be much vomiting, antifermentatives should be administered. 900 DISEASES OF CHILDREN. such as nitrate of silver, bismuth and resorcin. Sometimes antacids alone will suffice. DR. BROCHIN. This author says {Jotir. de Med., June 5, 1887,) we must first look to the milk and see that it is neither too weak nor too strong. Di- gestive«troubles are successfully treated with small doses of Vichy or other suitable alkaline waters, two teaspoonfuls being given at each nursing to children under one year of age, a dessertspoonful to older children. Gastric indigestion may be treated with syrup of ipecac, vomiting, with small quantities of lime-water, colic, with soothing enemataor enemata of oil, constipation, with a mixture of castor oil and oil of sweet almonds — a large teaspoonful at a time. DR. LOUIS STARR, OF PHILADELPHIA. According to this author (^Archives of Pediatrics, 1884,) when we find the tongue perfectly clean, the appetite good, and neither eruc* tation, increased thirst, nausea, nor vomiting, but great, uniform gaseous distention of the abdomen, without other symptoms, we have to deal with intestinal indigestion. In treating such cases, a careful regulation of the diet is important. The starches and fats must be excluded, the latter, because they are digested in the intes- tine. Three meals a day of the following articles of food should be taken : For breakfast at 7 : 30 a. m., a bit of fresh fish, or the lean of a mutton-chop, or a piece of tender beefsteak, with milk (either warmed or not, according to taste), and a single thin slice of stale bread without butter. For dinner, at 2 p. m., the soft part of half a dozen oysters, a bowl of. meat broth, entirely free from fat, or, in- stead of this, a piece of lean beefsteak, roast mutton or beef, a little spinach or well boiled cauliflower tops, and not more than a sitigle siice of thin unbuttered bread. For supper, at seven o'clock in the evening, one or more glasses of milk, with a single slice of un- buttered 'bread. For drink, nothing but filtered water. The medic- inal treatment must be directed to remedying the impaired pan- creatic secretion. For this purpose he orders : 1361. R. Ext. pancreatis (Faircfaild Bros. & Foster), gr. xxx Sodii bicarb., 5]. M. and ft. chart No. xi}. S. — One powder to be taken two and a half boors after each meal. Nux vomica is also indicated, partly to give tone to the muscles DYSPEPSIA. 901 a of the intestine, which must be in some degree weakened by the constant distention, and partly to encourage proper glandular action. He therefore orders three drops of tincture of nux vomica, with teaspoonful of compound infusion of gentian, before each meal. Finally, to assist in the reduction of the abdominal distention, it will be well to rub the belly thoroughly twice a day with a stimulat- ing liniment, such as turpentine and olive oil, one part to three. DR. E. W. DUNBAR, OF ZURICH. In The Practitioner, Dr. E. W. DuNBAR, of Zurich, says that for loss of appetite in children, with pain after eating, nausea, and de- pression, if accompained by a tongue either clean or slightly coated, but showing redness and enlargement of the papillae fungiformes, bismuth is very good. He gives it either in the form of subnitrate, in doses of one-half grain up to two, three, and five grains, or the solution of the oxide in ammonia and citric acid, in doses of from two minims under one year, to three, five, ten, fifteen, and twenty minims up to twelve years of age, the dose to be repeated twice or four times a day, according to the severity of the symptoms. Bis- muth is quite ineffectual in the dyspepsia of children, when the tongue is smooth, clean, and shows no enlargement or redness of the papillae fungiformes. DR. EDWARD HENOCH, OF BERLIN. This author teaches that the dangerous consequences which may develop from a neglected dyspepsia make early and careful treat- ment our duty, which can only be fulfilled with hopes of success when the surrounding conditions of life are favorable, and our direc- tions are carefully carried out. In many cases the patient is only seen after nature has removed the deleterious contents of the digestive canal by vomiting and diar- rhoea. Here you need simply regulate the diet. If the child is nursed at the breast, the possibility of any deleterious change in the milk must be considered. It will be well to let the breast be taken less often than usual for a period of from twenty-four to thirty-six hours, substituting some thin oatmeal or barley gruel. If the men- struation in the nurse always produces dyspepsia in the child, a change should be made, but this rarely happens. If the child is fed on artificial food, a series of experiments will re- veal the offending article. Dyspepsia will sometimes persist despite 902 DISEASES OF CHILDREN. several changes in the nurses, and only disappear when the child is weaned. As long as emesis continues it will be well to give cold milk by the spoon, as drinking from the bottle readily induces overloading and vomiting. In fresh cases (of not more than three or four days standing,) he uses calomel as the first remedy. 1362. R. Hydrarg. chlor. mitis, gr-j Sacch. alb., gr. xij. M. and ft. chart. No. xij. x S. — One every three hours. Next to calomel comes hydrochloric acid, which yields good re- sults in cases no longer acute. 1363. R. Acid, hydrocblor., gtt. ^xv Aq. destil.. f. S iij Acacije, gr. xv Syrup, alth., f. 3v Tinct. opii, gtt. ij-iv. M. S. — ^Teaspoonful every two hours. In recent cases, you should not add opium, as its constipating ac- tion causes tympanitic distention of the intestines. When calomel and hydrochloric acid fail, he uses creosote, especially when emesis is prominent, and also when, after the subsidence of acute symp- toms, thin, foul evacuations continue. 1364- R- Creosoti, gtt. ij-iv Aq. destil., f.gj Syr. alth., f.Siv. M. S. — Teaspoonful every two hours. * When there is diminished secretion of gastric juice, pepsin may prove useful. 1365- R- Pepsinse, gr.xv Add. hydrochlor., gtt. vj Aq. destil., f. § iv Sacch. alb., gr. cl. M. S. — One dessertspoonful four times daily. When the presence of mucus in the stools shows the beginning of a catarrhal condition of the intestinal mucous membrane, subnitrate of bismuth may be used. After recovery, he uses rhubarb as a digestive tonic, which must be given for several weeks in the form of tinct. rhei dulcis (five to fifteen drops, three or four times a day, according to age). DIARRHCEA. 903 DIARRHCEA .(ACUTE AND CHRONIC). DR. A. JACOBI, or NEW YORK. In the American Jotirnal of Obstetrics, 1879, Dr. Jacobi very fully covers the ground of treatment in diarrhcea and dysentery of infants. So far as nutriment is concerned, the amount of food should not be larger than we have reason to expect can be easily digested. At all events, either lengthen the intervals between the meals or re- duce the quantity of food given at one time, or both. When diar- rhoea makes its appearance in infants who have been weaned, it is desirable to return them to the breast. Those who never had breast- milk may be given the breast if they can be induced to take it, but only rarely will this be found possible. Whenever a child at the breast is taken with diarrhoea, the passages from the bowels should be studied as to their contents. If a certain amount of curd is found in them, the least that is to be done is to mix the breast-milk with barley-water. This may be done in the following manner : Each time before nursing, one or two teaspoons of barley-water is given the child, so that the farinaceous food and the breast-milk will mix in the stomach. Or, it may be found advisable to alternate breast-milk and barley-water. In bad cases, particularly when the milk is found to be white and heavy and contains a great deal of casein, it will be found necessary to deprive the child altogether of its usual food. In such cases, the child will do better on barley-water alone, (this to be continued for one or two days,) than to expose it to the injury which will certainly follow the continuation of the casein food. When diarrhoea occurs in children who have been fed only upon cow's milk, unmixed or mixed, it is necessary to reduce the quantity of cow's milk in the food. As a rule, we have to remember that cow's milk alone is apt to produce diarrhoea, and it should be con- sidered as a maxim that, whenever diarrhoea makes its appearance, the amount of cow's milk given to the child should be reduced. When a mere reduction of the quantity does not suffice, it is very much better to deprive the child of milk food altogether. Not infre- quently the removal of milk from the bill of fare is the only thing which will restore the child to health. In many cases, as a dietetic measure, it will be found advisable to add one or two tablespoonfuls of lime-water to each bottle of food with which the child is supplied. In those cases in which barley-water does not seem to suffice as a 904 DISEASES OF CHILDREN. nutriment, or where it would be dangerous to allow children to lose strength, a mixture which I have used to great advantage is the fol- lowing : Mix the white of one ^g with four or six ounces of barley- water, and add a small quantity of table salt and sugar, just suffi- cient to make the mixture palatable. The child can take this either in large or small quantities, according to necessity. In such cases in which. the stomach is irritable, and vomiting has occurred, it is now and then better to give a small quantity, even one or two teaspoonfuls, and repeat the dose every ten, fifteen, or twenty minutes, than to give large' quantities at longer intervals. In those cases in which the strength of the child has suffered greatly, it is necessary to add brandy to the mixture in such quantity . that the child will take from one drachm to one ounce (grammes 4.0 to 30.0), more or less, in the course of twenty-four hours. In those extreme cases in which the intestinal catarrh is compli- cated with gastric catarrh, where the passages are numerous and copious and vomiting constant, where both medicines and food are rejected, there is frequently but one way to save the patients, and that is to deprive them absolutely of everything in the form of either drink, food or medicine. It is true that such babies will suffer greatly from thirst for an hour or two, but it is a fact that, after two or three hours, these children will look better than before the ab- stemious treatment was commenced. Not infrequently four or five hours of total abstinence will suffice to quiet the stomach and di- minish both the secretion and the peristaltic movement of the intes- tinal tract. In some cases six or eight hours of complete abstinence will be required ; or such children may be starved for even twelve or sixteen hours, with final good results. The first meals afterwards must be quite small, and they will be retained, and, as a rule, such cases will subsequently do well. I need not here say that, in addition to the dietetics for the diges- tive organs, it is necessary to supply the patient with as much cool, fresh air as possible. The worst out-door air, when cooler, is better than close in-door air. The undeveloped condition of the nerve- centre in the normal infant, the relaxation of the inhibitory nerves by heat, the absence of radiation from the surface, the lacking stim- ulus — during hot weather — of the cutaneous sensitive nerves, the diminished metamorphosis of tissue, the diminution of the powers of digestion, not only by shortening nutrition, but by directly lowering the secreting powers of digestive gjands in the stomach and intes- DIARRHCEA. 905 tines, are just so many factors in the production of the very worst forms of infant diarrhoea. (I have kept very bad, desperate cases out all night upon the bluffs over the East river.) The windows must not be closed. If possible, the children should be sent immediately to the country and into the mountain air. The second indication consists in the removal of undigested masses retained in the intestinal tract. Not only in cases in which the diar- rhoea has resulted from previous errors in diet of the child, but also in those cases dependent upon sudden changes of temperature and exposure, it is desirable to empty the intestinal tract of its ballast. For this purpose castor oil, calcined magnesia, or calomel, may be used. So far as the latter is concerned, the discrepancy of opinion with regard to its efficiency will probably be found to depend upon the variation in the size of the doses recommended by different authors. When a purgative effect is desired, it should not be given in small doses, but, according to age, from two to six (0.1-0.4) grains should be administered. 3. Nothing should be given that contains salts in any sort of con- centration. Thus, beef tea should be avoided. It has come very largely into use in practice among children, both in this country and in Great Britain. In Germany, too, it has found very many advo- cates, and among some who have abandoned the obsolete notion that when prepared in the customary way it contains a large proportion of protein in its composition. It must be remembered that this form of meat extract contains a very large amount of salts, and that the direct effect of these upon the intestinal canal may be productive of very unpleasant consequences. It is a mistake to give it when the intestines are irritated or very susceptible of irritation, for the reason that diarrhoea is apt to directly follow its use. Nevertheless, I have often seen beef tea given under these circumstances, for no other object than the vain one of furnishing the child with a great amount of nourishing food. This is very commonly done during the obsti- nate and exhausting diarrhoea of summer. If the people insist upon giving it, and there is no special contra-indication to its use in a given case, it should be administered only in connection with some well-cooked farinaceous vehicle, and the best of all for this purpose is barley-water ; or it may be mixed with beaten white of egg, but no more chloride of sodium should be added — for the main danger in beef tea is the concentrated form in which its salts are given. 4. Everything should be avoided that increases peristaltic motion. Thus, carbonic acid and ice internally. 906 DISEASES OF CHILDREN. 5. Avoid whatever threatens to increase the amount of acid in the stomach and intestinal tract. There is so much acid in the normal, and still more in the abnormal stomach and intestinal tract, that it is absolutely necessary to neutralise it. For that purpose any alkali, perhaps, will suffice,. but it is Sjafer to resort to preparations of cal- cium than of sodium or magnesium. Soda and magnesia, when in- troduced into the stomach and duodenum, will find a number of acids and form laxative salts. Frequently I use carbonate of lime ; not infrequently phosphate of lime. Both of these will act as ant- acids, but the latter preparation is to be preferred in those cases in which free phosphoric acid is deemed of importance for the purpose of facilitating pancreatic digestion. So far as lime-water is concerned, its administration certainly is chemically correct. But we should not place too much reliance upon this popular remedy. We should not forget that it contains about one part of lime to eight hundred of water, and that it is ne- cessary to swallow at least two ounces of the fluid in order to obtain a single grain of lime. A further indication is the necessity for destroying ferments. For that purpose, most metallic preparations will do fair service. One of these, that has been extensively used, is calomel, and now, in small doses frequently repeated — ^, \, ox h a grain (o.i — 0.15 — O.03) every two or three hours. As to its effects as an anti-fermentative there can be no doubt. It is very- uncertain, however, as to how it produces this effect. It is possible that it acts by a portion of the drug being changed very slowly to the bichloride of mercury, which is known to be a very powerful agent in the prevention of fermenta- tion. It is certain that one portion, at least, of the mercury is used to bind sulphide of hydrogen, which often acts in a poisonous man- ner. Infants will bear calomel very well, perhaps for the reason that elimination is so much more rapid in them than in adults. Nitrate of silver, when given for the same purpose, should be largely diluted. From ?V to is of a grain (0.0015 — 0.004) dissolved in a teaspoonful or tablespoonful of water, may be given every two or three hours, and not infrequently with fair result. At all events, it does not answer to use a concentrated solution. Whenever it is concentrated, it acts more as a caustic than as an astringent. This remark is especially important with regard to injections of nitrate of silver into the rectum, where it is apt to do as much harm as good. Even a mild solution — one or two grains to the ounce of water DIARRHCEA. 907 (l : 500 or 250) — ^when injected into the rectum is apt to give rise to tenesmus and soreness about the anus ; whenever it is to be given in that way, the solution should be mild and largely diluted, or the anus and its neighborhood should be washed with salt water before the injection is administered. Bismuth acts very favorably. Moderate cases of diarrhoea will usually shows its effect very soon. Doses of from J^ to 2 or 3 grains (0.03 to 0.20) given every two or three hours, will act very favorably indeed. In those cases in which diarrhoea has lasted for a long time and a large surface of the intestinal tract is certainly implicated, the doses of bismuth should be large in order to be cer- tain of immediate contact of the drug with the sore surface. A final indication is the depression of the hyperaesthesia of the general system and of the intestinal tract in particular. The effect of opium is very probably an anatomical one, and brought about in such a manner that a combination takes place with the nerve plasma. As this is so much softer and more succulent in the child than in the adult, the effect is so much stronger. There have been authors who condemned the use of opium altogether, which certainly is incor- rect. The doses should be small, and they may be repeated fre- quently. Administered in this manner, opium can be used with perfect safety both internally and in an enema. For, when the doses are small, it is possible to stop before an overdose has been given. One of the rules for giving opium is this — the child should not be waked up for the purpose of taking the medicine. Opium does not always act as a depressant, but sometimes as an excitant. This difference in the effects produced by the drug is well known. Very small doses will act as an excitant, while relatively large ones will act as a depressant. The exciting doses will, when accumu- lated, also show their constipating effect, and whenever there is fear of collapse, it is safer to give sis of a grain (0.0003) every half- hour or hour, than to administer n'o of a grain (0.0012) every two hours. Alcohol. — Small and frequent doses will certainly stimulate the nervous system, digestion, and circulation, and they also stimulate the skin and increase perspiration. Alcohol, given in this manner, certainly arrests fermentation. Moreover, it takes the place of food, and will act favorably as food when no solid carbo-hydrates are toler- ated by the intestinal tract. As it is absorbed in the stomach, so does it protect the intestinal tract. It has been found that, when 908 DISEASES OF CHILDREN". only small quantities of milk and pure alcohol and water are given as food, the body increases in weight. But it is absolutely necessary that the alcohol or the alcoholic preparation should be pure. Fusel oil will dilate blood-vessels, produce and increase congestion, and prove dangerous. Where no good brandy or whiskey can be pro- cured, it is better to use alcohol in substance, diluted with water. Finally, it is necessary to reduce the amount of secretion taking place from the surface of the intestinal tract. For that purpose astringents may be used, such as alum, lead, tannic acid, pernitrate of iron, and, what has already been spoken of, nitrate of silver. In all those cases in which the stomach participates in the process to any considerable extent, almost any astringent will prove ineffective. Neither alum nor lead nor tannic acid may do otherwise than irritate the stomach, and it will be necessary to depend altogether upon nitrate of silver, or better, upon bismuth, for the purpose of meeting two indications. To fulfil several indications at the same time, it is often good practice to combine remedies. The main indications are to neutralize acids, to reduce nervous irritability, to arrest secretion, and to change the condition of the surface of the catarrhal mucous membrane. For that purpose, in the generality of cases, I combine bismuth, opium, and chalk according to the following formula : 1366. Et. Bismuth subnit., gc. \ Cretse praeparat, jgrs. ij Pulv. doveri, gr. J^. This combination is suitable for a baby ten or twelve months of age, and the dose can be repeated every two hours. In all those cases in which acid is very abundant, it is necessary to increase the doses of antacids without necessarily giving large doses of opium. Whenever it is necessary to stimulate, and alcohol alone does not meet the requirements, resort may be had to hot bathing. This is especially serviceable in those cases in which the surface is cool and the temperature of the body, measured in the rectum, is pretty high. A hot bath in which the child may be kept for two or three minutes will restore some warmth to the surface, dilate blood-vessels, reduce temperature, and act as a nervous stimulant. To relieve intestinal pain, plain warm fomentations ; to relieve heat, cold applications are sufficient. Camphor stimulates the heart and reduces temperature, and may DIARRHCEA. 909 be used internally or subcutaneously, according to the necessities in the case. For subcutaneous injections, camphor may be dissolved in either oil or alcohol. The effect derived from camphor as a stimu- lant, is not permanent, but still very much more permanent and steady than that produced by carbonate of ammonia. The dose may be from % to }4 3. grain (0.015 — 0-03) every hour or two, when only a moderate stimulation is required. In urgent cases, it may be given in doses of (rom Jive to iert grains (0.3 — 0.6) in the course of an hour, and usually the effect will be favorable. It is, however, only in cases in which real collapse is present that doses of five or ten grains will be required, and it may then be ad- ministered, dissolved in alcohol, and with or without musk. There is no remedy that will act more favorably in conditions of great debility and collapse — collapse with or without spasmodic symptoms — than musk. It is true it is scarce, very frequently spur- ious, is expensive, and must be given in larger doses than usually recommended. But in cases of collapse, doses of five to ten grains (0.3—0.6) should be given at once, and should be repeated every half-hour or hour. More than two or three such doses will be re- quired to yield a result. A writer in the Revue de Therapeutique Med. Chirurg., 1881, re- marks that the treatment of intestinal catarrh in infants, should be persevered in, until a complete cure is obtained ; the gastro-intestinal functions should be completely re-established before ceasing treat- ment. The proper therapeutic measures consist in the employment of bismuth and laudanum, and without this last medicament, it is very difScuIt to have complete cure, in infantile diarrhoea. The following potion may be given, a teaspoonful at a time, in the course of twenty-four hours : 1367. B- Bismutbi subnit., Sij Tinct. opii, "lij Mucilag. acacise, S iv. M. An enema of starch should be given morning and evening. The little patient should be kept in bed. This treatment should be con- tinued for eight days, then the doses should be diminished, but the progress of the case should receive careful attention. DR. WAUGH, OF PHILADELPHIA. In the Pkila. Medical Times, 1887, Dr, Waugh speaks very .highly of sulpho-carbolate of zinc. His successful cases included catarrhal 9IO DISEASES OF CHILDREN. gastro-enteritis, entero-colitis, and true cholera infantum. The zinc salt was given in doses of one-sixteenth of a grain every two hours, with one to five grains of bismuth. As the remedy was well borne, the dose was increased to one-fourth, of a grain for a child in its sec- ond summer. Its first effect was to stop the vomiting. The stools became less offensive, although in some cases quite copious and fre- quent. In these cases an enema of flax-seed tea, containing five grains of sulpho-carbolate and a half drachm of bismuth was given. This was effectual in all cases. The fever was treated with antipyrin, in doses of one to two grains, which also seemed to have a disinfect- ant action upon the stools. S. HENRY DESSAU, M. D., NEW YORK CITY. This specialist, in diseases of children, gives his treatment of in- fantile diarrhoea as follows : In cases of simple diarrhoea occurring in teething children, where there is no fever present, and absence of pain on pressure over the abdomen, he generally administers a sedative, such as the bromide of potassium, in doses of gr. ij— iv every three hours, and insists upon careful attention to the diet of the child. If an astringent is found necessary, give the following: 1368. R. Mist, cretae, ' f.3j Tr. catechu, Tr. opii cainph., ai gtt. iv. M. This quantity every three hours. When the patient has acquired a mixed dietary, and presents the same symptoms of simple diarrhoea as before mentioned, (the case being due to eating of improper food,) if seen shortly after the com- mencement of the attack, use the followirig : 1369' R- Ol- ricini, Syr. rhei aromatici, ai f. 3 S3 Sods bicarbonatis, gr. ij. M. To be taken every half hour until the bowels have been freely evacuated, and after- wards to be taken twice or three times daily. Where the stools present the condition of lientery, a tonic of qui- nise sulph. and tr. ferri chlorid. is given, together with 8 to 10 grs. of pepsin, taken with the food at meal time. Pepsin is also given in those cases of simple diarrhoea in growing children, where the stools are large, watery, frothy, and of foetid odor. DIARRHCEA. 911 Where simple diarrhoea is me.t with in strumous children, he pre- scribes : J370' R- 01. morrhuae, f.|iij Syr. prun. virg., Liq. calcis, aa f.§j. M. One or two teaspoonsfuls after each meal. When change of temperature, commonly termed cold, is the cause of the diarrhoea, by some writers styled intestinal catarrh, the follow- ing, given in a teaspoonful of equal parts of syrup and water, is pre- scribed for infants, and larger doses for older children : 137'- R- Tr. opii camph., gtt. iv Ext. ipecac, fl., gtt. \. M The castor oil mixture answers fully as well in such cases, and is more frequently given than the first-mentioned combination. For summer complaint, appearing in a child undergoing denti- tion, where the evacuations are frequent and present the familiar green or chopped-spinach appearance, and also contain mucus and undigested curd, (all more or less certain indications of inflam- matory destruction ; ) and when, moreover, during the first days of the complaint, it is attended with marked fever and tenderness upon pressure over the abdomen, and more especially in the region of the iliac fossae, he at once places the child upon an antiphlogistic treatment : 137^- R- Liq. ammon. acet., or Liq. potass, cit., gtt. xx Tr. opii camph., gtt. iv-x Ext. ipecac, fl., gtt. j-J. M, To be given in a teaspoonful of anisette water. The diet is to be carefully regulated, the breast to be given not oftener than every three hours, and if there be much vomiting, tea- spoonful doses of toast-water, containing ice, to be given. In cases where vomiting appears as the principal symptom : 1373. R. Hydrarg. chlor. mit., gr. j Sacch. albi, gr, xv, M, Make sixteen powders. One to be given every two hours. When the disease has progressed for several days, until the febrile symptoms have subsided, or where such changes appear in the evac- 912 DISEASES OF CHILDREN. uations as before remarked, following a previous simple diarrhoea, he employs : 1374. R. Pulv. rhei, gr. vj Pulv. ipecac, co., gr. x Sodii bicarb., gr. xij. M. Make twelve powders. One to be given every three hoars to a child under one year of age. He sometimes uses the following, for the same age : '375- R- Vin. ipecac, gtt. ii • Tr. calombae, gtt. xx Mist. salin2e, f. § ij. M. To be given every three hours. The mist, saline is made by adding lemon, juice in sufficient quan- tity to neutralize 20 grains of carbonate potassa dissolved in f..5j water. In addition to drugs and attention to diet, he generally re- commends a hot bath to be given twice daily, and the baby to be wrapped in a blanket, after being dried, so as to invite free perspira- tion. When this variety of diarrhoea presents itself in children over a year old, and in those under that age, also, where there are streaks of unaltered blood in the stools, he uses : '376. R. Bismuth, subnit., 3j Pulv. ipecac, co., gr. xx Pulv. zingib., gr. iij. M. Make twelve powders. One to be given every three or four hours. Where the disease has lasted for several months, and has assumed all the features of a chronic diarrhoea, whether the patient has com- pleted dentition or not, he gives the cod-liver oil mixture before mentioned, (F. 1370,) in the proportion of f..5iijss to f.^ss, of the syrup ferri iodid., a teaspoonful of which combination is to be given three times daily. It acts in the same beautiful and pleasing manner as in the simple diarrhoea of strumous children. DRS. MEIGS AND PEPPER, PHILADELPHIA. These writers recommend, in the treatment of simple diarrhcea in childhood, sulphate of magnesia combined with laudanum, as follows : '377- R- Magnesis sulphatis, 3j Tincturse opii deodoratse, gtt. xij Syrupi, f.gss Aquae menthse pip., f.|ijss. M. At one or two years, a teaspoonful every two or three hours. For older children, the proportion of magnesia and laudanum should be doubled. DIARRHOEA. 913 If this fails, recourse must be had to an astringent. The officinal mistura cretse must be given in teaspoonful doses, after each loose evacuation, three or four times a day ; or tincture of krameria may be added, thus : 1378. R. Tincturae kramerte, f-3j-ij Misturae cretae, f. § jj. M. Teaspoonful repeated as above directed. They also commend the aromatic syrup -i)/ galls : *379' R- Pulveris galloe optimi, gss Pulveris cinnamomi, 5 i) Pulveris zingiberis, 5s3 Spiritfls vini gallici optimi, Oss. M. Let the ingredients stand in a warm place for two hours, and then bum off the brandy, holding some lumps of sugar in the flames. Strain through blotting paper. Fifteen to forty drops, three or four times a day, or, when the discharges are very frequent, every two or three hours. In the chronic form of simple diarrhoea they have found, of late years, the following tonic very useful : 1380. R. Tincturx nucis vomicae, f. 3ss Tincturse gentians compositse, f. 3 iij Syrupi, f.3v Aquae, f-Sij. M. A teaspoonful three times a day, after meals, for children of three or four years of age. Wine of pepsin is also efficacious in such cases, in doses of ^ tea- spoonful thrice daily. PROF. ALFRED VOGEL, M. D., DORPAT, RUSSIA. This physician positively prohibits cow's milk in intestinal catarrh. He states that penciling of the mouth with laudanum, and the use of opiate clysters, stand at the head of all therapeutic measures. But, occasionally, in the profuse diarrhoea of summer, opium proves in- efficacious; then order small doses of calomel, gr. yi, three or four times daily, or: 1 38 1. R. Argenti nitratis, gr. ss Aqux destillatae, f. § iij. M. A teaspoonful three or four times a day. A drop of laudanum may be added to each dose. Vegetable remedies containing tannic acid, such as calumba, rhat- any, pure tannic acid itself, and astringents in general, are with difficulty administered to small children, unless mixed with large 58 914 DISEASES OF CHILDREN. quantities of syrup, and, on that account, should be seldom resorted to. In older children they may be oftener employed. 1382. E. Aluminis, P-^. Syrupi acacUe, '• 3 "j- "*. A teaspuonful thrice daily. This will sometimes check the diarrhoea, which has been uninflu- enced by any of the above remedies. Dr. V. has often convinced himself of the utter inefficacy of all therapeutic remedies in the treatment of this disease when the child is not sustained on milk diet. The best prophylaxis consists in rendering alkaline the cow's milk given the child, by the addition of the following soda solution to each meal: 1383. R. Sodii caibonatis, 3i Aquae, f-S'I- * M. Several authors have very forcibly urged the importance of co/d, in infantile diarrhoea. Mr. E. POCOCK, of London, invariably orders ice in large quantities, as well as frequent sponging with cold water, and he directs that all nourishment (unless the child be sucking) should be iced. Dr. McKenna, also of London, in cases of great exhaustion, em- ployed cold-water baths, stimulant ice injections, and iced drinks. Cold baths especially, are called for, where there are marked cere- bral symptoms. Dr. C. G. COMEGYS, of Cincinnati, has especially urged this treatment on the American profession. He says its great value is in cases where an inflammatory process is set up — entero- colitis, in which the discharges are more frequent, retaining, however, more or less traits of the "loose bowels" so-called, with the addition of a high fever — 102.5° to 106°. The pulse is much more frequent, 130 — 150; the mouth is dry, the thirst intense; eyes staring, con- tracted pupils ; insomnia, vomiting, rolling of the head, and distress- ing cries, due to hypersemia of the cerebral vessels and the unap- peased thirst. The frequent vomiting and diarrhoea inhibit digestion or absorption of nutritious substances, and the brain is imperiled, for an eff'usion is impending, and general collapse. In this alarming condition the greatest relief may be found in immersions of the body in cool or even cold water, from twelve to fifteen minutes, every three hours, until the fierce symptoms are relieved, and relief will posi- tively be obtained. It has now been a number of years since Dr. C. DIARRHCEA. 