QJnrttcU Inioerattg ffiibtarg Jtliaca, S?ew ^atk BOUGHT WITH THE INCOME OF THE SAGE ENDOWMENT FUND THE GIFT OF HENRY W. SAGE 1891 The date shows when this voliune was taken. To renew this book copy the call No. and give to the hbrarian. L > ^■•' ^'* HOME USE RULES All Book^ subject to Recall All borrowers must regis^ terin the library to borrow books for home use. ■ All books njust ,be re- turned at end of college year for inspection and repairs. . y^imited books must be re- . V tutned within the four week limit and not renewed. * Students must return all' books before leaving tpwn. Officers should arrange for the retiirn of books wanted during their absence from ^, town. Volumes of periodicals and of i>amphlet5 are held in the library as much as — ■• possible. For special pax- poses they are given out for a limited time. Borrowers should not use tkeir library privileges for - the benefit of other persom. Books of special value " snd gift books, when the giver wishes it, are not allowed to circulate. •»•»- •.-. Readers are asked to re- port aU cases of bo<^ marlnd wr mutilated. ^ D« aot deface books by marks and writiag. w-««--^°"*®" University Library arV18941 .. 3 1924 031 267 788 olin,anx Cornell University Library The original of tliis 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/cu31924031267788 Handbook of Therapy OLIVER T, OSBORNE, M.D. NEW HAVEN. CONN. AND MORRIS FISHBEIN,' M.D. CHICAGO FIFTH EDITION REVISED AND ENLARGED 1918 •AMERICAN MEDICAL ASSOCIATION 535 NORTH DEARBORN STREET. CHICAGO Copyright 1918 PREFACE The present edition of this handbook is necessitated by material changes in our knowledge of the etiology and pathology of many diseases as well as in our knowledge of the actions of drugs. Furthermore, it is based on a new revision of the United States Phar- macopeia which has been issued since the fourth edi- tion of this handbook was published. The article on acute anterior poliomyelitis has been entirely rewritten and is based on the extensive literature resulting from the severe epidemics of recent years. The articles on meningitis and pneumonia have been rewritten in view of investigations made last year in army camps. The article on diabetes was especially prepared for the Therapeutics Department of The Journal of the Amer- ican Medical Association by Dr. W. M. Marriott, of Baltimore. The section on "Useful Drugs," which concluded former editions, has been eliminated and the space it occupied utilized for the additions made to the discussions of various diseases. June, 1918. - Oliver T. Osborne, M.D. Morris Fishbein^ M.D. CONTENTS PAGE Preface to the Fourth Edition S Prescription Writing 13 Introduction 13 Official Preparations and Useful Drugs IS Synonyms -. 20 Thermometric Equivalents 21 Weights and Measures 21 Incompatibility 24 The Harrison Narcotic Law 26 Latin 26 Dosage , 29 Classification of Drugs 34 Treatment of Poisoning 40 Class I. Irritants of the Gastro- Intestinal Canal 40 Class II. Irritants of the Central Nervous System 43 Class III. Depressants of the Nervous and Circulatory System 45 Table of Special Symptoms and Special Treatment of Various Poisons 47 New and Nonofflcial Remedies 51 Useful Drugs S8 Some Therapeutic Principles 69 Individual Tendencies 69 The Family History 69 Unscientific Prescribing 70 Therapeutics More Than Medicine 71 Pain as a Symptom 72 Infectious Diseases 74 Measles 75 Scarlet Fever .- 19 Whooping Cough 91 Diphtheria 91 Laryngeal Diphtheria 112 Septic Sore Throat 113 German Measles 114 Chicken-Pox; Varicella. . .'. 115 8 CONTENTS PAGE Mumps ^^" Meningitis ^^° Acute Anterior Poliomyelitis 123 Hookworm Disease • ^^ typhoid Fever 149 Rheumatism 1°2 Chronic Arthritis . . . .' 166 Arthritis Deformans I'O Tetanus 171 Cholera 178 Pneumonia 1'° Erysipelas 196 Typhus Fever 1'58 Malaria ■ 200 La Grippe 203 Tuberculosis 209 Diseases of the Respiratory Tract 245 Common Colds • 245 Acute Pharyngitis , 253 Coughs 253 Acute Bronchitis 256 Asthma 258 Hay-Fever 268 Diseases of the Gastro-Intestinal Tract 276 Hygiene of the Mouth and Teeth 276 Mouth Infections 277 Foul Breath 281 Mouth- Washes and Gargles 283 Care of the Teeth 286 Pyorrhea Alveolaris 287 The Examination of Stomach Contents 291 Examination of Feces 296 Interpretation of Symptoms Referable to the Stomach 301 Acute Dysentery 305 Gastric and Duodenal Ulcer 311 Hyperacidity 319 Intestinal Stasis — Constipation 323 Spastic Constipation 327 Tapeworm 330 Ascaris Lumbricoides : Round Worm 332 Oxyuris Vermicularis : Pin Worms 333 Simple Catarrhal Jaundice 333 CONTENTS 9 PAGE Diseases of the Kidney 337 Pyelitis 337 Renal Tuberculosis 339 Albuminuria 340 Acute Nephritis 341 Chronic Nephritis 345 Uremia 349 Cystinuria 351 Indicanuria 352 Diseases of Metabolism 3S3 Diabetes Mellitus 353 Diabetes Insipidus 368 Pellagra . . . ., 369 Gout 374 Obesity 375 Disturbances of the Heart 379 Hypertension 379 Acute Pericarditis 384 Myocardial Disturbances 387 Endocarditis 390 Acute Heart Attack 403 Broken Compensation 404 Arfgina Pectoris 408 Auricular Fibrillation 410 Heart Block 414 Disturbances of the Blood 'and Blood-Making Organs... 416 Anemia 416 Pernicious Anemia 419 Leukemia 423 Hodgkin's Disease ' 425 Purpura Hemorrhagica 427 Hemophilia (Bleeders) 428 Disturbances of the Thyroid 434 Hyperthyroidism 434 Simple' Struma of the Thyroid 437 Hypothyroidism (Hyposecretion) 438 Diseases of the Nervous System 448 Chorea 448 Epilepsy 450 ; Headaches 455 10 CONTENTS PAGE Sciatic Neuralgia and Sciatic Neuritis 460 Pain in the Feet 466 Brachial Neuritis 467 Backache ' 470 Neurasthenia 479 Acute Intoxications 483 Drug Addictions 483 Lead- Poisoning 493 Delirium Tremens 497 Illuminating Gas Poisonhig 504 Heat Prostration and Sunstroke S06 Asphyxia Sll Trinitrotoluene Poisoning S14 Mercuric Chlorid Poisoning 516 Diseases of the Eye 520 Ophthalmia Neonatorum 521 Blepharitis 523 Hordeolum (Stye) 525 Iritis 525 Burns of the Eye from Lime .\ 528 Floating Spots — Muscae Volitantes 528 Diseases of the Ear 530 Otitis Media '. . . 530 Diseases of the Skin 532 Pruritus : Itching 532 Pruritus Ani '. 537 Pruritus Vulvae 541 Scabies 543 Ringworm : Tinea Trichophytina -. 545 Tinea Tonsurans 549 Tinea Cruris 549 Impetigo Contagiosa 552 Psoriasis SS3 Boils and Carbuncles SS6 Alopecia : Baldness S60 Urticaria 568 Roentgen Dermatitis 57] Hyperkeratotic Eczema of Palms and Soles 572 Chapped Hands 573 Chilblain 574 CONTENTS 11 PAGE Frostbite 576 Lichen Planus 578 Eczema 579 Sweating of the Feet and Axillae 582 Burns 584 Pediculosis 587 Plant Poisoning 588 Chloasma . . ; 590 Vaccines in Skin Diseases 591 Boric Acid in Skin Diseases ■. . r 592 Picric Acid in Skin Diseases 596 Syphilis and Diseases of the Genito-Urinary_Tract 598 Syphilis 598 Acute Gonorrhea 607 Prostatitis and Seminal Vesiculitis 616 Chancroid 619 Chronic Hypertrophy of the Prostate 620 Obstetrics and Gynecology 629 Toxemias of Pregnancy • 629 Vomiting of Pregnancy. 631 Eclampsia 636 Ectopic Gestation 639 Puerperal Fever 642 Postpartum Hemorrhage 650 Dysmenorrhea 652 Sterility in Women 654 Asphyxia Neonatorum 656 Diseases of Infancy 662 Infant Mortality and Feeding 662 Convulsions in Young Children 671 Acidosis in Children 675 Acute Diarrhea in Infants 679 Food for Children from Two to Seven 681 Incontinence of Urine in Children 685 Physical Therapy 689 The Local Application of Dry Hot Air 689 Hydrotherapy 691 Gruels and Starchy Drinks 696 Albuminous Drinks 700 12 CONTENTS PAGE Miscellaneous 703 Anesthesia 703 Disinfection 709 Anaphylaxis — Allergy 713 Vaccination Against Smallpox 721 Transfusion of Blood 724 PRESCRIPTION WRITING INTRODUCTION Correct prescription writing is such a close corollary to good therapeutics that it seems pertinent to introduce it in this book. Although some of the material which appears in this and subsequent chapters may seem ele- mentary, it is hoped that the physician who cares to read it will pardon such detail in order that the sub- ject may be presented entire. Therapeutics is the ultimate aim of the science and practice of medicine. It includes not only drug therapy, to which its definition is so often erroneously limited, but also everything that has to do with the treatment of the disease, the management of the patient, his convalescence, or his permanent return to health, and of the protection of tjie well against disease. THE MANAGEMENT OF DISEASE The administration of drugs is only a small part of the successful management of disease, which presup- poses all the physiologic, chemical, anatomic, patho- logic, bacteriologic and pharmacologic knowledge that can be obtained. This knowledge includes necessary hygienic changes, perhaps a change of climate, an arrangement of the food and drink, physical treat- ment if indicated, such mental treatment as is advisa- ble, such medicinal treatment as is needed, and neces- sary operative procedures. Altogether this is thera- peutics. The subject of therapeutics is, then, the broadest and the hardest one for the medical student to grasp, and it is safe to say that the young graduate in medicine, even after a hospital course, is less pre- pared in the bedside and office management of disease than in any other branch of his art. PSYCHOTHERAPY A proper understanding of and proper teaching of the ability of the mind to overcome many nervous disorders, to prevent the misinterpretation of, and the 14 PRESCRIPTION WRITING exaggeration of, slight physical disturbances should be encouraged. Psychotherapeutic instruction should be given in every medical school, and hospitals should have psychotherapeutic wards. PRESCRIBING PROPRIETARIES ■ While simplicity in prescription-wrriting is advisable, the art of combining drugs or of rendering a drug less disagreeable should be taught in the medical schools. Even with this laudable object in view, however, it is not justifiable for a physician to belittle his profession and forget rationality in his treatment of a patient by ordering proprietary mixtures. The physician who orders such preparations does not realize the positive harm he often does his patients, in some instances almost amounting to criminal negligence. No one deems it reputable, or scientific, or just to patients to prescribe preparations the ingredients of which he does not know. This is little less than malpractice. With the aid of an honest druggist, by means of the Pharmacopeia and National Formulary, we hardly need a single proprietary mixture in the medicinal treatment of disease. PHARMACOPEIA AND NATIONAL FORMULARY Few physicians know the range an.d compass of these books. No sane person would advocate using all of the heterogeneous mass of preparations included in them, but every physician can select the few formulas he may need that will be as elegant and pleasant methods of giving drugs as proprietary preparations and, moreover, will represent guaranteed doses of the various ingredients of the formulas selected. While the use of some of the ready made preparations is advised, it should be understood that it is much better to combine one's own prescription to fit the individual case. USEFUL DRUGS This is a list of drugs prepared under the direction and supervision of the Council on Pharmacy and Chemistry of the American Medical Association, OFFICIAL PREPARATIONS IS selected to supply the demand for a less extensive materia medica and especially to serve as a basis for the teaching of materia medica and therapeutics and for examinations on these subjects by state licensing boards. This book contains a total of some 350 sub- stances ancf their preparations selected from the vast number included in the Pharmacopeia, National Form- ulary and New and Nonofficial Remedies. NEW AND NONOFFICIAL REMEDIES This advice should not prevent a physician from trying a new drug if he thinks it is an honest one, because we should be ever ready to make use of a valuable discovery, but never to further fraud. Such a new drug should be ordered straight or used only in our own combinations, and never in a ready-made mixture ofifered by the firm interested. New and Non- official Remedies is a book containing a list of such approved remedies, with a description of their prep-" aration, their action and dosage. OFFICIAL PREPARATIONS AND USEFUL DRUGS The principal preparations of the United States Pharmacopeia may be classified as follows : 1. Solids mostly for internal use: A. Extracts (extracta). B. Pills (pilulse). C. Powders (pulveres). 