915 adopted this method of treating entero-colitis, and he has not lost a patient. He claims that the immersion plan, is much better than the wet pack, because the radiation of the febrile heat, is more rapid and equable from the surface of the body. He has also for many years used the pack about the chest and abdomen, in private and hospital practice, and he considers it not only more troublesome to apply, but of greatly inferior effect. Internally, Dr. C. uses small doses of mercurials and rhubarb. DR. LUFF, OF ENGLAND. Dr. Luff concludes (^Lancet, Dec. 20, 1890,) that milk ptomaine, (tyrotoxicon,) is the chief element in causing disturbance. The rational treatment is to destroy or render insoluble this substance, and to stop abnormal fermentative changes. To accomplish these objects, he prefers the soluble biniodide of mercury, regarding the bichloride as a feebler antiseptic, as more dangerous, and as not producing a precipitation of the ptomaine in an insoluble form. For administration, the biniodide is combined with chloral hydrate for its sedative action on the irritated bowel and the exaggerated peri- staltic action. A fiftieth of a grain of biniodide is used for a child up to six months of age. DR. JAMES TYSON, PHILADELPHIA. The treatment of this practitioner is by cold baths, chloral enemas and oxide of zinc. The cold bath is insisted upon at least three times a day, but not at a lower temperature than 80° — 85° Fahr. The enema he uses is : 1384- B- Chloral! hydratis, 3ss Aqux amyli, f. § ij. M. For an enema. One to two and a half teaspoonfuls to be forcibly thrown into the bowels from a small glass syringe. In some cases where the discharges were lienteric and the tenes- mus excessive, this spasmodic action of the sphincter and lower bowels could only be controlled by repeated resort to the remedy, two or three applications being requisite before it could be retained, and then only by directing the nurse or mother to compress the glutaei muscles on either side, close over the anal orifice, for two or 91 6 DISEASES OF CHILDREN. three minutes. When thus kept in immediate contact with the in- flamed, sensitive and irritable tissue, the benefits were prompt and enduring. Tenesmus, or choreal spasm of the bowel, was arrested, pain and inflammation were allayed, and the little sufferer would rest or sleep comfortably for several hours. A repetition of the enema was made once, sometimes twice, in the twenty-four hours, with in- creased comfort and alleviation of all the symptoms. The oxide of zinc is administered as follows : 1385. R. Zinci oxidi, 3ss Polv. acacise, Sacchari aibi, aa 3 ij Lactopeptinse, 3j Aqux cinnamomi, q. s. ad f. § j. M. A teaspoonful every five or six hours. This combination exerts a happy influence on the primas viae, en- abling the child to digest its food more thoroughly, and controlling the number while it alters the character of the evacuations in a day or two. It is needless to add that strict attention to diet should be enforced. DR. ARMAND SEMPLE, OF LONDON. This author tells us that the treatment of diarrhoea must, in a great measure, depend upon its causation. Very careful attention must be paid to the diet. The age of the child and its constitution must be regarded, and particular notice should be paid to the gradual or sudden nature of its illness. Before the appearance of teeth, milk in some form must be relied upon, and all farinaceous food must be forbidden ; a small quantity of lime water is a useful addition to the milk. Simple diarrhoea, arising from irritation of the lining membrane of the bowels, must not be too hastily checked, since by this means nature eliminates the offending matter ; but if the diarrhoea continues, it must be checked by such remedies as cas- tor oil, rhubarb, soda and magnesia. In older children, grey pow- der with Dover's powder, will be useful, or the administration of a little bismuth. As a rule, it is a mistake to give astringents in the early stages of diarrhoea, the best plan being first to eliminate the offending matters, and subsequently to check the diarrhoea, if it is excessive. If the child is strong, the motions containing blood or mucus, and there is no pain in the abdomen, a mixture of tincture of rhubarb, sulphate of magnesia, and peppermint water may prove ser- viceable. If there be much exhaustion, a few drops of brandy may DIARRHCEA. 91; be given in weak milk or arrow-root. For the treatment of bilious diarrhoea, alkalies, especially soda, may be combined with one or two minims of tincture of opium ; but this last drug must be administered with the greatest caution in the case of very young children. DR. EDWARD HENOCH, OF BERLIN. This author gives us some very explicit advice for the treatment of diarrhoea. He says that in the treatment of a recent catarrhal diarrhoea, we must first determine whether it was preceded by con- stipation, and also whether an attack of indigestion was the exciting cause of the disease. Under such circumstances, it is best to begin with a mild purgative, a teaspoonful of castor oil, or a few doses of calomel (r\ to J gr.), especially if tenesmus is present and the pass- ages are small in quantity and mixed with bloody points or streaks. After the purgative has operated, the diarrhoea not infrequently dis- appears in a few days. As almost all primary intestinal catarrhs of childhood have a dyspeptic origin, we may use purgatives at first in almost every fresh case, even if the causative indigestion and dys- pepsia cannot be positively proven. But if profuse, thin evacuations have lasted for some days, or if exposure, or the misuse of a purga- tive, such as tartar emetic, can be proven to be the cause, he would keep the child warm in bed, give only farinaceous food, and prescribe : 1386. R. Infus. ipecac, rad., f-Siij Mucil. gum. arab., Syrupi, aa f.3"ss Tinct. opii, gtt. ij-W- M. S. — Dessertspoonful every two hours. If the diarrhoea resists these remedies and lasts for a week or more, he uses subnitrate of bismuth in large doses. '387. R. Bismuthi subnit., gf- s-J Pulv. gummosi, ' gr. j. M. S. — Give this powder every two hours. This should be continued for from ten to fourteen days to prevent a relapse. In very obstinate cases he adds the aqueous extract of opium jV to t'j gr- to each powder. Some cases become chronic in spite of all these measures. He then uses : 1388. R. Decoct, rad. Colombo, f-i>ij Syrupi, f.3v Tinct. opii, gtt. iv. M. S. — A dessertspoonful every two hours. 91 8 DISEASES OF CHILDREN. Or, '3^9- B' Decoct, cort. cascariUse, f-§iij Syrupi, f.5v Tinct. opii, gtt. iv. M. S. — Dessertspoonful every two hours. These remedies are very effective, though difficult of administra- tion on account of their bitter taste. Tannic acid may impair the already diminished appetite, but is sometimes very useful. I390- R. Acid, tannici, gr. xv Tinct. nucis vom., gtt. xt Aq. destil., f. § iij Syrupi, f.3v. M S. — Dessertspoonful every two hours. He has sometimes used the following with success in apparently hopeless cases, and has never observed any injurious toxic action : '39'- R- Plumbi acetici, gr. J- Pulv. gummosi, gr. j. M. S. — Give this powder three times a day. But all these remedies may prove useless or even act injuriously, by producing anorexia, nausea or vomiting. For such cases, he re- sorts to the injection or pouring of medicinal fluids into the intes- tines, a plan which may produce surprising results if faithfully carried out. He employs an ordinary irrigator or glass funnel, to which ai rubber tube, with an end-piece of bone or ivory, is attached. The end passed into the rectum should be free in its cavity, so that the fluid can escape. The injections are best perfoi-med in the knee- elbow position, but it can also be done in right lateral decubitus. As a rule he employs a solution of acetate of lead, more rarely alum and tannin. This method requires persistent use, as a favorable effect cannot be expected in the first few days. Regulation of diet, without which recovery is impossible, meets with great obstacles in children. It should be confined to meat-broths, milk, red wine, soups, eggs, rice, farina, and finely-chopped meat; all articles which have a tendency to ferment — ^vegetables, fresh and cooked fruit, legu- minous articles, etc., must be prohibited. The only objection to raw scraped meat is that it may give rise to tape-worm. DR. J. LEWIS SMITH, OF NEW YORK. This author {Archives of Pediatrics, 1884,) urges strongly the im- DIARRHOEA. 919 portance of not over-feeding infants in summer, since the surplus of food, over and above that required for nourishment, will undergo fer- mentative changes and thus become a potent cause of summer diar- rhoea. In conjunction with Dr. Chadbourne, of New York City, he has made some important experiments upon the amount of food required by young children, and as a result, he concludes that under the age of two months, the stomach is so small that it cannot receive more than one or one and a half fluid ounces without distension ; at the age of six months, the infant can probably take and digest, with- out discomfort, three ounces, and in the last half of the first year, even four ounces. Infants nourished at the breast, may be allowed to nurse every two hours during the daytime, no matter what the age, after the second month, but less frequently at night. Frequent nursing promotes the secretion of milk, and the milk is of better quality than when it is long retained in the breast. If, by the fifth or sixth month, mothers or wet-nurses find, as is frequently the case, that they do not have sufficient milk, other food should be given in addition, perhaps after every second nursing, or every fourth hour- By knowledge on the part of the mother and nurse of the dietetic needs of the infant, and by consequent judicious alimentation, and by measures also to procure the utmost purity of the air, there can be no doubt that the summer diarrhoea can be, to a great extent, prevented. Curative Treatment. — ^The indications for treatment are: ist. To provide the best possible food. 2d. To procure pure air. 3d. To aid the digestive function of the infant. 4th. To employ such med- icinal agents as can be safely given to check the diarrhoea. The infant with this disease is thirsty, and is therefore prone to take more nutriment than it requires for its sustenance. If nursing, it craves the breast ; or, if weaned, craves the bottle at short intervals to re- lieve the thirst. No more nutriment should be allowed than is re- quired for nutrition, for the reason stated above, and the thirst may best be relieved by a little cold water, gum-water, or barley-water, to which a few drops of brandy or whiskey have been added. When the child, for some good reason, cannot receive human milk, Dr. Smith gives the preference to pancreatized milk. Five grains of extractum pancreatis CFairchild Bros. & Foster), and ten grains of sodium bicarbonate, are added to one gill of warm water. This is mixed with one pint of warm milk, and the mixture, in some conven- ient vessel, is placed in water kept at a temperature of 100° F. for 920 DISEASES OF CHILDREN. one hour, or less time if it begin to be bitter, when it is placed upon ice to prevent further digestion. With some specimens of milk, especially at a temperature of 1 15° or 120° F., a half hour, or even less, is sufficient. The artificial digestion is arrested either by boil- ing the peptonized milk, which destroys the ferment, or by reducing its temperature to near the freezing-point, which renders it latent and inactive, but does not destroy it. Milk from healthy, properly-fed cows, may be prepared without peptonizing, so as to agree with many infants, except in the warmest weather, but is obviously less easily digested than peptonized milk. It should be diluted as follows, with water boiled so as to free it from germs : In the first week after birth, one-fourth milk, with the addi- tion of a little sugar. The milk should be gradually increased so that it is one-third by the end of the fourth week ; one-half by the end of the third month ; and two-thirds to three-fourths by the end of the sixth month. After the sixth month, it is still proper to add one-fourth water, but pure milk may be given. It is very important to determine when and how farinaceous food shall be given in this disease. It is well known that infants, under the age of three months, digest starch with difficulty and only in small quantities, since the salivary and pancreatic glands, which se- crete the ferments which digest starch, are almost rudimentary at that age. But the artificial digestion of starch, is easily accomplished. Among the last labors of the renowned chemist. Baron Liebig, was the preparation of a food for infants, in which the starch is digested, transformed into grape-sugar, and thus infants at any age, who are fed with it, are relieved of the burden of digesting it. The Baron led the way, which has been so successfully followed since, in the artificial digestion of foods. A considerable part of the starch in wheat-flour is converted into grape-sugar by the prolonged action of heat. He frequently recommends that from three to five pounds of wheat-flour be packed dry in a firm muslin bag, so as to form a ball, placed in water sufficient to cover it constantly, and kept over the fire, three or four days. During the nights, the fire may go out for a few hours. At the expiration of the time, the external part, which is wet, being peeled off, the remainder resembles a lump of yellow- ish chalk. The flour grated from it, gives a decided reaction of sugar by Fehling's test. Starch is also quickly transformed into glucose, by the action of the diastase of malt, which, indeed, Liebig employed. If to a gruel of barley-flour, oatmeal, or other farinaceous substance, DIARRHCEA. 921 when hot, a little of a good preparation of extract of malt be added, it becomes thinner from the conversion of the starch into sugar. Farinaceous substances thus prepared may be used with peptonized* or other milk. To select the best food for the infant, is one of the most important duties of the physician. If called to an infant unfortunately deprived of wholesome breast milk, and suffering in consequence, from indiges- tion and diarrhoea, he would advise as follows : Use cow's milk of the best possible quality, peptonized in the manner stated above, and peptonized in small quantity at a time, as one pint, or better, half a pint. This may be the sole food till the age of five or six months. Farinaceous food can be allowed in addition, even to young infants, if a considerable part of its starch be converted into glucose. His pre- ference regarding farinaceous food is for the wheat-flour prepared by long boiling. For infants under the age of six months, one tablespoon- ful of the flour thus prepared should be mixed with twelve tablespoon- fuls of water, and heated. To one teacupful of this, one-half teaspoon- ful of the extract of malt (as Trommer's extract prepared for chil- dren) should be added. The diastase of the malt quickly converts a considerable part of the starch that has not already been converted into glucose by the boiling. The glucose renders it sweet and palat- able, and a little salt should be added to it. It does not seem to mix well with peptonized milk, and can be given separately through a nursing-bottle. He usually makes it the vehicle for brandy or whisky, which infants with diarrhoea, usually require. It is also a good vehicle for albumen. If the digestion of the infant be feeble, as in atrophic cases, and it seems to require more nutriment, the white of the fresh egg mixed with the food, aids in supplying the deficiency, and it is easily digested even by atrophic infants. Beef, mutton, or chicken-tea should not be employed, at least as it is ordinarily made, since it is too laxative. Occasionally for the older infants, the expressed juice of beef, raw-scraped beef, or beef- tea prepared by adding half a pound of lean beef finely minced to one pint of cold water, allowing it to stand cold half an hour, and then warming it to a temperature not exceeding 110° for another half hour. By this process, the albumen is preserved. Salt should be added to it, and he is in the habit of adding to it also about seven drops of ♦ The best and most ready method for peptonizing milk is by the use of " peptonizing tubes " prepared by Fairchild Bros. & Foster, of New York. An excellent substitute for molhtr's milk, is food prepared by the use of " peptogenic milk powder," manufactured by the same fiim. 922 DISEASES OF CHILDREN. dilute muriatic acid, to facilitate its digestion. It is chiefly for in- fants over the age of ten months that the meat-juices are proper. An infant weakened and wasted by summer diarrhoea, removed to a cool locality in the country, should be warmly dressed, and kept indoors when the heavy night dew is falling. Patients sometimes become worse from injudicious exposure of this kind, the intestinal catarrh from which they are suffering being aggravated by taking cold, and perhaps rendered dysenteric. Sometimes, parents, not noticing the immediate improvement which they have been led to expect, return to the city without giving the country a fair trial, and the life of the infant is then, as a rule, sacrificed. Returned to the foul air of the city while the weather is still warm, it sinks rapidly from an aggravation of the malady. Oc- casionally the change from one rural locality to another, like the change from one wet-nurse to another, has a salutary effect. The infant, although it has recovered, should not be brought back while the weather is still warm. One attack of the disease does not dimin- ish the liability to a second seizure, but increases it. DR. LEES, OF ENGLAND. This author {^Lancet, 1884,) calls attention to a form of diarrhoea in which the main symptom is an irresistible impulse to defecation almost as soon as food is taken ; pain may or may not be present ; there are no symptoms of dyspepsia. The passages are usually semi-solid, not watery or slimy, and frequently contain undigested food ; usually a passage after each meal and one or two more in the twenty-four hours. The explanation given, is that of increased peri- stalsis without increase of secretion. It is probably due to irritation of the vagus. The close connection of the nucleus of the vagus with that of the fifth nerve, suggests that probably dentition may some- times be a reflex cause. Astringents had always failed signally in the treatment, but remedies directed to the neurotic origin, such as opium and especially the bromides, had always given prompt relief. DR. GUAITA, OF ITALY. According to this writer (^Gaz. degli Ospitali, 1884,) the summer diarrhoea of children is due to a microbe, and is a zymotic disease. Acting upon this supposition, the author used benzoate of soda with very good results. The following is the plan of treatment which was adopted : A moderate purge of calomel or jalap was first given, and DIARRHOEA. 923 then from one to one and a half drachms of the benzoate in three ounces of water, in divided doses, during twenty-four hours. The same quantity was given upon the second day, and upon the third, a mild purge of magnesia or manna, after which the benzoate was resumed. Improvement invariably began after two days, the stools becoming less fetid, and the vomiting ceasing. During the treat- ment little food was given, but in its stead, lemonade and generous wine. Milk and soup were entirely discarded, the former because it had been observed that its use, especially in the form of cow's milk, was followed by fermentation, and consequently by an increase in the severity of the disease. When the patients were nursing children, they were allowed to take the breast only four times in the twenty-four hours. In addition to the benzoate of soda, other medication might be employed in all cases in which it would seem to be indicated. DR. WILLIAM B. ATKINSON, OF PHILADELPHIA. This author thus sums up the subject. When the case is seen early, and the symptoms lead up to the belief that the attack is the result of the presence of indigestible or undigested matter in the bowels (for either, being a foreign body, acts as an irritant), a small dose of castor oil, of calcined magnesia, or of the spiced syrup of rhubarb may be given, with the view of expelling such matters. It is rarely necessary to continue, or even to repeat these remedies. With a proper regulation of the diet, of the hygienic conditions, etc,, in very many cases, the attack ceases, and no further medication is requisite ; or a few doses of aromatic powder, v— x grs. every two hours, will complete the cure. Should the looseness of the bowels continue, it becomes necessary to employ an astringent; an alkali if there is much acidity ; and some form of narcotic to relieve pain. Of astringents, catechu, kino, and logwood are most frequently employed. As antacids, we have bicarbonate of soda, or potassa, lime water, chalk mixture, and bismuth. Perhaps no formula can be employed with better result, in the great majority of cases, than one combining the subnitrate of bis- muth with the compound powder of ipecacuanha. For a child one year old, we may give — 1392. R. Pulv. ipecac comp., grs. vj-ix Bisinuthi subnitral., 3j. M. Ft. chartulie. No. xij. Dose. — One every two to four hours, according to the urgency of the symptoms. 924 DISEASES OF CHILDREN. In cases where for any reason a mixture is preferable, we may use — 1 393- R- Bismuthi subnitrat., 3'i Tincturae opii camph., f.31v Syrupi, Mucilag. acaciae, aa f. § iss. M. Dose. — ^Teaspoonful, as before, It must not be forgotten that blackening of the stools will result from the use of bismuth, and this fact should be mentioned to the mother, as in some instances this condition has created great alarm, as portending a grave complication. When acidity is a prominent symptom, we may employ with the bismuth the compound powder of chalk, with opium, in doses of one to three grains for a child of one year. In all cases where opium is employed, it is important to watch its effects, and where drowsiness or cerebral symptoms occur, it should at once be omitted. Should a child die comatose, it is difficult to dis- suade its attendants from the belief that it has died from the effects of opium. It seems that the whole benefit obtained from the use of this drug, is the so-called " putting the bowels in splints." It checks the peristaltic action, quiets the restlessness due to the pain, and thus allows nature to return to her normal condition. In this connection, we must insist upon the great importance of rest in the horizontal position. This is constantly forgotten ; the child is carried about over the shoulder of the attendant, jolted on the knee, or in a rough rocker, thus keeping the bowels in a perpetual turmoil. We see the good effects of rest by the almost invariable improvement after a good nap. Therefore, never disturb a child from its sleep, even though the hour for giving the medicine may be at hand. In persistent cases we may give : 1394- R- Tr. Catechu, Tr. krameriae, Tr.kino, 5a f.3ij Tr. opii camph., f. 3 jv Spt. ammonise aromat., f. 3 ij Synipi, Aq. cinnamomi, 55 f. | iss. M. Dose, dessertspoonftil every two to four hours, according to age and urgency of symptoms. Where, for any reason, the alcohol may be objectionable, we may DIARRHCEA. 925 employ astringent infusions of catechu in doses of one or more tea- spoonfuls, repeated as above. When the discharges are quite offensive, the addition of a small quantity of the solution of chlorinated soda, two to five drops in each dose of the astringent mixture, will correct this trouble and aid in the cure. We prefer this to the use of carbolic acid, which rarely fails to prove so offensive to the child that it obstinately refuses to take the mixture. An old formula, and one which we have seen to be of great service both in chronic and other forms of diarrhoea, is the mixture of nitrous acid with opium and camphor water. '39S- R- Aviidi nitrosi, Itlxxv Tr. opii, IHxv Aq. campbone, Syrupi, aa f. § iss. M. Dose, teaspoonful every three or four bonrs. In a number of instances this has given most excellent and speedy results. Where opium may be contraindicated, we may substitute extract of hyoscyamus, say half a grain in each dose. We always prefer to give the above doses in two or three times the quantity- of solution of acacia, rice or barley water. In cases of great restlessness, employ the bromide of potassium or sodium, or chloral, or the bromide and chloral may be usefully com- bined, as mentioned previously. Rest is imperatively demanded for the cure of this condition. When the skin is hot and dry, tepid sponging is of great value, and by itself often gives so much comfort that the little patient sinks into a refreshing slumber, perhaps the first it may have had for sev- eral days. In cases where much flatulence is present, perhaps no remedies are more useful than chloroform and turpentine. The former may be employed in a formula like the following : 1396- B- Cbloroformi, gtt. xxx Tr. opii campb,, Tr. cardam. comp., aa f. 3 i) Mucilag. acacise, Syrupi, Aq. mentbse viridis, ii f. §j. M. Dose. — ^Teaspoonful every bour, or even every balf bour, or oftener, as occasion de- mands. 926 DISEASES OF CHILDREN. The turpentine may be given as follows : I397- R- 01. terebinthiniE, f.3j Tr. opii camph., Tr. cardam. comp., aa f.3ij Magnssiae calcinata. gr.x Mucilag. acacix. Syrupi, aa f.gis Dose. — ^Teaspoonful every two or three hours. M. In all cases it is well to commence early with some tonic, and we have found the best and most useful to be the solution of the per- nitrate of iron with calumbae, as mentioned in the previous paper. During the treatment, the physician must constantly remember that the child requires food as well as medicine. Give milk, with a due proportion of lime water, with stimulants added as required, beef essence, beef or mutton tea, chicken, or rice water, also cold water freely. Nothing is gained by cruelly keeping the child suffering with thirst. DR. E. H. BARTLEY, OF NEW YORK, Recommends the following formula, in the N. Y. Medical Journal, 1884, for imV^AV^ diarrhoea: 1398. R. 01. ricini, f.Siv Bismuth, subnitratis, 3 ij Magnes. carbonatis, 3j Sacchari, 3 ij 01. anisi vel ol. menth. pip., lUyj. M. Sig. — 3 j for a child of six months to one year. Or we may use : 1399- R- Vin. pepsinse, f. g iss Bismuth, subnit., 3i] Glycerini, 3iv. M. Sig. — 5j' at a dose. Dr. Mecray, of Cape May, New Jersey, highly recommends the following : M. 1400. B. 01. ricini. f.Siv Tr. opii, gtt. iv Pulv. acaciae, Sacch. alb.. aa q. s. adillij. Aq. mentb. pip.. Sig. — Dessertspoonful every three houra. DIARRHCEA. 927 DR. R. L. MOORE, OF MINNESOTA, Highly recommends the following : 1401. R. Hydrarg. cum creta, gr. x Sacch. alb., 5j. M. Triturate well and add : German tinct. bell., gtts. xv Aquae, f. § iij. M. S. — ^Teaspoonful every hour. DR. JAMES CRAIG, OF JERSEY CITY. This author considers (Archives of Pediatrics, 1884,) that the in- dications are to prevent nausea and vomiting, support the strength, and check diarrhoea. If nursing, no change in diet is made, but care should be taken not to nurse the child too often or too much at a time. If bottle-fed, the milk is stopped, and stale bread soaked in hot water, with a little sugar and brandy, added, or Robinson's pre- pared barley or arrow-root, made with water and given in small quantities, answers a good purpose. Milk is also prohibited where the child is weaned, but is gradually resumed as it improves. Where the child is weak, one teaspoonful of brandy to six or seven of water, a teaspoonful of which is occasionally given. Where a more power- ful stimulant is required, carbonate of ammonia, in one or two grain doses, mixed in syrup of acacia, is used, according to the age of the child. For the gastric and intestinal derangement his favorite pre- scription is : 1402. R. Liq. acidi carbolici, 5 per ct., f. 3j Bismuthi subcarb., Fepsini sacch., aa 3j Aquse cinnamomi, % iij Syr. aurantii cort., f. 3 ij- M. Sig. — A teaspoonful every two or three hours until relieved. He applies over the abdomen a spice plaster, composed of the following: Powdered cinnamon, cloves, nutmeg, ginger, allspice, of each 5ij. Honey and glycerine, of each, 5vj. White of an egg. Mix and spread on cheese cloth or fine mosquito netting. It may remain on over the region of the stomach and bowels for hours and days without blistering — it merely reddens the skin and is an excel- lent counter-irritant. A bandage should be applied over it to keep it in place. Change of air frequently brings about convalescence in a short time. When that cannot be had, the next best thing is to take the child out daily, for an hour or two at a time, early in the 928 DISEASES OK CHILDREN. morning and late in the afternoon. While in the house, the child should be kept in a well-ventilated room free from draughts. NOTES ON REMEDIES. Acacia in solution is both soothing and nourishing. Acidum Carbolicum is recommended in the British Medical journal. 1883, in half minim doses, combined with bismuth and aromatic confection, for the vomiting and diarrhoea of children. In chronic diarrhaea, espe- cially of the feculent variety, Dr. Ellis has found the greatest benefit from the use of carbolic acid intemally, in doses of gr. ^-^ in well- sweetened water, for children about two years old. Acidum Gallicum, gr. j-v, dissolved in hot water, well sweetened and then al- lowed to cool, is very serviceable in chronic diarrhoea. Acidum Salicylicum. Dr. J. M. Keating, of Philadelphia, has recently em- ployed with much satisfaction this drug in the acid diarrhoeas of chil- dren. His formula is 1403- R. Acidi salicylic!, gr. ss Spts. ammon. aromat, gtt. v Aq. menth. piper., q. s. M. For one dose for a child a year old. Acidum Tannicum is a useful astringent. Dr. Ellis prescribes : 1404. R. Acidi tannici, gr. v Acidi nitrici diluti, niyj Infusi gentianse comp., f>3ij. M. Every three or four hours, to a child of ten years. Alkalies are highly extolled by Dr. J. P. Oliver {Boston Medical and Sur- gical yournal, July, 1885,^ in diarrhoeal diseases of infants. The al- kaU should always be combined with an aromatic. 1405. R. Potassii bicarbonatis, 9j Aquse cinnamomi, . f-sij. M. A teaspoonful or two to a child of eighteen months, in milk or barley water. This prescription; wiih a few grains of pepsin if there is atony of di- gestion, and sometimes a little stimulant, will cure most cases. Argenti Nitras. In acute catarrhal diarrhoea, summer diarrhoea, and the diar- rhoea of dentition, this salt is used by Dr. Muixer and others, in doses of gr. 2*4-}. He says the special indications for it are : (i) Croupous deposits on the mouth and fauces ; (2) peculiar redness and smooth ness of the tongue ; (3) irrepressible thirst. In obstinate cases of the chronic forai, Trousseau recommends as an enema, 1406. £. Argenti nitratis, gr, j Aquae, f.5v. m. For an enema. A portion to be used twice daily. DIARRHCEA. 929 Arsenicum. Dr. Ringer advocates gtt. j-ij of the liquor acidi arseniosi in cases of children from eight to twelve years, where the motions are semi-solid, with lumps of half-digested food. Bael. This East Indian astringent is growing in popularity in Great Britain. Dr. R. P. Ritchie writes of it to the Medical Times and Gazette, 1879, that in the chronic diarrhoeas of children, especially those of a dysen- teric character, it seems especially valuable. Bismuthi Salicylas has been found very useful by Dr. Kilmer {St. Thomas Hospital Reports, 1879,) when the diarrhoea seems to be entirely de- pendent on the heat of the weather. He uses good-sized doses — two or three grains for a child under six months, and from three to five or more, when above that age. Bismuthi Subnitras is commonly used in the more chronic forms. It is also of value in the acute forms where there are sour-smelling and offensive stools. Large doses are necessary. Calcium Salicylas. See Bismuthi Salicylas {z!oo\€). The indications and doses are the same. Camphor may be given in acute diarrhoea of infants. Use a few drops of the tincture on sugar or in milk, every two or three hours. Catechu is a favorite astringent with some. 1407. R. Tinct. catechu, Tinct. kino, ia Hlx Sytupi, mxv Aqnse cinnamomi, f. 3 ij M. For one dose every three hours. Ceanothus Americanus or Jersey Tea is highly recommended by Dr. S. P. Hubbard, of Virginia {Med. and Surg. Reporter, 1880). He has found a weak decoction, made in an earthen vessel, sweetened with loaf sugar or honey and used as a drink, to be an excellent remedy in the diarrhoea of teething. Chalk. Mistura cretae, with or without opium, is highly useful in the diar- rhoea of children. Chamomile is highly recommended by Dr. Christopher Elliott, {Practi- tioner, 1882,) in infantile diarrhoea connected with dentition, and in which the stools are many in number, green in color, or are slimy and streaked with blood and accompanied by pain and cramp. He gives gss-j of the infusion to a child under one year, and double the quan- tity to a child over that age, giving it three times a day or oftener ac- cording to the severity of the attack. Ergota and Ergotin are recommended in some cases, especially where the diarrhoea is without febrile action, and rather a wasting mucous dis- charge. 59 930 DISEASES OF CHILDREN. Hamatoxylon is a favorite astringent with many. Hydrargyri Chloridum Mite. Many practitioners commence the treatment of acute infantile diarrhcEas with small doses of calomel, with soda, chalk or other alkali, and perhaps a few grains of rhubarb. Quite large doses of calomel, gr. x-xxx, are undoubtedly valuable in desperate cases. In rickety, scrofulous or tuberculous children, Ellis advises that no form of mercury be given. Hydrargyri Chloridum Corrosivum. Dr. RiNGER long since recommended minute doses of corrosive sublimate for the infantile diarrhoea with very slimy stools, especially if mixed with blood and accompanied by pain or straining. Lately in this dysenteric and other chronic forms it has been urged by Dr. Rudolph Ravenburg, of Washington, D. C, gr. ss-j to water Oj, of which a teaspoonfiil may be taken at a dose. Ipecacuanha, in small and repeated doses, is often most useful in the more acute forms. Krameria is a pleasant and efficient astringent. Naphthaline, {Jour, de Med., February 3, 1889,) may be given to children in the first period of life, in doses of one and a half grains every two hours. Pure naphthaline never causes any accidents, even when used in very large doses. The following formula is recommended : 1408. K- Naphthalini, 3 ss-j Sacchari albi, 3 ss-j Bergamot ess., gtt. j. Sig. — Ft., pulv. et div. in chart. No. xx. Naphthaline may also be given per rectum, in a mucilaginous mix- ture which will hold it in suspension, but will not dissolve it. The re- sult will be the more satisfactory the earlier one begins with the treat- ment. According to Bouchard, naphthol is superior in its action to naphthaline. Nux Vomica. In lienteric diarrhoea, where the food passes through the bowels almost unchanged. Dr. Muller regards nux vomica as a spe- cific. The child should have salt-water baths and its diet be carefully regulated. Oleum Ricini. It is excellent practice in acute cases to commence with a mild emulsion of castor oil. Opium may be given by enema, with starch, where there is a marked griping and tenesmus ; or by the mouth, as : 1409. R. Tincturse opii, THj ij Potassii citratis, gr. iij-vj Syrupi aorantii, 5ss Aquae cinnamomi, f. § jj. M. This at a dose every three or four hours. CHOLERA INFANTUM. 931 Pepsin in one of its various forms, is indispensable in many cases. Rheum. When at the outset of an attack it is desirable to cleanse the bowels of offending substances, rhubarb is one of the most appropriate means. The powder or spiced syrup may be used ; or the alkaline tincture of the German Pharmacopoeia, which is especially praised in infantile diseases by some writers. It is prepared as follows : I4I0. R. Rhei, Boracis, Potassii carbonatis, To these add ia 100 parts. 10 paits. Aquae buUientis, Set aside for fifteen minutes; then add 850 parts. Alcoholis, Aquae cinnamomi, 100 parts. 140 parts. Salicin is recommended by Dr. Lawson in summer diarrhoea induced by the direct action of heat on the nervous system ; and by Dr. Afiken in those from both this and other causes which deteriorate the tone of the system. Sodii Benzoas. Dr. E. Ullman, of Vienna, {Allg. Med. Zeit., September 6th, 1879,) states that he has repeatedly proved the value of this substance in the summer diarrhoeas of young children. The quantity is 3ss-ij, in solution, given in twenty-four hours. Tinctura Ferri Chloride. In diarrhoea from the use of impure water, or un- ripe fruit. Dr. Lawson has found the most effective treatment gtt. ij-vj of this tincture in an appropriate vehicle, several times a day. Valeriana. Dr. L. A. Davidson, of West Virginia, {Medical and Surgical Re- porter, November, 1877,) commends the following as a most efficacious prescription in the ordinary diarrhoeas of children : 1411. K- Extracti valeriani fluidi, f.§ss Pulv. calumbae, Dij-iv Syrupi rhei, f. § ss. M. CHOLERA INFANTUM. SAML. S. ADAMS, A. M., M. D., WASHINGTON D. C. Dr. Adam's, {Arc. Ped., July 1887) lays great stress upon the observance of domiciliary and personal hygiene. He says, "To con- trol the vomiting and purging usually taxes the patience and re- sources of the physician. Unless these are at least mitigated in a few hours, death is imminent. The stomach rejects not only food, bjit 932 DISEASES OF CHILDREN. everything, so that for a few hours all attempts at feeding should be abandoned. The greatest danger is from the rapid loss of the fluid constituents of the body. These should be replenished as far as possible, by administering cool water and pellets of cracked ice in small quantities at short intervals. Thirst is intense, and attempts to allay it should be frequently made, in spite of the vomiting. To quiet the stomachal irritability, I know of nothing seperior to creasote or carbolic acid, half a drop in a drachm of lime water every two hours. In many cases, rice water in small quantities will be retained when every other fluid is vomited. Rubefacients of mustard or cloves may be applied to the epigastrium as counter-irritants. To check the diarrhoea, I have found bismuth subnitrate in cinnamon, and lime-water, the best combination. In order to derive a good result, the bismuth should be given in three-grain doses every two hours to an infant between four and ten months old, and five grains from the tenth to the eighteenth. In some cases, where the bismuth fails, benefit may be derived from lead acetate, dissolved in acetic acid and lime water ; enough of the acid should be added to make a perfectly clear solution ; crea- sote or carbolic acid may be added to allay vomiting. Both of these mixtures exert a soothing effect on the irritated stomach. Not much benefit is to be expected from the vegetable astringents. In all cases the condition of the anterior fontanelle is my guide for stimulating. As long as this is depressed I do not hesitate to con- tinue, or perhaps increase, the stimulant. Children bear stimulating surprisingly well. For this purpose I use whiskey or brandy, and sometimes camphor. In extreme cases ether may be given hypo- dermically. As antipyretic measures, I use sponging with cool water, whisky and water, or bay rum and water. I do not favor the general bath. During this cooling process care should be taken to apply to the in- fant's head, cold wet cloths, which should be frequently changed. Of the opiates, I prefer the camphorated tincture, because it is more cer- tain in its action, and more easily controlled. If there is jactitation or convulsions, I rely on the potassium bromide, to correct it. The infant should be kept in the cool air as much as possible. It must be kept upon a pillow, and not in the nurse's arms, and all super- fluous clothing should be removed. The diaper should be removed and disinfected as soon as soiled. Stimulation and external warmth are the indications for the state of collapse. To excite cutaneous CHOLERA INFANTUM. 933 warmth, hot baths, warm blankets, and mustard foot baths, are em- ployed. The exercise of good judgment is necessary to the success of the stage of reaction. The infant must be given small quantities of milk and lime-water at short intervals. Cool water or pellets ot cracked ice must be given occasionally to allay thirst ; the stimulants must be gradually decreased ; sleep should be secured by the cam- phorated tincture if necessary ; give the child the benefits of pure, fresh air; and discretion in clothing must be exercised. DR. I. N. LOVE. This author {Weekly Med. Rev., July 7th, 1888,) believes strongly in the preventive treatment, and when called early, before the stage of collapse, when the temperature is high; favors cooling baths and infinitesimal doses of calomel to soothe the offended lining mem- brane of the stomach and bowel, and also for its antiseptic and anti- fermentative effect. During the stage of extreme depression, he gives antipyrin, in one or two grain doses, as a sedative and reducer of temperature. If rejected, he gives half the amount hypoder- mically in ten to fifteen drops of good brandy-. In the stage of collapse the author recommends a warm bath containing alcohol, and as an aid to reaction, one three-hundredth of a grain of sulphate of atropia hypodermically. He favors the hypodermic method for the administration of remedies, because of the faulty absorption by the stomach and bowels, and the danger of accumulated doses when absorption is reestablished. During the stage of convalescence the danger of a subsequent entero-colitis should be borne in mind, and the diet regulated ac- cordingly. Animal broths, peptonized milk bovinine and Mellin's Food will be of service at this stage. Whatever is selected should be used temporarily only, the child, as soon as convalescence is sufficiently advanced, returning to its usual diet. DR. ARMAND SEMPLE, OF LONDON, Sums up the treatment by saying that it must be the same in prin- ciple as that of the indigestion of weaning, but the measures must be very prompt. Immediate efforts should be made to arrest the purging and vomiting. The strength should be supported and stim- ulants given if necessary. Port wine may be given with arrow-root, and brandy and water, or a little burnt brandy, will be found ser- 934 DISEASES OF CHILDREN. viceable. Warm applications, frictions, sinapisms, or liniments may be necessary, and the internal remedies should consist of catechu or kino, with spirits of ammonia or spirits of chloroform. The ammo- nio-citrate of iron and chalk will be found valuable ; after recovery from cholera infantum, even though the bowels continue long confined, purgatives should be carefully avoided. DR. EDWARD HENOCH, OF BERLIN, Considers that the great danger of the disease explains the large number of remedies that have been employed. In his opinion there is no specific against cholera infantum, because we are unable tp de- stroy the infectious germs that have entered the stomach and intes- tinal canal. Neither quinine, carbolic acid, nor salicylic acid has proved efficient, and hydrate of chloral only possesses a palliative effect on the vomiting. As it is impossible to destroy the true pro- ducers of the disease, it only remains to combat their effect, i. e. the fermentative processes produced in the stomach and intestines ; and in all cases in which the quantity of the infectious material intro- duced has not been too large, we may succeed in securing recovery, after the complete evacuation of the toxic and fermenting substances. In the opposite event, treatment will be useless, and the children will die, despite all our efforts. He therefore considers that the imme- diate administration of opium, which serves to keep the offending masses in the intestinal canal, is very much out of place. In recent cases, i. e. in the first two or three days, he gives small doses of calomel : 1412. ]g^. Calomel, gr. j Sacch. alb., gr. j. M. S. — Give this powder and hydrochloric acid, twice a day. •413- R- Acid hydrochlor., , gtt. j-xv Aq. destil., f. | iij Gum. arab., gr. xv Syrupi, f.3v. M. S. — Teaspoonful every two hours. Or: 1414. R. Creasoti, gtt. ij-iv Aq. destil., f. | j Syrapi. f. I ss. M. S. — ^Teaspoonful every two hours. When signs of weakness appear, he orders twice daily a warm CHOLERA INFANTUM. g,c chamomile bath, in which the children remain five to ten minutes, and port or sherry wine (20 drops to a teaspoonful, according to age), every two or three hours. Wine is often retained, when other arti- cles of food and medicines are immediately rejected. He advises milk, only when cooled with ice and given by the teaspoonful. If the case has continued for a few days, then he commences the use of opium. According to age, he adds three to ten drops of laudanum, to the hydrochloric acid mixture, and sometirafes gives a starch in- jection containing one or two drops of laudanum, several times a day. The sick room should be as large as possible, and the bed- linen be kept carefully clean. When the hydrocephaloid condition becomes more marked, he uses injections of camphor : 1415. R. Camphoiae, gr. j Spirit, vini., Aq. destil., aa f. 3j. M. S. — Inject a hypodermic syringeful. He gives also cold champagne (a teaspoonful to a tablespoonful at a time), and finally resorts to hydropathic applications and affusions over the whole body. DR. S. K. JACKSON, OF VIRGINIA. This gentleman said at a recent meeting of the Medical Society of the State of Virginia (1883), that he had never had a case of this disease in his practice since he had commenced the use of the follow- ing preparation. He gives to any child that is liable to contract the disease, 1416. R. Sodii sulphit., Sodii hyposulpfait., Sodii bicarbonat., aa gr. xxxij Syr. rhei aromat., f. § ij. M. S. — One teaspoonful or less, according to age, every two hours each morning, until two or three doses are taken. DR. WILLIAM B. ATKINSON, OF PHILADELPHIA. According to this author {Medical and Surgical Reporter, 1880), cholera infantum may commence abruptly, or may be preceded by a diarrhceal stage. The latter is by far the most commonly observed. For several days the bowels are loose, the evacuations quite thin, and of a yellow or pea-green color, and in other cases nearly natural in color but of a watery appearance. This may continue for several days, and suddenly there occurs an explosion of the disease, heralded 936 DISEASES OF CHILDREN. by very frequent stools, consisting almost wholly of water, often colorless and without odor, and along with this there ensues great irritability of the stomach, so that it almost instantly rejects every- thing that is taken. This irritability speedily extends to the lower intestine, so that the evacuations are actually squirted from the anus, often in a frothy state. Where the preceding diarrhoea has existed for a time, emaciation has gradually occurred ; but when the attack is sudden, it is remarkable with what rapidity the child assumes the appearance of one that has been sick for a long time. Within a few hours it comes to look like " a little old man," with pinched features, sunken cheeks, hollow eyes, the fingers long and bony ; in short, it presents every symption of an extremely rapid abstraction of the fluid constituents of the body. In no way can we be enabled so readily to appreciate the fact that the fluids are so greatly in excess of the solids in the human body, as when we see one of these shriv- eled little mortals, a living skeleton, eagerly demanding fluids, which are almost instantly rejected. In many instances, the change of a few hours is so great that even those constantly in attendance upon the child, fail to recognize a familiar feature. The progress, unless fortunately checked, is now rapidly down- ward ; the dejections soon become almost clear water, and pass away involuntarily ; the child lies motionless, or with atn occasional fretful fling from side to side ; there is the most intense thirst ; fluids are swallowed with eager haste ; there is little or no pain ; great ac<:eleration of the pulse, without force ; the eyes remain half closed, the lips parted ; coma sets in, and death soon closes the scene. One great peculiarity of the stools is their entire want of odor, or the presence of a musty smell, which is very offensive, and the pres- ence of minute flocculi, so as often to give them the appearance of rice-water — hence the name "rice-water discharges"; as a general rule, the. urine is scanty, and often is wanting. In the early stages of the attack, the temperature usually runs high, perhaps as high as in any disease of childhood, 105° — 107°, but reduction of heat rapidly ensues, commencing at the extremities, the abdomen and head being the last parts to yield and become cold. Death usually occurs from exhaustion, and the child dies without an effort, though in some instances the irritation seems to extend to the brain and spine, and convulsions occur, or the child burrows with its head in the pillow, rolls the head from side to side with a CHOLERA INFANTUM. 037 monotonous, distressing motion, apparently unaware of what it is doing, and at intervals uttering short, sharp cries. Even at an early stage it is frequently the case that the child shows its irritability by a peculiar cry, which, once heard, is apt to impress the attentive physician as the herald of some dangerous complication. Epidemics of this disease differ in many ways. In some it seems to assume a very acute form, so that the majority of deaths occur within twenty-four to forty-eight hours. In others it is more chronic though not less fatal, and the case may be prolonged for several days or a week. When the special symptoms abate, the disease be- comes nothing more than a diarrhoea, but attended with great debility. The differential diagnosis between this and similar diseases of chil- dren is made by the peculiarity of the stools — thin, watery, soon be- coming colorless and odorless, or musty, irritability of stomach, great thirst, rapid emaciation, etc. The correct treatment of cholera infantum is of great importance, as thus a large number of cases may be saved which appear at first hopeless. The most prominent symptoms imperatively demanding immedi- ate relief, are the irritable stomach and the exhausting evacuations. To relieve the one and arrest the other, therefore, will be the pri- mary indication. For the first, the persistent vomiting, the exhibi- tion of small doses of calomel, say one-twelfth to one-sixth of a grain, repeated every hour, will almost invariably suffice. It will be best given, placed dry on the tongue and washed down with a sup of milk, or some bland, mucilaginous drink. Frequently, this so speedily relieves that the whole scene is changed, and often the di- arrhoea is equally checked. In this connection, it must be remembered that rest in the recum- bent position is of great value, and this should be strongly impressed upon the attendants, who, by their mistaken though kindly-meant treatment of the child, materially aid in keeping up a condition which is rapidly carrying it to the grave. When the calomel fails, the use of small doses of dilute sulphuric acid will often serve to put an end to the vomiting : 1417. R. Acidi sulpburici dU., gtt. xl Syr. simplicis, f. i j Aq. menthse viridis, f-Sij- ^'• S. — One teaspoonful every half hour or hour. 938 DISEASES OF CHILDREN. To aid our remedies, we may employ some form of warm fomenta- tion to the stomach. Or, by producing a positive redness of the surface of the epigastrium, by means of a mustard plaster, great re- lief is frequently obtained. Other and very useful methods are poultices of hops, spice plasters, and the appHcation of a few leeches to the surface of the epigastrium. Additional medicaments are chloroform, in drop doses frequently repeated, mixed with mucilage of acacia and a little syrup, followed immediately by the application of a small piece of ice in a cloth, so that it may slowly be dissolved ; small doses of camphor dissolved in ether ; or powders of the subnitrate or subcarbonate of bismuth. To arrest the frequency of th? discharges, a very useful remedy is the subnitrate of bismuth, in five to ten grain doses, with the com- pound powder of ipecacuanha : 1418. R. Pulv. ipecac, comp., gr. iv-yj Bismuth! subnitrat., 3 j. M. Ft. in chartulae. No. xij. S. — One every two to four hours, according to circumstances. Where the exhaustion is great, the bismuth may with much ad- vantage be combined with the aromatic spirits of ammonia, which is a most excellent stimulant in all cases of exhaustion in children ; or it may be given separately while the bismuth is continued, with or without the ipecac powder. In employing any narcotic, particularly opium, great watchfulness must be observed as to its results. It is always contra-indicated where the disease is complicated with brain symptoms. Give it in small doses with care, and withdraw it as soon as the evacuations are checked, or if necessary, continue it in greatly reduced doses. For children, the camphorated tincture of opium is preferable to the tincture. The diet must be mainly milk, with lime water, beef tea and muci- laginous fluids. Brandy or whiskey should be added from the outset, and continued in small but frequently repeated doses, until recovery has proceeded so far as to render stimulation unnecessary. To relieve the intense thirst, ice in small pieces may be rubbed over the gums and allowed to dissolve in the mouth, or a teaspoonful of cold water, at short intervals, may be given. The child should never be allowed to suffer for want of it. Frequent sponging with alcohol and water, or tepid water alone, will prove advantageous. This is better than the use of the bath, as CHOLERA INFANTUM. 939 the necessary movement of the patient, is liable to add greatly to the exhaustion, or to induce it. In addition to these measures, there must be the most scrupulous attention to ventilation and cleanliness. Never allow the child to remain in an overcrowded room ; better that it should sleep in the open air, night and day. Perhaps a most fruitful cause of bowel affections in children, and also in adults, is exposure to a draught at night, or rather toward morning, when the temperature is usually at its lowest. In their restless tossing, by reason of the heat, they become completely un- covered, and so lie exposed ; the legs and abdomen are chilled, pro- ducing congestion of the bowels, and a diarrhceal attack ensues. Regarding cholera infantum as usually, if not invariably, the result of congested bowels, good effects have been observed after the em- ployment of a positive counter-irritant to the surface of the abdo- men, and also to the whole length of the spine. The best rubefa- cient is a liniment composed of ammonia, turpentine, and castor-oil : 1419. g. Liq. ammonix, f.Sij 01. terebinthinae, f. § ij OL ricini, f. S iv. M. Fl. linimentum. Rub the abdominal surface and the spine briskly with this, so as to redden the skin, and repeat about every two hours. In many in- stances, immediate good results follow, and the patient rapidly con- valesces. As the case progresses, tonics may be given, to aid the recovery of strength. Quinine is especially the children's tonic, as it is readily tolerated, and rarely fails to prove of value. As a tonic for weak bowels, the solution of nitrate of iron, cannot be excelled. It is best combined with a vegetable bitter. In those cases where the progress is less favorable, where the brain becomes involved, it will be necessary to employ cool or cold appli- cations to the scalp, and this may be best done by the use of the ice cap, ice in a rubber bag or bladder, or pieces of ice in a folded towel. At the same time, hot pediluvia, sinapisms, or rubefacients to the lower extremities, will aid in inviting the blood from the brain. It must not, however, be forgotten that cerebral symptoms may be stimulated by exhaustion, for which the proper treatment will be more positive stimulation and larger doses of quinine and iron in some form. Blisters in very young children are always a remedy of 940 DISEASES OF CHILDREN. doubtful value. Often they do not seem to produce sufficient ad- vantage to compensate for the annoyance they give the Httle sufferer. A blister should never be placed upon the nape of the neck, as we thus inflict upon a child a terrible punishment, compelling it to He almost wholly upon its face, in order to escape the irritation caused by the rubbing and pressure of the blistered surface upon the heated pillow. When deemed absolutely necessary, they may be applied behind the ears, and most easily, by means of the blistering collodion. Where there exists positive evidence of cerebral congestion, a better plan will be the application of two or three leeches to the temples, being careful not to allow the bleeding to continue too long, and thus complicate the case further. After this, the cold applica- tions may be continued as indications present. For great restlessness, and to insure a good sleep, bromide of po- • tassium or sodium, and chloral may be given, without hesitation, and with the expectation of good results. Finally, never despair of a happy issue, as we constantly see ap- parently desperate cases, recover, as if to confound our evil prog- nostications. Persevere judiciously, but earnestly, until death itself prevents further efforts. With convalescence, it must be constantly borne in mind that re- lapse is extremely liable to occur. Therefore, eternal vigilance will be necessary in the diet, ventilation, clothing and exposure. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. After noting the prophylactic treatment, our authors divide the treatment of the attack into three stages, those of evacuation, col- lapse and reaction. If it be found that the child has certainly eaten some unwholesome article of food, and that it has not come away in the discharges, then it is right to give at first a moderate purga- tive, such as castor oil or syrup of rhubarb, with a small dose of laudanum, or two drops of chlorodyne, for a child two or three years of age. If two hours after the use of these drugs, the stools still continue frequent and watery, they resort to chalk mixture, with tincture of krameria and laudanum or paregoric. In the stage of collapse, supportive treatment is called for. Ten or fifteen drops of old and delicate brandy, in a teaspoonful or tablespoonful of ice-water, ought to be given every hour or two hours, at one year of age. Our authors allow ice and cold water, almost without limit, to chil- dren in this condition, and they consider it a most important and CHOLERA INFANTUM. 94 1 much neglected item of the treatment. During the stage of col- lapse, the only available food is thin chicken tea, Liebig's cold ex- tract of beef or weak wine-whey, given in small doses frequently re- peated. It is worse than useless to attempt more than this, as not only is it rejected, but it evidently tends to keep up the nausea and vomiting, and thus retards the natural effort at reaction. It is best to keep the child in bed, but if it clings to its mother's or nurse's lap, its inclination should be gratified. When the tendency to cooling of the body shows itself, (and this is usually first notice-, able in the hands and feet, ears and nose,) it should be kept wrapped in warm, dry, soft flannels or blankets. Flannels heated at the fire, thus supplying dry artificial heat, are of great use here. Botdes or tins filled with hot water, ought to be placed at the feet, under the blanket, A warm, soft, light poultice of Indian meal or flax- seed, with a little mustard incorporated with it, may be placed over the abdomen, or three or four thicknesses of flannel, wrung out of hot water and whiskey, may be laid over the lowest part of the thorax and abdomen, and covered with oiled silk, to retain their heat and prevent the wetting of the clothes. When the case takes a favorable turn, and the reaction stage be- gins, it is usually best to do nothing more than supply food and water with care, and keep the body tranquil and quiet. A very good food is that made of equal parts of milk, cream, lime water and plain water. If the case progresses well, drugs are not needed ; if, however, the fever runs high, we may use small doses of the spirits of nitrous ether. If, as often happens, the urinary secretion remains scanty, water, in such quantities as the stomach takes will- ingly, makes the best diuretic. In the early stage of cholera infan- tum, before collapse has begun, and whilst the child is still reason- ably strong, (and particularly when there is marked febrile heat and dryness of the body,) the use of the warm or hot bath, or of spong- ing with hot water and spirit, are excellent measures. The bath may be used twice or even three times a day, if the child does not resist and scream. The temperature should be 95° to 98°, and the patient may be kept in the water from five to ten minutes. It is an excellent plan to wrap the child, directly upon lifting it from the bath, in a heated muslin sheet, and to apply over this, a blanket and keep it, thus enveloped, on the lap, for half an hour or more, «f it is comfortable and disposed to rest. If it be somewhat weak, whiskey added to the water makes the bath more useful and safe. 942 DISEASES OF CHILDREN. J. LEWIS SMITH, M. D., Professor in Bellevue Hospital Medical College, New York. Prompt measures are required in cholera infantum, as the patient rapidly sinks under the prostrating influence of the frequent watery discharges. Some evacuant is indicated at the outset, if there be any irritating material in the stomach or bowels, causing or keeping up the trouble. Small doses of ipecacuanha (from two to five grains) are often beneficial. When, however, the stomach is irritable and the •alvine discharges fail to carry off the intestinal contents, calomel is the great remedy. As it is slow in its operation, castor oil may be administered after it with benefit, or its operation may be aided by a simple enema. It should not be given to the extent of more than one or two doses. If there be no indigestible substance in the intestines, purgatives are contra-indicated, as they are then hurtful. The continuance of the diarrhoea for several hours, afifords a pretty sure evidence of the removal of any irritating matter which may have been present, and hence no purgative is required. The object of the treatment then should be to diminish the frequency of the evacuations, and improve their character. No time should be lost. Opium in some form, is the chief reliance. If laudanum be used, it may be administered in one-drop doses, every two or three hours, to a child one year old. Its effect should be watched. If the evacuations are partially checked, and there are signs of stupor, stop the opiate, or at least, give it less frequently. Astringents, and often alkalies, may be employed as adjuvants to the opium. The opiates and alkali may be employed in the follow- ing combination : 1420. R. TinctunE opii, gtt. xij Misturae cretse, f. § iss. M. One teaSpoonful every two or three hours to an infant one year old. To this mixture, an astringent may be added, as tincture of catechu or kiqo. It should be borne in mind, however, that astringents are less tolerated by an irritable stomach than is opium or chalk. When they are vomited, therefore, they should be discontinued, even in cases in which they would doubtless be serviceable if the stomach were ;-etentive. By means of the opiate and astringents, if they be retained, in a few hours, the passages are rendered less frequent, and the stools more consistent. CHOLERA INFANTUM. 943 In cases in which calomel is employed, our author does not recom- mend its use in larger doses than one-fourth of a grain, morning and evening, together with the astringent and opiate, to a child of one year. To combat the irritability of the stomach. Dr. S. also advises small pieces of ice in the mouth, and the application of mustard to the epigastrium, at the beginning of the attack. In most cases, Bourbon whiskey or brandy, the best of the alcoholic stimulants, is required. It should be used from an early period of the disease, both for the purpose of sustaining the vital powers and of diminishing the gastric irritability. The diet should be simple, but nutritious, and taken often, but little at a time. If the child be at the breast, it should be confined to the mother's milk. If it be weaned, cold barley or rice-water, with whiskey or brandy, should be given in the commencement of the attack ; afterward, milk or broth may be employed in addition. 142 1. R. Creasoti, gtt- j Liquor calcis, f. § ij. M. One teaspoonful with a teaspoonful of milk, (breast milk if the infant nurses,) re- peated as required, for the vomiting so frequent in the summer epidemics of intes- tinal inflammation. This recipe is much used in the Nursery and Child's Hospital of New York City. Or, the following may be administered : 1422. ]J. Potassii bicarbonatis, gr. xxv Acidi citrici, gr. xvij Aquae amygdalae amarx, f. § j Aquae, f. § ij. M. Teaspoonful, repeated as required. Let it be remembered that while the use of appropriate medicines is imperative, their employment is entirely useless unless supple- mented by proper hygienic surroundings, and care in diet. THOMAS HAY, M. D., PHILADELPHIA. This practitioner has employed the following treatment in cases of • cholera infantum, with the best results : 1423. R. Hydrargyri chloridi mitis, gr- ij . Bismuthi subcarbonatis, gr- ?Xf" Pulveris ipecacuanhse compositae, gr. J-^jj Pulveris saccbari albi, gf- ^j- "^• For eight powders; one to be taken every three hours, for two or three days, or until the tongue and mouth become moist, and the alvine excretion changed m color and consistency. 944 DISEASES OF CHILDREN. Then the following powders are given, and will ordinarily com- plete the cure : 1424. R. Bismuth! subcarbonatis, gr. x^j-xl Pulveris ipecacuanhx compositie, gr. j ij Pulveris aromatic!, gr. viij-xvj • Pulveris saccbari albi, gr. xij. M. For eight powders; one to be taken every three or four hours, in the mother's or cow's milk. Counter-irritation is kept up over the abdomen, with mustard plasters, applied at intervals of three or four hours. The infant is allowed to suck a piece of ice held in its mouth. When stimulants are required, the doctor gives from 15 to 30 drops of port wine. When the infant is artificially fed, he gives it cow's milk and lime- water in the proportion of i fluid-ounce of the latter to 5 fluid- ounces of the former; also, broiled mutton or beef, minced very fine. All farinaceous food is forbidden. The child must be nursed or fed at regular intervals, and not allowed too much at a time. PROF. N. S. DAVIS, M. D., CHICAGO. In threatening cases, this physician recommends : 1425. R. Acidi carbolici crystallisati, gtt. iij GlyceriniE, f. § ss TinctunE opii camphoratEe, f. § j Aquae, f.fss. M. Give 20 drops every half hour, till the vomiting ceases, then every fcur hours. 1426. R. Hydrargyri chloridi mitis, gr. iv Pulveris opii, gr. j Saccbari albi, . gr. xx. M. Make eight powders. ' Give one every eight hours. If the vomiting ceases, but the discharge continues, and the child is fretful and emaciates, then : M. NOTES ON REMEDIES. Acidum Carbolicum has been tried with varying results. It cannot be said to have established a reputation in this disease. Argenti Nitras is recommended after the subsidence of the acute symptoms. Belladonna. Dr. Uhler, of Baltimore, has succeded in severe cases with this drug after opiates and other remedies had been tried in vain. 1427. R. Olei tereblnthime. f.3ij Olei gaultherise. gtt. XX Tincturse opii. f.3ij Pulveris acacise. Saccbari albi. aa 3iv Aquae, f-Siij. From 15 to 30 drops every three or four hours. CHOLERA INFANTUM. 945 Bismuthi Subnitras is valuable to control the evacuations in the later stages of the disease ; and as a preventive of vomiting and nausea in its ear- lier stages. Cerii Oxalas is recommended by a writer in the Concours Medicate 1880 ; he divides four grains into ten powders, one to be given every hour to a child under two years of age. Cocaine. Dr. Hfrr, (Ottawa,) extols this drug in the treatment of cholera infantum. He has used it successfully in cases where the limbs were cold, the eyes sunken, face cyanotic, and the pulse very rapid. He gives one-sixth of a grain every hour or two hours as indicated. Can- adian Pract., 1887. Creasotum is often efficient in relieving the nausea and vomiting. i upri Sulph. is a good remedy, but only the smallest doses are admissible. Hydrargyri Chloridum Mite has been very extensively used. In addition to authorities already given, we may quote Dr. Henry Hartshorne, of Philadelphia, who strongly advocates it, in moderate doses in the early stages. He always gives it with an antacid, as : 1428. R. Hydrargyri cbloridi mitis, gr. ij Sodii bicarbonatis, 9j Pulveris zingiberis, gr. xij. M. Make twelve powders. One three or four times daily. When the diarrhoea is more prominent, he gives the above ; when the stomach or head is more involved,, he replaces the bicarbonate of soda by magnesia. Hydrargyrum cum creta. By many practitioners this is preferred to calomel. Ipecacuanha is a desirable remedy when the stools assume a dysenteric char- acter. Lactopeptine administered at a sufficiently early stage modifies the secretions promptly and favorably, and leaves no after- effects of an unpleasant character. Opium in some form may be given, but with great caution. Potassii Bromidum has been pronounced by some a specific, by others worths less. It is certainly inefficient in many cases j it is especially indicated in cases characterized by nervous irritability and feverishness. Quinia Sulphas, or some similar cinchona alkaloid, is indispensable in cases of a malarial aspect. Rheum is a very valuable adjuvant. Spiced syrup of rhubarb is a popular form. Dr. W. M. Gross, of Illinois, pronounces calcined and pulver- ized rhubarb the " very best " remedy for the disease. ( Ohio Medical Rec0rder,'iamxziy, 1 878.) He gives gr. v. to a child of six months, re- peating as necessary, without other medication. 60 946 DISEASES OF CHILDREN. Tinctura Cantharidis , in doses of gtt. x. at intervals of ten or fifteen minutes to a child of eighteen months, has been uced successfully to combat the stage of collapse, by Dr. C. L. Gregory, of Ohio. (^Cincinnati lan- cet and Observer, July, 1876.) Zinci Oxidum is, in the opinion of Dr. V. S. McNideb, superior to astringents after the acute stage of the disease is past. {Medical and Surgical Reporter, August, 1876.) BROUGHroN, {Therapeutic Gazette, J^av. isth, 1S90,) recommends the following mixture in severe cases of cholera infantum with profuse and watery stools : •429. R. Salicj'late of bismuth, 2 drachms Sulj>ho-carbolate of zinc, 4 gfaius Chalk mixture, I ounce One drachm of this should be given every two hours until the bowels are controlled, after which the following is prescribed : r43°- B- Calomel, l grain Sulpho-carbolate of sodium, 20 grains Saccharated pepsin (P. D. & Co.), 19 grains. Divide in ten powders and give one every three hours. EXTERNAL MEASURES. Baths are of the highest importance. In the algid stage, Steiner strongly urges baths of 99° to 104° F. combined with stimulants internally. Mustard baths of not less than this temperature may be used. As more convenient. Dr. E. W. Emersox, of Boston, recommends wrap- ping the children to the chin in cloths wrung out with hot water and mustard, with a blanket outside, and while thus enveloped feeding them with ice water and a little brandy. (Boston Medical and Surgical Journal, July 27th, 1876.) In early stages, when the temperature is high and thirst great, cool sponging, or even the cool bath, is approved by some. Emplastra. For the relief of the vomiting, a spice poultice or plaster on the epigastrium is often of service. DYStNTERY. A. JACOBI, M. D. Dr. Jacobi says {Arc. Ped., January 1889), the sufferings from dysentery are so intense, and the dangers from its acute or chronic DYSENTERY. 