2. Liquids mostly for internal use: A. Waters (aquae). B. Elixirs (elixira). C. Emulsions (emulsa). D. Fluidextracts (fluidextracta). E. Infusions (infusa). F. Liquors (liquores). G. Mixtures (misturae). H. Spirits (spiritus). I. Syrups (syrupi). J. Tinctures (tincturse). 3. Semisolids for external use : A. Cerates (cerata). B. Ointments (unguenta). 16 PRESCRIPTION WRITING 4. Liquids for external use : A. Liniments (linimenta). B. Some waters (aquae). C. Some liquors (liquores). D. Some tinctures (tincturae). I. Solids Mostly for Internal Use A. Extracts are concentrated preparations . of a drug, and are mostly moist and sticky. A few extracts are dry. They should be prescribed in pill or capsule. Extracts are usually four times the strength of the drug. , The most important are: n Extractum belladonnae foliorum Dose, 0.015 gm. or gr. % Extractum cascarae sagradse ' Dose, 0.25 gm. orgr. iv Extractum colocynthidis Dose, 0.03 gm. or gr. Vz Extractum colocynthidis compositum Dose, 0.25 gm. or gr. iv Extractum fellis bovis Dose, 0.1 gm. or gr. iss Extractum nucis vomicae Dose, 0.015 gm. or gr. % Extractum opii Dose, 0.03 gm.orgr. % Extractum rhei Dose, 0.25 gm.orgr. iv B. Official pills are ready-made preparations, and consequently it should be remembered that they may have deteriorated or become moire or less insoluble. Only one of these appears in Useful Drugs : Blaud's pills (pilulae ferri carbonatis) contain 0.065 gm. (1 gr.) of iron. Should be made fresh when wanted. Dose, 2 pills. The following pills have been much used but are needlessly complex and therefore irrational. The irritant character of some of them makes their con- tinued use unwarranted. Pills of aloes (pilulae aloes) contain 0.13 gm. (2 gr.) of aloes. Dose, 2 pills. Compound cathartic pills (pilulae catharticae compositae) contain extract of colocynth comp. 0.08 gm. (1V4 gr.) ; calomel 0.06 gra. (1 gr.) ; resin of jalap 0.02 gm. (% gr.) ; gamboge 0.015 gm. (% gr.). Dose, 1 or 2 pills. Compound rhubarb pills (pilulae rhei compositae) contain rhubarb 0.13 gm. (2 gr.) ; aloes 0.10 gm. (1% gr.) ; myrrh 0.06 gm. (1 gr.). Dose, 1 or 2 pills. C. Official powders are dry preparations of two or more drugs. It is better to order a powder by its LIQUIDS FOR INTERNAL USE 17 official title, but below are the common names and the ingredients of the most used of these preparations: Dover's powder (pulvis ipecacuanhse et opii) contains 10 per cent, each of ipecac and opium. Dose, O.S gm. or gr. viii. Compound jalap powder (pulvis jalapse compositus) con- tains 35 per cent, of jalap and 65 per cent, of potassium bitartrate. Dose, 2 gm. or gr. xxx. Compound licorice powder (pulvis glycyrrhizse compositus) contains 18 per cent, of senna ; 23 per cent, of glycyrrhiza ; 8 per cent, of sulphur. Dose, 4 gm. or 3i. Seidlitz powder (pulvis effervescens compositus) ' consists of two powders ; one of Rochelle salt and bicarbonate of soda in blue paper, and the other of tartaric acid in white paper. IJose, one set of two papers. 2. Liquids Mostly for Internal Use A. Waters are solutions of volatile substances in water; mostly weak preparations. (Exception, ammo- nia waters.) H. Spirits are solutions of volatile substances in alcohol; mostly strong preparations. (Exception, sweet spirits of niter.) F. Liquors are solutions of nonvolatile substances in water; mostly weak preparations. (Exceptions, the arsenic solutions and thpse for external use.) J. Tinctures are solutions of nonvolatile substances in alcohol; mostly strong preparations. (Exceptions are the aromatic and stomachic [bitter] drug tinc- tures.) A. The following waters are included in Useful Drugs : Aqua ammoniae. Aqua camphoras. Aqua chloroformi. Aqua cinnamoni. Aqua menthse piperitae. Aqua rosae. H. Some of the commonly used spirits — included in Useful Drugs — are: Spiritus aetheris. Spiritus ammonii aromaticus. Spiritus camphorse. Spiritus chloroformi. Spiritus glycerylis nitratis. Spiritus menthse piperitse (essence of peppermint). 18 PRESCRIPTION WRITING F. Some of the commonly used liquors — Useful Drugs — are: Liquor alumini subacetatis. Liquor ammonii acetatis (spirit of mindererus). Liquor calcis (lime water). Liquor cresolis cotnpositus. Liquor formaldehydi. Liquor hydrogenii dioxidi. Liquor hypophysis. Liquor magnesii citratis. Liquor plumbi subacetatis. Liquor potassii arsenitis (Fowler's solution). Liquor potassii hydroxidi. Liquor sods chlorinatse (Labarraque's solution). Liquor sodii hydroxidi. Liquor zinci chloridi. J. The list of tinctures included in Useful Drugs are: Tinctura aconiti. Tinctura belladonnae foliorum. Tinctura benzoini composita. Tinctura capsici. Tinctura cardamoni. Tinctura cinchonae and tinctura cinchonse composita. Tinctura colchici seminis. Tinctura digitalis. Tinctura ferri chloridi. Tinctura gentianae composita. Tinctura hyoscyami. Tinctura iodi. Tinctura lobeliae. Tinctura myrrhae. Tinctura nucis vomicae. Tinctura opii, tinctura opii camphoratae and tinctura opii deodorati. Tinctura rhei aromatica. Tinctura scillas. Tinctura strophanthi. Tinctura zingiberis. B. Elixirs are sweetened liquid preparations con- taining alcohol. They are weak preparations, and the National Formulary contains a large number. Only one — Elixir Aromaticum — is in Useful Drugs. FLUID EXTRACTS AND SYRUPS 19 C. Emulsions are liquid preparations representing a suspended oil or resin. D. Fluidextracts are liquids representing exact strengths of. the drugs, i. e., 1 cubic centimeter (15 minims) contains the medicinal properties of 1 gram (15 grains) of the drug. D. Useful Drugs contains seven fluidextracts: Fluidextractum cascarse sagradse. Fluidextractura cascarae sagradse'aromaticum. Fluidextractum ergot». Fluidextractum glycerrhizse. Fluidextractum Hydrastis. Fluidextractum ipecacuanhae. Fluidextractum sennas. E. Infusions are weak watery preparations. One only is of value, viz., infusum digitalis. G. Mixtures are liquids containing more than one drug, often an insoluble one. Non'fe of these appear in Useful Drugs. Some much used in the past are : Brown mixture (mistura glycyrrhizse compositus). Chalk mixture (mistura crets). The National Formulary contains a long list of ipix- tures. I. Syrups are very sweet watery solutions of one or more drugs. These weak preparations are prescribed too frequently, as they readily cause disturbance of the stomach, and do not often modify a bad-tasting drug, but may even protract the taste. Sweet cough syrups are an abomination. Useful Drugs includes eight syrups : Syrupus. Syrupus ferri iodidi. Syrupus ipecacuanhae. Syrupus pruni virginiana;. Syrupus rhei aromaticus. Syrupus scillse. Syrupus sennse. Syrupus tolutanus. J. Semisolids for External Use A. and B. The principal difference between cerates and ointments is their melting-points. The ointments 20. PRESCRIPTION WRITING contain more lard or petroleum fat and less wax than the cerates, hence they have a lower melting point than the latter. Cerates do not melt when applied to the skin. Ceratum Cantharides is included in Useful Drugs. Also the following ointments : Unguentutn acidi borici. Unguentum belladonnae. Unguentutn chrysarobini. Unguentum hydrargyri. Unguentum hydrargyri ammoniatum. Unguentum hydrargyri. dilutum. Unguentum hydrargyri oxidi flavi. Unguentum picis Hquidse. Unguentum sulphuris. Unguentum zinci oxidi. 4. Liquids for External Use Some waters, some liquors, some tinctures and the liniments, as the name implies, are used externally only. Most of the liniments are stimulating to the skin, only two being sedative, viz., the belladonna lini- ment and the carron oil (linimentum calcis). SYNONYMS The following are frequently used synonyms : Aqua Foktis, Acidum nitricum, U. S. P. Aqda Regia, Acidum nitrohydrochloricum, U. S. P. Basham's Mixture, Liquor ferri et ammonii acetatis, U. S. P. Basilicon Ointment, Ceratum resiiiK, U. S. P. Black Draught, Infusion sennac compositnm, U. S. P. Black Wash, Lotio nigra, N. F. Blaud's Pill, Pilula ferri carbonatis, U. S. P. Bleaching Powder, Calx chlorinata, U. S. P. Blue Mass, Massa hydrargyri, U. S. P. Blue Ointment, Unguentum hydrargyri dilutum, U. S. P. Blue Vitriol, Cupri sulphas, V. S. P. Brown Mixture, Mistura glycyrrhizae composita, U. S. P. Cakron Oil, Linimentum calcis, U. S. P. Dobell's Solution, Liquor sodii boratis compositus, N. F. Donovan's Solution, Liquor arseni et hydrargyri iodidi, U. S. P. Dover's Powder, Pulvis ipecacuanha et opii, V. S. P. Epsom Salts, Magnesii sulphas, U. S. P. Fowler's Solution, Liquor potassi arsenitis, U. S. P Glauber Salt, Sodii sulphas, U. S. P. Goulard's Extract, Liquor plumbi subacetatis, U. S. P. Gray Powder, Hydrargyrum cum creta, U. S. P. Gregory's Powder, Pulvis rhei compositus, U. S. P, Hive Syrup, Syrupus scilla compositus, U. S. P. Hoffmann's Drops, Spiritus astheris, U. S. P. Huxham's Tincture, Tinctura cinchonas composita, V. S. P. WEIGHTS AND MEASURES 21 Labarraque's Solution, Liquor sodae chlorinatse, U. S. P. Luggl's Solution, Liquor iodi compositus, U. S. P. Lunar Caustic, Argenti nitras fusus, U, S. P. Magendie's Solution, Liquor morpbinse hypodermicus, N. F. Monsell's Solution, Liquor ferri subsulphatis, U. S. P. Sugar of Lead, Plumbi acetas, U. S. P. Vallet's Mass, Massa ferri carbonatis, U. S. P. Warburg'I Pill, Pilula antiperiodica, N. F; Warburg's Tincture, Tinctura antiperiodica, N. F. Yellow Wash, Lotio flava, N. F. THERMOMETRIC EQUIVALENTS To convert degrees Centigrade to degrees Fahrenheit, multiply by 9, divide by 5, and add 32 to the quotient. To convert degrees Fahrenheit to degrees Centrigrade, substract 32, multiply by 5 and divide by 9. A few commonly used equivalents are as follows : C. F.. = +32 Freezing point of water. 4 = 40 Greatest density of water. 15.5 = 60 Temperature at which most hygrom- eters are graduated. 25 = n Used in estimations as room tempera- ture. 37 = 98.6 Normal body temperature. 40 = 104 56 ^ 132,8 Point of inactivation. 60 = 140 Sterilizing and Pasteurizing tempera- ture. 100 = 212 Boiling point. WEIGHTS AND MEASURES ■ It is not necessary to describe here the old system or to give its tables of weights and measures, as they occur in every book on prescription-writing, but some tables of approximate equivalents to the metric sys- tem will be offered. Exact equivalent tables are a delusion and only tend to befog and discredit the metric system. When it is remembered how the doses of drugs vary, it will be recognized how absurd it is to figure an equivalent to its finer determinations. It is not necessary to declare, that the decimal (metric) system of prescription-writing is the better, because the fact is recognized- by all and the only hin- drance to its use is the supposed difficulty of mastering it. Science of all countries has adopted it — even our own Pharmacopeia. If the novice in the use of the metric system in prescription-writing will remember that it is a decimal system like our monetary system, that everything on the left of the decimal point or line represents grams or cubic centimeters [dollars], that everything on the right of the decimal line represents 22 PRESCRIPTION WRITING centigrams, milligrams, or fractions of a cubic centi- meter [cent-s and mills], he will soon understand the system. In this country it is customary in writing prescrip- tions in the metric system to write for solids in terms of grams and fractions of grams, and for liquids in terms of cubic centimeters or fractions of cubic centi- meters or mils. We shall for the present continue to use the cubic centimeter for liquid measure though the new Pharmacopeia has adopted the mil as a unit.- The same decimal line which should be ruled on the prescription blank answers for both solid and liquid metric measures, and precludes all possibility of care- less decimal mistakes, as : gra- ce. I It is best to use in prescribing only two denomina- tions, grams and milligrams. Liquids, of course, are expressed as cubic centimeters. TABLE OF THE APPEOXIMATE EQUIVALENTS IN THE TWO SYSTEMS gm. c.c. 1 grain (gr.i) = approximately 0|06S = 6S milligrams = 1 grain. 1 minim (Tn,i) = approximately 0|06S = ^om of a cu- bic centimeter = 1 minim. 15 grains (gr.xv) = approximately. . 1| =1 gram = IS grains. IS minims (iTLxv) = approximately. 1| =1 cubic centi- meter = IS minims. 1 dram (3i) = approximately 4| =4 grams = 1 dram. 1 fluidram (fl.Si) = approximately. 