947 State so threatening, that active measures must be taken at once. A brisk purgative ought to precede every other treatment. Castor oil in sufficient quantities, or calomel, (according to age) in doses of from one to eight grains, will have a favorable effect, the latter acting both as a laxative and a disinfectant. The food must be liquid. Milk and strained farinaceous decoctions must be the exclusive diet for the first acute stage. Great sensitiveness of the left hypogastric region, and local heat, will be alleviated by the application of ice. Very young infants however bear ice but a short time, whether ap- plied to head or abdomen. Often quite warm applications, of either water or poultices, prove more efficient in regard to the two indica- tions, which consist in alleviating irritation and reducing temperature. The subnitrate and the subcarbonate of bismuth not only cover and protect the mucous membrane, but have also a decided antifermen- tative effect. Thus bismuth is surely indicated, in irritated conditions of the mucous membranes ; it seldom fails when given in sufficient doses. There is no harm in sometimes giving it in such doses that part of the introduced material will pass through the entire length of the intestinal tract without undergoing decomposition. The daily dose ought not to be less than one drachm or a drachm and a half. If the passages are strongly acid, the additional administration of alkalies is required. On this account, carbonate of lime is preferred. Sometimes, par- ticularly when the stomach can be relied upon, the salicylate of sodium may be added to the internal treatment. Beside the favorable effect of the sodium, in the intestinal tract, the salicylic acid may prove beneficial, both by its antifebrile and disinfectant action. Salol one or two grains, or resorcin one-quarter or one-half of a grain, may take its place. The latter is better tolerated than the former, but salol has a better chance to reach the lower part of the intestine. Opium and its alkaloids are invaluable in the treatment of intestinal ulcers. The objections to their use are decidedly ex- aggerated. Dysentery, both requires and tolerates larger doses of opium than an average diarhcea. In this respect, dysentery stands abreast almost with peritonitis. The main indications are to relieve pain, reduce peristalsis, and diminish the copious serous secretion: no other remedy fulfils all of them so well. Astringents may either be given in combination with opium, or separately. Among those eligible, are tannin, gallic acid, and vegetables containing the same, (rhatany, catechu), besides subacetate of lead, nitrate of silver and 948 DISEASES OF CHILDREN. pernitrate of iron. A dose of tannin, when it is to be taken for a number of days in succession, is from ten to fifteen grains, subacetate of lead five to ten grains, nitrate of silver one-fourth to one-half grain. If possible, all of these medicines are best taken in the form of pills. The temperature will but rarely be so high as to require antipyretic medication. Frequent enemata will often reduce it effectively. Very young infants may demand an occasional dose of antipyrin or ace- tanilid (antifebrine) when the heat threatens either the nervous sys- tem, or the normal structure of the tissues of the body. DR. JOHN M. KEATING, OF PHILADELPHIA. This author (^Medical and Surgical Reporter) would treat an entero- colitis as he would a common coryza, only bearing in mind that the intestinal canal in children is much more important than the nasal organs. He gives alkalies internally, as sodium bicarbonate or am- monium bicarbonate, if the child is very weak, with a sjnall dose of ipecac as a stimulant to the mucous membrane, or bromide of po- tassium or ammonium, and minute doses of paregoric, if there is much paroxysmal pain. In some cases he gives the following: •431- R- Magnesise sulph., gr. iv Vin. ipecac, gtt. xyj Syr. rhei aromat., gtt. xl Spts. ammonix aromat., gtt. xvj Tinct. opii camph., gtt. xvj Syr. lactucarii, f. 5 ij Aq. menth. virid., q. s. adf.§j. M. S. — One teaspoonful every hour to a child aged six months. But should there be much pain or mucus in the stools, the treat- ment will consist of castor oil. When a mother says that her child has frequent, slimy, curd-like passages, and there is pain, straining, and the occasional appearance of blood, he gives : 1432. R. OLricini, f.fiss Glycerinse, £. 5 ij Pijv. acacise, 3iss Aq. cinnamomi, f.§j&f.3ij. M. Ft. emulsio. S. — ^Tablespoonful at a dose. The emulsion should be given every two hours, until the stools begin to change color — probably four doses will be required ; then the child should be placed upon bismuth and acacia in powder until the irritability of the bowel has entirely subsided. DYSENTERY. q.q In convalescence, after a severe protracted attack, hs gives : '433- R- Ferri et quinise citrat., gr. iv Tinct. nucis vomicae, gtt. j Syiupi, Aqua, aa q. s. adf.gj. M. S- — Teaspoonful three times a day for a child six months old. If the bowels have been very loose and the vomiting excessive, he gives: '434- R- Acidi sulphurici aromat., gtt. viij Ext. rhei fluidi, gtt. iv Spt. vini gallici, f.3ij Syr. acacise, Aq. menthse, £5 q. s. ft. f. |j. M. S. — ^Teaspoonful every two hours to a child six months old; give slowly with a little water. Should the passages not be very frequent, but the vomiting be the most important symptom, he gives : '435- R- Hydrarg. chlor. mite, gr. J Ipecac, (pulv.), gr. j Pulv. acaciae, Sacchari lactis, aa gr. ij. M. Ft. chart. No. iv. S. — One every hour, placed dry upon the tongue. This is to be followed by a teaspoonful of castor oil and a drop of essence of peppermint, poured into a tea-cup of hot water and skimmed off the top, the object being to thoroughly subdivide the oil before its administration. The oil may be preceded by quarter- grain doses of hydrarg. cum creta. Should there be marked sup- pression of urine, as soon as the vomiting has been controlled, he gives, at intervals of two or three hours, a tablespoonful or more of toast-water with ten to fifteen drops of sweet spirits of nitre, and, if the child will stand the extra stimulation, it can be made more diuretic by the addition of fifteen to twenty drops of good gin. DR. W. W. PENNELL, OF OHIO. This practitioner does not believe that paregoric is contra-indi- cated in cases where brain symptoms are present. If the case is seen early, or if there is reason to suspect the presence of any irri- tating substance in the bowels, he gives castor oil or glycerine. He uses the latter where there is much acidity of the gastro-intestinal tract, or if thrush is present. 950 DISEASES OF CHILDREN. After cleansing the bowels, he orders : •436- R. Tinct. opii camph., f.Siij Bismutbi subnit., Pepsinse sacch., 55 3l Aqu£E destil., f.^iiss. M. S. — One teaspoonful every' three or four hours to a child one year old. The bottle should be well shaken. RossBACH employs naphthaline in the following manner in this condition : >437' R- Naphthaline, gr. x Boiling water, Siv Decoction of marshmallow, Oj. This is to be used as an injection at a temperature of 100° F. CONSTIPATION. A. JACOBI, M. D. In all forms of constipation, says this distinguished authority, {Arc. Ped., September, 1889), few medicaments ought to be used. As there is so often an excess of acid in the gastric and even intestinal contents, calcined magnesia finds its twofold indication. It may be given in many small doses, or a single large one, which need not exceed five or ten grains a day. Doses of a grain or two grains may be continued for many days, and repeated from three to six times daily. Rhubarb acts well, when combined with it, for the purpose of overcoming protracted costiveness. Rectal injections may be given from the common fountain syringe, the nozzle of which must be introduced beyond the two sphincters. To facilitate the down- ward movement of the faecal masses and to stimulate peristalsis, fric- tion and kneading, (massage,) may be resorted to ; kneading must be performed with the palm of the hand gently and persistently ; fric- tion is best commenced in the right side, and continued over the epigastrium and down the left side in the course of the colon. Elec- tricity has been used successfully when constipation is the result of insufficient peristalsis. As an occasional purgative, for the purpose of relieving the intes- tinal tract of indigestible and injurious masses, castor oil is probably the best and mildest ; a few grains of calomel will act both as a pur- PARASITES OF THE INTESTINES. 951 gative and anti-fermentative. The compound powder of licorice will take the place of oil when the latter is not tolerated, or is objected to ; also the fluid extract of cascara segrada. Among the hydra- gogues, all of which are irritants, rhubarb and aloes are probably the mildest, and are tolerated a long time in successive doses. Of the salines, chloride of sodium is the simplest. Its main action is osmotic ; besides, it occasions thirst, and thereby induces the inges- tion of a large amount of water. The combination of the sulphate of sodium with the sulphate of magnesium and chloride of sodium, has a mild and happy effect. DR. FERRAND, OF PARIS. According to the Paris correspondent of the Archives of Pediatrics, the following prescription is used by Dr. Ferrand : 1432. R. Manna, 12J drachms Calcined magnesia, 1f^^^^ 2} drachms Sublimed sulphur, J Honey, 7} drachms. One or two teaspoonfuls in a cup of hot water. L' Union Medicale, August 5, 1890, speaks very highly of the fol- lowing : 1439- R- Podcphyllin, I grain Alcohol, ij drachm Syrup of raspberry, 3 ounces. Dose, from a teaspoonful to a dessertspoonful every morning, according to the obsti- nacy of the constipation. PARASITES OF THE INTESTINES. DR. A. JACOBI. In speaking of medicines available for dislodging intestinal worms, this author says {Arc. Ped., October, 1889,) they should never be given until the diagnosis has been made positive, because of their being strongly irritant. The tsnia which most frequently affects children, (the medio canellata,) is the most difficult to expel, and the child ought to be in fair general condition before treatment is under- taken. Moderate abstinence for days and a purgative (castor oil) ought to precede the administration of drugs. After the successful termination of the cure, the plainest diet, such as milk, strained 952 DISEASES OF CHILDREN. farinacea and peptones are indicated for days. After a wide experi- ence with both kamala and kousso, the author has had but indiffer- ent results. Extract of felix naas has proved to be his sheet anchor, which is administered in doses of fifteen grains, in an aromatic mix- ture, to a child of three years. A drachm is required by a child of seven or eight years. For the removal of ascaris, the general pre- liminary treatment ought to take place ; at least the bowels should be moved gently. To remove this parasite, santonin works pleasantly and well. The dose should be a sixth, a half, or one grain, accord- ing to the age of the patient, several times a day, followed by a pur- gative of magnesia, calomel or jalap. The oxyuris vermicularis, which is usually found in the neighborhood of the rectum, requires to be treated locally by means of inunctions. For this purpose a solution of corrosive sublimate about one to two or four thousand is recommended. Infusion of quassia has come to be regarded as almost a specific when used in this way. DR. VEILLARD. This authority {Jour, de Med., April 17, 1887), would emphasize the necessity of following any drug administered for the cure of these parasites, by a dose of oil or some purgative. He also strongly advises that the vermifuge shall be administered in some fatty substance, in this way allowing it to reach the intestine without being much changed while passing through the stomach. The following formulae are recommended : 1440. R. Pumpkin seed, cleaned and pounded, iss-§j Honey, | ss. M. and ft. electuarimn. Sig. — Dessertspoonful every half hour. POTION FOR T^NIA (DAVAINE). 1441. K. Tinct. kameelae, 5iss Syr. aurant. cort., § ss Aquae arom., § iv. Sig. — Take at one draught. Should the taenia not be expelled in two hours, take a full dose of castor oil. 1442. B. 01. aether. Blicis mas, gr. xl Tinct. vanillae, gr. xl Syr. terebinth., § ss Mucil. acaciae pulv., gr. xxx Aq. destil., | ss. Sig. — To be taken at one dose with an equal quantity of milk. A dose of castor oil should be taken a few hours later. PARASITES OF THE INTESTINES. 953 For ascarides lumbricoides the following formulae may be used with satisfaction : '443- R- Santonin pulv., gr. xx Sacchari albi, z jj Mucil. tragacanth., gr. ixxx. To be made into tablets containing i of a grain each of santonine. From five to t*enty tablets are to be taken at a dose. 1444. R. Chocolate, §j Santonin, gr, x]y_ To be made into three hundred lozenges. Dose, five to twenty of the lozenges. 1445. R- Calomel, gr. ij Santonin, gr. iss Sugar of milk, gr. xv. To be given in the morning with a small spoonful of honey to children about four years of age. It is useful for both lumbrici and oxyures. The following are recommended for oxyures vermiculares : 1446. R. Sodii chlor., §j Aquae, §yj. To be injected per rectum. 1447. R. Calomel, gr. iv Mucil. sem. lini, § iv. Mix and inject § j, per rectum, morning and evening. DR. SIDNEY MARTIN. This author (^Lyon Medical, February 8, 1891,) in comriienting on the difficulty of freeing children from the oxyuris vermicularis, says that he has had excellent results from the use of small doses of rhubarb. The drug appears to regulate the movement of the intes- tines, and this action has been so pronounced and uniform that it has been unnecessary to use injections at all. He advises the fol- lowing formula : 1448. R. Tr. of rhubarb, 20 drops. Carbonate of magnesia, 3 grains. Tr. of ginger, I drop. Water, 3 drachms. This mixture to be given three or four times a day, according to the effect produced on the intestines. It does not seem to be clear whether the rhubarb acts as a germi- cide, or whether it simply causes the worms to be detached from the intestines and expelled in the stools. 954 DISEASES OF CHILDREN. DR. MIROVITCH. This author says {Mercredi Medical, May 2, 1891,) that naphtha- line is a powerful taeniacide, being superior to other anthelmintics both in the certainty of its action and in the absence of any toxic effect. For children the following formula is employed : 1449. R. Naphthaline, 4J to 7 grains. Castor oil, i ounce. Essence of bergamot, 2 drops. For two days before administering this remedy, the diet should be well salted, acidified and highly spiced. In all cases observed by the author, a single dose was sufficient to bring away the taenia complete, even in cases in which other remedies have failed. DR. M. T. PARKER. Dr. Parker says, {Medical News, July 18, 1891,) that after an extended experience with these parasites among the Chippewa In- dians, in which he found some cases so severe as to cause fatal ter- mination, he of recent years does not use vermifuges, but relies almost entirely on copious rectal injections of chloride of sodium in solution, or of boro-glyceride one to twenty, followed by small rec- tal suppositories of boro-glyceride. A dose of fluid extract of spigelia and senna in the morning, with a moderate dose of castor oil a few hours later, with reasonable at- tention to errors in diet, is all the additional treatment required. MiNERTI {Medecine Modern) employs an injection prepared ac- cording to the following formula : 1450. R. Naphthaline, 15 grains Olive oil, 10 drachms. This can be used every five or six hours, and usually effects a cure in less than a week. Martin {Revue Obstet. et Gynecol., May, 1 890) : Use tepid, as a small rectal injection : 1451- B- Tincture of rhubarb, 30 drops Carbonate of magnesium, 3 grains Tincture of ginger, I drop Water, 4 ounces. This shoidd be repeated two or three times in twenty-four hours. INTUSSUSCEPTION. 955 INTUSSUSCEPTION. A. JACOBI, M. D. This author says {Arc. Ped., October, 1889,) that twenty-five per cent, of all the cases of invagination or intussusception of the bowels occur in the first year of life. (Two-thirds of them between the fourth and fifth month.) Thus a knowledge of the condition, and a means to remedy it, are essential to every person who has many children entrusted to him. The only successful treatment consists of the reposition of the intestine. The use of large stomach sounds for the reduction of the invaginated mass, is condemned. Dr. Jacobi uses, with great success, the following simple plan : The baby is turned on its belly, the hips are raised, the abdomen gently sup- ported by a soft pillow. The mouth and nose having thus the low- est position, must be protected. The baby is then anaesthetized with chloroform, and warm water is poured into the rectum with but little pressure. The injection is frequently intermitted, while the anus is closed with the finger. At the same time the abdomen is gently kneaded from below upwards, and its contents moved about. When reduction has been completed, the baby must be kept absolutely quiet, take opium, now and then a rectal injection of chloral in solu- tion, and wear an abdominal bandage just tight enough to steady the bowels. When the simple measure proposed has not been success- ful after a number of trials, laparotomy should be performed. The successful cases of laparotomy are not very numerous, but suffi- ciently so to justify the operation as the only means that promises a favorable result in irreducible cases. DR. W. R. GILLETTE, OF NEW YORK. This physician states, in the N. Y. Medical Journal, 1882, that he has succeeded in curing three cases of intussusception in infants by the administration of chloroform, injections of warm water, and the application of massage to the mass felt through the abdominal walls. He knows of two other cases where all the usual measures failed and reduction was effected by chloroform and massage. The children, in all these cases, were held, and the injections forced into them against all voluntary and involuntary efforts that they could make. In one case the gut had been invaginated for forty hours, and in another for three days. In one case, the water, after three or 956 DISEASES OF CHILDREN. four bulb-fulls were thrown in, was ejected. This was repeated con- stantly ; it seemed almost immpossible to get the gut to retain any water. Finally, an assistant resorted to massage (the child being under chloroform). Immediately there was a roar of rushing wind and water, and a large amount of water forced in, and was apparently retained. The child was laid down, and warm bottles put around it, to rally it after the ordeal ; the bowels were moved in a short time, and a rapid recovery ensued. DR. A. GEIGER, OF OHIO. This physician reports {Medical and Surgical Reporter, 1881,) a case of intussusception in an adult that was cured by injections of cold water. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. According to these authors, there is no special plan of treatment for intussusception deserving the name of preventive, owing to our ignorance of any symptoms which can be definitely regarded as the precursors of the invagination. The fact, however, that various de- rangements of digestion, such as pain upon going to stool, diarrhoea, or constipation alternating with diarrhoea, have been occasionally noticed to precede the attack, should be an additional motive to urge us to meet these symptoms by the most assiduous attention to the hygiene of the child and to the regulation of its alimentary functions. The curative treatment may be divided into three classes, the medical, mechanical, and surgical treatment. Medical Treatment. — Depletion is strongly contra-indicated by the tender age of the patients, and by the necessity of preserving the vital powers, since elimination, which affords the principal chance of re- covery, does not occur until after the eighth day. In order, how- ever, to relieve the engorgement at the point of constriction, without reducing the strength of the patient, it is advisable to apply a few leeches or cups to the abdomen, preferably to the right iliac region, unless a tumor can be detected, when they should be applied over its seat. During the early stage of the attack, before the symptoms of in- tussusception are very positively developed, they advise the admin- istration of a mild but thorough laxative, such as castor oil, in con- junction with large laxative enemata. If, however, at the end of twenty-four or forty-eight hours, the administration of these reme- INTUSSUSCEPTION. 957 dies, aided by the local depletion, has failed to produce an evacua- tion from the upper bowel, these measures should be abandoned, and recourse be had to means of calming pain and nervous disturb- ance, and to the sustentation of our patient. Among the best rem- edies to accomplish these results are opium, warm anodyne poultices to the abdomen, and warm baths carefully given. These latter are especially serviceable, when the symptoms of nervous disturbance are marked, even amounting, as they occasionally do, to general convulsions. In endeavoring to sustain the child's strength, atten- tion must be paid to the vomiting, which is generally so severe as to prevent any nourishment being retained. The remedies of most service against this are counter-irritants to the epigastrium, opium, hydrocyanic acid, carbonated water, small pieces of ice kept con- stantly in the mouth or swallowed whole. Nutritious enemata may be tried, but they are rarely retained. The mechanical treatment consists in the injection of fluids or air into the bowel in such quantities as to distend it; and in the intro- duction of a large sound, with the view of pushing up the invagi- nated portion of the intestine. The fluid may be introduced by an ordinary syringe, the limbs being held together so as to prevent, as far as possible, any reflux. SiMON recommends hydrostatic pres- sure, as follows : A glass funnel attached to a long india-rubber tube terminating in an olive-shaped plug is used. The plug is inserted in the anus, and the funnel is held on a level with the body, and water is poured in until it is filled. The funnel is then gradually elevated, and more and more water poured in to replace that which is forced by hydrostatic pressure into the bowel. Owing to the gradual and uniform increase in pressure thus brought about, ex- treme distention of the entire colon can thus be produced. To introduce air, we can use a pair of ordinary bellows; the noz- zle being inserted well into the rectum, the inflation being continued until the obstruction yields. The return of the invaginated intestine is sometimes attended by a clearly audible sound, a species of crack, but it never gives any pain and has generally seemed to afford relief. The complete restoration of the calibre of the intestine is proved by the copious feculent stools, which frequently come away soon after the inflation. To obtain the best results, inflation should be em- ployed early in the case, before any considerable amount of adhesive inflammation has taken place between the sheath and the contained intestine. Dr. NiESSEN has recommended the pushing up of the 958 DISEASES OF CHILDREN. invaginated portion by means of an oesophageal sound projected by a sponge. This proceeding, our author considers, would probably be readily accomplished, if the intussusception occurred far down in the large intestine ; but it would appear very difficult to replace, in this way, an invagination as high up as the ileo-caecal valve. The surgical treatment consists in the performance of the opera- tion of gastrotomy, finding the invaginated portion of bowel and reducing it by gentle traction. Our authors have seen that in the majority of cases the invaginated portion of bowel will be found in the neighborhood of the left iliac fossa. The great danger of the operation is, of course, apparent, but should hardly be considered an objection, when we consider the fatal nature of this affection. Our authors thus sum up : After having tried for two or three days the medical and mechanical means recommended, without success, we must forbear and decide whether to trust the case to nature, with the hope of elimination of the invaginated bowel occurring, or to resort to gastrotomy. And in this decision, the circumstances of each case must be taken into account ; for, if the case has not yet progressed so far that adhesive inflammation has certainly taken place, and if we are able to detect the exact seat of constriction by the presence of a tumor, the operation certainly has strong arguments in its favor, and should not be hastily rejected. In those cases which have been trusted to nature, and when elimination has fortunately occurred, we must treat the child, during this crisis, with the utmost care. The diet must be rigidly regulated, and the child kept in absolute repose. Nor must we relax these precautions for several weeks, and allow either indigestible food, or too large a meal of even the most digest- ible articles, since death has been several times known to follow this imprudence, from a rupture of the imperfectly-formed cicatrix. PROLAPSUS ANI. DR. EDWARD HENOCH, OF BERLIN. Prolapsus ani is most common during the first year, though cases are quite often met with from two to six years. It is always pro- tracted, and may last for months or years. Temporary improve- ment and unexpected relapses are not infrequent. As a rule, re- PROLAPSUS ANI. gjg position and the use of the tampon are merely palliative measures, which do not prevent the return of the prolapse. In replacing the prolapse (performed best in the knee and elbow position) the cen- tral portion, which was last protruded, should be pushed back first, two fingers of the right hand, which is covered with an oiled piece of linen, being placed in the central opening of the prolapse and gently pushed upward. If the children struggle violently, it may be necessary to use chloroform, and then introduce a tampon to prevent the immediate recurrence of the prolapse. Our author has had the best results from the subcutaneous injection of ergotin in the peri- neum and in the immediate neighborhood of the anus. In children, one and one-half to three years old, he injects daily ^ of a grain of ergotin at once, and distinct improvement is usually observed in a week. We may introduce, daily, ice into the rectum, or use enemata of tannin, alum or other astringents. When all these methods fail, surgical treatment alone remains, either excition of some folds of skin around the anus (Dupuytren) or punctate cauterization with a fine actual cautery in the immediate vicinity of the anus, the action of which is intended to penetrate to the external sphincter. In every method of treatment, we should see to it that the children dis- continue violent straining. The prolapsus occasionally remains ab- sent, if the faeces are passed while lying in bed, as the abdominal pressure acts much less vigorously ; and he therefore advises that the children be not allowed to sit on the chamber in the usual manner, with the feet braced against the floor, but that the vessel be placed on a firm chair or table, and the children be held firmly upon it, with the feet hanging loosely. If the patient is constipated, the passages should be softened by purgatives. ARCHIVE DE PHARMACIE. In this journal (1882), a physician reports most satisfactory re- sults from the use of suppositories, containing from two to three grains of ergotin. He remarks that the effects of this remedy were almost miraculous ; after the application of a few suppositories, the ailment was cured. NOTES ON REMEDIES. Opium. Two minims of laudanum in water three dmes a day, with an astringent lotion locally, has been used with some success by Mr. Scott Battams {Med. Times and Gazette, 1882). 960 DISEASES OF CHILDREN. PERITYPHLITIS. A. JACOBI, M. D. This great authority on children's diseases {Arch. Ped., October, 1889,) considers absolute rest necessary for the successful treatment of this grave disease. The patient must use the bed-pan and urinal, and must not be permitted under any circumstances to change his position without being aided. No purgatives must be given except a dose of oil in those rare cases where no evacuation has taken place for some time, and the accumulation in the colon of large quantities of faeces is considered probable. In these cases, however, a large enema of soap and water will nearly always fulfil all the indications. " Thus I am not prepared to advise, with a few modern authors, the universal treatment of perityphlitis (and peritonitis in general) with the sulphate of magnesium, or a large dose of calomel." The injeC' tion, however, first of a few ounces of olive oil, and afterwards of large quantities of soap and water, through a fountain syringe, is in- dicated after a week or ten days. Opium must be given freely by the mouth, rectum or subcutaneously, in full doses. In almost every case, ice applications must be made for days to the right hypochon- drium. The food must be liquid, and given in small quantities at a time. The patient must remain in a recumbent posture for weeks after apparent recovery, and must be kept quiet even then, for an abscess may be capsulated, and perforation may occur. When the diagnosis is undoubted and the presence of pus can be safely inferred, there is no objection to an aseptic puncture, which may be repeated a number of times for the purpose of ascertaining whether such be the case. Sometimes there is but a small quantity of pus, which may not be easy to discover, but requires an operation. There is a great diversity of opinion, even among the best authorities, in regard to the indications and time for performing the latter. Some recom- mend and practice the operation as soon as perforation of the vermi- form process has taken place. Some favor procrastination until the beginning of the second week. In a number of instances, the time for the operation depends on the condition of the patient ; immedi- ately after the perforation of the gut, collapse is sometimes so great as to render the operation inadvisable. In these cases, ice, opium and stimulants are required to bridge over the imminent danger PERITONITIS. 961 until the operation can be safely performed. " I have seen such cases," he says, " in which it was considered positively fatal at first, but which proved successful a week afterwards." Not every case terminates in suppuration. In some there is a great deal of inflam- matory exudation. In these the protracted use of iodide of potas- sium or sodium internally and ointments of these same drugs (the base of which is lanolin) externally, with the addition of occasional vesication, will do good service. For a long time after recovery, purgatives must not be given, but as a matter of precaution, warm enemata must be administered daily. PERITONITIS. DR. OSCAR SILBERMANN, OF GERMANY. In Jhrbch.f. Kindhlkde, 1882, this author says that peritonitis in infancy is not marked by the clear and characteristic symptoms which it presents in adult life. Of 1 86 cases in the first year of life, 102 were in the first two weeks and 62 in the next two. There are two varieties: i. A non-septic (chronic) form, and 2. A septic (acute) form. The non-septic form develops usually early in fcetal life, and its most important cause is undoubtedly syphilis. The children are either born dead, and often partially macerated, or they die shortly after birth with symptoms of marasmus. In the latter case the strik- ing appearances are the aged face and drawn and decrepit appear- ance, the distended abdomen, more or less ascites, spleen and liver enlarged, respiration rapid and pulse small, extremities cool, cya- nosis. It is, however, not always limited to these symptoms, but often by involving the intestines and their coverings, leads to atresia ani, and sometimes stenosis or complete atresia of the small intes- tines. The author reports an interesting case of this latter kind. In considering the septic or acute form, the author makes a fur- ther subdivision into two classes, both of which usually depend on infection through the navel. The first is general septicemia, of which the peritonitis is only one symptom. The other is peritonitis appearing as the single and only effect of septic infection, and char- acterized by clear features. In the midst of apparent health the 61 962 DISEASES OF CHILDREN. children become restless, cry, refuse the breast, begin to fall away, and the pulse and respiration rapidly increase. The prodromal ap- pearances may, however, be wanting, and then we have at once vomiting, sharp diarrhoea, meteorismus, tenderness of the abdomen, frequent respiration, very rapid pulse, and intense icterus. After a few days, or even hours, the extremities become cold, the pulse small and imperceptible, and the child dies in collapse. .In some cases the symptoms are less stormy, and pass over in a few days (Quinquaud's " abortive form"). With such clear symptoms, with septic disease of the mother or septic appearance of the navel, it would seem that there could scarcely be any difficulty of diagnosis ; the author, however, takes up the separate symptoms, and shows that hardly one of them is constant. The vomiting may be absent, there may be constipation instead of diarrhoea, meteorismus occa- sionally is wanting ; exudation is always present, but it is sometimes so slight that especially if there is meteorismus it cannot be detected ; tenderness of the abdomen occurs in other diseases also, pulse, tem- perature, and respiration may offer the same variations from other causes, etc., etc. The rapid loss of weight is one of the most un- failing symptoms. The only other disease which causes this so rap- idly, is a severe dyspepsia, with which in fact a peritonitis is most likely to be confounded, especially if it occur late, after the umbilical wound is closed. The treatment of septic peritonitis, is first of all prophylactic. The umbilical wound must be kept perfectly clean, and the child removed from the mother if she shows any signs of septic trouble. For the high fever, quinine and Priessnitz' compresses — never salicylic acid, which may cause severe collapse. For the vomiting, chloral hydrate. 1452- R. Chloralis, gr. xv-xxx AquiC, f. I iij. M. S. — Teaspoonful hourly. To keep up the strength, stimulants are necessary, and the author especially recommends green tea, and rum-water, which is often well borne when every other drink, and especially wine, is constantly vomited. Opium and cold are contraindicated, as causing collapse. The prognosis is bad, but this must not deter us from using every means at hand. PERICARDITIS. 