4| =4 cubic centi- meters = 1 fluidram. 1 ounce (Si) = approximately 30| = 30 grams = 1 ounce. 1 fluidounce (fl.Si) = approximately. 30 1 = 30 cubic centi- meters = 1 fluidounce. 1 quart = approximately 1000 c.c, or 1 liter. 1 pint = approximately 500 c.c. 1 teaspoonful = approximately S c.c. METRIC EQUIVALENTS 23 As above declared, it is useless to translate the old_ system into exact equivalents of the new system. One" must compute the doses in the new system; one must forget the size of stock bottles and order amounts of liquids in multiples of five, as 15 c.c, 25 c.c, 50 c.c, 100 c.c, or 200 c.c. ; one must remember that 5 c.c. is a teaspoonful dose, i. e., an ordinary teaspoon holds 5 c.c. and not 4 c.c. or a liquid dram ; in other words, every prescriber in the old system has always given a larger dose. than he intended when he computed the dose by fluidrams and then administered a teaspoonful ; one should remember that the drop, so much used in prescribing strong liquid preparations, is as correct in the new system as in the old. All of these suggestions must be followed out to use the metric system suc- cessfully. It is always a good plan to use a stub prescription blank, arid on the stub the individual doses may be written. This is another check on mistakes and also preserves for. reference the exact dose given on the exact date, as : Stub (one dose) Prescription for 20 doses gin. Old 5 c.c. system 001 Strychninas . sulphatis . .. 102 gr.Vs OS Ferri reducti 1 or gr.xv 10 QuininK sulphatis 2| gr.xxx M. et F. capsulas 20. Sig. : A capsule 3 times a day, after meals. Strych. sulph. Ferri reducti. Quin. sulph.. M. et F. cap. Sig. : ti.d., p.c, Name. Age. Date. Or, Stub (one dose) IJ Codein. sulph.. .01 Ammon. chlor. .25 Syr. acid. cit... 1.2S Aquae q. s..ad S. M. Sig.: S c.c.q. 2 h. in H2O. Prescription for 20 doses gm. Old B c.c. system (approximately) Codeinse sulphatis . . \2Q gr.iv Ammonii chloridi.. SI Siss Syrupi acidi citrici. 2S| fi.Si Aquae q. s ad 100 1 q. s. ad. fl.Siv M. Sig.: A teaspoonful, in water, every two hours. Shake. 24 PRESCRIPTION WRITING It is well to use the Arabic numerals instead of the Roman in the new system, as : Pilulas rhei compositas No. 20. Sig. : One pill after supper. Stub (single dose) Prescription gm. Old IJ U c.c. system Tr. digitalis. Tincture digitalis. .. 2S| or fl.Si Sig. : 10 drops in Sig. : Ten drops, in water, twice a day, H2O b.i.d., p.c. after meals. Stub Prescription gm. Old 5 B c.c. system Ung. hg. ammon. Unguenti hydrargyri or Petrolati aa 10 ammoniati 101 aa Siiss M. Petrolati 10| Sig. : Externally. M. Sig. : Use externally as directed. INCOMPATIBILITY This is prevented only by great care and simplicity. Too many drugs should not be prescribed. Too many solutions should not be combined. Too many drugS) and too much medicine should not be given to one patient on any one or two days. Many drugs are cumulative and many of their physiologic activities are antagonistic. Drugs may be incompatible thera- peutically, chemically and pharmaceutically. Therapeutic incompatibility occurs when drugs are com- bined which have antagonistic physiologic actions. Chemical incompatibility occurs when from the combination of two or more drugs a new and undesired chemical com- pound results. Pharmaceutic incompatibility occurs when drugs are com- bined which form, either immediately or later, cloudy, pre- cipitated or decomposed solutions. An educated physician should be ashamed to perpe- trate a therapeutic incompatibility either in a prescrip- tion or in a patient. It is not therapeutic incompati- bility, however, to modify a too decided action of a drug with one that corrects an undesired effect. This is a part of therapeutic science. INCOMPATIBILITY 25 Pharmaceutic incompatibility is so closely related to chemical incompatibility that many times both are governed by the same rule. Such incompatibility is difficult to avoid, and therefore it is advisable to adopt simplicity in prescription-writing; this is really a therapeutic gain. Below is given an alphabetic list of drugs compris- ing those that should generally be given alone, especially in solutions. The chemical reasons are appended : Aci.ds, unless very dilute and in small amount, should be prescribed alone. They combine with bases to form salts, and are incompatible with oxids, alkalies, alkaline salts, hydrates and carbonates. They usually precipitate albumin. Alkalies and alkaline carbonates should rarely be prescribed in solution with other drugs. They form salts with acids and precipitate many metallic and alkaloidal salts. , Alkaloidal salts should rarely be combined with other drugs in solutions. They are precipitated by alkalies, alkaline car- bonates, earthy carbonates, preparations containing tannic acid, and by iodids in solution. Arsenic (arseni trioxidum, arsenioiis acid) should gener- ally be prescribed in solutions alone. It is precipitated by salts of iron, magnesia, and solutions of lime. Bromids in solution should not be combined with alkaloids. 'They precipitate the salts of morphin, quinin, and strychnin from neutral solutions. Ferric and ferrous salts should generally be prescribed alone. They are incompatible with tannic acid and all drugs containing it; with alkaline carbonates, ammonia, and acacia. Iodids should generally be prescribed alone. They are incompatible with salts of alkaloids and metals and with mineral acids. Mercuric chlorid (corrosive sublimate) should generally be prescribed alone. It is incompatible with many drugs. Mercurous chlorid (calomel), though insoluble, had best not be prescribed in mixtures. In solutions containing chlorids it may be converted into the mercuric salt. Resins, including oleoresins, and fluidextracts and tinctures containing resins, should not be prescribed in watery solu- tions, though they may be ordered in emulsion by suspending them with the mucilage of acacia or tragacanth. "They are all precipitated by water. 26 PRESCRIPTION WRITING Silver nitrate solutions and solutions of all silver salts must, be ordered alone, and kept in dark bottles. If silver salts are prescribed for internal administration they must be alone or combined with some earth, and given in capsules. Strophanthus in the form of the tincture _shoul,d not be prescribed in solutions containing water. Spirits (spiritus) should not be prescribed with watery preparations. They become cloudy on the addition of water. Tannic acid, and all drugs containing tannic acid, should not be prescribed with most drugs. They are incompatible with alkaloids, salts of iron, lead, silver and antimony. THE HARRISON NARCOTIC LAW This law affects the physician both as a prescribe! and as a dispenser of drugs. It requires the pre- scribing physician to register with the collector of internal revenue of the district. In writing a prescrip- tion for narcotic or habit forming drugs, coming under this act, the physician must write thereon the name and address of the patient, and must have on the pre- scription his office address and his registry number. He must date the prescription and sign his name in full. He need not keep either copies or records oi prescriptions ; this is done by the druggist. These pre- scriptions cannot be refilled. If the physician' desires any of the specified drugs for his own use, he must then make out an order fot them on a blank form bearing his registry number. These blanks are furnished by the Internal Revenue Department in packages of ten for ten cents. The physician cannot order drugs for his own use on a prescription blank. When he dispenses, the physician assumes the work of the druggist and is subject to the same rules. He must then keep a record in a suitable book of all habit- forming drugs dispensed, the names and addresses of persons dispensed to and the dates. Such treatments as he may personally administer or cause to be admin- istered when away from his office need not be recorded. LATIN Enough has been said in the introduction concern- ing the desirability of writing prescriptions for Phar- macopeial or National Formulary preparations ana LATIN 27 of the desirability of limiting one's prescription to a few drugs such as the limited list in "Useful Drugs." The corollary to this advice is to write a prescription correctly, as to dosage, compatibility and Latin. Many instructors are beginning to teach the writing of prescriptions in English. Some physicians will no doubt use English alone in prescriptions, but whether English or Latin is used, the prescription should be correct. The two should not be combined or mixed indiscriminately. It is presumed that the groundwork of prescription-writing has been acquired from some elementary book, and it is proposed here merely to furnish some hints which may be an aid in writing prescriptions simply, correctly and elegantly, and in preventing some of the more serious mistakes in Latin. The beginning of a prescription is usually the letter ^, meaning recipe ("take," imperative mood of the verb recipio) ; the cross over the tail of the ^, it has been said, is an abbreviated zodiacal sign or invocation to Jupiter. Others have claimed it is simply an abbre- viation. This verb recipe takes the quantities of the drugs ordered in the accusative, while the names of the drugs are in the- genitive case, as: imperative verb genitive case accusative case take of soda 1 gram (or IS grains) IJ sodii bicarbonatis 1 gm. or gr.xv In the following lists of words and rules for the correct use of Latin in prescriptions, Osborne's "Introduction to Materia Medica and Pharmacology" has been »freely drawn on. Rules ^ for Cases in Prescriptions 1. The verbs fac and recipe ( i^ ) take objects in the accusative case: 2. When the object of the verb is the quantity ordered, the name of the medicine is in the genitive case. 3. In the following instance, the name of the sub- stance is governed by q. s. {quantum sufficit) which takes the genitive case. The quantity is given m a dependent phrase (ad 30 c.c.) and therefore cannot be the object. 28 PRESCRIPTION WRITING B Aquae q.s. ad 30 c.c. or fl.Si Take of water as much as up to 30 c.c. or 1 fluidounce necessary Here the object of recipe is q. s., on which aqua depends. The Declension of Pharmacopeial Latin Nouns With few exceptions nouns ending in — a have the genitive ending in — ae; nouns ending in — um and — us have the genitive ending in — i ; all others have the genitive ending in — is. Abbreviations Used in Prescription-Writing It is common to use certain abbreviations in pre- scription-writing. This is perhaps due to the fact that abbreviations dispense with the need of remembering the various endings. The last U. S. Pharmacopeia has made official abbreviations of pharmacopeial titles. The following are abbreviations of Latin phrases commonly used in directions : Abbreviation Latin Translation ' aa ana (Greek) of each ad ad up to ad lib. ad libitum to the desired amount cap. capsula,- — ae. a capsule CO. or comp. compositus-a-um compound div. divide divide ext. extractum, — i an extract ft. fiat or fiant let it (or them) be made flext. fluidextractum, — i, a fluid extract gtt. gutta, — ae drop or drops liq. liguor, — is. a solution m. misce mix mist mistura, — ae a mixture pil. pllula, — ae a pill pulv. pulvis, — eris a powder q. a. quantum sufficit a sufficient quantity ss. semis, semissis a half sig. signa write sol. solutio,— onis a solution spts. spiritus a spirit t. i. d. ter In die three tifnes a day tr. tinctura, — ae a tincture Latin Verbs The Latin verbs used are best placed in the impera- tive mood. The most frequently used are: adde (add) divide (divide) filtra (filter) fac (make) misce (mix) recipe (take)- signa (write) solve (dissolve DOSAGES 29 DOSAGE The dose of a drug should be based on the age, weight and individuality of the patient, and the neces- sity for a strong action of the drug. The frequency of the dose is determined by the results obtained, by the length of time it takes the drug to be eliminated or cease its action, and the possibility of its causing a cumulative effect. While age is an alWmportant element in the deter- mination of the dose, the weight, unless in the obese, is the most important element, except in the case of narcotics given to children. Children have more cen- tral nervous system as compared to their weight than adults, and therefore are more