963 PERICARDITIS. KEATING AST) EDWARDS. In speaking of pericarditis, the above authors (Arc. Ped., May, 1877,) caution us to remember that the disease is apt to be intercur- rent. Should it occur with rheumatism, the treatment of this affec- tion must be pushed actively. Locally we may apply heat and moisture by poulticing, or the praecordia may first be painted with iodine and then the poultice appUed. Some writers advise the application of an ice bag to the region under consideration. Gendrin is of the opinion that it immediately diminishes the local pain and calms the tumultuous pulsations of the heart and the extreme anxiety of the patient; as a rule also, its re- frigerant action diminishes the fever. The authors are of the opinion that it should be used only in very robust children, and even then with great caution. They also think that mercurialization.is never allowable, and that venesection is only occasionally admissible. The application of a large blister to the praecordia is often accompanied by happy results. It is usually the safer plan to restrict this treat- ment to children over ten years of age. Much nourishment is re- quired, together with alcoholic stimulants. Should marked depres- sion arise, brandy and digitalis may be administered. The patient must be at absolute rest. The depression of vital energies may be further combatted with quinine, musk, champagne, carbonate of ammonia, hypodermic in- jections of brandy, ether, or camphor ; wine-whey also should be included in the dietary. If an effusion forms, and is not readily absorbed, we may make applications of flying blisters or strong iodine, with iodide of potassium internally. We must also endeavor to raise the general health by the administration of mist, ferri et ammonisE acetatis (Basham's mixture). As a diuretic, the acetate and citrate of potassium are preferred. In rare instances, in prac- tice among children, paracentesis will be demanded. In performing this operation, it is best to use an aspirator with a vacuum jar. The two points of puncture preferred by the authors are, first, the left costoxiphoid angle, and the position in which the apex beat is felt normally before being displaced by the effusion. In operating in the first site, introduce the needle as close to the ensiform cartilage as possible, and push gently upward towards the heart, in this way 964 DISEASES OF CHILDREN. avoiding the mammary artery. As the quantity of liquid begins to diminish, gradually withdraw the needle, so as not to wound the heart muscle. It is never well to draw ofif large pericardial effu- sions rapidly. It is perhaps better to use a capillary tube, in this way lessening the danger of cardiac arrest. ENDOCARDITIS. DRS. KEATING AND EDWARDS. These gentlemen (Arc. Ped., May, 1887,) agree in saying that cases of endocarditis should be placed at perfect rest ; all excitement of whatever kind is contra-indicated. There should be but little bright light admitted to the child's roOm, and conversation should be limited around the bedside. Cool acidulated drinks, as lemonade sweetened with glycerine, or neutral mixture, will be gratifying to the patient and will assist in reducing temperature. Locally, the praecordia may be irritated by iodine in the following combination : 1453. R. Tr.iodi, 3iij Spts. chloTofonni, 5j Tr. aconit. rad., gtt. xxv. M. Apply with a brush twice daily. This mixture will not cause pain by its application, and will not be likely to strip off the epidermis early in the case. In older children, a blister may be applied as large as the praecordial surface. In the rheumatic cases, much benefit may be derived from salicylate of soda, lithia or quinine. The salicylates 'may be pushed if they ap- 4)ear to act favorably upon the rheumatism, and if the cardiac action is not irregular, agitated or intermittent, and if the pulse is regular and not too frequent. Digitalis may be exhibited in the form of the tincture, in six to eight drop doses, three times a day, for a child of five years, the dose being gradually decreased or increased as the case may require. In many cases they much prefer the infusion of digitalis, in drachm doses, flavored with cardamon seed. Veratrum and aconite are to be administered only with the extremest care. Opium, if given at all, must be given in small doses, and carefully watched, especially should there be any tendency to cyanosis. Bromide of potassium has been found of service in quieting the pa- tient and allowing the heart an opportunity to establish its equilib- ANAEMIA. C)65 rium. They consider that under no circumstances would it be justi- fiable to administer chloral. Upon the whole, the most benefit will probably be derived from an early supersaturation of the blood by the use of alkalies. The ordinary fever mixture of spts. etheris nit. and liq. ammoniac acetatis, is alkaline and sedative. During conva- lescence, great care is to be exercised, and diet and hygiene care- fully attended to. ANEMIA. DR. EDWARD HENOCH, OF BERLIN. According to this author, iron can have very little permanent ben- efit, because the most frequent cause of the afifection is the constant presence of the anaemic children in the poisoned air of large cities, especially in over-crowded school-rooms, where they are subjected to mental over-work. Hence the beneficial effects of the iron are constantly antagonized by the bad hygienic surroundings. When circumstances permit, it is best to remove the children altogether from the city, and to have them educated in country schools, as very little is accomplished, as a rule, by a vacation of several weeks at the sea-shore or in the mountains. He regards a stay at the sea- shore as a doubtful experiment. While it has a decidedly favorable influence in a certain number of cases, it is entirely useless or acts unfavorably, in many others, especially if the timid children are forced to bathe, and he therefore always prefers a sunny mountain- ous district. In a series of cases which obstinately resisted the use of iron, he found very good results from the use of Fowler's solution of arsenic. DR. ARMAND SEMPLE, OF LONDON, Considers that the treatment depends greatly upon the state of the patient and upon the cause. The most important drug is iron in some form. The ammonio-citrate of iron is perhaps the best prep- aration, since it seldom disagrees ; it may be combined with syrup and water. The tincture of the chloride of iron, with glycerine, is especially indicated when there is a hxmic murmur. Among other remedies he mentions the syrup of the hypophosphite of iron, the syrup of the phosphate of iron, the compound syrup of the phos- 966 DISEASES OF CHILDREN. phates, (Parrish's Chemical Food), the syrup of the iodide of iron, and steel wine. The lozenges of reduced iron are often very useful. The constipating effect of the iron may be counteracted by combin- ing with it a few grains of sulphate of magnesia. Belladonna, in doses of 2 to 5 minims of the tincture, is sometimes advantageously combined with the iron salts, especially when the heart's action is rapid. J. MILNER FOTHERGILL, M. D., LONDON. The general treatment of anaemia in children is by troft. But there are conditions, both where a syphilitic taint exists and where symptoms of it are not discoverable, where iron by itself fails ; but if combined with minute doses of mercurials, it acts promptly and beneficially. DR. BOSSU, PARIS. '454- K- ferri redacti, , 3ss Pulveris canellae, Pulveris gentianse, Magnesiae, ia gr. xt, M. Divide into twenty powders; one, morning and evening, for children, in cases of atony of the digestive tube. NOTES ON REMEDIES. Calcii Phosphas is strongly recommended by Dr. Ringer, in the anaemia of young, rapidly-growing persons, in the dose of i or 2 grains, several times a day. Ferri et Ammonii Citras is usefiil, especially in irritable states of the stomach, when it may be given with infusion of caJumba. Oleum Morrhua. Dr. Ellis remarks that the secret of giving cod-liver oil successfully, is not to give too much, and to give it at the right time. Two or three drops for a young infant, J^ a teaspoonful for a child of six or seven, is sufficient. The proper time is soon after meals and on going to bed. Phosphorus. Dr. Elus says that perhaps the very best remedy for anaemia in children, is this drug. He combines it with nux vomica and iron : 1455- R- Phosphori, gr. ^1^ Ferri redacti, gr. j—ij Extract! nucis vomica, gr. X. M. For a pill. Twice daily. Or with quinine : 1456. R. Phosphori, gr. 1 Quinise sulphatis, gr. j. j^. For one pill, thrice daily, for a child of eight or ten years. PERNICIOUS AN.EMIA — CHLOROSIS. 967 PERNICIOUS ANEMIA. KEATING AND EDWARDS. {Arc. Ped., December, 1887.) Arsenic is undoubtedly our main reliance in combatting this almost hopeless malady. Full and in- creasing doses of Fowler's solution may be administered with occa- sionally a favorable result. Iron is of secondary importance ; in this disease it has seemingly lost its almost specific powers, which are so well shown in cases of secondary anaemia or in chlorosis. Transfu- sion of blood or milk may be tried. Inhalation of oxygen has been recommended, but medicinal or therapeutic measures should be as- sisted to their utmost by careful hygieneic and dietetic regulations. CHLOROSIS. Eloy gives the following summary of the best treatment for this condition. The treatment should be chiefly hygienic, and associated with arsenic and iron. The hygienic treatment consists in the use of out-door exercise and baths, though he does not approve of the sojourn by the sea, but prefers residence in the mountains. Gym- nastic exercise, and those movements which tend to increase the respiratory capacity and develop the muscles of the thorax, are par- ticularly indicated. The diet should be carefully arranged ; only foods which are easy of digestion should be given. The medicinal treatment consists in the administration of small doses of quinine and the following pre- scription, particularly if constipation is constantly present : '457- R- Phosphate of soda, i J drachms Phosphate of potassium, \ drachm Red wine, 6 ounces Syrup of bitter orange, i ounce. A teaspoonful to a dessertspoonful after each meaL If the child is old enough to take bitter substances it may use the following : 1458. R. Tincture of cascarilla, 1 Tincture of gentian, |- of each i J drachms. Tincture of rhubarb, ) To be used the same as in the case of the former prescription. 968 DISEASES OF CHILDREN. For the improvement of digestion the following may be employed : •459- R- Dilute hydrochloric acid, 15 drops Syrup of bitter orange peel, i ounce Tincture of bitter orange peel, i drachm Infusion of cascarilla, 2 J ounces. A teaspoonful after each meal. In the use of the iron salts, he prefers the lactate of iron in small doses, being careful not to produce constipation. Arsenic, when administered, should be given in small doses, carefully watching it, that it does not produce irritation of the kidneys or gastro-intestinal tract. HEMOPHILIA (HEMORRHAGIC DIATHESIS\ A. JACOBI, M. D. This eminent physician (ArcA. Fed., November, 1888,) believes that the treatment of this grave affection is to a great extent pre- ventive. He thinks that a depraved social condition of a large pro- portion of our inhabitants is to answer for the majority of cases. Zymotic disorders and eruptive fevers must be treated with the view of sustaining the strength of the system and the vigor of the circula- tion. The heart's action must be constantly watched, and cardiac tonics given before heart failure sets in. The dietetic treatment of this disease is at least as important as the medical management. Medicines can accomplish a great deal, but ergot less than it is often credited with. It must be remembered that this drug frequently plays havoc with digestion. Iron also is not to be relied upon ; among its preparations the tincture of the chloride is probably the best. Digitalis has a favorable effect on the heart's action ; an in- fant of one year, may take the equivalent of from one to four grains daily for some days, and two grains daily afterwards. With it, may be combined strychnia, about a fiftieth of a grain daily. For the invigoration of the blood vessels, which is the main object, from one to three drops of Fowler's solution may be given every day for a long time. This drug should be largely diluted with water before being administered. Better still is phosphorus, in very small doses. The author says that he is much dissatisfied with the use of lead and tannin. Local hemorrhages must be treated by applications of ice and compression. Dr. Jacobi emphasizes the point that the suc- cessful preventive treatment, is largely a social question. CHOREA. gQg CHOREA. DR. SHEADLE. Although some writers insist that arsenic has no bearing upon the course of chorea, the author {Jahrb. f. K., xxviii, 2) found that in a large number of cases in which this disease had lasted from thirty to fifty-two weeks before treatment was begun, only one of them continued uncured at the expiration of twelve weeks after the arsenic treatment was instituted. The average duration of treatment was only thirty days. In sixty-two cases, which were treated by various methods, the average duration of treatment was thirty-six days, while in one hundred and five others in which the treatment was ex- clusively arsenic, the average duration was only twenty-six days. The arsenic treatment consisted in giving from three to five drops of Fowler's solution in water or wine two to three times daily, and gradually increasing the quantity until ten or twelve drops were taken at a dose. If symptoms of poisoning appeared, the drug was suspended for two or three days, calomel being given in purgative doses, and the arsenic resumed in small quantities as soon as the symptoms would warrant it. The constipation and indigestion which are so common in chorea, were treated with calomel in pur- gative doses, with or without jalap. The arsenic may be used alone, or if necessary, it may be combined with iron, opium, chloral, etc. M. Jules Simon, in Le Bulletin Medicale, 1889, recommends anti- pyrin in the treatment of chorea. He begins the first day with a dose of about seven grains, and progressively augments the amount by seven grains each day until from forty to sixty grains are given in twenty-four hours, if the child be as old as twelve or fifteen years. He states that it is exceptional for the remedy not to be well borne. If taken with food or drink, it is claimed that the remedy will not disorder the stomach. DR. EDWARD HENOCH, OF BERLIN. Arsenic holds the first place in the estimation of this distinguished authority, but even this drug does not show any constant effects. He orders : 1460. K. Liq. potassii are., Jlf? Aquae destil., '-oy- ^' S. — Ten to fifteen drops three times a day, one hour after meals. 970 DISEASES OF CHILDREN. Given in this way, it rarely produces nausea or diarrhcea. If the stomach will not tolerate the remedy, he would give it by hypo- dermic injection. In very severe cases, the addition of a small quan- tity of opium seems to increase the efficacy of -the above formula. If violent movements continue at night on account of insomnia, he gives chloral hydrate. But chloral is only useful in beginning treat- ment, and must give way to arsenic, after quiet and sleep have been secured. If the patients are not anaemic, purgatives have proved beneficial. In the beginning he gives purgatives for a couple of days, and afterwards discontinues the arsenic once a week, for twenty-four hours, giving castor oil or compound infusion of senna instead. Mental exertion should be avoided as much as possible during the continuance of the chorea, and attendance at school should, therefore, be prohibited. In very severe cases, the children must be held in bed, surrounded by pillows, to prevent contusions. Nourishing diet, pure air, cold water friction in the morning, if not distasteful to the children (lukewarm baths, in the other' event), and finally, preparations of iron, are to be strongly recommended as after treatment. 1461. R. Ferri lactici vel reducti, gr. ss-j Sacch. alb., gr. j. M. Give in one powder two or three times a day. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. According to these distinguished authorities on "diseases of chil- dren," the only rules to be laid down for the treatment of chorea are those which apply to all the convulsive affections depending on functional disorder of the nervous system, and on disordered states of the general health, connected with a faulty condition of the func- tions of digestion and assimilation. These are attention to the gen- eral health, and especially a careful regulation of the diet and other hygienic conditions of the patient, the removal of any local derange- ment or disease that may exert an unhealthy influence upon the nervous system, the use of tonics and iron, and the employment of such remedies as have been found to exert a controlling influence upon spasmodic and convulsive affections generally, and upon this disease in particular. When the discharges from the bowels are clay-colored, or dark and offensive, when the mouth is pasty, the tongue loaded with a thick yellowish fur, and the breath heavy, it is proper to employ a CHOREA. 971 mercurial. Of the antispasmodics, our author prefers the root of the cimicifuga or black snake-root, valerian, assafoetida, oxide of zinc, camphor, bromide of potassium, conium and Calabar bean. The cimicifuga is given in powder, tincture, decoction, or fluid ex- tract, and should be continued for several weeks, in gradually in- creasing doses, until some visible effect is produced, as nausea, headache, vertigo, or disordered vision. Our authors prefer the decoction, of which they give to children of eight or nine years old, from four ounces to half a pint a day, made in the proportion of half an ounce of the root to a pint of boiling water. The bromide of potassium has proved serviceable in cases of rheumatic origin, in combination with iodide of potassium and iodide of iron. Of the preparations of valerian, they prefer the fluid extract, of which half a teaspoonful may be given to a child eight or ten years old, three times a day, and the quantity gradually increased. Arsenic has been used with excellent results, in a large proportion of cases. They administer it in the form of Fowler's solution, given in ordinary doses, immediately after eating, and persisted in until some of its constitutional effects are produced. We should care- fully watch for these, and immediately reduce the dose until the signs of irritation have passed away, and then cautiously increase it. The bitter wine of iron may be advantageously combined with the arsenic. In some cases, the hypodermic use of arsenic, in large doses, will prove serviceable. When the symptoms indicate the approach of nervous exhaustion, alcoholic stimuli are to be used. Whenever the disease occurs in anaemic and debilitated individuals, ferruginous tonics are called for, the best of which are the subcarbonate, Vallet's pills, the syrup of the iodide, and the pure metallic iron (ferrum per hydrogen). Qui- nine may be combined with the iron. When there is any reason to suspect a tubercular predisposition, cod-liver oil should be ordered. Cold plunge and shower baths, as well as cold affusions to the nape of the neck and along the spine, may be used if there is full reaction, and the child is willing to submit to them. In violent cases the patient must be confined to bed, and it may be necessary to have padded sides made for it, to prevent him from dashing himself out of bed in his uncontrollable and violent move- ments. 972 DISEASES OF CHILDREN. ANTIPYRINE IN CHOREA. WOLLNER {Munchener Medic. Wochenschr.) prescribes antipyrine, in doses of three grains daily, with uniform beneficial results. The patients were almost immediately able to sleep, and all movement stopped in from ten to twelve days. LEGROUX AND DUPRfe. The result of these authors' experience {Rev. Mens, des Mai. de I'Enf., March, 1887,) is, that antipyrin has been proven to be one of the most rapid, certain and inoffensive agents for the treatment of St. Vitus' dance, whether occurring before or after puberty. Dimi- nution of the abnormal movements will usually begin in four tp six days — that is, after twelve or eighteen grains have been taken. In a few cases there was an eruption which resembled that caused by copaiba. The drug was usually given in doses of five to eight grains, five or six times daily in a suitable medium. CONVULSIONS. DR. SIMON. The author {Gaz. Med. de Paris, March 3, 1888,) says that first of all, attention should be directed to the alimentary canal; an enema with glycerine or any other appropriate agent should be given, then vomiting should be excited by tickling the throat, or by administering a suitable quantity of syrup of ipecac, with powder of ipecac during an interval between the spasms. . If these means are not effective, an enema may be given com- posed of: 1462. R. Sodse sulpb., g ss SenmE fol., 5ii Aquae, f.gviij. If the attack still persists, inhalations of chloroform or of ether should be used, and these inhalations may be continued for an hour if necessary. In the mean time, an enema may be given consisting of: I463- R- Chloralis, gr, xv Tinct. moschi, gtt. xx AqusE, f.|ij. This should be administered in two doses, by means of a glass syringe. CONVULSIONS. 973 If, after this treatment, the attack still continues, a mustard bath should be prepared at the temperature of 38° C, into which the child must be immersed. This will diminish the circulatory troubles which always accompany eclampsia. Should the eclampsia be due to uraemia, the only remedy which will act rapidly and efficiently is bleeding. In children two or three years of age, this may be ac- complished by placing a leech behind each mastoid process ; for older children, five or six wet cups may be used in the region of the kidneys. In addition a hot-air bath may be given. To this treat- ment may be added the use of chloral, bromides, etc., as indicated. DR. EDWARD HENOCH, OF BERLIN. When he finds a child in convulsions, this author considers that there is no time to enter minutely into the cause of the attack, but you must commence treatment at once. If an attack lasts more than five minutes he does not dally with other drugs, but resorts at once to chloroform. A drachm of chloroform poured on a hand- kerchief and held in front of the child's nose, so that a stratum of air supervenes, often proves sufficient. When the convulsions are due to overloading of the stomach or intestines, the treatment indi- cated is, of course, purgatives and emetics— ol. ricini, inf. sennae comp., etc. When the abdomen is markedly distended, it is advis- able to give an anema, (even during the spasm,) of milk and honey (2 to i) or of cool water, in order to empty the bowels. When worms are known to have been present, or when there is good rea- son to suspect their presence, anthelmintics may be given. DR. ARMAND SEMPLE, OF LONDON. According to this author, recovery is the usual termination ; but when death occurs, it is . usually from asphyxia, shock or syncope ; in cases where the convulsions rapidly recur, the prognosis is very grave. As the frequency of recurrence diminishes, so does the danger to life lessen ; but there is a risk of their becoming habitual. He thinks that there appears to be a marked relation between the convulsions of early infancy and the development of epilepsy in subsequent childhood. He considers that the chief point in the treatment, is to ascertain the cause. The child should be placed at once in a warm bath, cold water being simultaneously poured over the head and face. For great distortion of the body during the fit, he uses chloroform ; though there is no necessity to produce deep 974 DISEASES OF CHILDREN. ansesthesia. If dentition is the cause, and the gums are tense, they should be freely lanced. If irritation of the bowels is present, they should be cleared by appropriate remedies. Worms should always be suspected, and remedies suitable for their removal should be given. If the child cannot swallow, an enema may be given in the intervals of the convulsions; to ward off the attacks, he regards the bromides of potassium and ammonium as useful. If there is sleep- lessness, a few grains of hydrate of chloral often do good. When the convulsions have ceased, the proper remedies are cod-liver oil and iron preparations, such as vinum ferri and syrupus ferri hypo- phosphitis. DR. C. POLLOCK, OF INDIANA. This author relates in the Medical and Surgical Reporter, 1883, the case of a healthy baby aged five months, in whom very severe con- vulsions were caused by a narrow prepuce which enclosed a large amount of smegma, which had irritated the glans penis and caused the convulsions by reflex action. This is a cause that is often over- looked by both physicians and parents, and yet it is a not infrequent cause of infantile convulsions that are overlooked or attributed to some other cause. Dr. Pollock slit up the prepuce and removed the smegma, and as soon as the cut surfaces healed, the convulsions ceased. PROFESSOR DUJARDIN-BEAUMETZ, OF PARIS, Thus conc^ludes a lecture in the N. V. Medical Journal, 1 883 : In eclamptic convulsions, or in those which have for their point of de- parture, reflex action, the best mode of treatment consists in the internal ad.ministration of bromide of potassium, or chloral, or in inhalations of chloroform or ether. All medicaments which anae- miate the brain seem to do good in these cases ; it is from this con- sideration that Trousseau proposed compression of the carotids. He warns us to be chary in the use of revulsives — such as sinapisms and blisters — in these cases ; for severe cutaneous gangrenes, more difficult to cure than the convulsions themselves, have more than once been produced by the prolonged action of even a mustard cataplasm, and this in consequence of the insensibility which results from the fit. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. There are some general rules to be followed in the treatment of CONVULSIONS. 975 convulsions, which apply to all cases. They are : to place the child in a large well-ventilated room, if such can be procured ; if it has been seized in a little close room, where the atmosphere is dense and impure, removal to another room, or exposure to fresh air be- fore an open window, has sometimes sufficed to terminate the crisis. At the same time, the clothes should be loosened, in order to pre- vent all constriction, and, if necessary, taken off, to allow of a care- ful examination of the whole body. It is always a good rule, no matter what the cause of the convulsion, to place the child in a warm bath (96° or 97° Fah.). If the convulsion occur in a strong and vigorous subject; if it be violent and be accompanied by a deep red or livid flush of the face, and distension of the veins of the head and neck ; if it lasts more than a few minutes or is re- peated, after intervals of rest, blood-letting is to be resorted to. When the convulsion is prolonged or a tendency to its recurrence is manifest, our authors believe that the use of an emetic is very desir- able, even though no gastric irritation exists, and for this purpose they prefer ipecacuanha. Cold applications to the head are useful when the convulsion is of any considerable violence, but they would be improper when the surface is pale, the features contracted, and the pulse small and feeble. If the child has been constipated prior to the attack, a purgative should be given ; and, in healthy children, calomel is the best ; the dose being from two to four grains, accord- ing to age. It should be followed in one or two hours by a dose of castor oil or rhubarb. In most cases purgative enemata will prove of service. They may consist of water, holding in solution castile soap, common salt, molasses, castor oil, sweet oil, or spirit of tur- pentine. If the first fails to operate in ten or fifteen minutes, an- other or even a third ought to be given. Mustard sinapisms, (shifted from place to place,) are very efficacious. They should always be covered with gauze or fine muslin, to avoid the danger of leaving any of the mustard upon the skin when they are taken off, for our authors once saw very bad ulcerations upon the feet of a child from neglect of this precaution. Antispasmodics, especially the bromides of potassium and sodium, may be used as a means of prevention in children threatened with convulsions. When there are no evidences of determination of blood to the brain, or when it has been removed by blood-letting and revulsives, opium proves useful in allaying irritability and restlessness. Somnolence and coma contra-indicate the use of opium. Our authors prefer sttl- 976 DISEASES OF CHILDREN. phuric ether to chloroform, for the production and maintenance of anaesthesia in convulsions. PROFESSOR JOHANN STEINER, M. D., PRAGUE. It is not always easy to detect the cause of infantile convulsions. In such cases, the causal treatment must give place to the sympto- matic. Of the various remedies, our author prefers in such instan- ces, the following combination : 1464. R. Zinci oxidi, gr. iv Hydrargyri chloridi mitis, gr. ij Saccbari albi, 3}- ^• Make eight powders ; give one every hour. Remove all constricting clothing, apply mustard poultices to the trunk and extremities, and use clysters of cold water. The warm bath is often serviceable. Convulsions from malarial toxaemia demand quinine; from worms, anthelmintics ; from phimosis or elongated uvula, excision, etc. NOTES ON REMEDIES. Amyl Nitrite, Dr. Bridger {Lancet, 1882) says that he has obtained good results from the use of nitrite of amyl in the following cases : i. Con- vulsions resulting from an abscess in the tympanum. 2. From tuber- cular meningitis. 3. From dentition. One-third of a minim in mu- cilage was applied to a child's nostrils every three hours. AncBsthetics. Either chloroform or ether, by inhalation, is effective in emer- gencies. Belladonna is valuable in the constitutional treatment. Chloral. Dr. Jacobi, New York city, recommends the following : 1465. R. Chloralis, gr. iv Potassii brom., gr. viij Aquse, Syrupj, aa f.3j. M. Sig. — Take at one dose. Chloral, in doses of gr. v-x, every six hours, to a child of ten, frequently an- swers the purpose. Dr. Poiaiixon has administered it with success to children as an enema (three grains in five drachms of water.) Calm sleep and a cessation of the convulsions follow, and a similar enema given twenty-four hours later completes the cure. Moschus. When musk can be obtained fresh and pure, it is an admirable HYSTERIA. Q77 anti-convulsive agent in children. When the child will not swallow. Dr. Jules Simon recommends it in the following enema : 1466. R. Moschi, gj_ ijj Camphoroe, ~ ^y Chloral bydratis, „' vii Vitelli ovi, f ' •" Aquae, |v. M. For an enema; to be preceded by an ordinary one, to wash out the rectum. Opium, in some form, is preferred by many practitioners. It may be admin- istered hypodermically, or by enema, every twenty minutes, until the pupils contract. Potassii Bromidum, gr. x-gj, is usually a reliable means in idiopathic convul- sive disorders. Dr. Blanchez {Gazette Medicale, 1875,) recommends a mixed treatment, the bromide being given during the day and the chloral at night. Zinci Oxidum, especially when combined with tonics, aids much in restoring the nervous equilibrium. EXTERNAL REMEDIES. Warm Baths, in infants, often act as potent sedatives. Cold to the head, as compresses wrung out with ice water or dilute ether, is valuable". Trousseau commends pressure on the carotid arteries. (See page.) Of course all reflex irritation should be sought for in the first instance, and removed. HYSTERIA. PROFESSOR F. FORCHHEIMER, OF OHIO. Accfording to this author, {Archives of Pediatrics, 1884,) hysteria in children has received altogether too little attention. From his experience, he believes, that in nearly all cases of severe hysteria, the inception took place during childhood, and that fully one-half of all cases show nervous symptoms long before puberty. The heredity factor plays a very important fole in the production of this disease ; therefore, with children of neurophathic parents, we should aim to develop their bodies as much as possible, even, if need be, to the neglect of their minds. For this purpose, gymnastics of all sorts are advisable ; riding, swimming, if the child be old enough ; in younger children, massage, beating and rubbing of the muscles, and cold sponge-baths, are very eflfectual. The child must be allowed to go 62 978 DISEASES OF CHILDREN. out of doors ; if unwilling, it must be compelled to do so with its attendant. If possible, the child should be removed from the influ- ence of its nervous parent. If necessary to send such a child to school, the ideal school will be one in which there are a great many pupils, but the hours very short, so that a great deal of time will be spent out of doors. He especially cautions against the study of music, since there are very few who are able to pass through a thor- ough course in this branch without suffering more or less from hysteroid troubles. These children seem to have weak stomachs ; their digestion is easily affected by articles of food that seem to have no evil effect upon their companions. Their appetite is capri- cious. The diet, therefore, should be a light one ; albuminous food, easily digested, starchy material, young vegetables and fruit, cooked, or, if raw, quite ripe. Medicine is of little benefit. It sometimes becomes necessary to give iron, and great care should be taken to select a preparation that will not disorder the stomach. The prep- arations of valerian have a palliative effect. Electricity may be used with temporary advantage. In obstinate cases that resist the meas- ures already suggested, we must resort to the treatment recom- mended by Dr. S. Weir MITCHELL. The plan of treatment, in detail, is as follows : The patient must be confined to the care of a nurse, i. e., must be removed from rela- tives or parents. This is imperative. If circumstances do not permit of the removal of the patient to another building, he confines the child with its nurse to a room, forbidding visits of any sort. This part of the treatment is probably the most difficult to carry out; and if it is at all possible, the patient ought to be taken from the house of its parents. The next step in the treatment, is to put the child to bed, where it remains until one week has elapsed from the time of disappearance of all symptoms. It is impossible, in any individual case, to predict how long it will be necessary to confine the patient in bed ; upon the whole, the time is shorter in children than in adults. He always, during the first period of the treatment, insists upon a strict observance of the following rules : The child is to be left to itself as much as possible. Neither playthings nor books arc to be permitted. It is necessary that a certain amount of moral force be allowed to act upon the patient in the beginning of the treatment. After the symptoms of the disease have begun to disappear, the nurse visits the child more frequently, or if necessary remains with it all the time ; the other restrictions are taken away, books and PAYOR NOCTURNUS. 979 playthings are permitted, and the child is allowed to amuse itself. The patient is to have massage of the whole muscular system, ap- plied every day, and this requires a trained nurse or manipulator. A weak interrupted current should always be applied daily. The sit- tings are not to be made too long, and the electricity especially seems to be very grateful to the patient. The diet at first should be milk only, the quantity given varying with the age of the patient. Very much less trouble is experienced in giving to children an ab- solute milk diet than to adults. After the digestive organs are per- fectly restored to their normal condition, other albuminous food can be given, especially boiled and roasted meats. The condition of the bowels must be looked to. Sometimes we find constipation, some- times the opposite, the result of the milk treatment. On account of continued diarrhoea, it even becomes necessary, in some cases, to desist from an absolute milk diet and to order meats from the begin- ning. The object of the diet, is to give to the patient as much digestible food as his digestive apparatus will bear. The quantity is to be regulated by the condition of the individual, and food must be given frequently. It is not always that the patient is ansemic ; some of these patients are occasionally very fat, and with them nothing succeeds so well in reducing fat and making blood a= this method of treatment. The principles of this treatment are so well stated by Dr. S. Weir Mitchell, and so thoroughly carried out by his re- sults, that it is necessary only to refer to his works upon the subject {Fat and Blood, Rest in the Treatment of Disease, and Nervous Dis- eases). PAYOR NOCTURNUS (NIGHT TERRORS). DR. EDWARD HENOCH, OF BERLIN. This author would not hesitate to use morphia or chloral in very severe cases. He differs from WEST, that nocturnal terrors are caused usually by disturbances of digestion. He has rarely, with any cer- tainty, detected dyspeptic symptoms, the removal of which relieved the affection. Hence he confines his treatment to the prohibition of any stimulation of the youthful imagination by the recital of tales at night, and to the administration of a dose of bromide of potassium before retiring. 98o DISEASES OF CHILDREN. PROFESSOR WILLIAM PEPPER, OF PHILADELPHIA. When, as sometimes happens, we find in these cases of " Night Terrors," a history of long continued irritation of the stomach and bowels, an exaggerated sensibility of the nervous system, and a de- fective state of nutrition, this author would give after meals, {Med- ical and Surgical Reporter, 1882,) a teaspoonful of an emulsion of cod-liver oil with the hypophosphites. He would then use one or two sorts of remedies : first, remedies directed to the nervous system — and of these he would select one or two, either the bromides, by the mouth, or quinine and assafcetida, by the rectum. He would use as a suppository, 1467. R. Qoiniae sulphatis, Assafcetida, aa gr.jss. Or if this irritates the bowels, it would have to be omitted, and he would give: 1468. R. Potassii bromidi, Sodii bromidi, aa gr. jss, in a little calisaya elixir three times a day, between meals ; or, in the second place, if he found, under close observation, that digestion was not right, that the stools were broken, irregular in color, and imperfectly digested, and that there was a good deal of flatulent dis- tention of the bowel, he would not give the remedies above men- tioned, unless, perhaps, a little quinine and assafcetida at night, but he would give remedies directed to the mucous membrane of the stomach and bowels. These would be either pepsin and bismuth, or oxide of silver. This is the class of cases, either of spasmodic nervous trouble, or of epilepsy associated with gastro- intestinal irri- tability, where the salts of silver have earned their reputation ; ni- trate of silver is considered by the laity as one of the most reliable remedies in the treatment of epilepsy. Nearly all the cases, if not all, that have been cured by this drug, have been cases in which the attacks have been reflex from irritation of the gastro-intestinal mu- cous membrane. If, on careful examination, there are evidences of a long-continued subacute irritation of the stomach and bowels, he should give from one-twelfth to one-eighth of a grain of oxide of silver in a small pill, or else one twenty-fourth grain of nitrate of silver in solution. With this he should give the cod-liver oil, regu- late the diet, keep the patient where he would not be frightened by PAYOR NOCTURNUS. 