profoundly affected by drugs which act on the-'brain than are adults. In other words, a given dose of a narcotic, especially of the opium series, for an adult must be more reduced in size for a young child than any table of reduction computed by age or weight would determine. The best simple rule of dosage by age is the fol- lowing : At 20 years, the adult dose. At 10 years, % the age, % the dose. At 5 years, % the age, %, the dose. At 2% years, % the age, % the dose. At 1 year, Ms the dose. Children whose ages are between the ones here specified may readily be prescribed doses a little more or less than the dose determined by the age nearest theirs in the table. The relation of size and weight to the dose is all- important. A large child of 2 years should certainly receive a larger dose than a weakly, small child of the same age. Also a small adult of 20 should receive less than a large muscular individual of the same age. The blood of an adult represents about one-thirteenth of his total weight. This is not true of children or of the obese. Hence the dose of an obese individual may be even less than if his weight were normal. The following are the average weights for normal adult males. It should be femembered that females up to the age of 45 or 50 generally weigh less than 30 PRESCRIPTION WRITING males ; also that a range of from 25 to 30 pounds above or below the average weight, the patient's general con- dition being good, is not necessarily considered a weight too high or too low for acceptance as an insur- ance risk. Above or below this range of 25 to 30 pounds from the average is generally considered over- weight or under-weight, and the acceptance of such an individual for insurance becomes questionable. TABLE OF AVERAGE Vi^EIGHT TO HEIGHT AT DIFFERENT AGES ?t. In. 15-24 25-29 30-34 35-39 ear ■ 40-44 45-49 50-54 55-60 5-0 120 125 128 131 133 134 134 134 5-1 122 126 129 131 134 136 136 136 5-2 124 128 131 133 136 138 138 138 5-3 127 131 134 136 139 141 141 141 5-4 131 135 138 140 143 144 145 145 5-5 134 138 141 143 146 147 149 149 5-6 138 142 145 147 150 151 153 153 5-7 142 147 150 152 155 156 158 158 5-8 146 151 154 157 160 161 163 163 5-9 150 155 159 162 165 166 167 168 5-10 154 159 164 167 170 171 172 173 5-11 J 59 164 169 173 175 177 177 178 6-0 165 170' 175 179 180 183 182 183 6-1 170 177 181 185 186 189 188 189 6-2 176 184 188 192 194 196 194 194 6-3 181 190 195 200 203 204 201 198 In determining the dose it is most important to con- sider whether or not the patient has any exceptional susceptibility to the given drug. When an idiosyncrasy or abnormal susceptibility to a certain drug or to drugs of a certain class is known, the drugs causing it should, if possible, not be administered. That peculiar phenomenon, now known as anaphylaxis, is one which also should be taken into account in this connection. Sometimes such undesired action of a drug occurs with the first dose only, notably in the case of quinin, and a tolerance to the drug is, after this first dose, temporarily acquired. Another idiosyncrasy a patient may represent is a tolerance to a drug such that large doses must be given to produce any efifect. This tolerance may be natural or acquired by previous use of the drug. Still other very important modifications of the dose are caused by the disease, by the condition of the patient's digestive and absorptive system, and by the DOSAGES 31 condition of his eliminative organs. The disease pres- ent may create a tolerance or an increased suscepti- bility to a drug. Slow absorptive powers may render the action of the drug almost impossible or allow accumulation of dangerous amounts of the drug (under which conditions the drug should be given hypodermically, if it is needed). Slow or retarded elimination due to defective eliminative organs will allow accumulative action of many drugs. The drugs which are most frequently found unex- pectedly to cause undesirable or evfen serious symptoms in susceptible individuals are quinin, salicylates, atro- pin-containing drugs, iodin-containing drugs, and opium and its alkaloids. The diseased conditions that most seriously modify (lessen) the dose of a drug are nephritis and cirrhosis of the liver. A condition of shock precludes immediate absorp- tion from the stomach, hence such a condition must be combated, if by drugs, hypodermatically. i Frequency of the Dose It should be carefully learned how long, ordinarily, it takes a given dose of a drug to act, and how long before it is mostly eliminiated. This determines the frequency of the dose. Also some drugs are elimi- nated so slowly that they tend to accumulate in the system or are deposited in the various organs so that medication may occur days and even weeks after the cessation of the administration of the drug. A few of the rapidly acting drugs are : Alcohol lodids Ammonia Salicylates Camphor Sfrophanthin Caffein Strychnin Chloral These act in a few minutes to an hour or so, hence the intervals at which they may be given range from every hour to every three hours, or three times a day, according to the drug. 32 . PRESCRIPTION WRITING A few of the slowly acting drugs are : Arsenic Quinin Atropin Synthetic antipyretics Bromids Synthetic hypnotics Digitalis Thyroid Mercury These act in from several hours to twenty, hence should be given once or twice a day, according to the drug. A few of the drugs that tend to accumulate in the system are : ' Arsenic Digitalis Atropin Mercury Bromids Strychnin Many drugs cause eruption on the skin either due to irritation of >he stomach and duodenum or to their being more or less excreted by the skin and irritating the glands during such excretion, or they may cause flushing of the skin. Examples of drugs causing the first kind of irrita- tion are: copaiba, chloral, opium, quinin, salicylates,- synthetic compounds, volatile oils ; drugs of the second type are arsenic, bromids and iodids; those of the third type are antitoxin, atropin and thyroid. It should always be remembered that sortie drugs are excreted into the milk; hence if the mother is nursing her baby, some drugs should be avoided, and some given only infrequently; or, on the other hand, the baby may be medicated through the mother. Generally speaking, most narcotics (opium, bromids, etc.), most so-called alteratives (arsenic, mercury, iodids, thyroid), most cathartics and quinin are excreted by the milk. METHODS OF. ADMINISTERING DRUGS Drugs and serums are more than occasionally admin- istered intravenously, but as the technic requires skill, most perfect asepsis, and should require the enforce- ment of at least twenty-four hours of rest, this method is not likely to be frequently resorted to. Moreover, it seems to be a fact that, when a drug or serum is injected intramuscularly, the rate of absorption and ADMINISTERING DRUGS 33 activity of a substance is almost as rapid as when it is given intravenously, and the danger of accidents is much less. The hypodermatic or subcutaneous method is of very great value in all emergencies, but should not be used too frequently. Of course, the most frequent need for such medication is caused by pain, which must be combated by morphin or its equivalent, and the danger of acquiring a habit is greater when the drug is used hypodermatically than when it is given in any other way. The usual method of giving a drug is by the mouth, either in liquid, powder, pill, cachet, capsule or tablet. A drug will act more quickly if given in liquid solution, and more effectively on an empty stomach. If it is dis- agreeable, however-, it should be given in capsule if the character and dose of the drug will allow. If a drug is irritant, it should not be given on an empty stomach. A disagreeable liquid drug should not be combined with a syrup, which does nothing but prolong the taste and upset the stomach, but should be given in plain water to be followed by any kind of taste the patient prefers, such as orange, lemon, or by a peppermint or wintergreen candy, for example. Or the liquid may be given in a sour mixture, as lemonade or syrup of citric acid and water, or it may be given in a mineral or car- bonated wa-ter^,. A powder may be given in milk or in an effervescing water. Capsules are the nicest means of giving drugs dis- agreeable in taste and small in dose. The contents of a capsule should be dry for rapid solution, the princi- pal advantage of a capsule over a pill. If rapid action is desired, or if it is feared that the capsule, slowly dis- solving on a small part of the mucous membrane of the stomach, will irritate the membrane, the capsule may be uncapped at the moment of swallowing, and the result is the same in the stomach as though the drug had been taken in powder. Alcohol in any form in the stomach will retard the solution of a capsule. Pills are not so much used as before the capsule became so popular. The solution and absorption of a pill must be slow, unless it contains some particles of a substance that swells with water, as starch. Sugar, chocolate. 34 PRESCRIPTION WRITING or gelatin-coated pills and tablets make the solution still slower, though in the case of drugs to act on the, intestine this may be of advantage. The much-used tablet, compressed or triturate, doubtless renders much medication valueless, and per- haps, fortunately, harmless. The speed of solution of most tablets on the market is problematic; hence if the action of a tablet is immediately desired it should be predissolved, or at least crushed by the teeth before swallowing. All antipyretic coal-tar tablets should be crushed before swallowing and then a got)d drink of water taken with them. It should not be for- gotten that anything that may bite or irritate the mem- brane of the mouth will do the same to the mucous membrane of the stomach. Hence bromid tablets should never be taken undissolved. Potassium chlo- rate tablets dissolved in the mouth or swallowed are dangerous. Potassium chlorate solutions for the mouth and throat are valuable, but there is no justifi- cation for ever taking potassium chlorate into the stom- ach or into the system. A very soluble tablet dissolved and absorbed from' the mouth will give almost as. rapid action as when given hypodermatically. The rectum absorbs drugs given by means of sup- positories or injections nearly and sometirnes quite as rapidly as does the stomach.- Sedatives and some laxatives only are administered by suppositories for systemic effect. A few drugs are given endermically, but except in the case of mercury the method is uncertain. Mucous membranes may be treated by douching, injection, insufflation, and those of the air passages by inhalation. Some drugs are absorbed by all of these methods, and if poisonous drugs are used, the possi- bility of too great an absorption must always be kept in mind. . CLASSIFICATION OF DRUGS While dictionaries and encyclopediaes must be arranged alphabetically for ready reference, alpha- betic arrangement of drugs for the practicing physician is very unsatisfactory. For a practicing physician, CLASSIFICATION OF DRUGS 35 classification based on chemical constituency, pharma- cologic peculiarities, or toxic action is absolutely of no value. A drug may have a chemical, physiologic or toxic activity that is of no value from a therapeutic standpoint. The classification always of value and always necessary for the practicing physician is one based on therapeutic uses. The following classification, arranged according to therapeutic indications is taken chiefly from .Useful Drugs. While this enumeration of drugs does not comprise all that are of value, it does comprise the best, and any drug that aspires to a place in such a classification must show positive physiologic activity and therapeutic success to prove that it should be classed among these, the best drugs. Under each heading the drugs are named alphabetically and not in the order of their value. I Drugs Applied for Their Local Action on the Skin, Wounds or Visible Mucous Membranes. Corrosives or Caustics. — Acetic acid, nitric acid, alum, sil- ver nitrate, phenol, potassium hydroxid, sodium car- bonate and sodium hydroxid, zinc chlorid. Disinfectants and Antiseptics. — Benzoic, boric and salicylic acids, silver nitrate, chlorid of lime, camphor, cresol, eucalyptus, formaldehyde, mercuric chlorid, mercuric iodid, hydrogen peroxid, iodoform, phenol, tar, potas- sium permanganate, sulphur thymol and zinc chlorid. Astringents. — Tannic acid, alcohol, alum, liquor alumni subacetatis, bismuth subcarbonate, subgallate and subnitrate, copper sulphate, iron chlorid and sulphate, lead and zinc acetates, zinc oxid and sulphate. Styptics. — Soluble astringents, iron chlorid and alum. To Contract Vessels. — Epinephrin. Emollients: Powders. — Starch, bismuth subcarbonate and subnitrate, magnesium carbonate, talcum, zinc oxid. Protectives. — Lard, wool fat, white wax, collodion, fixed oils and petrolatum. Local Anodynes and Analgesics for Pain and Itchings. — Ammonia water, atropin, chloroform, cocain, phenol, and sodium bicarbonate. Local Anesthetics. — Ether, ethyl chlorid, cocain, menthol, novocain and quinin and urea hydrochlorid. 