981 the cars, and be very careful that he did not get over-fatigued or excited. DR. WILLIAM B. ATKINSON, OF PHILADELPHIA. This author says that the treatment must be directed to the avoid- ance of the causes, (^Alienist and Neurologist, 1884,) as fright, silly- shines, sleeping without a light, injudicious feeding, the relief of con- stipation, the use of abundance of fresh air, and exercise, the latter even to the point approaching fatigue, so that the child may sleep soundly, without dreaming, and the employment of nervines and tonics, preferably those containing phosphorus and iron. DR. MOIZARD, OF FRANCE. According to this author, {Revue des Malades de V Enfance, 1884,) the preponderating influence of digestive troubles, indicates the ne- cessity of a rigid diet. Intellectual hygiene is of no less importance, and any excess of mental work should be strictly avoided. As chil- dren of delicate complexion are often involved, regular exerise and a regime both restorative and tonic are necessary. As to the par- oxysm itself, bromide of potassium and chloral appear to be the best remedies indicated. It should be remembered that these attacks almost invariably supervene in the first part of the night, and they should, therefore, be guarded against and prevented, by securing a sound and quiet sleep during the first three or four hours of the night. DR. HARKIN, OF IRELAND. This teacher tells us in the Dublin Medical Journal, 1880, that young children, from the first to the sixth year, particularly those sleeping in over-crowded rooms, are subject to frequent attacks of screaming at night, with insensibility and semi-convulsions, and somnambulism, if not watched, and something approaching to the petit tnal, due to the protracted inhalation of air deficient in oxygen, and laden with carbonic acid and other morbid products, a persist- ence in this habit often leading to tubercule of the brain or lungs. For this condition, he has always found the chlorate of potassium a sovereign remedy. 1469- R- Strychnise sulphatis, gr-j Quini£e sulpbatis. Ferri pyrophosphatis. aa 3j Acidi phosphorici diluti, Syrupi zingiberis, aa f-SiJ. Sixteen drops contain gr. y^^ of strychnia. 982 DISEASES OF CHILDREN. INFANTILE PARALYSIS. ALLEN M'LANE HAMILTON, M. D., NEW YORK. The most active and useful agent in the therapeusis of this dis- ease, is electricity, either as galvanism or faradism, applied to the muscles. As, however, there is a central lesion, it is advisable to begin an energetic course of bromides and ergot (gtt. v of the fluid extract), with the actual cautery, before the atrophic condition com- mences. Strychnia is also an efficient agent. Young children may commence with gr. tji. which may slowly be; increased. A pala- table form is : HAMMOND'S SOLUTION. M. Cod-liver oil, sea-air, good food and tonics are all important. The paralyzed muscles should be treated by massage, heat and cold, and the faradic and galvanic currents. Some writers speak highly of " JOUNOD'S Boot," the paralyzed limb being placed in the boot and the air exhausted. Much may be done to prevent the contractions and deformities which accompany old cases of this disease, by the daily use of pass- ive exercises and shampooing; recovery of power is often con- tributed to by the use of galvanism. The mild continuous current is found to be especially useful in the class of flaccid muscles, whilst no good is ever done by galvanism in the class of rigid muscles. Dr. West gives in this disease nux vomica, gr. ^ to a child three years old, increasing the dose till it reaches J^ of a grain, thrice daily. The use of ergot has also been advocated, gtt. v of the fluid ex- tract thrice daily, to a child two years old. The etiological treatment has reference to dentition, worms, con- stipation, anaemia, praeputial irritation, etc. DR. ARMAND SEMPLE, OF LONDON. Infantile paralysis proper, sometimes called infantile spinal para- lysis, occurs in young children, and its exact nature, even now, is not INFA>rnLE PARALYSIS. 983 thoroughly understood. It shows a special tendency to affect chil- dren under two years of age. Sensation is totally unaffected, the paralysis being intrinsically motor. The invasion is usually sudden, is accompanied by pyrexia, and terminates in atrophy of the muscles and complete paralysis. The limbs are not always affected exclu- sively. The lumbar muscles may be implicated, and the spine curved to a greater or less extent. No morbid appearances are found in the brain or the cranial nerves. It may be caused by feb- rile or nervous affections ; or it may follow cold and convulsions, diphtheria, ulcerated sore throat, or some eruptive fever. Blows and falls on the hip, may produce the disease. Delayed dentition in a rickety child must also be regarded as causative. As for treatment* absolute rest is imperative ; fever symptoms must be combatted with saline aperients and other appropriate remedies. A few leeches to the spine or counter-irritation by vesicative liniments may prove of service. Subcutaneous injection of ergotine has been recommended, since it is said to control hyperaemia by contracting the small ves- sels of the spinal cord. Belladonna also controls hyperaemia of the spinal cord and its membranes. Iodide of potassium, in small doses, combined with some vegetable infusion, may prove useful. Quinine, iron preparations and strychnia are also considered useful. The affected limb should be exercised daily, and friction should be con- stantly employed. When the paralysis is advanced, no benefit can be expected, save from faradization and galvanism. The continuous current should be applied to the affected muscles, at first two or three times a week, and eventually oftener. It should be used for about a quarter of an hour at a time, increasing the power of the current by degrees, as improvement results. After a time, the induced or far- adaic current may be used instead of the continuous variety. This form of paralysis is sometimes chronic and obstinate, and the treat- ment has been continued in some cases for months and years. Those which are apparently the most hopeless, may recover com- pletely under proper local and constitutional remedies. The warmth of the affected muscles, may be maintained by enveloping them in stockings of "chamois leather" or "pure spun silk." In some cases the seaside or mountain air is valuable. DR. WILLIAM PEPPER, OF PHILADELPHIA. This distinguished authority on diseases of children says, {Medical and Surgical Reporter, 1884,) that in treating the early stage of this 984 DISEASES OF CHILDREN. disease, he thinks that it is well to act upon the supposition that there is irritation and congestion of the spinal cord. Counter-irritation along the spine and the use of ergot, belladonna and iodide of po- tassium internally, are indicated. At a later stage of the disease, when there has passed off as much of the paralysis as will clear away, and there remains only the permanent paralysis which is associated with a serious lesion of the spinal cord, this line of treatment does not produce good results. We then have to depend upon remedies as iron and cod-liver oil, to promote the general nutrition, with correct hygiene, taking great care that the child is dressed properly and not exposed to dampness, draughts, etc. Friction of the skin should be employed to maintain the circulation, for the child cannot take that incessant exercise by which young children maintain a healthy con- dition of their muscles and functions. In addition to this, there should be treatment especially directed to the paralyzed parts, hop- ing that the tone of the spinal centres will be sufficient to enable them to maintain their integrity and prevent disintegration and atrophy of the nerve cells, which will be followed by wasting of the corresponding muscles. He does not know that we have any rem- edy that specially influences the nutrition of these important nerve cells. Strychnia has no effect upon them, but acts only upon the motor nerves and the muscles. It is proper to use strychnia at a late period of the case, and it may be administered by the mouth or hypodermically, being injected into the affected muscles. The ob- ject of this treatment is to improve the nutrition of the muscle, and not to act upon the spinal cord. Massage, friction and passive movements should also be employed with the same object. The circulation of the skin should be stimulated by friction and warm clothing. Good results are often obtained by putting the affected member under an air-pump and exhausting the air. The limb is as it were enclosed in a large cupping glass, a vacuum is created, and the blood is drawn into the part. This, carefully repeated, is fre- quently of service. In private practice," we have scarcely the means of treating these patients as they should be treated. All that form of apparatus which has been brought to such perfection in Sweden, serves an excellent purpose in the treatment of atrophic infantile paralysis. Electricity is an important agent in the treatment of this affection, but its use requires judgment and gkill. That current is employed which will give contractions of the paralyzed muscles, and the in- MENINGITIS — ACUTE. 985 terrupted galvanic current is practically the only one which is of service. It is to be used of such a strength, and with the current interrupted at such a rate, and applied over the nerve points, the nerves themselves, or the muscles, according as you get the best results. There is no fixed rule to be laid down for the use of elec- tricity, save that the currect should be moderate, and used in such a way as to secure contractions of the affected muscles. What we do for these cases in private practice, is to promote nutri- tion by the use of iron, cod-liver oil, later employ strychnia, keep- ing up friction of the skin, and training the parents in the use of massage and passive movements, carefully regulating all matters of hygiene, and if we have time and a suitable battery, apply the gal- vanic current. These are the cases which are more satisfactorily treated in institutions especially designed for this purpose. They require a long treatment, and if this is neglected, the para- lyzed muscles may pass into a condition of hopeless atrophy from disuse, and although the trophic centres of the cord may not be ruined by the original disease, the muscles from lack of proper treatment may become hopelessly wasted. DR. THOROWGOOD, OF ENGLAND. According to this author, {Lancet, 1883,) cases of paraplegia, (and sometimes of the knee,) of apparently obstinate kind, have been met with, where the cure has been missed from a want of attention to the condition of the intestinal canal. The late Dr. GRAVES, of Dublin, gives a case where a youth who had fed freely on nuts, had a dis- tinct attack of paraplegia, only cured by the effectual purgation of his intestines from the crude mass formed by undigested nuts. In- testinal worms are sometimes a cause, and here the line of treat- ment is clearly indicated. MENINGITIS- ACUTE. DR. WILLIAM T. PLANT, OF NEW YORK. This author considers that if you are clever enough to recognize the disease at its invasion, there is some little hope, {N. Y. Medical Journal, 1883). The child should be kept quiet in a darkened 986 DISEASES OF CHILDREN. room, and spared all causes of annoyance and worriment. The diet should be as nutritious as the child will take. Milk, cream,^ and meat broths are best. A hot mustard foot-bath lessens the cerebral congestion and soothes the child. It may be used as often as four or five times in the twenty-four hours. Keep the feet and legs warm by bottles of hot water or other means. If there is a heavy growth of hair, it should be thinned, and cloths, not too thick, wrung from iced water and changed often, so as to make constant impression of cold, may be laid upon the head. When there is intense heat of head, bladders of pounded ice may be applied, some layers of cloth coming between the ice and the scalp. Correct constipation hy an agreeable laxative, but beware of hypercatharsis. Iodide of potas- sium is the only drug that has any effect. It should be early and continuously given, in doses of from two to five grains. To relieve the headache and ward off convulsions, bromide of potassium is the best remedy. When there is great restlessness, chloral may be com- bined with the bromide. Give them boldly, until the purpose is effected. Valerian tends to quiet muscular twitching. It is better to dispense with opium, but in some cases the agony is so great that hypodermics of morphia must be given. A child with inherited tuberculous or scrofulous tendencies should be well looked after, especially if it begins to exhibit those vague but growing evidences of poor health that are so often precursory to this affection. Cod-liver oil should be given, a half teaspoonful or more ter die. Stimulants are in order — Bourbon or brandy with milk. If there are moist eruptions about the head and face, he would flot attempt to dry them by local applications, but rather trust them to disappear with the improvement in the general condition. M. VOVARD, OF BORDEAUX. According to this author, {Gazette des Hopitaux, 1883,) the follow- ing method of trea'tment has yielded good results in cases that are not complicated with tuberculosis : The child's head is shaved, and a thin layer of croton oil is spread over the scalp with a soft brush, after which the head is covered with a linen cap. This procedure is repeated three times daily until an abundant pustular eruption re- sults. Next, beet-root leaves are sewed into a small hood, with which the head is covered, this also being done two or three times a day. At the same time iodide of potash is given in reasonable doses. The result of this treatment will depend upon the extent MENINGITIS — ^ACUTE. 987 and duration of suppuration. The author saved eleven out of thirty cases by this method. DR. EDWARD HENOCH, OF BERLIN. According to this author, antiphlogisis plays the principal part in the treatment of meningitis. Even here many authors dread bleed- ing, but this must be regarded as a grave sin of omission. The bleeding must be regulated by the general condition of the patient. In small, poorly nourished, anaemic children, two to four leeches should be applied, according to the age of the patient, and the bites should not be allowed to bleed afterwards. In older children, espe- cially if robust, six to ten leeches, or an equal number of wet cups, to the neck or spine, are requisite. So long as symptoms of collapse are absent, an ice-bag should be constantly applied to the head, in- unctions of ung. ciner. mercur., every three hours, applied to the neck, back, arms and legs, and calomel should be given internally (gr. J^-ss every two hours). When there is great restlessness or convulsions, he resorts to injections of morphia or chloral hydrate, and also to lukewarm baths, with cold affusions to the head. He always uses iodide of potassium after the termination of the acute stage. 1470. R. Potass, iodid., gr. xv-xxx Aq. destil , f. S iij Aq. mentb. pip., f-3v. M. S. — Dessertspoonful three or four times a day. During the continued use of this remedy, he has frequently seen children gradually awake from the comatose state ; the contractures disappear and complete recovery finally occurs. DR. J. CHEWNING, OF ILLINOIS, Reports good results from the use of salicylic acid, {Medical and Surgical Reporter, 1884). He uses it in doses of from ten to twenty grains every six hours. Dr. D. C. Ramsey also recommends it very highly. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. Our authors think it must be evident that but little dependence can or ought to be placed on any but prompt and powerful anti- phlogistic treatment. Depletion, therefore, mercury, cold applications to the head, laxatives, counter-irritants, and the most rigid diet, ought to be employed from as early a period as possible. If there 988 DISEASES OF CHILDREN. is any case, excepting those in which venesection is indicated for the relief of mechanical engorgement of the right heart, when general bleeding would appear to be preferable to local depletion, acute sim- ple meningitis in a vigorous child, may be cited to be such. The amount of blood to be drawn, must depend upon the age and con- stitution of the subject, and the violence of the attack, in some measure, though it should always be as much or more than is neces- sary in any of the other acute affections of childhood. In a child two years old, of good constitution, from two to four ounces would not be too much at first, and should the symptoms not moderate in six or eight hours, as much more may be taken. The application of cold to the head is another most efficient remedy. We may use a bladder, containing water and pounded ice, or cloths wrung out of ice-cold water. If there is reason to suspect undigested matter in the alimentary canal, we may give a dose of castor oil, citrate of magnesia, or rhubarb. It is well to give calomel in small and fre- quently-repeated doses until the bowels are moved, and afterwards to continue it in smaller doses, given at longer intervals, to secure its specific influence on the inflammation. Iodide of potassium should be given in full doses as soon as the calomel is suspended, or from the beginning, in case this latter remedy is not employed. Bromide of potassium and bromide of sodium are the most valuable sedatives in the acute stage of this disease, when there exists marked symptoms of cerebral excitement or a tendency to convulsions. The doses should be full and frequently repeated, as, for instance, at one year of age, from three to five grains every two or three hours. Counter-irritants are useful as adjuvants to the more powerful remedies already indicated. During the first day or two, they should consist chiefly of sinapisms and mustard poultices, applied from time to time to the trunk and extremities. We should not use blisters until the active symptoms of the disease have been subdued. They may be applied to the head itself, to the nucha, or to the extremities. TUBERCULAR MENINGITIS. DR. WARFWING. The author {ArcA. de Patol. Inf., May, 1888,) reports a number of cases of this very dangerous affection, which were successfully treated by the following process. TUBERCULAR MENINGITIS. 989 The plan of treatment consisted in first shaving the hairy scalp, and then rubbing upon the skin a quantity of ointment composed of one part iodoform to five of vaseline, the head being then covered with a tarletan hood leaving an opening for the face. At each daily friction, two grammes (a half drachm) of this ointment were used, and the treatment was continued from nine to thirty-two days. MOLESCHOTT first advised the use of iodoform for internal diseases in 1878, and he successfully treated three out of five cases of tubercular meningitis, by applications of iodoform collodion to the scalp. NiLLSCEZ and SOUDERS have each reported a successful case of this disease treated in the same manner. The author thinks that the success of this treatment is due to the drug being absorbed into the subcutaneous adipose tissue, which acts as a vehicle for its transmis- sion. According to Binz it is broken up, with the liberation of iodine, and this is absorbed and carried along by the organic fluids. Future experience may show that more rapid results may be ob- tained by some modification of this method. The prolonged use of iodoform does not seem to be followed by any bad results. DR. EDWARD HENOCH, OF BERLIN. This author considers that all physicians who are conscientious in making a diagnosis, will regard every case of tubercular meningitis as lost. However, the possibility of recovery cannot be denied. In the first few days of the disease, he applies, according to age, from three to six leeches behind the ears and an ice-bag to the head, giv- ing calomel (gr. ^ every two hours) and compound infusion of senna, (if the evacuations are not profuse,) and orders inunctions of unguent, ciner. on the throat and neck a couple of times a day. Although we can hope for success from this treatment in only very exceptional cases, it cannot prove injurious in a disease which always proves fatal when left to itself. If not adopted in the first few days of the disease, all methods are useless. DR. CHARLES W. EARLE, OF ILLINOIS. In the Chicago Medical Journal and Examiner, 1879, this author very truly says that in almost every case in which the disease is fully developed, death is the final result, and only in prophylaxis can a physician obtain any results at all satisfactory. The presence of the tubercular or scrofulous diathesis, may in a great number of cases be removed, if one could but have the hearty co-operation of the pa- 990 DISEASES OF CHILDREN. rents. Mothers with this peculiarity, should be informed in regard to the probable taint they will communicate to their offspring, and everything in the way of nourishment and nutritious medicaments should be administered. It would be better that such mothers should not be allowed to nurse their children, although Dr. EarlE is always unwilling to deprive any child under one year of age, of its proper maternal food — " a food for which nature does not afford, nor can art supply, a substitute" — unless there is some grave reason for such de- privation. Children in whom there is the faintest possibility of such a taint, should be given the benefit of the country air, if possible — good hygienic surroundings, perfect nutrition — especially a sufficient dietary, for, in this blessed land of ours, children do starve to death. Diseases which produce a tendency to the diathesis should be pre- vented by avoiding the opportunities of receiving the contagion into the system. It is wholly impossible to prevent all children from coming in contact with whooping-cough, measles, diphtheria, and the like ; but there is no reason why the effort should not be made with this peculiar class of children. They should have the benefit of cod-liver oil and syrup of the iodide of iron — the malt and hypophosphate preparations. Above all, we should not, because a child is slightly tubercular or scrofulous, despair of either staying the disease or of ultimately restoring it to the anxious parents, healthy and robust. The hopeless pathology of fifty years ago, indeed, gave no hope, but more recent conclusions give a brighter future. While it is doubtful if tubercle in the brain is ever cured, it has been abundantly shown by NiEMEVER and oth- ers that in other parts of the body, it is amenable to treatment, and that by several modes, recovery does take place. PROPHYLACTIC TREATMENT. DRS. MEIGS AND PEPPER, OF PHILADELPHIA. Our authors consider that it must be evident that the prophylactic treatment is of special importance in a disease so little amenable to curative measures. When, therefore, there is reason to suspect a tendency to tubercular meningitis in a child, eithei- from the fact that other children in the family have perished from it, or from a bad state of the general health, and frequent complaints of headache, it becomes proper and necessary to regulate both the moral and physi- cal education with a view to its prevention. For this end the hygienic TUBERCULAR MENINGITIS. 99 r management of the child ought to be such as is best calculated to prevent the formation or development of tubercles in the constitution. During" infancy, such a child should be nursed, if this be possible, by a strong, hearty woman, with an abundant flow of milk. If the mother is not possessed of these qualities — if there be, indeed, the least doubt upon the point — she ought herself to give up nursing and procure a wet-nurse of the kind described. This alone will, in all probability, often make the difference between a vigorous and a fragile constitution. When the time for weaning arrives, the change ought to be made with the greatest care and circumspection. Dur- ing and for some time after weaning, the diet must consist princi- pally of milk preparations and bread, and of small quantities of light broths, or of meat very finely cut up. As the child grows older, the meals ought to be arranged at regular hours, and should consist of four in the day. The principal food must be bread and milk, well chosen, well-cooked meats, and rice and potatoes as almost the only vegetables. After the first dentition is completed, a moderate use of ripe and wholesome fruits may be allowed, but always with care, in order to avoid injury to the digestive organs, and also so as not to mar the appetite for more wholesome and nutritious food. Coffee and teas ought to be forbidden at all times, since, when the palate of a child is taught, by habit, to become accustomed to these more highly sapid substances, it is very apt to abandon the use of milk, which ought to constitute a very large proportion of its food, at least up to the age of twelve or fifteen years. The child should not taste improper articles of food, so that it may escape the torment of de- siring what is improper. After diet, the most important points in the treatment, are air and clothing. The child should inhabit, if possible, a large, dry, well-ven- tilated room, which ought to be kept as cool as possible in summer, and moderately warm in winter. Not a day should be allowed to pass, unless the weather is totally unfit, without the child's being sent for several hours into the open air. The clothing should be cool in summer and warm in winter. In our country, there is a great in- clination to harden children by dressing them very slightly in cold weather, so that they frequently suffer from catarrh, pneumonia, and spasmodic croup, brought on by improper exposure. This cannot but be wrong in a child who shows the least evidence of tendency to tubercular affections. Our authors, from their own experience, are fully convinced that by far the most certain and effectual means 992 DISEASES OF CHILDRKN. of preventing the development of a tubercular, or indeed any other cachexia in a child, is to have it brought up in the open country, or in some healthy village, until the epoch of puberty has passed by safely. A very good plan for parents whose occupations compel them to live in cities or large towns, is to have their residence a few miles in the country, and to come to town every day. Children brought up in this way have a far better chance of obtaining strong and vigorous constitutions, than those reared entirely in the close and confined dwellings and streets of crowded cities. When a child, who, from the health of its parents, or from its own appearance, may be suspected of having any tubercular or scrofulous taint in its system, becomes subject to frequent attacks of apparently causeless headache, and especially when such headaches are asso- ciated with a constipated habit of body and with occasional vomiting, it ought to be looked upon as threatened with tubercular disease of the brain. Under these circumstances, in addition to the precau- tions already recommended, our authors advise that the child be at once put upon the use of cod-liver oil, iodide of iron, and mild laxa- tives, and that these be persevered in for several weeks or months, until, in fact, the strength and general health are restored and the headaches cease. When the appetite is poor, and the digestion is imperfect, we may use with advantage, besides the above reme- dies, solution of pepsin, a teaspoonful three times a day with the meals, or tincture of nux vomica, three or four drops in a mixture of syrup and compound tincture of gentian, or in a teaspoonful of elixir of cinchona three times a day. If the child is of an age to be going on with its education, this should for the time cejise, or be carried on in such a way as to avoid all excitement and fatigue. If in any child whose hereditary tendencies, or whose physical char- acteristics, are such as to make us fear a predisposition to tubercu- losis, there should also be evidences of marked nervous irritability or precocious mental development, it is desirable to use every means to prevent a continuance of such undue cerebral activity which might tend to induce tuberculosis of that organ or its membranes. We must, however, for the most part be satisfied with a careful attention to all the details of hygiene, in addition to which, however, the fol- lowing points deserve mention, viz., to keep the head cool, by not allowing it to be too warmly covered and by keeping the hair short, to keep the extremities warm, and to avoid stimulating the intellec- tual faculties to any considerable extent by education until after eight or ten years of age. HYDROCEPHALUS. gg-, Warfwing Speaks very highly of inunctions of iodoform oint- ment (30 per cent.) in tubercular meningitis. In five cases reported the result was almost miraculous. The inunctions should be made twice daily, and be persisted in for ten, twenty, or even thirty days. HYDROCEPHALUS. DR. EDWARD HENOCH, OP BERLIN. According to this author, the treatment in the beginning of the affection should consist of local bleeding, by means of a few leeches applied behind the ears or upon the forehead, ice fomentations to the head, and purgatives, preferably calomel (gr. %-}4 a few times a day). At a later period, when the inflammatory stage has passed and we wish to initiate the absorption of the fluid, he recommends the continued use of mercurials in small doses, inunctions of un- guent, cinerit. on the head and neck (15 grs. every day), and a blister to the neck, concerning the use of which great fear is now un- justly entertained. But the antiphlogistic method is applicable only in those cases in which the primary inflammatory stage has either been directly observed, or can, at least, be proven to have been present. He always regards internal chronic hydrocephalus as in- curable, after the head has increased in siz^ to any considerable extent. He has achieved no results whatever, either with mer- curial inunctions, iodide of potassium, or application of tincture of iodine to the head, nor from compression of the skull with adhesive strips, nor from puncture through the fontanelles. When these methods of treatment have proven successful (this has happened in very rare cases) the case must have been one of external hydro- cephalus. DR. ARMAND SEMPLE, OF LONDON. If the child be robust, it may be placed in a warm bath, a few leeches may be applied to the temples, or the ice-bag and cold evaporating lotions to the scalp ; in every case light and sound should be excluded, and one grain of calomel mixed with a little sugar should be placed on the tongue every three or four hours ; saline aperients, as tartrate of potash, may also be given combined with syrup of senna. When effusion comes on, iodide of potassium 63 994 DISEASES OF CHILDREN. may be employed with advantage, followed by the administration of the syrup of the iodide of iron and cod-liver oil. DR. HUGH P. DUNN, OF ENGLAND. In the Lancet, 1882, Dr. HUGH P. DUNN recommends paracente- sis in cases of hydrocephalus, believing that when the operation is properly performed it is not dangerous, but on the contrary is pro- ductive of much good. A small aspirator, of about half an ounde capacity, furnished with a double-cock arrangement, is the instru- ment he uses. The child being held on the nurse's lap, with its head facing the light, the operator marks a point in the situation of the coronal suture, about an inch from the longitudinal sinus, and hold- ing the needle firmly in his right hand, thrusts it into the cranium with its point slightly inclined inward. It is a good plan to first thoroughly cleanse the needle in a solution of carbolic acid. The needle having entered the cranium, the surgeon grasps it close to the scalp by the forefinger and thumb of the left hand and steadies the head with the right, and the assistant manipulates the piston of the aspirator. The piston should be slowly withdrawn, and pauses of a few seconds now and again allowed to elapse, in a manner similar to the application of the ecraseur. The position of the needle may be altered from time to time, according as the tension on the piston shows that the fluid has diminished. After about half an ounce of fluid has been abstracted, compression of the cranium should be se- cured. The bestwaylo secure this is to use a piece of India-rubber tubing, corresponding in diameter to a quarter-inch gas pipe. The tube, around which some lint may be wrapped or sewed, should be made to encircle the cranium twice, at a level with the occipital pro- tuberance behind and the centre of the forehead in front. As the fluid is gradually withdrawn, the tube is, from time to time, read- justed and tightened. When the operation is completed, the punc- tured spot is covered with a piece of dry lint, and attention directed to compression of the cranium, which can be accomplished by fixing tjie tube in situ, or a capeline bandage of flannel carefully applied. PROFESSOR S. D. GROSS, OF PHILADELPHIA. This late distinguished authority {Medical and Surgical Reporter, 1 88 1,) considers that very little can be done for the relief of this condition. The late Dr. CONQUEST, of England, published a series of cases, in all about fifteen or eighteen, where a cure followed the HYDROCEPHALUS. 995 operation of tapping. Dr. GROSS places no reliance on his state- ments, for the experience of the entire medical and surgical profes- sion is against his conclusions. Due attention to hygiene is, in the opinion of Dr. GROSS, about all that can be recommended for these patients. C. WEST, M. D. The value oi purgatives can scarcely be overrated in acute hydro- cephalus, but they must be given so as not merely to obtain free action of the bowels, but to maintain it for some days. This end is best secured, after having once overcome the constipation, by giving small doses of a purgative every five or six hours. The administra- tion of strong cathartics every morning will not answer the end nearly so well ; if they cause sickness, it is better to give a single full dose of calomel, and follow it up with sulphate of magnesia at short intervals. The following mixture is then advised : 1471. R. Magnesiae sulpbatis, 3j Potassii nitratis, gr. x Syrupi limonis, f. 5 iij Aqxise, f.3ix. M. A dessertspoonful (f. 3 >j) thrice daily, for a child of one year. In all cases, of course, the solution and regulation of the purga- tives must be determined by the strength of the child. The local abstraction of blood by leeches sometimes proves ser- viceable when there is much febrile action. They should be placed on the crown of the head rather than on the temples. They are inadmissible when the patient is much debilitated. J. S. RAMSKILL, M. D. The iodide of iron is usually well borne by hydrocephalic children, unless there be a tendency to congestion or inflammatory action. Among the children of the poor, the combination of cod-liver oil and syrup of the iodide almost always gives satisfactory results. The mercurial plan of treatment advised by Prof. GOLIS, of Vienna, is regarded by Dr. Ramskill as one of the best. The head should be shaved, and the following ointment prescribed : 1472. K- Unguenti hydrargyri, gr. xx-xl Unguenti olel juniperis, S )• ^• To be rubbed on the shaved scalp, twice a day. The child should wear a woolen cap, to prevent the risk of the 996 DISEASES OF CHILDREN. perspiration being checked by the cold air. Calomel (gr. ^-ss) should be given thrice daily. If this purges too much, the mercurial inunction should be alone employed. The treatment is to be perse- vered in for thirty or forty days, when, if there be some improve- ment, the remedies may be gradually diminished, but the cap is to be worn after the inunction has been discontinued. If there be no marked improvement after six or eight weeks, some diuretic, as ace- tate of potash, or squill, may be added, and a couple of issues may be inserted in the occiput. Blisters to the nape of the neck njay be advantageously substituted for these. Whenever there is heat of the head, and the child grows fretful, restless and irritable, a couple of leeches behind the ears will be found of service. When convales- cence has begun, it may be accelerated by small doses of quinine. After the acute stage has passed, and convalescence has been fully established, a favorable progression can be greatly encouraged by keeping the child during the daytime in a chair which has had a "swing" or "extension" attached to it in such a way as to support the weight of the patient's head. DR. A. N. READ, OHIO. This writer has reported remarkable success in several cases of chronic hydrocephalus, by the external use of pure glycerine. {Transactions of the Ohio Medical Society, 1876.) He gives, for instance, the case of a child eighteen months old ; head, twenty-four inches in circumference ; sutures separated, and bulging of integu- ments. He applied twice daily to the head, glycerine, with a little tincture of iodine, and directed the use of a close-fitting cap. The application caused the child "to sweat dreadfully." This suggested that glycerine, because of its strong affinity for water, had caused an exudation of serum, which, if continued, might cure the child — a hope strengthened by remembering the drain following its applica- tion to indurations of the uterus. After a year's use, the child was cured. In 1874, the child was attending school, with fair intellect and good health. Dr. Mervel, of Monroeville, Ohio, has reported the result of a partial trial in one case. Child under one year old ; head circum- ference, twenty-two inches ; eyes much protruded, as well as integu- ments over separated sutures. Applications of glycerine were fol- lowed by profuse serous flow. In three weeks the eyes were restored to their natural position, and there was no protrusion between cra- nial sutures ; but the head was not reduced in size. HYDROCEPHALUS. 