36 PRESCRIPTION WRITING II. Drugs Used for Affections of the Alimentary Tract. Mouth and Throat. Demulcent. — Acacia, glycerin and potassium chlorate. To Lessen Salivation. — Atropin. Stomach. Digestives. — Hydrochloric acid and pepsin. Emetics.— Apomorphin hydrochlorid, copper sulphate, emetin hydrochlorid, ipecac, mustard, sodium chlorid, zinc sulphate. To Lessen Irritation and Vomiting. — Bismuth subcar- bonate and subnitrate, chloral, choloroform, codein, lime water, menthol, raorphin and opium. To Lessen Acidity. — Calcium and magnesium carbonates, lime water, magnesium oxid, sodium bicarbonate. To Increase Secretion, Bitters. — Quinine, gentian, nux vomica, strychnin. Carminatives. — ^Alcohol, camphor, capsicum, cardamom, cloves, volatile oils, ginger. Intestine. To Promote Digestion. — Pancreatic extract (?). To Promote Evacuation. — Vegetable Purgatives. — Aloes, aloin, colocynth, elaterin, jalap, podophyllum, cascara, rhubarb, castor oil, senna, croton oil. Saline Purgatives. — Magnesium carbonate, sulphate, oxid and citrate, potassium bitartrate, potassium and sodium tartrate, sodium phosphate and sodium sul- phate. Mercurial Purgatives. — Calomel, mercury with chalk. Miscellaneous. — Pel bovis, glycerin, sulphur, and phenol- phthalein. To Lessen Movement and Reflex Spasm. — Tannic acid, atropin, belladonna, bismuth subcarbonate, subgallate and subnitrate, lime water, morphin and opium. To Destroy Parasites, Anthelmintics.— Aspidium, chloro- form, calomel, pelletierin, salol, santonin, turpentine, thymol. III. Drugs Used for Their Effects on the Circulation. Heart. To Strengthen Contraction.— Digitalis, strophanthus. To Accelerate Pulse.— Atropin, caffein, camphor. To Slow Pulse.— Aconite, digitalis, strophanthus. CLASSIFICATION OF DRUGS 37 Vessels. To Contract Caliber and Raise Blood Pressure. — Epi- nephrin, ergot, hypophysis, atropin, caffein. To Relax Vessels and Lower Blood Pressure. — ^Amyl nitrite, nitroglycerin, sodium nitrite. To Remove Fluid. — Diuretics, diaphoretics, vegetable and saline purgatives. Also digitalis, calomel, squill, strophanthus. IV. Drugs Used for Their Effects on the Genito-Urinary System. To Increase the Flow of Urine, Diuretics. — Ammonium acetate, caffein, digitalis, calomel, potassium salts, squills, spartein sulphate, strophanthus, theobromin. To Render the Urine Less Acid. — Potassium acetate, bicar- bonate and citrate, sodium carbonate and bicarbonate. To Render the Urine Aseptic. — Benzoic and salicylic acids, acetylsalicylic acid, hexamethylenamin, salol, sandal- wood oil, sodium benzoate, sodium salicylate. To Promote Menstruation, Emmenagogues. — ^Vegetable pur- gatives, corpus luteum. V. Drugs Used ' for Their Effects on the Respiratory System. To Stimulate the Respiratory Center. — ^Atropin, caffein, camphor, strychnin. To Reduce the Irritability of the Center in Cough. — Chloro- form, codein, heroin, morphin, opium. To Increase and Liquefy the Bronchial Secretion. — Ammo- nium carbonate, apomorphin, ipecac, potassium iodid, squill, sodium iodid. To Lessen the Secretion of the Bronchi(f).— Benzoin, turpentine, atropin. To Relax Bronchial Spasm in Asthma. — Amyl nitrite, atro- pin, belladonna, nitroglycerin, potassium iodid, sodium iodid, sodium nitrite, chloral, morphin. VI. Drugs Used for Their Effects on the Central Nervous System. Stimulants. — (a) (the spinal cord) strychnin, (6) (the brain and medulla) atropin and caffein. Depressants. — (o) (to paralyze sensation) ether, ethyl chlorid, chloroform; (&) (to induce sleep and rest) alcohol, chloral, codein, morphin, opium, paraldehyde, scopolamin, sulphonal, veronal; (c) (to relieve pain) 38 PRESCRIPTION WRITING acetanilid, phenacetin, salicylic acid, alcohol, anti- pyrin, aspirin, chloral, codein, roorphin, sodium salicylate. VII. Drugs Used to Reduce Fever Temperature. Acetanilid, phenacetin, salicylic acid, aconite, ammonium acetate, antipyrin, aspirin, quinin, sodium salicylate. VIII. Drugs Used for Their Effects on the Liver. To Increase Bile. — Salicylic acid, fel bovis. IX. Drugs Used for Their Effects on the Blood. To Increase the Hemoglobin. — Arsenic and iron salts and combinations. To Render the Blood Alkaline. — Potassium acetate, bicar- bonate and citrate, sodium bicarbonate and carbonate. To Increase the Coagulability (f). — Calcium salts, horse or human blood serum. X. Drugs U^ed for Specified Diseases. Malaria. — Arsenic, quinin. Syphilis. — Mercury, iodids, arsenic, salvarsan. Rheumatic Fever. — Salicylates. Diphtheria. — Serum antidiphthericum. Tetanus. — Serum antitetanicum. Trypansomiasis. — Antimony and potassium tartrate, sodium arsanilate. Gout. — Acidum phenylcinchonicum colchici semen. XL Drugs Used for Their Effects on the Skin. Irritants. — Alcohol, ammonia, camphor, cantharides, capsi- cum, menthol, mustard, turpentine, croton oil. Disinfectants or Irritants Used , Chiefly in the Form of Ointments in Parasitic Skin Diseases. — Balsam of Peru, benzoin, camphor, chrysarobin, mercury, ich- thyol, iodin, tar, resorcin, sulphur, thymol. To Increase Sweat. — Camphor, ipecac, opium, pilocarpin. To Lessen Sweat. — Atropin, belladonna. XII. Drugs Used Locally for Their Effects on the Eye. To Dilate the Pupil and Relax Accommodation. — Atropin cocain, homatropin, scopolamin. To Contract the Pupil and the Ciliary Muscle. — Physostig- min salicylate, pilocarpin hydrochlorate. CLASSIFICATION OF DRUGS 39 OTHER PROPERTIES OF WELL KNOWN DRUGS The following classification is taken from "Introduction to Materia Medica and Pharmacology" by Oliver T. Osborne. Drugs and Preparations Which May Cause an Eruption on, or Itching of, the Skin. — Antitoxin, arsenic, belladonna, bromids, chloral, copaiba, iodid, opium, quinin, salicylic acid, synthetic compounds, volatile oils and drugs con- taining them. Drugs Which May Change the Color of the Urine: Drugs that increase its amount cause it to be lighter. Drugs that irritate the kidneys cause it to be darker. Methylene blue causes it to be green, if acid. Phenol may cause it to be brown. Santonin causes it to be yellow, if acid; purple, if alkaline. Senna may cause it to be red if alkaline; yellow, if acid Sulphonal may cause it to be very dark. Drugs Which Color the Feces: Bismuth salts color them black or dark gray, Colchicum colors them greenish. Iron colors them black. Mercury colors them green. Purgatives cause them to be darker. Drugs Which Are Excreted with the Milk. — Arsenic, bromids, hexamethylenamin, iodids, lead, mercury, opium, quinin, sulphur, vegetable cathartics, volatile oils. TREATMENT OF POISONING As the symptoms and treatment of poisoning are many times so similar, it seems best to divide poisons into classes, and then to describe the treatment of each class, rather than to multiply individual descriptions. The following classification is of types of drugs. The individual drugs with references to the class to which they belong, and therefore to the treatment advisable, will be found in a table on another page. Class 1. — Irritants of the Gastro-Intestinal Canal. Acids. Alkalies. Irritant metallic salts. Class 2. — Irritants of the Central Nervous System. Atropin-containing drugs. Caflein-containing drugs. Cocain. Scopolamin (hyoscin). Strychnin. Volatile oils. Class 3.— Depressants of the Nervous and Circulatory Systems. All cardiac drugs in large doses. Coal-tar products. Cyanids. Hypnotics. Narcotic drugs. Nicotin. Most phenol-containing drugs. CLASS I. IRRITANTS OF THE GASTRO-INTESTINAL CANAL Most irritants in weak dilutions are astringent, while most astringents in strong solutions are irritant. The action of astringents and irritants on mucous mem- branes IS, therefore, largely one of degree. Some astnngents act chemically to form albuminates with the protein substance found on moist mucous mem- branes, thus coating and preventing the further irri- tation of the membrane. At the same time the blood- vessels of the membrane are contracted, the membrane GASTROINTESTINAL IRRITANTS 41 is dried, and the secretion diminished. This is typical metallic astringent aQtion. If this albuminate is insol- uble or very slowly soluble in the media surrounding it the action just described is the only action due to the astringent, viz., there'Tnay be more or less pro- nounced irritation at first, but the after-effect is seda- tive. If, however, this albuminate tends, to dissolve at its junction with the mucous membrane, the action of astringency is then continued and may become so irritating as to cause severe inflammation or with some metallic salts or acids cause ulceration and corrosion. Such drugs or preparations- are called "gastro-intes- tinal irritants," and in poisonous doses will all pro- duce the same immediate symptoms. Later individual symptoms or conditions develop due to the character of the substance absorbed, to its chemical nature and to the amount of local corrosion that it can cause. Different metals have different powers of astrin- ■ gency and irritant action ; also different salts of the same metal vary in the irritation which they will pro- duce. The acid formed after the dissociation of the metallic ion decides the amount of irritation that the salt will cause. Also the greater the ease with which the metallic ion is dissociated from its acid ion the greater the corrosion; therefore, the soluble nitrates and chlorid are much more corrosive than the ace- tates, citrates and tartrates. The sulphates are between these groups in their irritant effect. The most astringent metals in the order of their astringency are lead, iron, aluminum, copper, zinc and silver. The most astringent salt is lead acetate, while the most irritant salts are mercuric nitrate, mercuric chlorid and zinc chlorid. The sulphates and acetates of copper and zinc and the nitrates of silver and lead, if applied in weak solutions, are astringent, but are irritant if in large quantities or in strong solutions. Insoluble preparations of mercury may irritate and corrode, but insoluble salts of other metals are gen- erally only astringent. Double salts of the metals are less likely to irritate, because they ordinarily do not precipitate albumin. A styptic strongly coagulates albumin and hence causes a clot which stops hemor- rhage. 