997 PROF. ELLERSLIE WALLACE, M. D., PHILADELPHIA. The following is one of the best tonics which can be given in this disease : 1473- B- Fotassii iodidi, 3i Syrupi tolutani, f. § ss Aquae, f. | ij. A teaspoonful morning and evening, after food. In some cases, the elix. quinice, ferri et strychnice, acts in a most satisfactory manner. DR. NATHAN S. DAVIS, CHICAGO. The method in chronic hydrocephalus proposed by Prof. Brain- ARD, of puncturing the head and injecting a weak solution of iodine and iodide of potassium, has been tried, but no successful case has been reported. The objects toward which the medical treatment must be directed, are, first, to allay the morbid excitement of the cerebral structures ; and, second, to exert a gentle yet persistent alterative and diuretic influence, avoiding, carefully, any impairment of the digestive organs. Dr. Davis has succeeded in accomplishing these purposes by the following prescription : 1474. B- Extracti scutellarice fluidi, f. § ij Tincturae digitalis, ^- 1 ^ Potassii iodidi, 3>i Extracti fluidi hyoscyami, f. § ss. M. Twenty drops, four times a day, in sweetened water. If the digitalis is found to be exerting too much influence, the dose must be diminished. Mercurials are of no advantage in the chronic stage ; though, in the early inflammatory stage, combined with mild laxatives, they might check the progress of the disease. NOTES ON REMEDIES. Antimonii et Potassce Tartras is now much less employed than formerly, being considered less efficacious than cod-liver oil, iodine and nutritives. Hydrargyri Chloridum Corrosivum has been given in doses gr. iis to t's with good results, but calomel is generally preferred, when mercury at all is given. The mercurial treatment of acute hydrocephalus, once so general, is now rarely resorted to, and is regarded as of little value, if not actually hurtful. In chronic hydrocephalus, it is, however, still em- ployed. Magnesii Carbonas has been advised in doses of .^j-ij, saturated with lemon- 998 DISEASES OF CHILDREN. juice, taken every two or three hours, as a purgative, which sets well on the stomach, even when very irritable. Oleum Terebinihina is recommended by Dr. Copland in incipient hydro- cephalus, in doses of "Lv-x, with ni,xx-xl of castor oil. He also speaks highly of turpentine enemata. Poiassii lodidum is recommended by Dr. Hillier, gr. j every four hours, for young children, when the disease is declared, together with ice or cold lotions to the head, mercurial aperients and absolute rest in a quiet, darkened room. Cathartics have a high value in cases of acute hydrocephalus. Leeches to the crown of the head are of service when there is much febrile action, if the patient be not too miich debilitated. EXTERNAL REMEDIES. Croton Oil counter-irritation . 472.489, 498, SOS. 508, S«o. 614. 66s, 667. Arcbambault, M., Paris, 742, 788, 843. Ardnin, Dr., 308. Armaingaud, Dr., France, 526. Armitage, S. W., United States, 398. Armor, Prof., 250. Armstrong, J. M., Iowa, 801. Ashurst, Samuel, United States, 588. Ashwell, S., England, 473, 543. Atkinson, W. B., United States, 353, 397, 923. 935. 981. Atlee, W., United States, 402. Aufrecht, Dr., Germany, 148, 352. Avellis, Dr., Germany, 487. Ayers, Dr., United States, 508. Ayler, John W., West Virginia, 737. Ayre, Joseph, England, 228. Babieff, Dr., 583. ^acelli. Dr., Europe, 574. Baginsky, Dr., 852. 896. Bailey, T., United States, 587. 931. 264, 852. 290, 184. 194. 492, 739. Baker, W. J.. 861. Balfour, G. W., Scotland, 176, 179, 196, 201, 382, 659. Bamberger, Dr., Germany, 359 Bamsler, Prof., Germany, 152. Bardet, Dr., France, 507. Barety, M., Nice, 833. Barker, Fordyce, New York, 803, 806. Barlow, G. H., England, 433, 439. Barlow, W. H., England, 57, 208, 308, 345, 35°. 372. 383. 403. Barlow and Parker, Drs., 879. Barry, Dr., India, 227. Bartbel and Moritz, Russia, 867. Barthez, Dr., United States, 326. Bartholow, Roberts, United States, 29, 35, 37, 44, 54. 73. 84. 92, 93. '35. '36, I45. '49. 161, 182, 183, 185, 196, 198, 199, 207, 216, 236, 238, 248, 249, 274, 277, 290, 301, 303, 324, 332, 343, 348, 358. 37'. 376. 378. 383. 403, 404, 406, 423, 425, 427, 428,489, 493, 514, 538, 548, 559, 572.584. 589. 592. 595. 613, 520, 630, 632,664, 665, 749, 751, 759, 825, 853, 1003. Bartlett, Dr., United States, 81,631, 797, 829. Hartley, E. H.,New York, 926. Baruch, S., United States, 66, 515. Basham, Dr., England, 360, 383, 390, 611. Baskell, A. M., United States, 360. Bassi, Dr., Italy, 593. Bastin, Dr., England, 435. Bastings, Dr., Belgium, 145. Bates, Henry, United States, 751. Bates, W., England, 228. Battey, Dr., England, 178. Beale, L. S., England, 407. Beard, Geo. M., United States, 20, 88, 93, 236, 250, 524, 617. Beardsley, Dr., Canada, 582. Beaumetz and Dujardin, France, 365, 377. Begbie, J. W., Scotland, 436. Beigel, Dr., England, 21, 48, 807. Bell, Benjamin, Scotland, 305, 631. Bell, James E., United States, 94. Bell, Robert, Glasgow, 775. Bell, S. D., United States, 351. Belot, Charles, Cuba, 647, 651, 653. C1OI9) I020 INDEX OF AUTHORS. Bemiss, Prof. S. M., United States, 569, 571. Benat, Dr. F., 20. Benedikt, M., Germany, 433. Bennett, Prof., Scotland, 561, 634, 643. Benson, J. S., 792. Benzon, }., Buccari, 780. Bergeron, Dr., France, 30, 1 1 r, 797. Berkhart, Dr., Germany, 30, 78. Bernard, Dr., France, 853. Bematzek, Prof., 580. Bemheim, H., France, 196. Besnier, Dr., 837. Betz, Dr., Germany, 274, 530. Bigg, Dr., England, 89. Billington, Dr., 774. Billotti, Tbomaso, 800. Billroth, Prof., Germany, 508. Binet, Dr., France, 216. Birch, S. S., England, 240, 248. Bird, Golding, England, 286, 293, 439, 827. Biscboff, Dr., 544. Blacbe, Dr., France, 434. Blacbez, Dr., 881, 882. Blacklock, A., India, 229. Blancbez, Dr., 977. Blackbourn, Dr., Coblentz, 799. Bleyer, Dr., United States, 97. Blockley Hospital, see Philadelphia Hospital. Bocquillon, Prof., France, 177. Bonamy, Dr., France, 264. Bond, S. T., United States, 328. Bonfigli, Prof., Italy, 264. Bossu, Dr., Paris, 966. Boteler, W. €., United States, 604. Botkin, J. W., United States, 624. Bottare and Lacbner, Drs., 829. Bouchard, Dr., France, 341, 375, 621. Boucbardat, A., France, 373, 378. Boubila, Dr., Europe, 488. Bouchut, Prof., France, 198, 205, 215, 321, 323. 349. 35'. 429. 431. 5'9. 609. Boudin, Dr., France, 275. Boughter, Dr., United States, 263. Bousse, Dr., 430. Bouvard, Dr., France, 501. Bowditch, Henry M., United States, 197. Bozzolo, Dr., England, 163. Bradnack, F., United States, 666. Braunville, Byron, England, 543. Brand, Dr., Austria, 61, 619. Breckenridge, Dr., 728, 753. Brehmer, Dr., 128. Bremond, Dr., France, 617. Briand, I >r. E., France, 104. Brickwell, Dr., 319. Bridger, Dr., 976. Bright, Dr., England, 372. Brinton, Wm., England, 84, 282, 287, 291, ^92. 297. 3°5. 308. 343, 404- Brisbane, Dr., England, 455. Bristow, John Syre, Englandr37, 96, 146, 279, 294. 439. 678. 679. Brochin, Dr., 900. Brookes, Dr., Germany, 593. Brooks, J. G., United States, 315. Brougbton, Dr., 946. Brown, F. J., England, 530. Brown-Sequard, C. E., France, 63, 177, 441, 449. 453, 454. 45^. 505- Brown, R. M., United States, 401. Browne, C, England, 449. Browne, Lennox, England, 69, 98, loi. Brown, Bedford, Virginia, 743, 833, 892. Bruen, E. T., United States, 205. Brunton, T. Lauder, England, 180, 206, 349, 35°- Buchanan, Prof., Glasgow, 816. Buckler, Dr., United States, 212. Bucquoy, Dr., France, 160. Bufalini, Prof., Italy, 215. Bull, Dr., New York, looi. Bunz, H., United States, 652. Burkart, Dr., Germany, 256. Butler, R. J., England, 611. Byrd, Harvey L., United States, 463, 577. Byvalkevitscb, Dr., Russia, 82. Calderwood, G., England, 323. Caldwell, J. J., 834. CaldweU, W. C, 776. Camp, Dr. United States, 316. Campbell, Watson, 800. Cantani, Dr., Italy, 217. Capart, Dr., 859. Cardot, Dr., France, 175. Carney, R., 798. Carpani, Dr., France, 606. Carpenter, W. W., California, 792. Carre, Marius, France, 315. Carreau, Prof., France, 334. Carriere, Dr., France, 251. Carter, Charles, United, States, 524. Carter, J. M. G., United States, 158. Cartledge, Dr., 510. Casarelli, Dr., France, 382. Casselberry, Dr., United States, 97. Cauldwell, C. M., United States, 384. Celsus, Dr., 453. Cema, David, United States, 382, 385. Chakovski, Dr., 729. Chambers, Dr., 1017. Chambers, J. K., England, 431, 605. Chambers, Thos. King, England, 78, 170, 540. Chandler, A. H., New Brunswick, 601. Chandler, S. T., United States, 219. Chapman, E. N., Brooklyn, 392, 771, 792. Chapman, Prof. N., 278, 512. Chapman, J., England, 89. Charcot, Prof., France, 483, 522. Charteris, Prof. M., Glasgow, 39, 77, 100, 283, 406, 634, 757. Chateaubourg, Dr., France, 346. Cheatham, Dr., United States, 64, 92. Chewning, J., Illinois, 987. Chiarmelli, Prof., Italy, 141. Chiricozzi, Dr., 831. Chiron, J., 507. • Chiron, Paul, France, 281. Chipperfield, Dr., 278. Christison, Robert, Scotland, 372, 391, 669. INDEX OF AUTHORS. 102 1 Christoph, Dr., Turkey, 405. Oiiirchill, J. F., Fiance, 125. Churton, Dr., 437. Civiale, Dr., France, 398. Qaibome, J. H., 577. Claridge, W. R., United States, 639. Qark, j. E., icx>4. Clark, Sir Andrew, England, 91, 536. Clark, Thomas, 53, 830. Clarke, Prof. Alonzo, United States, 261, 618. Cleland, J., Scotland, 247. Clemens, Dr., Germany, 452. Clement, Dr., France, 643. Qouston, T. S., Scotland, 444, 454, 477, 478, 482, 515. Qubbe, C. P. B., 374. Cobbold, T. Spencer, 325. Cohen, J. Solis, Philadelphia, 18, 151, 833. Cohen, S. Solis, Philadelphia, i z8. Coghill, J. G. S., England, 107. Coleman, Dr., Virginia, 725. CoUeville, Dr., United States, 643. Collier, M. W., 182. Comegys, C. G., United States, 501, 914. Concato, Prof., Italy, 148. Condie, C. F., United States, 323. Conquest, Dr., England, 994. Conrad, Dr., Germany, 479. Cook, A. B., United States, 488. Cook, J L., United States, 36. Coons, J. N., Missouri, 777. Cooper, John, Philadelphia, 833. Coopreider, J., Indiana, 830. Copeland, J., England, 32, 84, 159, 181, 236, 2sr, 200, 264, 313, 335, 371, 386, 392, 394, 424, 452, 454, 455, 998. Copeman, Edward, 750. Cormac, John Rose, Paris, 790. Coming, Dr., 496. Corrigan, Dr., Ireland, 610. Corson, Hiram, United States, 408, 730, 753, 7S8- Corson, J. W., United States, 21. Cowden, Dr., United States, 501. Craig, James, United States, 927. Craig, Wm., 244. Crandall, J. B., United States, 262. Cressler, Dr., Spain, 319. Crichton, Dr., England, 248. Cripps, Dr., England, 449. Cross, J., England, 549. Crothers, T. D., United States, 661, 669. Cressi, Dr. Germany, 290. Cullen, R. J., New York, 455, 783. Curran, J. W., Ireland, 132, 144, 193, 196, 264, 277, 448, 45s, 658. Currie, James, England, 730. Cursbman, Dr., 643. Gushing, J. R., United States, 273. Curtin, Roland G., 216. Cyr, Dr., France, 311. Da Costa, Dr., Philadelphia, 17, 23, 40, 56, 73, 80, 84, 103, 124, 133, 140, 147. 183, 186, 197, 199, 200, 239, 255, 279,305, 312, 360, 374, 407, 430, 437, 450, 453, 461, 471, 494, 498, 502, 510, 532, 540, 559, 565, 584, 607,611,812,886. Dagnino, Dr., Italy, 652. Daland, Judson, United States, 615. Dana. Dr., United States, 437, 439, 451,457, 467, 472. D'Ancona, Dr., France, 667. Darmecy, Guiot, France, 386. Date, Wm., England, 327. Davaine, Dr., 952. Davidson, Dr. W., Virginia, 931. Davis, Herbert, £12. Davis, F. H., United States, 55. Davis, N. S., 153, 163, 495, 525, 545, 559, 944. 997- Davis, Dr., New York, 758, 759. Day, John, England, 385. Day, Dr., United States, 646. Day, John, Australia, 752, 772. Day, Wm. H., England, 467, 805, 863, 1005. Debout, Dr., 533. Debove, Dr., France, 196, 304. Dedat, M., France, 587, 645. De Lacaille, Dr., Rio Janeiro, 645. De Guinard, Martin, France, 595. De Mussy, Prof. Gueneau, France, 641. Dehio, Dr., Russia, 224. Delafield, F., United States, 613. Delioux, Dr., France, 534. Dellenbaugh, Z. T., 828. Delthil, Dr., France, 785. Demlitz, Dr., United States, 42. Demme, Dr., 752. Denhard, Dr., 813. Denker, Dr., Russia, 780. Descroizilles, Prof., Paris, 595. De Sabbata, Dr., Venice, 798. De Schweinitz, G. E., United States, 432. Desplats, H., France, 626. Dessau, Henry, New York, 878, 910. Dewar, J., Ireland, 93. Dewees, Dr., 899. Dexter, Ransom, United States, 435. Dick, Forbes, England, 317. Dickenson, W. N., England, 350, 351,434' Diller, Dr., U. S., 451. Dixon, Dr., United States, 613. Dobell, Horace, England, 58, 69, 84, 90, 142, 14.3. »44- Doboue, Dr., France, 150. Dochmann, Dr., Germany, 112. Docker, Wm., England, 275. Dodge, W. T., United States, 341. Dolan, Dr., England, 825. Donaldson, R., British India, 271. Donkin, A. S., Ireland, 381. Donkin, Dr., Germany, 300. Dowell, J. G , United States, 550, 571. Dowell, Greenville, United States, 645. Draper, F. W., 621, 623. Dresch, Dr., Germany, 438. DrosderfT, V. J., United States, 512. Druitt, Dr., England, 138. Drysdale, Dr., Philadelphia, 343, 752, 772- 1022 INDEX OF AUTHORS. Duboin, Dr., France, 631. Duchesne, Dr., France, 501. Duclos, M., France, 536.. Duer, Dr., Philadelphia, 794. Duhring, Lewis A., Philadelphia, 1009, Dujardin-Beaumetz, Paris, 974. Dumm, Dr., 430. Dunbar, E. W., Zurich, 901. Duncan, J. F., England, 560. Dunglison, Prof. R., United States, 56, 245. Dunn, Hugh P., England, 994. Dupont, Dr., France, 77. Durand, Dr., France, 213, 215. Durant, C. M., England, 173. Dusart, M., 852. Duval, E. R., Arkansas, 803. Earle, C. S., Chicago, 753. Earle, Chas. W., Chicago, 728, 989. Earnest, J. G., United Slates, 267. Easton, Prof., Scotland, 46, 539. Ebstein, Dr., Germany, 675. Eccles, A. S., England, 478, 484. Eckstein, Prof., Germany, 378. Edison, Dr., 753. Eddison, Dr., 437. Eicbolt, Dr., Germany, 515. Eichorst, Dr., Germany, 1 75. Eickholt, G., Germany, 484. Elliott, Christopher, 929. EUiotson, Dr., England, 138, 437, 506. Ellis, Calvin, England, 346. Ellis, Edward, England, 694, 759, 762, 840, 846, 858, 878, 928, 930, 966. Eloy, Dr., France, 303, 307, 557. Emerson, E. W., United States, 946. Emerson, N. B., United States, 424, 530. Empis, Dr., 600, Engel, Prof. Hugo, United States, 85, 330, 416. Engelman, F. F. K., Germany, 801. Erb, W. H., Germany, 437, 486, 526. • Erichsen, A., 795. Erlenmeyer, Dr., Germany, 444, Eulenberg, Dr., Germany, 584. Evers, Dr., England, 585. Ewart and Benham, Drs., 880. Eyre, Sir J., England, 286, 308. Fahie, Charles, England, 802. Fahlberg, Dr., Germany, 386. Fahnestock, Dr., United States, 673. Farquharson, Robert, England, 396. Farre, F. J., England, 194, 603. Farrini, Dr., Tunis, 793. Faulkner, R. B., United States, 25, 617. Favier, Dr., France, 530. Fayrer, J., British India, 255, 550. Fedoroff, Dr., 819. Fennel, Sydney, 751. Fenwick, Dr., England, 37, 232, 304. 40X. 491. Fere, Dr., 456. Fereol, M., France, 506, Feris, Brazile, France, 78. Ferrar, Dr., Spain, 329. Ferrier, Dr., London, 60, 531. Fetz, Dr., Germany, 148. Fiesenburg, Dr., Germany, 70. Finchaw, Dr., England, 602. Finlay, Dr., 452. Finn, Dr., Canada, 611, Fischer, Dr., 487. Fleischmann, A., England, 612. Fleming, Dr., England, 229, 604. Flick, Lawrence F., 115. Flint, A., United States, 56, 113, 139, 151, 190, 362, 377, 386, 436, 474, 511, 519, 524, 534. 579- Fonssagrives, Prof., France, 210, 396, 398. Forcheimer, F., United States, 826, 851, 895, 896, 977. Forrest, J. A., England, 137. Forrest, W. E., United States, 591. Foster, Dr., 836. Foster, Balthazar, 125. Foster, N. S., England, 139, 385. 424. FothergiU, J. Milner, England, 50, 136, 168, 180, 196, 424, 455, 576, 580, 591, 614, 966. Fowler, EMward, United States, 628, 650. Fowler, J. Kingston, England, 309. Fowler, R., United States, 886. Fox. Wm., 260, 305. Fox, Wilson, England, 287, 290, 293. Frantzel, Dr., Austria, 137. Fraser, Dr., Scotland, 45. Freire, Domingos, Brazil, 644. Friedlander. Dr., Russia, 750, 883, 891. Frost, H. R., United States, 653. Fuller, Henry W., England, 95, 141, 187, 193, 194, 390, 489, 510, 553, 601, 609, 610, 611, 614, 616. Fuller, Wm., Canada, 184,453,489, 509, 513. S47. 592- Furbringer, Prof., Germany, 204. Furter, Prof., France, 132. Fussell, Dr., United States, 175, 185, 503. Gadbury, W. T., United States, 585. Gairdner, Dr., England, 435. Galezowski, Dr., Paris, 1000. Galluis, Dr., France, 18, 24, 180, 209. Gamgee, A., England, 526. Garcine, M., France, 117. Garland, Dr., United States, 61. Garner, J. H., Canada, 100. Garrettson, J. E., United States, 673, 1014. Garrod, A. B., England, 194, 399, 559, 610. Gaspacini, Dr., Italy, 785. Gassicourt Cadet, De, 882. Gaiint, T. I., United States, 344. Gauthier, Dr., Europe, 164. Gay, Dr., 814. Gayet, Dr., 1002. Gavoy, Dr., France, 117. Gazzo, J. B. C, United States, 584. Gebhard, Lewis P., 741. Geiger, A., United States, 956. Gendre, Dr., France, 567. Gerhardt, Prof., 78. Germain-See, Prof., France, 26, 33, 165, 522. INDEX OF AUTHORS. 1023 Gerne, Paul, France, 737. Getz, Dr., Iowa, 781. Gibb, Dr., Scotland, 148. Gibbes, Heneage, United States, 1 10. Gibbons, Henry, United States, 280. Gibler, Dr., 644. Gilbert, Dr., France, 114, iif. Gillette, Dr., France, 434, 436. Gillette, W. R., New York, 955. Gilliford, R. H., United States, 384. Giordano, Dr., Italy, 323. Girgensohn, X., Germany, 596. Gleason, J. G., United States, 148. Goodell, Wm., United States, 470, 853. Golis, Prof., Vienna, 995. Goodeve, 229, 262. Goodhart, J. M., England, 427, 727. v Goubert, Dr., France, 438. Granby, Dr., United States, 553. Granville, J. M., England, 239, 523, 606. Gratzer, Eugene, Germany, 153. Graves, Dr., United States, 32, 54, 135. Graves, Prof. R. J., Ireland, 58, 85, 205, 209, 248, 249, 263, 287, 389, 455, 465.472, 473. 489, 509, 520, 637, 658, 667. Gray, E. B., England, 440. Grazzini, Dr., Italy, 384. Green, W. E., 860. Greenhow, Dr., 44, 48, 55, 6oo._ Gregory, C. L., Ohio, 946. Griffiths, J. P. C, United States, 456, 488. Grimshaw, Dr., England, 626, 630. GrisoUe, Dr., France, 398. Gross, Dr., England, 274, 336. Gross, S. D., United States, 380, 395, 402, 495. 509. 539, 554. 559. 675- 994. 995. J003. Grove, J., England, 229. Grunert, Prof., 37. Guaita, Dr., Italy, 922. Gubler, A., France, 138, 264, 279, 334, 387, 393. 504. 59°- Guersant, Dr., France, 70. Guibert, Dr., France, 389. Guerder, Dr., France, 535. Guichon, Dr., France, 327. Gull, W. W., England, 184, 187. Giinter, Dr., Germany, 487. Gumey, Thomas, England, 783. Habershon, S. O., England, 167, 261. Hadjes, Dr., 488. Hagar, M., Germany, 772. Hahn, Dr., Germany, 189. Haig, Alexander, 409, 469, 471. Hall, A. R., India, 578. Hall, F. De HavUand, England, 347. Hall, Marshall, 425, 446, 454. Haller, Dr., Germany, 455. Hamilton, A. M., United States, 423, 521, 524, 525, 982. Hamilton, A. McLane, 656. Hamilton, A. W., 429. Hamilton, J. B., United States, 437, 448, 547. Hamlin, Dr., United States, 225. Hammond, Wm. A., 419, 426. 428, 429> 454. 465, 472, 484, 497, 506, 517, 527, 660, 672, 6; 6, Hanks, Dr., 794. Happel, T. J., United States, 275. Hardy, Prof., France, 556. Hare, E. J., England, 40. Hare, Prof. H. A., Philadelphia, 125,436, 883. Harkin, Dr., Ireland, 981. Harley, George, England, 33, 199, 211, 215, 3»o. 333. 336, 350. 357. 437. 438. 453. 5°8. 627, 666. Harlow, Alonzo, United States, 628. Harman, G. H., 721. Hartshorn, Henry, United States, 178, 185, 296, 597. 613. 633, 945. Hassall, A. H., 136. Hausmann, Dr., Germany, 82, 195. Hay, George, United States, 147, 149, 182, 378, 393- Hay, Thomas, Philadelphia, 943. Hayden, Dr., Ireland, 138, 190, 201. Hayem, Dr., France, 253, 543. Haywood, John W., London, 735. Headland, F. W., England, 57,424, 454, 517. Heberden, Dr., England, 455. Helvetius, Dr., Germany, 275. Henoch, Dr. Edward, Berlin, 681, 721, 733, 756, 7C6, 776, 821, 835, 842, 849, 867, 877, 883, 895, goi, 917, 934, 958, 965. 969. 973. 979. 987. 989. 993. 1007. '0'4- Henocque, Dr., France, 82, 308. Henry, F. P., United States, 617. Hepburn, W. M., Pennsylvania, 799. Herard, Dr., France, 177. Heroguelle, Dr., France, 507. Herpin, Dr., Geneva, 448, 454. Herr, Dr., Ohio, 945. Herschell, George, England, 610. Hertzka, Dr., Germany, 528. Heuser, P., Germany, 735. Heuter, Dr., 764. Hewson, A., United States, 328. Higgins, J. J., New York, 810. Hill, J., England, 812. Hill, J. Shelton, Maryland, 833. Hill, Thomas, 452, 583. Hill, Dr., England, 93. Hillier, A., Germany, 308. Hillier, Thomas, England, 253, 432, 436, 438, 439, 440, 800, 871, 988. Hinkel, F. W., United States, 82. Hinton, R. K., United States, 181. Hirschlield, J., Vienna, 84. Hitchman, W., England, 640. Hoag, J., United States, 380. Hodder, Dr., Canada, 230. Hoffman, Dr., Germany, 86. Holcombe, Dr., United States, 357. Holden, E., United States, 34, 185. Holden, J. S., England, 91. Holland, H., England, 393, 427- HoUoway, George, 819. Holt, Dr., 762. Holmes, Dr., United States, 83, 85. Home, Dr., England, 455. I024 INDEX OF AUTHORS, Hood, Donald W., England, 298. Hope, J., England, 31, 188, 192, 208, 259, 390, 392, 451. Horion, Charles, France, 402. Hortz, F. C, New York, 797. Hubbard, S. P., Virginia, 770, 929. Huber, F., 815. Huchard, M., France, 23, 172, 176, 177, 214, 308. 557. 564. 630. Hughes, C. H., United States, 426. Hughes, Dr., France, 140. Huguenin, Dr., France, 540. Hunt, Dr., United States, 513. Hunt, F., United States, loi. Hunter, George Y., India, 579. Hurd, E. P., 498. Huss, Dr., France, 210, 666. Hutchius. Dr., United States, 392. Hutchinson, J. C, 593. Hutchinson, J. H.. United States, 134. Hutchinson, Jonathan, England, 231. lUingworth, C. R., England, 29, 796, 806. Ingalls, J. Fletcher, Chicago, 861. Ingraham, Dr., United States, 92. Isambert, Dr., France, 99. Isnard, Dr., France, 247. Jaccoud, Dr., Paris, 113, 121, 176, 307. Jackson, J., United States, 213. Jackson, J. H., England, 422. Jackson, -S., United States, 594. Jackson, S. K., Virginia, 935. Jacobi, A., New York, 140, 513, 715, 762, 764, 804, 817, 899, 903, 946, 950, 951, 955, 960, 968, 976. Jameson, Dr., Ireland, 655. Jamieson, W. A., Scotland, 510. Jenner, W., England, 292. ^ Jewett, Dr., United States, 392. Joal, Dr., France, 464. Johnson, F. N., United States, 609. Johnson, George, England, 41, 221, 223, 228, 449, 629, 632, 753. Johnson, James, England, 471. Johnson, L. C, Cincinnati, 754. Jones, C. Handfield, England, 31, 104, 184, 187, 289, 533. Jones, L. M., United States, 594. Jones, Podmore, England, 339. Jones, H. McNaughton, Ireland, 635, 637. Jones, J. T., United States, 219. Jones, Roberts Arthur, England, 1003. Josephson, Dr., Hamburg, 77, Jounod, Dr., France, 86. Jurgensen, T., Germany, 162. Kaatzer, Dr., Germany, .343. Kahler, O., Germany, 56. Kaiser, Prof., Germany, 315. Kalb, Dr., England, 631. Keating, J. M., Philadelphia, 716, 749, 836, 850, 869, 928, 948, 1013. Keating and Edwards, Drs., 963, 964, 967. Kelley, H. A., United States, 504. Kellogg, A. O., United States, 415, 475. Kennedy, Henry, England, 375. Kennedy, N. B., United States, 598. Kennard, Dr., St. Louis, 780. Kennedy, S., Michigan, 31.0 Kenyon, George, England, 463, 464. Kerr, Dr., England, 262. Kilner, Dr., 929. Kilpatrick, A. R., United States, 321. Kimberger, Dr., 542. Kimmer, F., New York, 1006. King, F., United States, 405. King, W. S., 830. Kinnear, Dr., United States, 89. Kissel, Dr., 160. Kitchen, D. H., 666. Klebs, Dr., Germany, 771, 796. Knaggs, Dr., 769. Knight, O. C, United States, 386. Knoll, Dr., Germany, 616. Koch, Robert, Germany, 109, 118, 140. Kocher, Dr., 544. Koniger, Dr., Germany, 83, 85. KoUer, Dr. E., Germany, 32. Korbach, S., Cologne, 780. Korytin, Dr., United States, 268. Kraft, Ebing, Germany, 488. Kraus, Emil, Germany, 320. Krause, Dr., Germany, 102, 103. Krishaber, Dr., Germany, 96. Krull, Dr., Germany, 330, 336. Krummel, Dr., 544. Kustiner, Dr., 544. Laborde, Dr., France, 502, 515. Laboulbene, Dr., France, 321, 350, 370. Laennec, Dr., France, 149. Lamande, Dr., France, 436. Lambert, W., United States, 524. Lamere, Dr., France, 318. Lancereaux, Prof., France, 57, 369. Lange, W., Germany, 402. Lasegue, Prof., France, 286. Lannois, Dr., France, 385. Lanion, Dr., Marianna Y., 207. Lanphear, Dr., United States, 22. Larrabee, J. A., Kentucky, 728, 781. Lasinsky, Dr., 832. Lassear, Dr., France, 1008. Latham, Dr., England, 192. Latour, M., France, 591. Laurencin, Dr., France, 430. Laurent, Dr., France, 437. Lawson, Henry, England, 339, 501, 931. Lax, Dr., 768. Leahy, A. W. D., India, 265. Leared, A., England, 282. Lebert, H., Switzerland, 299, 308. Leclerc, Dr., France, 24. Ledamenda, Prof., 691. Lefferts, G. M., United States, 19,63,67, lOI. Lee, Benjamin, 578. Lees, Dr., England, 922. Legroux, Dr., 430, 622, 726. Legroux and Dupr£, Drs., 972. INDEX OF AUTHORS. 1025 Leibemieister, Karl, Germany, 136. Leichenstern, Dr., 739. Leidesdorf, Dr., Germany, 445. Lemaire, Dr., France, 109. Lemoine, Dr., France, 265, 450, 476. Leourst, Dr., Germany, 579. Lepine, Prof., France, 383, 632. Lesser, Dr., 831. Leube, Dr., Germany, 302. Levi, Dr., France, 444. Leviez, Dr., France, 57. Levitsky, Dr., Germany, 548. Lewintaur, Dr., Turkey, 639, 813. Lewis, D., United States, 285. Lewis, Prof. J., 838. Lewis, M., United States, 473, 590. Lewis, Dr., France, 738. Ley, Dr., France, 77, 78. Leyden, Prof., Germany, 521. Lichtermann, Dr., 767. Lichtheim, Dr., Germany, 352. Liddell, Dr., United States, 27c. Liebig, Prof., 667. Liigeois, Prof., France, 537, 538. Lincoln, R. P., United States, 90. Lisfranc, Dr., 399. Lloyd, T. M., United States, 477. Lockie, Dr., England, 195. Loffler, Dr., 801. Logan, Dr„ England, 185. Lombard, Dr., Switzerland, 64, 130. Lombardo, Antonio, Italy, 143. Long, St. John, England, 58, 566. Loomis, A. L., United States, 130, 146, 155, •63. 177. 182, 186,191, 196, 201, 353, 359, 407, 408, 629, 655. Lortet, Dr., France, 319. Louvet, Lamar, Dr., 829. Love, I. N., 933. Loving, S., United States, 586. Lowe, John, 820. Lowenfeld, Dr., 180. Lowndes, T. M., India, 227. Ludlow, J. L., United States, 234, 830. Luflf, Dr., England, 915. Lutland, Dr., 243. Luton, M., France, 510, 528. Lutz, Dr., France, 677. Lyman, Henry M., United States, 524, 590. Lynch, John L., United States, 193. Lyndon, E. G., United States, 641. Lynn, Geo. A., Pennsylvania, 786. Lyons, Hartwick, Ireland, 658, 665. MacDonald, Keith Norman, Scotland, 736. Macfarlane, W., 829. Mackelkan, Dr., Canada, 832. Mackenzie, Dr., 1005. Mackenzie, Moore, 19. Mackenzie, Stephen, 403. Mackey, Edward, England, 206, 345. Maclachlan, Dr., Ireland, 47. Maclagan, T. J., Ireland, 60, 94, 193, 598. Maclaren, R., England, 130. Maclean, Prof. W. C., England, 268, 275, 277, 310, 314. 65 Madden, Dr. England, 130. Madigan, Dr., 506. Maffitt, A., England, 623. Magendie, Dr., England, 289. Magnan, Ernest, France, 666. Main, John S., Scotland, 283. Malet, A., Brazil, 132. Malgaigne, Prof., France, 274, 501. Maminoff, Dr., 594. Mann, E. C, United States, 62,415,427,430, 522, 531- Mannott, Dr., England, 566. Maragliano, Dr., Italy, 32, 204. Marcet, Dr., England, 144, Marchand, Charles, United States, 70, 92, 1 08. Maris, D., United States, 394. Markel, S, B., United States, 663. Marsh, Madison, United States, 066. Marshall, John S., United States, 637. Marson, J. F., 643. Martelli, Dr., Italy, 31. Martin, John, Ireland, 319, 599. Martin, Ranald, 312, 314, Martin, Sidney, France, 326, 953, 954. Martin, Wm. L., New Jersey, 802. Martineau, Dr., France, 378. Masse, Dr., France, 321. M asset. Dr., France, 33. Massiah, B. J., England, 335. Massini, Prof., Italy, 507. Matlack, Mary J., United States, 187. Mattison, J. B., United States.. 671. Maury, R. B., United States, 271. May, G. P., England, 194. Mayer, E. R., United States, 91, 588, 589, 590. Mayer, Dr., Germany, 542. Maynard, Dr., 800. Mays, Dr., 891. McBean, Dr., England, 637. McClellan, Ely, United States, 218, 219. McClure, Dr., England, 191. McConnell, Dr., England, 254. McDowell, Dr., England, India, 269. McEwen, F. A., 752. McGuire, L., United Stages, 584. McKee, Dr., South Carolina, 728. McKenna, Dr., 914. McKenzie, Morrell, London, 781. McLane, Allen, United States, 447. McLaury, Dr., United States, 496. McLean, Prof., India, 575. McNider, Dr., 946. McNutt, Dr., United States, 500. McNutt and Maxwell, 829. McPhail, Dr., United States, 405. McPhedran, W. B., United States, 541. Meadows, Dr., England, 519. Mecray, Dr., 926. Mehring, Prof., Germany, 383, 488. Meigb, Charles D., United States, 540. Meigs, J. F., United States, 49, 245, 256, 262, 322, 540, 812. Meigs and Pepper, Drs., 686, 728, 760, 763, I026 INDEX OF AUTHORS. 765, 826, 846, 856, 857, 862, 865, 887, 912, 940, 970, 974, 987, 990, 1004. Meleas, Dr., Germany, 552. Mellersh, A. H., 140. Melsens, Dr., 672. Melsheimer, C. S., Indiana, 797. Memminger, Dr., 362. Menneret, Dr., France, 286. Mennier, Dr., France, 506. Menche, H., Germany, 670. Mensche, Dr., England, 392. Mercy Hospital, Chicago, 787. Meredith, M., Iowa, 801. Mervel, Dr., Ohio, 996. Messier, M. J. B., United States, 265. Metcalf, Prof., United States, 245, 497, 791. Mettauer, Dr., 244. Meyer, L., Germany, 454, 517. Michailoff, Dr., Russia, 257. Michou, Dr., France, 149. Millard, Henry B., United States, 354, 357. Millet, Dr., France, 296. Minerbi, Dr., France, 268. Minerti, Dr., France, 954. Mirovitch, Dr., Europe, 315, 954. Minkowsky, Dr., Germany, 383. Mitchell, Giles, 749. Mitchell, R. W., 218. Mitchell, S. Weir, United States, 438, 454, 514, 522, 532. Mohn, Dr., 834. Moinet, F. W., Scotland, 178. Moizard, Dr., France, 981. Moleschott, Dr., 385, 998. Moncorvo, Dr., Rio Janeiro, 430, 823. Monell, J. S., United States, 27. Money, Angel, 727. Monk, Jacques, 832. Montgomery, E., Philadelphia, 816. Monti, Dr., Vienna, 320, 847, 1013. Moore, J. W., New York, 782. Moore, R. L., United States, 697, 927. Moore, V. H., Ontario, 822. Mooreman, J. W., United States, 262. Mordough, Dr., United States, 455. Morey, H. C, 668. Morje, Dr., New York, 830. Morris, W. J., England, 403. Morse, E. M., United States, 276. Morton, N. K., United States, 662. Mosler, Prof., 316, 319, 584, 636. Mueller, G. A., 820. Muhlberger, A., Germany, 180. Muir, Wm., Scotland, 399. Mulian, J. M., 887. MuUer, Dr., 928, 930. Miiller, W., Germany, 378. Munro, W., England, 499. Munter, Prof., Russia, 37. Murdoch, S., Missouri, 784. Murchison, Dr., England, 214, 232, 256, 336, 388, 597, 637. Murray, John, India, 184, 223. Murray, W. W., United States, 187, 235, 589. Murrell, Wm., England, 54. Musser, J. H., United States, 77, 78, 135, 340, 355. 463- Mussy, Prof. Gueneau de, France, 384, 668. Nairne, J. T., England, 137. Napier, C. O. G., England, 664. Neff, Joseph, United States, 254. Negrie, Dr., 430. Nelson, A. W., United States, 633. Nichell, H., United States, 18. Nicholls, R. M., 403. Niemeyer, Dr., 750. Niemeyer, Dr. Felix, Germany, 25,35,36, 61, 71, 74, 78, 81, 106, 116, 127, 140,184,328, 362, 433, 475, 499, 502, 546. Niermiejer, Dr., 456. Noble, C. P., United States, 244. Nonat, Auguste, 592. Norwood, Dr., United States, 162. Nothnagel, Prof. H., Austria, 238, 437, 454, 455- Nowlin, J. H., United States, 656. Nussbaiun, Prof., Germany, 499. Obersteiner, Dr., Austria, 477. Octerlony, J. A., United States, 211. O'Daniei, W., United States, 577. O'Dwyer, Dr., United States, 97, 105. Oertel, Dr., Europe, 195, 202. Ogle, Dr., England, 385, 438. Oglesby, W. W., Oregon, 792. Oliver, J. G., England, 24. Oliver, J. P., 928. Opitz, Dr., Prussia, 374. Orfila, Dr., 669. Osborne, Dr., 252, 372. Otto, Richard, United States, 146. Oulment, Dr., France, 437. Oxley, Dr., England, 489. Paget, Sir James, England, 616. Palmer, Prof. A. B., 151. Pancoast, J., United States, 20. Parisel, L., France, 49. Paris, Dr., France, 275. Parker, M. T., 945. Parker, W. I., United States, 832. Parks, N. O., United States, 192, 632. Parry, F. W., United States, 135. Pasquet, Dr., France, 428. Patton, J. M., United States, 166. Paul, Constantin, France, 188, 205, 349, 425, 539, 542, 617. Pavtsi, Carlo, Italy, 775. Pavy, F. W., England, 249, 384, 385. Peabody, J. H., United States, 589. Pecholier, Dr., France, 537. Peek, Dr., 672. Pennell, W. W., Ohio, 949. Penzolt, Dr., Germany, 32, 695. Pepper, Wm., United States, 322, 333, 460, 622, 630, 676, 980, 983. Percival, Dr., 863. Pereira, Dr., England, 86, 263, 451,562,576, 678. Perroncito, M., France, 542. INDEX OF AUTHORS. 102; Perroud, Dr., 429. Peter, M., France, 129. Peters, J. C, New York, 729. Petit, Dr., France, 83. Petresco, Prof., Hungary, log. Phares, D. L., United States, 232, 586. Phillips, C. D., England, 34, 151, 196, 344, 424, 507. Phillips, W. H., United States, 6i6. Phillips, W. E., England, 93. Picard, Henry, France, 409. Piffard, Dr., 61, 94, 489, 556, 616. Pigeon, Henry, 753. Pigne, Dupuytren, United States, 630. Piorry, Prot., France, 338. Pircher, Dr., France, 77. Piso, Prof., Italy, 275. Pitts, Bernard, England, 814. Plant, W. T., New York, 985. Pocock, E., United States, 914. Polaillon, Dr., 796. Politzer, Dr., Vienna, 688. Polk, W. M., New York, 755. PoUi, Prof., Italy, 642. Pollock, C, 974. Pollock, Julius, England, 452, 536. Pontain, Dr., 177. Poore, G. V., England, 518, 528. Porcher, Dr., France, 389, 728. Porcher, F. Peyre, United States, 529, 551, 650, 656. Porter, P. B., 830, 842, 847, 852. Potsdamer, Joseph B., 812. Potts, Charles S., United States, 445, 451. Poulet, Dr., France, 24, 594. Powel, Douglas, England, 345. Powell, \V. B., Louisiana, 755, 787. Power, R. E., England, i6i. Prangley, Mr., England, 284. Pratt, H. J., United States, 443. Prentiss, Dr., United States, 596. Prideaux, E., France, 600, 639. Pritchard, Owen, London, 751. Prestwich, Mr., 831. Prout, J. S., United States, 60. Prout, W., England, 214, 283, 386. Pugh, T. J., United States, 581. Putnam, C. P., United States, 258. Quinlan, F. J. 6., Ireland, 144. Rachel, Dr., 818. Radcliffe, C. B., 436, 438, 630. Radlauer, Dr., England, 490. Ragland, A. M., United States, 273. Ralfe, Dr., England, 403. Ramsey, D. C, United States, 455. Ramskill, J. S., 438, 447. 454, 5'9. 533. 539. 561. 995. 998- Randolph, Dr., United States, 613. Ransom, Dr., United States, 371. Rape, W. A., United States, 315. Raspail, Dr., France, 458. Ravenburgh, Rudolph, Washington, 930. Rawie, F., England, 266. Rawson, A. A., United States, 488. Read, A. N., Ohio, 996. Read, W., United States, 548. Rebovy, Dr., England, 140. Recamier, Dr., France, 278. Redenbacher, Dr., 811. Reece, Dr., France, 210. Reece, Madison, 794. Reed, C. A. L., United States, 33. Reid, E. M., 798. Reiss, L., Germany, 298. Reith, Dr., Scotland, 609. Renduer, Dr., France, 376. Renoy, Dr. Jumel, France, 620. Reveil, Prof. O., France, 18. Reynolds, Russell, England, 19, 199, 275, 455. 533. 549, 609. Rhode, Dr., Germany, 329. Richardson, B. W., England, 139, 386, 820. Richie, C. Currie, England, 848. Ricker, Dr., Germany, 256. Riebe, M., France, 152. Rilliet, Dr., 729. Rienzi, Prof., 207. Ringer, Sidney, England, 34, 70,93, 134, 136, 151. '92. 