42 TREATMENT OF POISONING SYMPTOMS The symptoms common to all 'gastro-intestinal irri- tants are irritation or corrosion of the mouth, throat and esophagus, 'depending on the concentration of the poison swallowed. Other symptoms are : more or less gastric pain; nausea; vomiting, first of the contents of the stomach, then of mucus, then often of blood; later diarrhea, first of the contents of the bowels, then mucus and, perhaps, blood are passed. There are more or less symptoms of shock due to the reflex action on the heart from irritation of the gastric branches of the pneumog&stric nerve. The symptoms of collapse are a rapid, weak heart, dyspnea, cold sur- face of the body, clammy, cold perspiration, tendency to syncope, and a gradual failure of the pulse. The symptoms of poisoning by gastro-intestinal irri- tants are : Immediate Symptoms : Pain, nausea, vomiting, colic, diar- ■ rhea and collapse. Frequent After- Symptoms : Inflammation and ulceration of the mouth, throat and esophagus, gastritis, duodenitis (jaun- dice), enteritis, albuminuria, nephritis, and ulceration, per- foration, peritonitis. Possible Remote Symptoms : Fatty degeneration of the liver, kidneys and heart; strictures from the healing of the corrosions and ulcerations. TREATMENT OF CORROSIVE POISONING Immediate Treatment : Warm water drinks contain- ing the antidote, if there is one (an emetic or a stom- ach-tube is rarely needed and, if necessary, should be used with great caution and gentleness) ; albuminous and mucilaginous drinks, as milk, egg albumin, flax- seed infusions, slippery elm infusions, etc.; hypoder- matic injections of morphin sufficient to stop pain and continued vomiting. For corrosive acids the most convenient antidote is usually a solution of soap Treatment of Collapse : Rest, quiet ; dry heat, espe- cially to the region of the heart; atropin sulphate, 1/100 of a grain hypodermatically ; strychnin sulphate or nitrate, .1/30 of a grain hypodermatically; repeated in three hours, if needed (large doses of strychnin are not advisable, as it cannot stimulate the heart or raise CENTRAL NERVOUS SYSTEM IRRITANTS 43 the blood-pressure as so long believed) ; camphor, a syringeful hypodermatically of a saturated solution in sterile olive oil (or a ready-prepared ampoule), every half hour for several doses ; caffein as strong coffee, by rectal injection if there is no diarrhea. Af ter-Treatment : Give a saline purge, if deemed necessary. For acute gastritis give morphin sufficient to stop the pain, mucilaginous drinks, rectal alimenta- tion. Give cardiac stimulants, if needed. Later give bismuth subcarbonate in large doses (2 grams or 30 grains) twice a day; later, a milk diet. Treat duodeni- tis and nephritis, if they occur. Order absolute rest in bed for 'one or two weeks, if the irritation or cor- rosion was severe, lest perforation from ulceration be precipitated. Treat ulcer of the stomach and stric- tures, if they occur. CLASS II. IRRITANTS OF THE CENTRAL NERVOUS SYSTEM The principal symptoms of poisoning by drugs of this class are those of irritation of the central nervous system. There is restlessness and nervous excitement ; there may be, later, delirium and convulsions and, perhaps, still later, coma. The pulse is full, bounding, and generally rapid ; there may even be delirium cordis or tachycardia. Respirations are increased in rapidity, the face is flushed and the skin of the body feels hot and dry, and there often is increased temperature. There may be vomiting; there often is diarrhea; there is vesical irritability, and often strangury, depending on the drug. Some drugs of the atropin series may cause vesical paresis. There are muscular twitchings ; there may be cramps; and, as above stated, convul- sions may occur. The pupils are of course dilated if the poisoning is by any member of the atropin series or by cocain, and they often become dilated during cerebral excitement from other members of this group. The symptoms of poisoning by irritants of the cen- tral nervous system are: Immediate Symptoms : Gastro-intestinal burning and pain, perhaps nausea and vomiting, if the poison contains an aro- 44 TREATMENT OF POISONING raatic or volatile oil; cerebral excitement, rapid heart, rapid respiration, erythemas and flushing of the face and surface of the body. Frequent After- Symptoms : Purging, frequent urination, muscular twitchings, delirium, convulsions, coma and failure of the circulation. Possible Remote Symptoms : Abortion in pregnant women ; albuminuria and nephritis if the poison is a renal irritant as are many of the volatile oils; prolonged sleeplessness and nervous irritability TREATMENT OF POISONING BY IRRITANTS OF THE CENTRAL NERVOUS SYSTEM Administer warm water with the antidote, if there is such. Give an emetic. The emetics in the order of their strength are: mustard (a tablespoonful in a glass of warm water) ; ipecac (2 gm. [30 grains] of powdered ipecac, or a tablespoonful of the syrup) ; zinc sulphate (2 gm. [30 grains] dissolved in water) ; copper sul- phate (0.50 gram [7% grains] dissolved in water) ; apomorphin (1/10 of a grain given hypodermatically). Any of these emetics may be repeated in fifteen min- utes if there is no satisfactory result. It should be remembered that apomorphin is depressant to the cir- culation. Wash out the stomach by means of a stomach-tube if there is no satisfactory emesis^ If the vomiting is satisfactory, continue to administer warm water until the stomach washes clean. Administer one or more nerve sedatives. The best are bromids and chloral, aiid the dose depends on the character of the poison. They are best administered by the rectum, at least provided nausea and vomiting is continued after the stomach has" been cleared of the poison. If there is much circulatory depression, the best sedative to administer is morphin, hypodermati- cally, perhaps combined with scopolamin (hyoscin). An adjunct to the action of the morphin as a central nervous sedative and as a strengthener of the circula- tion is ergot, given intramuscularly. If there are con- vulsions, inhalations of chloroform are required. Apply dry heat to the body, if the surface is cool or there is a tendency to collapse. DEPRESSANTS 45 If heart failure occurs later in the poisoning, from shock o.r from the depression caused by nausea, such circulatory stimulants should be given as camphor (a saturated solution in olive oil hypodermatically) ; strophanthin (given hypodermatically or intravenously in a dose of 1/500 of a grain) ; epinephrin in aseptic ampoule or 1 c.c, 15 minims, of a 1 part to 10,000 solution; or intramuscular injection of some aseptic ergot preparation (1 ampoule) and repeat in an hour, if needed. Give plenty of water with a demulcent, if there has been irritation of the stomach either from a volatile oil poisoning or from the emetic used. CLASS III. DEPRESSANTS OF THE NERVOUS AND CIRCULATORY SYSTEM The symptoms of poisoning by drugs of this class are, as their name implies, those of circulatory and nervous depression. The pulse is eithex slow on rapid, but generally weak; the surface of the body generally becomes cold ; respirations are slowed ; pupils are gen- erally dilated unless the poison is morphin or nicotin ; often the patient becomes faint ; drowsiness soon devel- ops, and if a narcotic has been taken stupor soon devel- ops; perhaps convulsions will occur; later paralysis and coma. Immediate Symptoms (if the poison is a depressant of the nervous system)*: Depression, drowsiness, slow, weak pulse; slowed respiration, paralysis, and coma. Later Symptoms: Muscular weakness and circulatory weakness. Immediate Symptoms (if the poison is a circulatory depres- sant) : Rapid or slow, weak pulse; cardiac anxiety; cold, clammy perspiration; face pale; perhaps convulsions, and syncope. TREATMEiNT Wash out the stomach (emetics or stomach tube, as see above). Administer not only the chemical but a physiologic antidote, if there is such. Apply dry heat to the body. 46 TREATMENT OF POISONING If the poison was a narcotic, give cerebral and nervous stimulation, as caffein (coffee), camphor, atropin, strychnin. If the poison was a circulatory depressant, give atropin, efgot, epinephrin or strophanthin, as above described. Compel prolonged mental, circulatory and physical rest. The accompanying table is arranged alphabetically. The second column gives the class to which the poison belongs, and the treatment for this class has been given under the headings of the general treatment for each class. Therefore the number of the class to which the poison belongs refers to the treatment there outlined. Column 3 ("special symptoms") suggests symptoms of poisoning which are characteristic of the drug, such symptoms being in addition to those which are charac- teristic of the class of poisons to which the drug belongs. 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S„- 1 a, p CO fi ^ S'g §•= ,.| >,ja *- m m « :S 3>H w tn ( 3 £ l-f . .h-f .l-r -l-H l-ft-Ti-i I .l-HK-Th-f h-f h-f M-WW rt nl Cd cO id^ nj ci} rt nl cij ^,£2 cdcdcit cd cd cdcdcd oOuuuuDu uou GuoOo u cj Gou g "• -^ -, e.s 9 " '.S i •^ B^ o !5« '■ s22 f^ «j 01 u>.a l4'g,>i _ O o >, J5 p g'Xja J3 u ei3B CLiPnA^hP^PJC^W WWC/3 CflIQW|/l(/l W H t^>> NEW AND NONOFFICIAL REMEDIES The following substances have been accepted by the Coun- cil on Pharmacy and Chemistry for inclusion in New and Nonofficial Remedies to Jan. 1, 1918. Not all of the prep- arations on the market of each drug, serum, tuberculin or. vaccine are enumerated here. For the complete list reference should be had to the last edition of New and NonoiBcial Remedies. AGAR AND AGAR PREPARA- TIONS Arsenic Compounds, Complex- Organic Cacodylates Agar-Agar Phenolphthalein-Agar Calcium Cacodyhte Ferric Cacodylate Agaric Acid Sodium CacodjHate ALUMINUM COMPOUNDS ANESTHETICS Anesthetics, General Arsenic Compounds, Complex- Organic Arsen-Triferrin Elarson Ethyl Bromide Ethyl Chloride Kelene Methyl Chloride A T R P I N DERIVATIVES AND ANALOGUES Synthetic Mydriatrics Anesthetics, Local Alypin Homatropine Hydrochloride Barium Sulphate for Roent- gen-Ray Work Anesthesin Benzene, Medicinal Beta-Eucaine Hydro- chloride Benzidine Benzyl alcohol Holocaine Hydrochloride Procaine Novocaine (Procaine) Novocaine Nitrate (Procaine nitrate) Benzyl Benzoate Berberine Hydrochloride BILE SALTS AND BILE SALT COMPOUNDS Bilein Propaesin Bile S^lts Stovaine Glycotauro Arbuten Ovogal ARSENIC AND ARSENIC COMPOUNDS Arsenic Compounds, Complex- Arsanilates Sodium Arsanilate Arsenic Compounds, Complex- Arsenophenol-Amines Arsphenamine Neoarsphenamine Diarsenol Neodiarsenol Salvarsan Neosalvarsan BISMUTH COMPOUNDS Bismuth Compounds, Soluble Bismon Bismuth and Iron Citrate (soluble) Bismuth and Lithium Cit- rate (soluble) Bismuth Compounds, Insoluble Airol Bismuth Betanaphthalate Bismuth Tribromphenate Crcmo-Bismuth 52 NEW AND NONOFFICIAL REMEDIES Crurin Pvirum Lac Bismo BROMINE DERIVATIVES Adalin Brometone Bromural CALCIUM SALTS Calcium Cacodylate Calcium Ichthyol Calcium Peroxide Calcium Fhenolsulphonate Camiophen Ointment Cantharidin CHLORAL DERIVATIVES AND SUBSTITUTES Butyl-Chloral Hydrate Chlorajformamide Chloralamid Chlorbutanol Chloretone CHLORINATED EUCALYPTOL, DAKIN Chlorinated Paraffin Oil, Dakin Citresia CODEINE DERIVATIVES Eucodin COPPER SALTS Copper Citrate COTARNINE SALTS Cotarnine Hydrochloride Styptol CREOSOTE AND GUAIACOL COMPOUNDS Calcreose Creosote Carbonate Guaiacol Carbonate Duotal Guaiamar Theocol-Roche CRESOL AND CRESOL PREP- ARATIONS Cresol Tricresol Disinfectant Krelos, Mul- ford Phenoco ■ CRESOL DERIVATIVES Cresatin Cypress Oil DIETHYL-BARBITURIC ACID AND COMPOUNDS Barbital Veronal Barbital Sodium Plienobarbital Sodium DIGITALIS PRINCIPLES AND PREPARATIONS Digitalis Principles Digitalein, Crude Digitalin, True Digitalin, "French" Digitalin, "German" Digitoxin Related Digitalis Princitiles ■ Cymarin Ouabain, Crystallized Digitalis Preparations Digipoten Digitan Digitol Dimazon Dolomol EPINEPHRINE AND EPI- NEPHRINE PREPARATIONS Epinephrine Adrenalin L-Suprarenin Synthetic Bi- tartrate Purified Extract of Adrenal Gland Suprarenal Liquid Tyramine Tyramine Hydrochloride ERGOT PRINCIPLES AND PREPARATIONS Cornutol Ergotinine Citrate Extract of Ergot, Purified Histamine Hydrochloride Imido-Roche Secacornin Tyramin ETHYLENE AMINES AND DERIVATIVES Ethylene Diamine Prepara- tions Ethylene Diamine Ethylene Diamine Solution, 10 per cent, Fermentdiagnosticum NEW AND NONOFFICIAL REMEDIES S3 FERMENTS, DIGESTIVE Pancreatic Ferments Diazyme Essence Diazyme Glycerole Holadin Fanase Peptic Ferments Elixir of Enzymes Enzymol Essence of Pepsin Gastron Trypsin FIBRIN FERMENT AND THROMBOPLASTIC SUB- STANCES (KEPHALIN) Brain Lipoid Solution Brain Extract Thromboplastin Coagulen Ciba Kephaline Armour FILICIC ACID AND RELATED SUBSTANCES ; Filmaron Fluorescein FORMALDEHYDE PREPARA- TIONS AND COMPOUNDS WHICH LIBERATE FOR- MALDEHYDE Formaldehyde Preparations Paraformaldehyde " Trioxymethylene Solution of Formaldehyde Formalin Veroform The Simpler Formaldehyde Compounds Formicin HEXAMETHYLENAMINE AND HEXAMETHYLENAMINE COMPOUNDS Hexamethylenamine Aminoform Formin Urotropine Amphotropin Hexamethylenamine Meth- ylene Citrate Helmitol Hexalet FORMIC ACID COMPOUNDS Formic Acid Hediosit HYDROCHLORIC ACID AND SUBSTITUTES Betaine Hydrochloride Acidol HYPOCHLORITES AND HYPO- CHLORITE SUBSTITUTES Hypochlorite Preparations Antiformin Chlorine Soda Ampoules Hyclorite Surgical Solution of Chlori- nated Soda Chloramine Preparations Chloramine-B Chloramine-T Chlorazene Chlorcosane Dichloramin-T Halozone IODINE COMPOUNDS Iodine Preparations Contain- ing Free Iodine Jocamfen Iodine Dusting Powders Airol Thymol Iodide Aristol Vioform IODINE COMPOUNDS FOR INTERNAL USE Protein Compounds lodalbih lodo-Casein Non-Protein Compounds Lipoiodine-Ciba Siomine IPECAC PRINCIPLE AND PREPARATIONS Emetine Bismuth Iodide Emetine Hydrochloride IRON AND POUNDS IRON COM- Iron Salts, Simple Ferric Cacodylate Ferrous Lactate 54 NEW AND NONOFFICIAL REMEDIES Iron 'Salts, Complex Arsenoferratin Arsenotriferrin Bismuth and Iron Citrate (soluble) Ferro-Mangan-Dieterich Ovoferrin' Proferrin Triferrin LACTIC ACID-PRODUCING ORGANISMS AND PREPA- RATIONS B. B. Culture Bacillary Milk Bulgara Tablets Culture of Bacillus Bulgari- cus Galactenzyme Kefir Fungi o Lactampoule Lactic Bacillary Tablets — Fairchild Swan's Bacillus Bulgaricus Vitalait Starter Lanolin Liquid Petrolatum LITHIUM SALTS Bismuth and Lithium Ci- trate (soluble) MANGANESE COMPOUNDS Ferro-Mangan MEDICINAL FOODS Liquid Mixed Foods Enemose "Liquid Peptonoids Panopepton Dry Protein Foods Close Dry Peptonoids Larosan-Roche Carbohydrate Foods Malt Sugar Dextri-Maltose, Mead's Dextrose Diabetic Foods Gluten Food A, Barker's Gluten Food B, Barker's Gluten Food C, Barker's Hepco Flour Lister's ^ Prepared Casein Diabetic Flour Meat Extracts Meat Juices MENTHOL COMPOUNDS Coryfin MERCURY AND MERCURY COMPOUNDS Mercuric Compounds, Organic Mercurol Mercuric ' Compounds, Inor- ganic Mercurialized Serum Mercuric Benzoate Mercuric Cyanide Mercuric Oxycyanide Mercuric Salicylate Mercuric Succinimide Mergal Potassium Mercuric-Iodide Soloid Mercuric Potassium ■ Iodide Mercurous Compounds Calomelol M'ercury, Metallic Electr-HG Mercurial Oil Mercurial Ointment, Im- proved — Mulford NAPHTHOL COMPOUNDS Betanaphthyl Benzoate Betanaphthyl Salicylate Bismuth Betanaphtholate NITRATES-ORGANIC Erythol Tetranitrate AND NUCLEIC NUCLEINS ACIDS Nuclein Nucleic Acid Sodium Nucleate OPIUM PRINCIPLES, DERIV- ATIVES, ETC. Diacetyl-Morphine Diacetyl-Morphine Hydro- chloride Ethyl Morphine Hydrochlo- ride Morphine Meconate NEW AND NONOFFICIAL REMEDIES 55 Pantopon Papaverine Papaverine Hydrochloride Papaverine Sulphate ORGANS OF ANIMALS Leukocytes Leukocyte Extract Mammary Gland Mammary Substance — Ar- mour Ovary Ovarian Substance — Armour Desiccated Corpus Luteum — Armour Lutein Tablets— H. W. & Co. Parathyroid Gland Desiccated Para thyroid Gland — Armour Pineal Gland Desiccated Pineal Gland — — Armour Pituitary Gland Pituitary Body Desiccated — Armour ' Desiccated Pituitary Sub- stance (Anterior Lobe) — Armour Desiccated Pituitary Sub- stauce (Posterior Lobe) — ^Armour Solution of Hypophysis Pituitary Liquid Solution Pituitary Extract Osmium Tetr oxide Osmic Acid PARAFFIN FOR FILMS Stanolind Surjrfcal Wax Parresine PARSLEY-SEED PREPARA- TIONS Apiol PERBORATE PREPARATIONS Sodium Perborate Parogen Bath PEROXIDES ■ Hydrogen Peroxide Prepara- tions Perhydrol Metallic Peroxides Calcium Peroxide Magnesium Peroxide Sodium Peroxide ^ Oxone Strontium , Peroxide Zinc Peroxide Organic Peroxides Acetozone. PHENETIDIN DERIVATIVES Acetphenetidin Phenacetin Phenocoll Salicylate Salophen PHENOCOLL * COMPOUNDS Phenocoll Hydrochloride Phenocoll Salicylate Phenolphthalein PHENOLSULPHONATES Calcium Phenolsulphonate Phenolsulphonephthalein ■PHENYLCINCHONINIC ACID AND DERIVATIVES Phenylcinchoninic Acid Atophan Novatophan Phloridzin POLLEN EXTRACT PREPARA- TIONS Hay Fever Fall Pollen Hay Fever Rag Weed Pollen Hay Fever Spring Pollen PYRAZOLON DERIVATIVES Antipyrine Compounds and Derivatives Salipyrin Melubrin Pyramidon and Compounds Pyramidon Pyrafnidon QUININE DERIVATIVES Quinine Dihydrochloride Quinine Ethyl Carbonate Quinine Tannate Quinine and Urea Hydro- chloride 56 NEW AND NONOFFICIAL REMEDIES RADIUM AND RADIUM SALTS Radium Bromide Radium Carbonate Radium Chloride Radium Sulphate Radio-Rem Saubermann Radium Ema- nation Activator Standard Radium Compress Standard Radium Earth Standard Radium Solutions RESORCIN COMPOUNDS Euresol SALICYLIC ACID COM- POUNDS Acid Derivatives of Salicylic Acid iAcetylsalicyiic Acid Type) Acetylsalicylic Acid Aspirin Alkyl Derivatives of Salicylic Acid i_M ethyl-Salicylic Type) Benzosalin Ethyl Salicylate Sal-Ethyl Mesotan Spirosal Phenol Derivatives of Salicy- lic Acid iSalol Typ^) Betanaphtholsalicylate Guaiacol-Salol ^ Salophen Salicylic Compounds in Which the Salicylate A ction is Subordinate Salipyrin Mercuric Salicylate Phenocoll Salicylate Santyl SANDALWOOD OIL DERIVA- TIVES Arheol Carbosant Santyl Scarlet R Medicinal, Bie- brich SCOPOLAMINE Euscopol Scopolamine Stable — Roclic gERUMS AND VACCINES /. Antibodies Used for' Pro- phylactic or Therapeutic Purposes Normal Horse-Serum Diphtheria Antitoxin Un- co ncentrated Diphtheria Antitoxin Con- centrated Diphtheria Antitoxin, Dried Tetanus Antitoxin, Uncon- centrated Tetanus Antitoxin, Concen- trated Tetanus Antitoxin, Dried Anti-Anjhrax Serum Antidysenteric Serum Antigonococcus Serum AntimeningocDccus Serum Antipneumococcus Serum Antistreptococcus Serum II. Antigens Used for Prophy- lactic or Therapeutic Pur- poses Vaccine Virus — ^Virus Vac- cinium Antirabic Vaccine Old Tuberculin New Tuberculin, T. R. New Tuberculin, B. E. Tuberculin Denys, B. F. Detre Differential Test Acne Bacillus Vaccine Cholera Vaccine Colon Bacillus Vaccine Friedlaender Bacillus Vac- cine Gonococcus Vaccine Meningococcus Vaccine Pertussis Bacillus Vaccine Plague Bacillus Vaccine Pneumococcus Vaccine Staphylococcus Vaccines Streptococcus Vaccine Typhoid Vaccine Erysipelas and Prodigiosus Toxins III. Diagnostic Agents Bass Modification of the Widal Test Borden's Modification of the Widal Test Noguchi Modification of the Wassermann Test Luetin Diphtheria Immunity Test — Schick Silk Peptone "Hoechst" NEW AND NONOFFICIAL REMEDIES 57 SILVER COMPOUNDS THIOSINAMINE AND THIO- Silver Salts, Simple SINAMINE COMPOUNDS Albargin Thiosinamine Silver Citrate Fibrolysin Silver Lactate THORIUM SALTS Silver Sails, Complex Thorium Nitrate Thorium Sodium Citrate Argyrol Solution ■Solargentum Protargol UREASE Sophol Arlco-Urease Urease-Dunning Silver Preparations, Colloidal Urease-Squibb Cargentos URETHANES (CARBAMATES), Collargol UREA AND UREIDS Electrargol Adalin Sodium Acid Phosphate Bromural Sodium Oleate Ethyl Carbamate Sodium Succinate, Exsic- cated Urethane Hedonal SOFOS Thermodin Urea SULPHANILATES Veronal Snlphanilic Acid VALERIC ESTERS Icthalbin Ittiolo Amyl Valerate Bromural SULPHONE METHANES Borneol Valerates Sulphonmethane Gynoval Sulphonal Sulphonethylmethane XANTHINE DERIVATIVES Trional Theobromine and Theobromine , Compounds SULPHUR COMPOUNDS Theobromine Ichthalbin Theobromine Sodium Ace- Thigenol tate Theophorin TANNIC AND GALLIC ACID DERIVATIVES Theophyllin and Theophyllin Tannic Acid Derivatives Compounds Protan Tannigen Theophyllin Theophyllin Sodio-Acetate YEAST PREPARATIONS Gallic Acid Derivatives Cerolin Airol Xerase Gallogen ZINC COMPOUNDS TERPINE DERIVATIVES Soloid Nizin Apinol Zinc Permanganate Oil of Pine Needles Zinc Peroxide USEFUL DRUGS A book has been prepared by the Council on Phar- macy and Chemistry, entitled "Useful Drugs." It discusses a selected Hst of remedies, including only those drugs which usage has proved are efficient and reliable. A list of these drugs follows : Acacia. — Aciicla, II. S. P. Mucilago Aoaciae. — Mucilage of Acacta, tl. S. P, Acetanilidum.— Acetanilid, U. S. P. Dosage: 0.20 gm. or 3 grains. Acetphenetidlnum.— Acetphenetidin, U. S. P. Dosage: 0.50 gm. or I'A grains. Acidum Aceticum. — Acetic Acid, V. S. F. Diluted Acetic Acid, U. S. P. Acidum Acetylsallcylicuin. Acidum Benzoicum. — Benzoic Acid, XT. S. P. Dosage : 0.5 gm. or 7% grains. Acidum Boricum. — Boric Acid. Glyceritum Boroglycerini. — Glycerite of Boroglycerin, U. S. P. Unguentum Acidi Boricl. — Ointment of Boric Acid, U. S. P. Acidum Citricum.— Citric Acid, U. S. P. Dosage; 0.5 gm. or 7% grains. Acidum Diaetliylbarbituricum. — See under Veronal. Acidum Hydrociiloricum. — Hydrocliloric Acid, U. 8. P. Acidum ilydrocliloricum Dilutum. — Diluted Hydrochloric Acid, U. S. P. Dosage : 1 o.c. or 15 minims. Acidum Hydrocyanicum Dilutum. — Diluted Hydrocyanic Aold, U. S. P. Dosage: 0.1 c.e. or 1.5 minims. Acid Nitricum Nitric Acid, U. S. P. Acidum Phenylcindionmicum-ataphan. — Dosage: (.5 em. or 8 grains Not- atophan. Acidum Picricum. — Picric Acid, N. N. R. (to be added). Dosage: 0.025 to 0.1 gm. or ^ to 2 grains; used locally in 1 per cent, solution. Acidum Sallcylicum. — Salicylic Add, U. S. P. Dosage : 0.5 gm. or 7^ grains. Acidum Tannicum. — Tannic Acid, U. S. P. Dosage : 0.3 gm. or 5 grains. Glyceritum Acidi Tannici. — Glycerite of Tannic Acid, U. S. P. Dosage : 1 c.c. or 15 minims. Tannalbin. — Tannalbin, N. N. R. Dosage ; 2 gm. or 30 grains. Aconitum. — Aconite, 17. S. P. Tinctura Aconitl. — Tincture of Aconite, U. S. P. Dosage : 0.2 c.c. or 3 minims. Adeps Lanae Hydrosus. — ^Hydrous Wool I'at, IT. S. P. Adeps Benzoinatus. — Benzolnated Lard, U. S. F. Adeps Lanae Hydrosus. — Hydrous Wool Fat, U. S. P. Adrenalin. — See Epinephrine. Aether. — Ether, IT. S. P. Dosage : 1 c.c. or 15 minims. Spiritus Aetheris, IT. S. P. Dosage: i c.c. or 1 fluidram. Spiritus Aetheris Compositus. IT. S. P. (to be deleted). Dosage: 4 c.c. or 1 fluidram. Aether Nitrosus. — ^Used only in the form of Spiritus Aetheris Nltrosi. — Spirit of Nitrous Ether, U. S. P. Dosage : '2 c.c. or 30 minims. Aethylis Chloridum.— Ethyl Chloride, U. S. P. Aethyl-Morphinae Hydrochloridum. — Bthyl-Morphin Hydrochloride, N. N. R. Dlonin. Dosage : 0.015 gm. or % grain. USEFUL DRUGS 59 Alcohol.— Alcohol, U. S. P. Elixir Aromaticum. — Aromatic Elixir, V. S. P Aloes.— Aloe, U. S. P. Dosage : 0.15 to 0.3 gm. or 2 to 5 grains, purgative; 0,03 to 0.05 gm. or % to 1 grain, laxative. Extractum Aloes. — Extract of Aloes, U. S. P. Dosage : 0.10 gm. or 2 grains. Aloinuiti. — Aloin, U. S. P. Dosage: 0.05 gm. or 1 grain. Alumen. — Alum, U. S. P. Alumen Exsiccatum. — Exsiccated Alum, U. S. P. Alumini Acetas. — Aluminum Acetate. Liquor Alumini Acetatis. — Solution of Aluminum Acetate, N. F. Ammonia. Aqua Ammoniae. — Ammonia Water, U. S. P. Linimentum Ammoniae. — Ammonia. Liniment, U. S. P. Ammonii Acetas. — Ammonium Acetate. Liquor Ammonii Acetatis. — Solution of Ammonium Acetate, U. S. P. Dosage: 15 c.c. .or 4 fluidrams. Ammonii Carbonas. — Ammonium Carbonate, U. S. P. Dosage; 0.25 gm. or 4 grains. Spiritus Ammoniae Aromaticus. — ^Aromatic Spirit of Ammonia, U. S. P. Dosage : 1 to 5 c.c. or 15 to 60 minims. Ammonii Chloridum. — Ammonium Chloride, U. S. P. Dosage: 0.30 to 1 gm. or 5 to 15 grains. Amylis Nitris. — Amyl Nitrite, U. S. P. Dosage: 0.2 c.c. or 3 minims, by inhalation. Amylum Starch, Corn Starch, U. S. P. Antimoni) et Potassii Tartras. — Antimony and Potassium Tartrate, U. S. P. Dosage : 0.001 gm. or 1/60 grain. Vinum Antimonii.— Wine of Antimony, XI. S. P. Dosage: 1 c.c. or 15 minims (0.004 gm. or 1/15 grain tartar emetic). Antipyrina. — Antipyrine, U. S. P. Dosage : 0.25 gm. or 4 grains Apomorphinae Hydrochloridum. — Apomorphine Hydrochloride, U. S. P. Dosage ; expectorant 0.002 gm^ or 1/30 grain, emetic 0.0005 gm. or 1/10 grain. Aqua.— Water, U. S. P. Aqua Destillata.— Distilled Water, TJ. S. P. Argent! Nitras. — Silver Nitrate, U. S. P. Dosage; 0.01 gm. or 1/5 grain. Argenti Nitras Fusus. — Molded Silver Nitrate, U. S. P. Argenti Proteinas. — Silver Proteinate. See Protargol, N. N. E. Aristol. — See Thymolis lodidum. Arseni Trioxidum. — Arsenic Troixide, II. S. P. Dosage: 0.002 gm. or 1/30 grain. Liquor Acldi Arsenosi. — Solution of Arsenous Acid, U. S. P. Dosage: 0.2 c.c. or 3 minims. Liquor Arseni et Hydrargyri lodidi. — Solution of Arsenous and Mercuric lodids, U. S. P. Dosage ; 0.1 c.c. or 1% minims. Liquor Potassii Arsenitis. — Solution of potassium Arsenite, U. S. P. Dosage : 0.2 c.c. or 3 minims. Asafoetida. — Asafetida, TJ. S. P. Dosage : 0.25 gm. or 4 grains. Aspldium. — ^Aspidium, U. S. P. Oleoresina Aspidii. — Oleoresin of Aspidium, U. S. P. Dosage : 2 gm. or 30 grains. Aspirin. — Aspirin, N. N. R. Dosage ; 0.3 to 1 gm. or 5 to 15 grains. Atophan. — ^Atophan, N. N. R. (to be added). Dosage: 0.5 to 1 gm. or 7^ to 15 grains. Atoxyl. — See Sodii Arsanilas. Atropina. — Atropine, U. S. P. Dosage : 0.00025 gm. or 1/250 gr. Atropinae Sulphas. — Atropine Sulphate, TJ. S. P. Dosage: 0.4 mg. or 1/160 grain. Bacterial Vaccines. — See Vaccines. Balsamum Peruvianum. — Balsam of Peru. TJ. S. P 60 USEFUL DRUGS Balsamum Tolutanum. — Balsam of Tolu, C. S. F. Syrupus Tolutanus.