227. 260, 261, 287, 305, 343, 344, 370, 384, 396, 436, 524, 530, 612, 828, 929, 930, 966. Rirey, P. M., United States, 191. Ritchie, R. T., 929. Rixey, P. M., United States Navy, 68. Rockwell, A. D., United States, 20, 236, 250, 524. 617. Roberts, F. T., 307, 323, 384, 732. Robinson, Beverly, United States, 59, 173, 192, 198, 365. Robinson, Dr., United States, 68. Robsin, Mayo, 358. Roe, John O., United States, 88. Roger, Dr., France, 434, 436. Rogers, Lewis, United States, 212. Rokitansky, Dr., 793. Romberg, Dr., Germany. Rony-Saucerotte, Dr , Paris, 160. Rosenbacb, Dr., Germany, 77. Rosenberg, Dr., 102, 103, 213. Rosenbusch, Dr., 36. Rosenstein, Prof. S. S., Germany, 202. Rosenthal, Prof. M., Austria, 502. Rossbach. Dr., Germany, 75, 268, 950. Ross, G. €., India, 220. Rotch, T. M., 698. Rothrock, Dr., 526. Rougier, Dr., 438. Roziere, M., France, 18. Rumbold, Dr., 319. Runge, F., Germany, 528. Ruschenbergher, Dr. 225. Rutherford, Prof., Scotland, 337. Sajous, C. E., United States, 62, 87, 99, 102, 103. Salter, Hyde, England, 27, 32, 34, 35, 37, 554- Samson, Dr., 728. Sandby, Dr., England, 246. I028 INDEX OF AUTHORS. Sanky, Dr., 831. Sansom, Dr., 144, 191, 852. Sartorius, Dr., Germany, 695. Saundby, Robert, England, 295. Sassjadke, Dr., Germany, 348. Sawarosky, Dr., 828. Sawyer, James, England, 489, 490, 590. Sayre, Dr., United States, 522. Scearce, J. B., 151. Schaeffer, Dr., 795. SchaBrt, A. J., United States, 377. Schanz, Dr., 226. Schenck, W L., United States, 666. Scherbakoff, Dr., 144. Schidowsky, Dr., Russia, 324. Schiltz, Dr., 793. Schilling, Dr., Scotland, 599. Schneider, H., Vienna, 86. Schnitzler, Dr. J., 19, 139. Schoenman, Dr., United States, 561. Scholz, Dr., Germany, 537, 636. Schrotter, Prof., Germany, IC5. Schrumpf, Dr., Germany, 506. Schwalbe, Carl, Costa lUca, 267. Schwarz, M., Germany, 544. Schwimmer, Dr., 641. Scott, Dr., United States, 35. Scriven, J. B., India, 582. Scudamore, SirC, England, 145, 561, 562. Scudder, John M., 104, 376, 751. Sedgwick, G., 797. Sedgwick, Wm., 221. Sedgwick, L., England, 71. See, Prof. Germain, Paris, 179, 182, 204, 349, 440, 600. Seegen, Prof., Germany, 383. Seguin, E. C, United States, 90, 411, 443, 461, 482, 491. Seller, Carl, United States, 65, 87, 854. Selden, Dr., 795. Selma, Dr , 581. Siek, J. F. W., England, 437. Semmola, Prof., Italy, 311, 359. Semple, Armand, London, 6S2, 821, 843, 849, 869, 876, 916, 933, 965, 973, 982, 993. Senator, Dr., Germany, 552, 359. Seure, A., France, 462. Sevetlin, Dr., Germany, 445. Seymour, Dr. A., United States, 460. Shaw, Dr., 445. Sheadle, Dr., 969. Shearer, Frank, Edinburgh, 752. Shearer, J. Y., United States, 589, 738. Sbeshemnitzyofif, United States, 158. Shoemaker, W., United States. 83, 85, 456. Shurley, G., United States, 1 10. Sibson, F., England, 362. .Sieffert, R., 784. Silbermann, Dr., Germany, 869, 961. Sim, F. L., Tennessee, 753. Simon, — ., 430. Simon, M. J., Paris, 752, 802, 871. Silverthome, United States, 152, Simpson, Prof., Scotland, 288, 453, 505. Sinkler, Wharton, United States, 588. Skoda, Dr., Germany, 189. Skinner, Dr. Stephen, England, 625. Slane, Dr., India, 586. Smelt, Isaac, United States, 656. Smith, A. A., United States, 656. Smith, Eustace, England, 436. Smith, J. Lewis, 322, 546, 727, 729, 740, 772, S09, 829, 873, 885, 918, 942. Smith, Q. C, California, 874. Smith, H. Pye, England, 202. Snell, Dr., 483. Snow, Edward M., 830, 832. Snow, C. F., Chicago, 832. Snyder, Dr., Sydney. 56. Sokalowsky, Dr., Russia, 97. Spencer, Dr., 620. Spender, J. K., England, 244, 263, 464. Spitzka. E. C, United States, 449. Sprimon, V. F., Germany, 583. Squibb, E. R., United States, 224, 259. Squire, W., England, 181, 318, 793, 796, 797. Starr, Louis, 875, 900. Stedroan, Dr., United States, 621. Steffen, Dr., 893. StefHer, Dr., 726. Stierlein, Dr., 892. Steinbruck, Dr., Germany, 142. Steiner, Johann, Prague, 825, 846, 946, 976. Stellwagen, T. C., United States, 259. Stengel, Alfred, United Slates, 266. Stepp, Dr., 819. Sternberg, Dr., United States, 44, 653. Stevens, Geo. T., United States. 432. Stevens, Wm., England, 220, 277. Stewart, F. E., United States, 544. Stewart, G. F., Tennessee, 796. Stewart, Wm., India, 311, 812. Stille, Dr., 49, 64, 139, 391, 436, 470, 505, 557. 728- Stiller, Prof., Hungary, 214, 216. St. George, George, Ireland, 45. St. Martin, M., France, 72. St. Philip, lir., France, 155. St. Pierre, Dr., France, 537. Sterling, Dr., Australia, 83. Stokes, Prof. Wm., Ireland, 47, 49, 524. Stohrer, Dr., 440. Stone, Dr., England, 439. Storch, Dr., 892. Storer, Dr., 113. Strahan, John, England, 998. Strange, Wm.,' England, 430. Strieker, Dr., Germany, 542, 599. Strohl, 161. ■ - Stuckert, 313. Sturgis, F. R., 504, 837. Sturgis, Russell, 1004, 1006. Styrap, J., 675. Suckling, Dr., England, 340. Suell, Simon, 1000. Sullivan, John, India, 225, 632. Sunderland, Dr., United States, 133. Sweeting, Dr., 750. Sweringen, H. V., United States, 18, 33, 533. Sydenham, Dr., England, 393. INDEX OF AUTHORS. 1029 Syme, James, Scotland, 674. Symonds, J. A. England, 36, 84, 143. Tait, Lawson, England, 340. Talamon, Dr., Franre, 638. Tanner, Thos. H., England, 98, 124, 137, 139, 145, "78. 243. 262, 384, 465, 472, 473, 509, 533, 594- Taylor, A. S., England, 513, 568. Taylor, Dr., Baltimore, 812. Taylor, R. W., New York, 841. Taylor, Seymour, England, 79. Thatcher, Prof., United States, 542. Thibon. M., Belgium, 803. Thomas, Dr., 727, 845. Thompson, A. T., 235, 292, 453, 525. Thompson, Ashburton, England, 492, 510. Thompson, B. F., England, 270. Thompson, Sir H., England, 403, 404. Thompson, R. E., England, 35. Thompson, Symes, England, 131. Thompson, Wm., United States, 240, 587. Thompson, W. H., New York, 732, 751. Thorogood, J. C, England, 22, 31, 53, 57, 515, 892, 985. Thurston, G. B., United States, 218. Tichbome, Dr., England, 297. Tillmans, Dr., England, 118. Tilt, Edward J., England, 345, 489. Tisne, Dr., France, 141. Todd, J. F., 422. Townsend, C. W., 866. Tordnes, Dr., 833. Traichler, Dr., 1005. Trechinsky, Dr., 64. Trosseau, Dr., France, 18, 26, 63, 71, 73, 92, 144, 184, 278, 291, 320, 326, 375, 422, 433, 438, 498. 5". 520, 521, 524. 730. 928. Troubert, C, France, 510. Tuckwell, H. M., England, 440. Tumbull, James, England, 50. Turner, R. S., 998. TyUio, Dr., Italy, 82, 86. Tyrrell, Walter, England, 446. 454, 665. Tyson, James, United States, 374, 400, 408, 633.774,915- Ullman, E., 931. Upshur, J. N., United States, 404. Ulrici, Dr., 508. Vachetta, Prof. A., Italy, 543. Valleix, M., France, 328. Van Bibber, John, United States, 435. Van Buren, Prof. W. H., United States, 243. Vance, Reuben A., United States, 526. Van C^e, Dr., France, 629. Van Sant, Dr., United States, 588. Varich, Dr., United States, 140. Veillard, Dr., 952. Velpeau, Dr., France, 642. Vickery, H. F., United States, 257. Vidol, M., Paris, 1009. Vogel, Dr., Russia, 875, 913. Vogelsang.Dr., Switzerland, 833. Vogt, Dr., Germany, 162, 502. Voison, August, France, 448, 453. Volner, Dr., 430. Von Gueser, Dr., 821. Von Niemeyer, Felix, Germany, 808, 827. Von Swerengen, H., India, 274, 301. Vovard, M., France, 986. Waakes, Edward, England, 500, 502, 507. Wade, D. €., United States, 424, 451. Wade, W. F., England, 434. Wagner, Dr., Friebourg, 800. Wairenburg, Dr., Germany, 174. Waldenburg, L., Germany, 64, 129. Walker, B. M., 500. Walker, E. F., United States, 328, 329. Walker, J. B., Philadelphia, 728. Wallace, E., United States, 540, 997. Walske, Dr., England, 84, 86, 145, 184, 194, 388, 474. Waller, Dr., Geneva, 511. Warburg, Dr., India, 575. Warfering, W., 988. Waring, Dr., England, 226, 228, 260, 262, 272, 276, 693. Warner, Muller, Germany, 387. Warren, Dr.. 109, 781, 796. Waters, A. F. H., England, 157, 192, 195, 206. Waters, Eben, Scotland, 524. Watson, Thomas, Scotland, 37, 50, 225, 289, 3«7, 322, 339. 372. 384. 404. 454, 517- Waugh, Dr., Philadelphia, 79, 633, 909. Waylen, C. W., 569. Waxham, Dr., United States, 97.' Webb, F., United States, 327. Webb, R. D., United States, 581. Webb, W. C., 823. Webber, S. G., United States, 342. Weber, Leonard, New York, 874. Weber, Hugo, 114. Weill, Dr., France, 30. Weir, A. M., Scotland, 84. Welsh, Wm. M., United States, 27. Wertner, Dr., Vienna, 53. West, Charles, England, 326, 436, 439. West, Dr., 828, 995. Westbrook, B. F.,'47. Westmoreland, J. G., United States, 94, 453. Wetherell, Henry M., United States, 477. Whipham, T., England, 98. White, John M., United States, 294. White, W. Hale, 800. Whitehead, W. E., United States, 270. Whitehead, P. F., 794. Widerhofer, Dr., Austria, 863. Widermuth, Dr., 446, 452. Wilkes, S., London, 733. Wilkes, G., England, 624. Wilkins, H. S., United States, 319. Wilks, Samuel, England, 163, 184, 187, 393, 437. Willebrand, F., Russia, 582, 589. Williams, C. J. B., England, 59, 71, 123, 161, 584. I030 INDEX OF REMKDIES. Williams, John, England, 50. Williams, J. D., United States, 26, 129, 628. Williamson, J. M., England, 84. Willis, Dr., 455. Willoughby, Dr., England, 481. Wilson, Thomas, England, 289, 351. Wilson, J. C, United States, 619, 625. Wilson, E., 750, 759. Winn, Dr., England, 194. Wintreben, Dr., 834. Wintemitz, Dr., 261. Wood, G. B., United States, 623, 652. Wood, Andrew, Edinburgh, 727. Wood, H. C, 46, 93, 156, 272, 322, 371, 376, 425. 43O1 451. 567. 623, 892. Woodbury, Frank, Philadelphia, 557. Woodhull, A. A., United States, 271, 310. Woolbridge, Dr., United States, 627, 630. Woods, F. H., Australia, 353. Woodworth, J. M., United States, 219. Worthington, A., Canada, 738, 739. Wright, H. G.. 458, 464, 466, 468, 471, 472. Wunderlich, Dr., Germany, 630. Wyman, Morrell, England, 90. Wycsk, Dr., 160. Wyld, P. T., 769. Yandell, L. P., United States, 445. Yeaman, J. B., United States, 151. Yeo, L. B., England, 109, 134, 280. Young, David, Italy, 252. Zacharum, Prof., Russia, 301. Zarerzhevski, Dr., England, 139. Zarzana, Dr., Italy, 385. Ziehen, Dr., Germany, 477. Ziemssen, Prof, von, Germany, 301, 548. Zounis, Dr., 893. II. INDEX OF REMEDIES. EITHER OF LATE INTRODUCTION, OR RARELY EXHIBITED. Acidum hydiobromicnm, 50, 52, 423, 424, 437. 4SI- hydrocyanicum, 28, 52, 85, 98, 133, 153, 283, 295, 343, 589. hyp'rosmicum, 508. oxalicum, 25. phosphoncum, 73, 86, 221, 357, 386, 394, 420- pipitzahoic, 249. salicylicum, 152, 273, 325, 500, 545, 561, 598, 599, 611, 639, 642, 652, 729, 742, 749, 773, 928, 1007, 1008. Aucupuncture, 394, 511. Adonis vemalis, 174, 184, 206, 246. .ffither, 31, 36, 77, 213, 233, 236, 504, 511, 597, 876. Ailanthiis glandulosa, 319. Allyl hydrobromate, 489. Ammonium bromidum, 43, 90, 181, 446, 451, 466, 472, 661, 665, 670. formeis, 519. sesquicarbonas, 283. valerianas, 452. Amyl nitrate, 29, 34, 138, 176, 181, 185, 345, 452. 454. 586, 828, 833, 976. Aniline, 140, 436. Antifebrin, 92, 93, 451, 505, 630. Antipyrin, 29, 31, 82, 92, 93, 139, 159, i8i, 308, 376. 383, 430. 446, 45°. 472. 505. S« 5. 552, 564, 630, 750, 829. Apiol, 505. Apomorphia, 31. Arlentin, 392, 399. Armoracia radix, 393, 520. Arsenicum bromidum, 452. chloro-phosphide, 522. Asclepias lyriaca, 392. Asparagin, 187. Aurum bromidum, 438. Bael, 929. Beberia sulphas, 505. Bismuth salicylate, 258, 368, 565, 625, 726, 929. Blatta orientalis, 393. Bray era, 319. Bromides, 32, 199, 343, 424, 441, 443, 445, 45°. 75». 810, 831. Bromine arsenite, 384. Brucia, 446. Bryonia, 829. Butyl chloral, 405. Caffeine, 28, 165, 175, 204, 206, 366, 393, 474. Calamus, 104. Calcis carbolas, 261, 834. hypophosphis, 126. iodide, 132. phosphas, 53, 140, 261, 281, 966. saccharis, 247. Calcium chloridum, 140. salicylas, 929. INDEX OF REMEDIES. 103 1 Cannabinum tannicom, 515. Carbo-bisulphis, 463. Casca bark, 184, 206. Cascara sagrada, 243, 244, 247, 287, 482. Castoreum, 32, 453. Centaurea benedicta, 453. Cerii oxalas, 53, 453, 945. Chimaphila umbellata, 371, 393. Chinopodium, 322. Chloramid, 488. , Chloride of gold, 348, 371, 376, 428, 483. Chlorine, 20, 21, no. Chlorodyne, 225, 234, Cocaine, 29, 33, 62, 71, 89, 92, 94, 308. Cocillama, 248. Condurango bark, 298. Convallaria, 164, 175, 184, 206, 357. Coronilla scorpioides, 175. Cotoin, 256, 262. Creohn, 274, 293, 297, 353. Croton chloral, 498, 506. Cusparia cortex, 262. Datura tatula, 33. Dobell's solution, 69. Dracontium, 33. Duboisia, 138. Emetina, 50. Eserine, 278. Ethyl bromide, 181. Ethyl iodide, 26. Eucalyptol, 109, 144. Eucalyptus, 91, loi, 160, 199, 288, 305, 351, 473. 589. 631, 798. Euonymin, 335, 337, 357. Euphorbia carolatta, 371. Euphrasia officinalis, 94. Exalgine, 507. Fattening food, 515. Fel bovinum, 210, 235, 248, 332, 660. Felix mas, 319. Ferrum acetas, 203. Ferrum bromidum, 437. Fir-leaf oil, loi. Fuligo ligni, 318. Franklinization, 512. Guarana, 94, 263, 472. Grindelia robusta, 33, 77, 91, 94, 589. Hamamelis, 83, 85. Heluuias dioiua, 358. Hydrastis canadensis, 70, 83, 85, 288, Hyoscine, 486. Hypnotism, 512. Ignatia, 245, 489. lodol, 385. Iridin, 338. Jaborandi, 138, 149, 207, 358, 37 1, 376, 385, 393, 398. Jambul, 382, 385. Juglans, 142. Kameela, 320, 952. Koumiss, 55, 142, 344. Kousso, 315, 320. Larix Europoea, 55. Leptandrin, 260, 338. Listerine, 65, 67. London paste, 68. Manaca, 610. Massage, 237, 250, 290, 513. Matico, 85, 263, 308, 404. Methylal, 488. Methyl chloride, 513. Monarda, 44. Muscarine, 94, 376. Mussonin, 321. Napelline, 515. Naphthaline, 55, 268, 297, 315, 321,930,950, 954. Naphthol, 726. Nickel bromide, 453. Nickel sulphate, 279. Nitrogen, 34, 142. Oenothera, 55. Oxygen, 34, 44, 77, 108, 145, 351, 376, 454, 543, 812. Papayotin, 795. Paracotoin, 229, 257. Paraldehyde, 35, 483, 488. Parthenicile, 508. Pelletierine, 321. Pbellandrium, 44. Phenaticine, 508, 632. Picrotoxin, 138, 519. Pilocarpine, 35, 44, 56, 139, I43, 149, 361, 393, 406, 481, 483.567. 752. 768, 795- Piscidia erythrina, 508. Polygala, 23. Pyridin, 29. Quebracho, 29, 35, 77, 207. aspidospermine, 32. Quillaya, 72. Resorcin, 294, 593. Rhamnus frangula, 249. Salol, 260, 568,611, 860. Santonin, 323, 324, 327, 438, 454, 953. Saoria, 321. Sodium arsenias, 438. sulphas, 389. sulpho-carbolas, 144* tannate, 358. Somnal, 490. Sparteine, 165, 175. „ ^ » Strophanthus, 164, 174, 185, 196, 204, 208. Sulphonal, 382. Terebene, 114. Terpene, 44, 57- j Thompson's solution, 492. I032 Thymol, 19, 109, 283. Toxicodendron, 520. Urethan, 483, 488. Urtica dioica, 394. INDEX OF DISEASES. Zincum bromidum, 429, 527, 660. cbloridum, 99, 100, 104, 526. phosphas, 89, 421, 422, 473, 510. sulpho-carboias, 67, 71. 111. INDEX OF DISEASES. Abscess, hepatic, 309. Acidity of the stomach, (see Pyrosis), 338. Acute coryza, 854. Acute rheumatism, 598. Ague, 569. Albuminuria, 346. Alcoholism, 654. Anaemia, 535, 965. of the brain, 429. of phthisis, 131. pernicious, 541, 967. symptomatic, 539. Aneurism, 175. Angina pectoris, 176. Aphonia, 17. catarrhal, 17, nervous, 19. paralytic, 20. Apoplexy, 415. Appetite, loss of, 209, Arsenicism, 668. Ascaris lumbricoides, 322. Ascaris vermicularis, 324. Asthma, 21. catarrhal, 26. humid, 30. spasmodic, 25, 29, Autumnal catarrh, 87. Biliary calculi, 211. Bright's disease, 352. acute, 352. chronic, 359. Bronchitis, acute, 37, 883. capillary, 38. of the aged, 45. chronic, 45, 991. of the aged, 46. Broncho-pneumonia, 893. putrid, 51. Calculi, biliary, 211, Cancer of stomach, 298. Cardiac derangements, functional, 196. secondary', 169. dilatation, 182. disease, valvular, 201, hypertrophy, 185. Carditis, 188. Catarrh. 58. Catarrh, post-nasal, 65. Catarrhal jaundice, 330. Cerebral anaemia, 427. hyperemia, 415. Cerebro-spinal meningitis, 544. Chill, congestive, 571, 577. Chlorosis, 535. Cholera Asiatica, 216. Chorea, 428. anaemic, 431, dental, 431. electric, from moral causes, 431. partial, 431, ocular, 432. organic, 431. verminal, 431. Cirrhosis of Lion, 311. Cocaine habit, 672. Colic, 230. renal, 404. Congenital jaundice, 333. Congestive chill, 571* 577. Constipation, 237. Contagious jaundice, 333. Convulsif tic, 527. Coryza, 58. Chlorosis, 967. Cholera infantum, 931, Chorea, 969, Constipation, 950. Convulsions, 972. Cramp, muscular, 530. piano-player's, 528. writer's, 527. Croup, 802. Debility of phthisis, 131. Delirium tremens, 657. Dengue, 550. Dentition, 1012. Diabetes insipidus, 373, mellitus, 377. Diaphragm, spasm of, 529. Diarrhoea, acute, 251, 903. chronic, 251. of phthisis, 135. Dilatation, cardiac, 182. Diphtheria, 766. Dropsy, 387. INDEX OF DISEASES. 1033. Drunkenness, 654. Dysentery, acute, 265, 936. chronic, 270. Dyspepsia, 274, 899. atonic, 285. cerebral, 283. climacteric, 284. flatulent, 280. irritative, 285. Dyspncea of phthisis, 136. r^suria, 398. Eczema, 1006. Emphysema, 72. Empyema, 880. Endocarditis, 188, 964. Enlargement of spleen, 583. Enteritis, 293. Epilepsy, 441. Erysipelas, 764. Facial neuralgia, 498. Fatty degeneration of heart, 195. Fever, break-bone, 550. hay, 87. hemorrhagic malarial, 581. intermittent, 569. pernicious malarial, 571. relapsing, 596. scarlet, 727. typhoid, 618, 721. yellow, 644. Functional cardiac derangements, 196. derangement of liver, 336. urinary disordera, 395. Gastric cancer, 298. Gastric ulcer, 298. Gastro-enteritis, 298. Glossitis, mercurial, 674. Gout, SS3. Grippe, 563. Hsematemesis, 307. Hsematuria, 400. , ■ Hsemoglobinuria, paroxysmal, 403. Haemophilia, 968. Haemoptysis, 79. Hay asthma, 87. Hay fever, 87. Headaches, 457, 1004. anaemic, 470. bilious or dyspeptic, 458. congestive or plethoric, 459. Headaches, gouty, 469. hysterical, 465. malarial, 464. nervous, 465. neuralgic, 461. periodical, 461. rheumatic, 468. sick, 461. Heartburn, 338. Heart, fatty degeneration of, 195. functional derangements of, 196. Heart, irritable, 200. valvular disease of, 201. Hemicrania, 464. Hemorrhagic malarial fever, 581. Hepatic abscess, 309. cirrhosis, 311. • torpidity, 336. Hepatitis, 309. Hiccough, 529. Hydrargyrism, 672. Hydrocephalus, 993. spurious, 998. Hyperaemia of the brain, 415. Hypertrophy, cardiac, 185. Hypochondriasis, 475. Hysteria, 977. Hysterical paralysis, 518. Incontinency of urine, 395, 1003. Influenza, 363. acute, 476. chronic, 482. general paralysis of, 482. Insanity, 474. Insomnia, 484. Intercostal neuralgia, 498. Intermittent fever, 569. Intestinal worms, 314. Intoxication, 654. Intussusception, 955. Irritable heart, 200. Irritation, spinal, 525. Jaundice, catarrhal, 330. congenital, 333. contagious, 333. malarial, 333. pyaemic, 333. simple, 333. Laryngitis, 95, 861. acute, 95. chronic, 99. oedematous, 96. phlegmonous, 97. syphilitic, 102. tuberculous, lOl. Laryngismus stridulus, 863. Lead-poisoning, 676. Leukaemia, 542. Litbaemia, 408. Liver, abscess of, 309. cirrhosis of, 311. functional derangement of, 336. torpidity of, 336. Locomotor ataxia, 521. Lumbrici, 322. Malaria, 76(x Malarial fever, 569. hemorrhagic, 581. jaundice, 333. Meningitis, acute, 985. cerebro-spinal, 544. tubercular, 988. .I034 INDEX OF DISEASES. Mercurialism, 672. Migraine, 461. Mimetic facial spasms, 527. Muscles, cramp of, 530. Nephralgia, 404. Neuralgia, 491. facial, 498. of the fifth nerve, 491. intercostal, 498. malarial, 503. sciatic, 500. syhilitic, 503.. toxic, 503. Nenras&enia, 514. Nictitans, spasmus, 530. Night sweats, 136. Ophthalmia neonatorum, lOOQ. Opiuna habit, 669. Oxyuris, 324. PalpitatioD of &e heart, 196. Paralysis, 516. Parasites of intestines, 951. general, of insane, 482. infanlile, 982. hysterical, 518. Parotitis, 762. Paroxysmal hxmoglobinurta, 403. Pavor noctamus,979. Perityphilitis, 960. Pernicious malarial ferer, 571. Pericarditis, 188, 963. Peritonitis, 961. Pharyngitis, 859. Phthisis, 105. acute, 105. anaemia and debflity in, 131. chronic, 106. coi^h in, 133. dianhoea, 135. dyspnoea in, 136. fever in, 136. gastric symptoms in, 134. night sweats in, 136. Piano-player's cramp, 528. Pleurisy, 146, 875. Pleurodynia, 498. Plumbism, 676. Pneumonia, 150, 866. Polydipsia, 373. Polyuria, 373. Prolapsus ani, 858. Purpura bsemorrhagica, 594. Pyaemic jaundice, 333. i^rosis, 338. Rachitis, 847. Kelapsing fever, 596. Renal colic, 404. Rheumatism, acute, 598. chronic, 613. Rose cold, 87. Round worms, 322. Rubeola, 754. Sciatica, 500. Sclerosis, spinal, 521. Scrivener, palsy, 527. Scurvy, 617. Scrofula, 835. Seat worms, 324, Singultus, 529. Sleeplessness, 484. Small-pox, 638. Sneezing, spasmodic, 531. Spasm of the diaphragm, 529. Spasmodic diseases, 526. Spasmus nictitans, 530. Spinal irritation, 525. Spinal sclerosis. 521. Spleen, enlargement of, 583. Spotted fever, 544. Stomatitis, aphthous, 896. catarrhal, 895. follicular, 896. gangrenous, 896. parasitic, 895. St. Vitus' dance, 428. Sweats, night, 136. Syphilis, inherited, 837. Taenia, 314. Tape worm, 314. Tetany, 530. Thread worms, 324. Tic convulsif, 527. Tic douleureux, 498. Tonsillitis, 860. Torpidity of liver, 336. Trichinae, 329. Trichinosis, 329, Typhoid fever, 6 1 8. Typho-malarial fever, 628. Typhus fever, 633. Ulcer, gastric, 298. Ulitis, mercurial, 673. Uraemia, 406. Uric acid diathesis, 408, Urinary, disorders, functional, 395. Valvular heart disease, 201. Variola, 638. Vertigo, 531. aural, 533. gastric, 531. of old persons, 533. Vomiting, 342. Whooping-cough, 817. Worms, intestin^ 314. round, 322. seat, 324. tape, 314. thread, 324. Writer's cramp, 527. Yellow fever, 644. 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(Univ. of 'Ireland), £te Res. Surgeon Belfast Union Infirmary and Fever Hospital. Octavo. Cloth, I1.50 STTTTON. Lectures on Pathology. Delivered at the Ldndon Hospital by the late Henry Gawen Sutton, m.b., f.r.c.p.. Physician and Lecturer on Pathology at the London Hospital. Edited by Maurice E. Paul, m.d., and Revised by Samuel WiLKS, m.d , ll.d., f.r.s. Octavo. 503 pages. Cloth, $4.50 SUTTON'S Volumetric Analysis. A Systematic Handbook for the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids and Gases. By Francis Sutton, f.c.s. Sixth Edition, Revised and Enlarged, with Illustrations. 8vo. Cloth, I5.00 8WANZY. Diseases of the Eye and their Treatment. A Handbook for Physi- cians and Students. By Henry R. Swanzy, a.m., m.b., f.r.cs.i.. Surgeon to the National Eye and Ear Infirmary ; Ophthalmic Surgeon to the Adelaide Hos- pital, Dublin. Fourth Edition, Thoroughly Revised. Enlarged. 158 Illustra- tions. i2mo. In Press. SYMONDS. Manual of . Chemistry, for Medical Students. By Brandreth Symonds, a.m., m.d., Ass't Physician Roosevelt Hospital, Out- Patient Department ; Attending Physician Northwestern Dispensary, New York. i2mo. Cloth, $2.00 TAFT'S Operative Dentistry. A Practical Treatise on Operative Dentistry. By Jonathan Taft, d.d.s. Fourth Revised and Enlarged Edition. Over loo Il- lustrations. 8vo. Cloth, J4.2S ; Leather, $5.00 Index of Dental Periodical Literature. 8vo. Cloth, $2.00 TALBOT. Irregularities of the Teeth, and Their Treatment. By Eugene S. Talbot, m.d.. Professor of Dental Surgery Woman's Medical College, and Lecturer on Dental Pathology in Rush Medical College, Chicago. Second Edi- tion, Revised and Enlarged by about 100 pages. Octavo. 334 Illustrations (169 of which are original). 261 pages. Cloth, 53.00 TANNEB'S Memoranda of Poisons and their Antidotes and Tests. By Thos. Hawkes Tanner, m.d., f.r.c.p. 7th American, from the Lajt London Edition. Revised by Henry Leffmann, m.d.. Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Philadelphia Polyclinic. i2mo. Cloth, .75 MEDICAL AND SCIENTIFIC PUBLICATIONS. 23 TAYLOR. Practice of Medicine. A Manual. By Frederick Taylor m n Physician to, and Lecturer on Medicine at Guv's Hosnifal T^nJ^„ dk ■' ' ' Evelina Hospital for Sick Children, and LSn\"rnfie^"fer'ar^^^^^^^ r^n^^lT^ Chemistry. University of London. Cloth. VT'lheep J 5 cS TEIttEEATTOE Charts for Recording Temperature. Respi ation Pulse D^yTf I^r^?2f • R^^'S^ ^^'^^' ^''''^'•^ °^ *^ U""^ Organs. Containing 32 Lectures By Sir HE>niY Thompson, f.r.c.s.. Emeritus Professor of Clinical Sur- gery m University College. Eighth London Ed. Octavo. 470 pag^ CloA $3 50 *'l?}?'" ?'IT®''V J^" Preventive Treatment of Calculous Disease, and the Use of Solvent Remedies. Third Edition. i6mo. Cloth $1 00 THOMTTEir. Surgery of the Spinal Cord. A Contribution to the study of Bv William Thorburn, b.Sc.. m.d. Illustrated. Octavo. Cloth U 50 THOEITTON. The Surgery of the Kidney. By John Knowsley Thornton M.B. Edin. With 19 Illustrations. dotjj^ 4, ' TILT'S Change of Life in Women, in Health and Disease. A Practical Treatise By Edward John Tilt, m.d. Fourth London Edition. 8vo. Cloth, $1.25 TOMES' Dental Anatomy. A Manual of Dental Anatomy. Human and Compara- tive. By C. S. Tomes, D.D.S. 212 Illustrations. 3d Ed. i2mo. Cloth. $4.00 ^®"J*l Spre^T- A System of Dental Surgery. By John Tomes, f.r.s. Third Edition. Revised and Enlarged. By C. S. Tomes, dds With 292 lUustrations. i2mo. 772 pages. Cloth. $5.00 TEAirSACTIOirS of the College of Physicians of Philadelphia. Third Series Yr?}r- hll- }}}■ }^' ^' ^'°*^' «^^'=**' *2-SO- VI. VII. Cloth, each, JI3.50. Vol. VIII. 1886, Cloth. $3.75. VoL IX. Cloth. $2.50. .«i. voi. TKANSACTIONS American Surgical Association. lUustrated. Royal 8vo. I^ce of VoL I. II. III. IV. V. each. Cloth. $3.00. Vol. VI. Cloth. $4.50. Vol. VII. VIII. each. Cloth. $3.00. TEANSACTIOH'S of the Association of American Physicians. Vols. I and II Cloth, $2.50 each. Vol. III. Cloth. $3.50. Vol. IV. Cloth. $3.00. Vol. V. Cloth, $2. 50! Vol. VI, $3.00. TREVES. Oerman-English Medical Dictionary. By Frederick Treves. f.r.c.s.. assisted by Dr. Hugo Lang, b.a. (Munich). i2mo. }i Russia, J3.75 Physical Education, Its General Effects, Value, Methods, etc. Octavo. Cloth. jSi.25 TRIMBLE. Practical and Analytical Chemistry. Being a complete course in Chemical Analysis. By Henry Trimble, ph.m.. Professor of Analytical Chem- istry in the Philadelphia College of Pharmacy. Fourth Edition. Enlarged. Illustrated. 8vo. Cloth, #1.50 TTJRNBULL'S Artificial Anaesthesia. The Advantages and Accidents of Artifi- cial Anaesthesia ; Its Employment in the Treatment of Disease ; Modes of Ad- ministration ; Considering their Relative Risks ; Tests of Purity ; Treatment of Asphyxia; Spasms of the Glottis; Syncope, etc. By Laurence Turnbull, ji.d.. PH. G.. Atiral Surgeon to Jefferson College Hospital, etc. Thu-d Edition. Re- vised and Enlarged. 40 Illustrations. i2mo. Cloth, $3.00 TUSOIT. Veterinary Pharmacopoeia. Including the Outlines of Materia Medica and Therapeutics. For the Use of Students and Practitioners of Veterinary Medicine. By Richard V. Tuson. f.c.s. Third Edition. i2mo. Cloth, I2.50 TUKE. Dictionary of Psychological Medicine. Giving the Definition. Ety- mology, and Synonyms of the terms used in Medical Psychology, with the Symptoms. Pathology, and Treatment of the recognized forms of Mental Dis- orders, together with the Law of Lunacy in Great Britain and Ireland. Edited by D. Hack Tuke, m.d.. ll.d.. Examiner in Mental Physiology in the University of London; Co-Editor of '^The Journal of Mental Science." Two Volumes. Octavo. Cloth. 24 P. BLAKISTON, SON r will be saved. Dr. Potter has thus conferred a boon on both the student and practitioner alike, by publishing his Compend of Anatomy. The tables and plates of the nerves and arteries are excellent ; these constitute the Appendix, and by their aid one can review this important part of the work in a short space of time." — Canada Lancet, Toronto, February, i8gt. . Robinson. The Latin Grammar of Pharmacy and Medicine. 1890. By H. D. Robinson, ph.d.. Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Introduction by L. E. Sayre, ph.g., Professor of Pharmacy, and Dean of the Dept. of Pharmacy, in the University of Kansas. i2mo. 275 Pages. Cloth, $2.00 " It is a work that meets with my hearty approval. There is great need of just such a book in our American schools of pharmacy and medicine." — E. S. Bastin, Pr^asor of Botany, Dept. of Pharmacy, Northwestern University, Chicago. " The object of this useful took is a very laudable one, namely, to improve, if possible, the Latin used by both physicians and druggists, chiefly in the prescribing of drugs. While it is true diat many of the profession find it unnecessary to remember the genitive endings of words used in medicine, because of the customaiy abbreviations in prescribing-writing, there are others who frequently desire to write their directions to the druggist in Latin, in order that the patient may not leam of facts about which it is often necessary for him to remain in ignorance. We hope that the book will prove a success, and by its general employment in both pharmaceutical and medical schools, improve the knowledge of latin in both professions." — The Medical News, Philadelphia, January loth, 189I. " The plan of the book is excellent, the field new, as it fills a long-felt want All medical students should have it, both the collegian, as it will give a practical turn to his knowle^e of Latin, and the non- graduate, as it will give him a direct and usefiil acquaintance with that language. The country doctor who has not had the advantages of the younger men will find it a great help in overcoming this defect,.and may speedily acquire a familiarity with this language that will surprise his classical confrere." — Southern Col. Practitioner, December, 1890. NURSING, MASSAGE, ETC. Ostrom. Massage and the Original Swedish Move- ments. Illustrated. Second Edition. 1891. AND THEIR APPLICATION TO VARIOUS DISEASES OF THE BODY. A Manual for Students, Nurses, and Physicians. By KuRRE W. OsTROM, from the Royal University of Upsala, Sweden; In- structor in Massage and Swedish Move- ments in the Hospital of the University of Pennsylvania and in the Philadel- phia Polyclinic and College for Gradu- ates in Medicine, etc. Illustrated by 87 explanatory Wood Engravings, drawn specially for this purpose. i2mo. Sec- ond Edition. Cloth, ^i.oo "This book, which is well written and carefully illustrated, will be of service both to physicians and nurses as well as to manipulators. Mr. Ostpom, who came to this country from Sweden, has proven himself a capable teacher as well as a good masseur, his instructions being careiiil, accurate, and complete " Universiiy Medical Magazine, Philadelphia, March, i8go. Parvin. Obstetric Nursing. 1889. LECTURES DELIVERED AT THE TRAINING SCHOOL FOR NURSES OF THE PHILADELPHIA HOSPITAL. By Theophilus Parvin, m.d.. Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College ; Obstetrician to the Phila- delphia Hospited. Revised and Enlarged, i amo. Cloth, $ . 75 Humphrey. A Manual for Nurses. 4th Edition. 1891. including general anatomy and physiology. Management of the Sick-Room, etc. By Laurence Humphrey, m.d., .m.r.c.s., Ass't Physician to, and Lecturer at, Adden- brook's Hospital, Cambridge, England, iamo. 79 Illustrations. Cloth, j| 1.25 " That a work of such a character should be addressed to nurses at all is in itself a significant indication of the high standard to which the art of nursing has risen in recent years, and also a good proof of the estimation in which really good nursing is held alike by the public and by medical men. To the intelligent and often well educated women who now take up nursing either as an occupation or as a profession, some theoretical training in the elements of anatomy and physiology is very generally recognized as necessary by . all hospital authorities. . . ." — The Practitioner, London, April, iSqo. FuUerton. Obstetrical Nursing. Illustrated. 1891. A handbook for nurses, students, and mothers. By Anna M. Fullerton, m.d., Demonstrator of Obstetrics in the Women's Medical College ; Physician in charge of, and Obstetrician and Gynaecologist to, the Woman's Hospital, Philadelphia, etc. 34 Illustrations, several of which are original. Second Edition, Revised and Enlarged. i2mo. 222 pages. Cloth, I1.25 BY the same Ain'HOR. Nursing in Abdominal Surgery and Diseases of Women. 1891. comprising THE REGULAR COURSE OF INSTRUCTION AT THE TRAINING SCHOOL OF THE woman's HOSPITAL, PHILADELPHIA. 70 Illustrations. i2mo. 284 pages. Cloth, Ji. 50 OBSTETRICS— GYNAECOLOGY. Winckel's Text-Book of Obstetrics. With many- Original Illustrations. INCLUDING THE PATHOLOGY AND THERAPEUTICS OF THE PUERPERAL STATE. By Dr. F. Winckel, Professor of Gynaecology and Director of the Royal Hospital for Women in Munich. Authorized Translation, by J. Clifton Edgar, m.d.. Adjunct Prof, of Obstetrics, Medical Depart. , University of the City of New York. 192 hand- some illustrations, the majdtity of which are original with this work. 927 pages. 8vo. Cloth, ^6.00; Sheep, ;J7.oo " His practical experience and laborions researches in the literature of the subject have qualified bim to place before the profession a book which is certainly of great value, and we desire to compliment Dr. Edgar upon his foresight and admirable work in the preparation of the American translation. One of the useful things about the work is that bibUographies accompany the articles upon each special subject, while the illus- trations seem to us to be almost entirely original, which is but natural when we consider the enormous amount of material from which the author may obtain figures. The work of the American publisher has been well carried out, as it is usual under the circumstances, and we venture to say the translation is put before the pro- fession of this country in much better form than the German publishers placed the original before the physi- cians of the Fatherland." — Medical News, Philadelphia. " These additions make the perusal of the work a labor of pleasure, besides adding greatly to its value. One lays down the book with a heightened admiration for the author's learning, as well as a deep respect for his carefiil and conservative teaching." — American Journal of Obstetrics, New York. " In this hasty manner we have only sought to call attention to the salient points of this admirable work, which, though intended and especially adapted to the student, nevertheless will well repay a careful perusal by all who aspire to practice obstetrics according to the most improved modem methods. We would like to see this text-book used in this country, for the reason that it is clear and concise, that it gives special prominence to pathology, and that every page bears evidence of that thoroughness and sound conservatism which makes its distinguished author unequaled as a teacher of obstetrics." — Medical Record. Winckel. Diseases of Women. By Parvin. Second Edition, Enlarged. INCLUDING DISEASES OF THE BLADDER AND URETHRA. By Dr. F. WlNCKEL,ProfeSSOr of Gynaecology and Director of the Royal University Clinic for Women in Munich. Authorized Translation. Edited by Theophilus Parvin, m.d.. Professor of Obstet- rics and Diseases of Women and Children in Jefferson Medical College, Philadelphia. Second Edition, Revised and Enlarged. 152 Engravings on Wood. izmo. No. 2, New Series of Manuals. 766 pages. Cloth, I3. 00; Leather, ^3.50 " The popularity of the work is shown by the rapidity with which the first edition was exhausted. There * is, perhaps, no more scholarly or influential authority on gynaecological subjects among our German confreres than Winckel, and this fact, added to the respect and esteem in which his American editor is universally held, may serve to explain the early demand for a second edition in advance of a second German edition. . . . A novel feature is furnished by the chapters on diseases of the mammary gland. They are not generally dis- cussed in works of this character, but we have always been of the opinion that their consideration was quite as appropriate as that of any other portion of the genital apparatus, of which they form an essential element" — The American Journal of the Medical Sciences, Philadelphia. " It is nearly three years since we had the pleasure of reviewing the English translation of Professor Winckel's ' Diseases of Women.' The favorable comments we then made we have now but to endorse in connection with the second edition of this excellent, lucidly written gynaecological work. Dr. Theophilus Parvin has most thoroughly revised the former issue, so that the reader meets with only the latest and most matured opinions on the various debatable topics. We should like again to direct the attention of those inter- ested in gynaecological literature to the subjects on pelvic neoplasms and diseases of the female urethra and bladder. . The work is profusely illustrated, and we feel confident that those of our readers who accord it careful study will derive much pleasure and instruction from its pages." — The Practitioner, London.