— Syrup of Tolu, U. S. P. Dosage: 16 c.c. or 4 fluidrams. Belladonnae Folia. — Belladonna Leaves, TJ. S. P. Tinctura Belladonnae Foliorum. — Tincture of Belladonna Leaves, U. S. P. Dosage : 0.5 c.c. or 8 minims. Extractum Belladonnae Foliorum. — Extract of Belladonna Leaves, U. S. P. Dosage: 0.01 gm. or 1/5 grain. Emplastrum Belladonnae. — Belladonna Plaster, IT. S. P. Unguentum Belladonnae.— Belladonna Ointment, U. S. P. Benzoinum. — ^Benzoin, XT. S. P. Tinctura Benzoinae Composita. — Compound Tincture of Benzoin, U. S. P. Benzosulphinidum, — Benzosulpbinide, • Saccbarin, U. S. .P. Dosage: 0.2 gm. or 3 grains. Betanaphthol. — Betanaphthol, U. S. P. Dosage: 0.1 to 0.3 gm. or 2 to 5 grains. Bismuthi Subcarbonas. — Bismutb Subcarbonate, 17. S. P. Dosage : 1 gm. or 15 grains. Bismuthi Subgallas. — Bismuth Subgallate, U. S. P. Dosage: 0.25 gm. or i grains. Bismuthi Subnitras. — Bismuth Subnitrate, V. S. F. Dosage: 1 gm. or 15 grains. Bismuthi Subsalioylas. — Bismuth Subsalicylate, U. S. P. Dosage: 0.25 gm. or 4 grains. Caffeina. — Caffeine, U. S. P. Dosage : 0.06 gm. to 0.3 gm. or 1 to 5 grains. Caffeina Citrata. — Cltrated Caffeine, II. S. P. Dosage: 0.1 gm. or 2 grains. CafFeinae Sodio-Benzoas. — Caffeine Sodio-Benzoate, N. F. Dosage: 0.10 gm. or 2 grains. Calcii Carbonas Praecipitatus. — Precipitated Calcium Carbonate, U. S. P. Dosage : 1 to 3 gm. or 15 to 45 groins. Calcii Chloridum. — Calcium Chloride, U. S. P. Dosage: 0.5 gm. or 7^ grains. Calcii Lactas. — Calcium Lactate, M. N- R. Dosage : 0.5 gm. or 7^ grains. Calx Calcium Oxide, U. S. P. Liquor Calcis. — Solution of Calcium Hydroxide, U. S. P. Dosage: 15 c.c. or 4 fluidrams. Linimentum Calcis. — Lime Liniment, V. S. P. Calx Chlorinata. — Chlorinated Lime, Chlorinated Calcium Oxide, U. S. F. Liquor Sodae Chlorinatae. — Solution of Chlorinated Soda, TJ. S. P. Dosage : 1 c.c. or 15 minims. Camphora. — Camphor, U. S. P. Dosage : 0.10 gm. or about 2 grains. Aqua Camphorae. — Camphor Water, U. S. P. Dosage ; 10 c.c. or 2 fluidrams. Spiritus Camphorae. — Spirit of Camphor, U. S. P. Dosage : 1 c.c. or 15 minims. Linimentum Camphorae. — Camphor Liniment, U. S. P. Cantharis. — Cantharldes, U. S. P. Ceratum Cantharidis. — Cantharldes Cerate, U. S. P. Tinctura Cantharidis, t). S. P. — Dosage : 0,1 c.c. or 1% minims. Capslcum.^Capsicum, V. S. P. Dosage : 0.05 gm. or about 1 grain. Tinctura Capsici. — Tincture of Capsicum, U. S. P. Dosage : 0.5 c.c. or 7% minims. Carbo Ligni. — Charcoal, U. S. P. Dosage: 1 gm. or 15 grains. Cerdamomum. — Cardamom, U. S. P. Tinctura Cardamomi. — Tincture of Cardamom. Dosage ; 5 c.c. or 1 fluidram. Caryophyllus. — Cloves, U. S. P. Oleum Caryophylli.— Oil of Cloves, U. S. P. Dosage: 0.2 c.c. or 3 minims. USEFUL DRUGS 61 Cascara Sagrada, Cascara Sagrada, U. B. P. Fluidextractum Cascarae Sagradae. — ^Fliildextract of Cascara Sagrada, TJ. S. P. Dosage: 1 c.e. or 15 minims. Fluidextractum Cascarae Sagradae Aromaticum — Aromatic Fluldextract of Cascara Sagrada, U. S. P. Dosage : 2 c.c. or 10 to 30 minims. Extractum Cascarae Sagradae. — Extract of Cascara Sagrada, TJ. S. P. Dosage : 5 gm. or 2 to 8 grains. Cera Alba — White Wax, U. S. P., is the bleached form of Cera Flava. — Yellow Wax, TJ. S. P. 'Chenopodii Oleum. — Oil of Chenopodium, U. S. P. Dosage: 0.2 c.c. or 3 minims. Chloralum Hydratum. — Hydrated Chloral, U. S. P. Dosage : 0.30 to 1.30 gm. or 5 to 20 grains. Chloroform. — Chloroform, U. S. P. Dosage: 0.05 to 0.3 c.c. or 1 to 5 minims. Aqua Chloroforml. — Chloroform Water, U. S. P. Dosage : 15 c.c. or 4 fluidrams. Spiritus Chloroforml. — Spirit of Chloroform, U. S. P. Dosage : 2 c.c. or 30 minims. Linimentum Chloroforml. — Chloroform Liniment, IT. S. P. Chromii Trioxldum. — Chromium Trioxide, U. S. P. Chrysaroblnum.— Chrysarobin, U. S. P. Unguentum Chrysarobinl. — Chrysarobin Ointment, TJ. S. P. Cinchona. — Cinchona, U. S. I'. Tinctura Cinchonae.— Tincture of Cinchona, U. S. P. Dosage : 4 c.c. or 1 fluidram. Tinctura Cinchonae Composlta.— Compound Tincture of Cinchona, TJ. S. P. Dosage: 4 c.c. or 1 fluldram. Clnnamomum..^Cinnamon, TJ. S. P. Oleum Cassiae. — ^Dil of Cinnamon, TJ. S. F. Dosage : 0.05 c.c. or 1 minim. Aqua Cinnamoml. — Cinnamon Water, TJ. S. P. Dosage: 15 c.c. or i fluidrams. Cooaina. — Cocaine, TJ. S. P. Dosage : 0.03 gm. or Ms grain. Cocalna Hydrochlorldum. — Cocaine Hydrochloride, TJ. S. P. Dosage : 0.03 gm. or % grain. Codeina. — Codeine, TJ. S. P. Dosage: 0.03 gm. or % grain. Codelnae Phosphas. — Codeine Phosphate, TJ. S. P. Dosage : 0.03 gm. or % grain. , Codelnae Sulphas. — Codeine Sulphate, TJ. S. P. Dosage: 0.03 gm. or % grain. Colchici Semen. — Colchicum Seed, TJ. S. P. Tinctura Colchici Semlnis. — Tincture of Colchicum Seed, TJ. S. P. Dosage : 2 c.c. or 30 minims. Collodium.— Collodion, TJ. S. P. Collodlum Flexile. — ^Flexible Collodion, TJ. S. P. Colocynthis. — Colocynth, TJ. S. P. Extractum Colocynthidis. — Extract of Colocynth, TJ. S. P. Dosage : 0.03 gm. or % grain. Extractum Colocynthidis Compositum. — Compound Extract of Colocynth, TJ. S. P. Dosage : 0.5 gm. or 7% grains. Copaiba. — Copaiba, TJ. S. P. Dosage: 1 c.c. or 15 minims. Creosotum. — Creosote, TJ. S.P. Dosage: 0.2 c.c. or 3 minims. Cresol. — Cresol, TJ. S. P. Dosage : 0.05 c.c. or 1 minim. Liquor Cresolis Compositus. — Compound Solution of Cresol, U. S. P. Dosage: Solutions containing 1 to 5 per cent. CuprI Sulphas. — Copper Sulphate, TJ. S. P. Dosage: 0.01 gm. or 1/5 grain, astringent; 0.3 gm. or 5 grains (not repeated), emetic. Diacetyl-Morphinae Hydrochlorldum. — Heroin Hydrochloride, N. N. B. Dosage : 3 mg. or 1/20 grain. 62 USEFUL DRUGS Digitalis. — Digitalis, V. S. P. Dosage : 0.065 gm. or 1 grain, infusum Digitalis. — Infusion of Digitalis, TJ. S. P. Dosage: 8 c.c. or 2 fluidrams. Tinctura Digitalis. — Tincture of Digitalis, V. S. P. Dosage: 1 c.e. or 15 minims. Diplitlieria Antitoxin. — See Serum Antidipbthericum. Elaterinum.— Elaterin, U. S. P. Dosage: 0.005 gm. or 1/10 grain. Emetinae Hydroctiloridum. — Emetine Hydrocliloride, U. S. P. Dosage : 0.03 to 0.45 gm. or from % to % grain as an amebicide; 1/12 to 1/16 grain as an expectorant. Epineplirine.— Epinephrine, N. N. R. Dosage: 1:10,000 to 1:1,000. Internally, 5 to 10 drops, of 1 :1,000 solution. Ergota. — Ergot, TJ. S. P. Dosage : 2 gm. or 30 grains. Fluidextractum Ergotae. — Fluldextract of Ergot, U. S. P. Dosage : 2 c.c. or 30 minims. Eucalyptus.— Eucalyptus, TJ. S. P. Eucalyptol. — Eucalyptol, TJ. S. P. Dosage : 0.3 c.c. or 5 minims. Oleum Eucalypti. — Oil of Eucalyptus, U. S. P. Dosage : 0.5 c.c. or 8 minims. Fel Bovis. — Oxgall, TJ. S. P. Extractum Fellis Bovis. — Extract of Oxgall, TJ. S. P. Dosage : 0.1 gm. or 1% grains. Ferri Carbonas. — Ferrous Carbonate. IMassa Ferri Carbonatis. — Mass of Ferrous Carbonate, U. S. F. Dosage : 0.25 gm. or 4 grains. Pilulae Ferri Carbonatis. — Pills of Ferrous Carbonate, U. S. P. Dosage: 2 pills. Ferri Chloridum. — Ferric Chloride, TJ. S. P. Tinctura Ferri Chloridi. — Tincture of Ferric Chloride, U. S. P. Dosage : 0.5 c.c. or 8 minims. Ferri et Ammonii Citras. — Iron and Ammonium Citrdte, TJ. S. P. _J>o'sage: 0.25 gm. or 4 grains. Ferri lodidum.^ — ^Ferrous Iodide. Syrupus Ferri lodidi. — Syrup of Ferrous Iodide, U. S. P. Dosage : 1 c.c. or 15 minims. ,»-■ Ferri Pliosphas Solubiiis. — Soluble Ferrlc\ Pho.sphate, U. S. P. Dosage: 0.25 gm. or 4 grains. .-^ Ferri Sulphas. — Ferrous Sulphate, U. S; P. Dosage: 0.2 gm. or 3 grains. Ferri Sulphas Exsiccatus. — Exsiccated Ferrous Sulphate, TJ. S. P. Ferrum. — Iron, U. S. P. Ferrum Reductum. — Reduced Iron, TJ. S. P. Dosage: 0.06 gm. or 1 grain. Formaidehydum. — ^Formaldehyde. Liquor Formaidehydi. — Solution of Formaldehyde, U. S. P. Gelatinum. — Gelatin, TJ. S. P. Gentiana. — Gentian, U. S. P. Tinctura Gentianae Composita. — Compound Tincture of Gentian, U. S. P. Dosage : 4 c.c. or 1 fluidram. Extractum Gentianae. — Extract of Gentian, U. S. P. Dosage : 0.25 gm. or 4 grains. Giycerinum. — Glycerin, TJ. S. P. Suppositoria Glycerin!. — Suppositories of Glycerin, TJ. S. P. Glycerylis NitPas. — Glyceryl Trinitrate. Spiritus Glycerylis Nitratis. — Spirit of Glyceryl Trinitrate, U. S. P. Dosage : 0.05 c.c. or 1 minim Glycyrrhlza. — Glycyrrhiza, Licorice Root, TJ. S P. Fluidextractum Glycyrrhizae.— Fluidextract of Glycyrrhiza, TI. S. P. Dosage : 2 c.c. or 30 minims. Pulvis Glycyrrhizae Compositus. — Compound Powder of Glycyrrhiza. TJ. S. P. Dosage ; 4 gm. or 60 grains. Guaiacol.— Guaiacol, TJ. S. P. Dosage: 0.1 to 0.6 c.e. or 1% minims to 10 minims. USEFUL DRUGS 63 Guaiacolis Carbonas. — Guaiacol Carbonate, IT. S. P. Dosage: 1 gm. or 15 grains. Heroin Hydrochloride. — See Diacetylmorphinae Hydrocliloridum. Hexametiiylenaniina. — ^Hexamethylenamine, U. S. P. Dosage : 0.3 gm. or 5 grains. Homatropinae Hydrobromidum. — Homatropine Hydrobromlde, U. S. P. Dosage : 0.0005 gm. or 1/125 grain. Hydrargyri Clilariduin Corrasivum. — Corrosive Mercuric Cliloride, XT. S. P. Dosage : 0.002 to 0.01 gm. or 1/30 to 1/6 grain. Hydrargyri Chloridum Mite Mild Mercurous Cliloride, TJ. S. P. Dosage: 0.005 to 0.02 gm. or 1/10 to 1/3 grain. i Hydrargyri lodidum Flavum. — Yellow Mercurous Iodide, U. S. P. Dosage : 0.015 gm. or y, grain. Hydrargyri lodidum Rubrum. — Red Mercuric Iodide, IT. S. P. Dosage: 0.003 or 1/20 grain. Hydrargyri Oxidum Flavum. — Yellow Mercuric Oxide, U. S. P. Dosage: 0.5 to 2 per cent, ointment. Unguentum Hydrargyri Oxidi Flavi. — Ointment of Yellow Mercuric Oxide. U. S. P. Dosage: It should be diluted with from 10 to 100 parts of petrolatum. Hydrargyri Salicylas. — Mercuric Salicylate, N. N. R. Dosage : 0.6 c.c. or 10 minims of a 10 per cent, suspension in liquid parafBn. Hydrargyrum. — Mercury, U. S. P. Hydrargyrum cum Creta.— Mercury with Chalk, U. S. P. Dos.ige: 0.250 gm. or 4 grains. Massa Hydrargyri.— Mass of Mercury, IT. S. P. Dosage : 0.250 gm. or 4 grains. Unguentum Hydrargyri.— Mercurial Ointment, U. S. P. Unguentum Hydrargyri Dilutum. — Blue Ointment, U. S. P. Dosage : 2 gm. or 30 grains. Hydrargyrjtn Ammoniatum. — Ammoniated Mercury, D. S. P. Unguentum Hydrargyri Ammoniati. — Ointment of Ammoniated Mercury, U. S. P Hydrastininae Hydrochloridum. — ^Hydrastinin Hydrochlorid, U. S. P. Dosage • 0.03 gm. or % grain. Hydrastis, — ^Hydrastis, IT. S. P. Fluidextractum Hydrastis.— Fluidextract of Hydrastis, U. S. P. Dosage : 2 c.c. ur 30 minims. Hydrogenii Dioxidum. — Hydrogen Dioxide. Liquor Hydrogenii Dioxidi.— Solution of Hydrogen Dioxide, IT. S. P. Dosage : Apply diluted with four volumes of water. Hyoscyamus.— Hyoscyamus, U. S. P. „ „ „ „ an Tinctura Hyoscyami.— Tincture of Hyoscyamus, U. S. P. Dosage : 0.6 to 2 c.c. or 10 to 30 minims. Hypophysis Secca. — Dessicated Hypophysis, II. S. P. Liquor Hypophysis.— Solution of Hypophysis, U. S. P. Dosage: 1 c.c. or 15 minims. Ichthyol.— Ichthyol, N. N. R. Dosage: 0.2 to 2 c.c. of 3 to 30 minims, lodoformum.— Iodoform, U. S. P. Dosage: 0.25 gm. or 4 grains. lodum. — Iodine, IT. S. P. Tinctura lodi.— Tincture of Iodine, U. S. P. Dosage: 0.1 c.c. or 1% minims. Ipecacuanha.— Ipecac, U. S. P. Dosage: 0.05 gm. or 1 grain, expectorant; 1 gm. or 15 grajps, emetic. Fluidextractum Ipecacuanhae.— Fluidextract of Ipecac, IT. S. P. Dosage: 1 c c or 15 minims, emetic; 0.05 c.c. or 1 minim, expectorant. SvruDUS IpBcacuanhae.— Syrup of Ipecac. D. S. P. Dosage: 0.25 c.c. or 4 minims, expectorant; 15 c.c. or 4 fluidrams, emetic. Jalapa—Jalap, U. S. P. Dosage : 1 gm. or 15 grains. ,, „ „ Pulvis Jalapae Compositus.— Compound Powder of Jalap, U. S. P. Dosage: 2 gm. or 30 grains. 64 USEFUL DRUGS Li num. — Flaxseed, U. S. P. Oleum Lini.— Linseed Oil, V. S. P. Dosage: 30 c.c. or 1 fluidounce. Lobelia.— Lobelia, U. S. P. Tinctura Lobeliae.— Tincture of Lobelia, U. S. P. Dosage ; 0.5 c.c. to 1.5 c.c. or 10 to 20 minims. lUagnesii Carbonas. — Magnesium Carbonate, TJ. S. P. Dosage : 3 gm. or 45 grains. Magnesii Citras. — Magnesium Citrate. Liquor lUagnesii Citratis Solution of Magnesium Citrate, II. S. F. Dosage: 360 c.c. or 12 fluidounces. Magnesii Oxidum. — Magnesium Oxide, U. S. P. Dosage: 0.6 to 3 gm. or 10 to 4S grains. Magnesii Sulphas. — Magnesium Sulphate, U. S. P. Dosage: 15 gm. or 240 grains. Mentiia Piperita. — Peppermint, U. S. P. Oleum Menthae Piperitae. — Oil of Peppermint, V. S. P. Dosage : 0.2 c.c. or 3 minims. Spiritus Menthae Piperitae. — Spirit of Peppermint, U. S. P. Dosage : 2 c.c.' or 30 minims. Aqua Menthae Piperitae. — Peppermint Water, XJ. S. P. Dosage: 16 c.c. or 4 Huidrams. Menthol. — Menthol, U. S. P. Dosage: 0.065 gm. or 1 grain. Methylis Salicylas. — ^Metbyl Salicylate, 17. S. F. Dosage : 1 c.c. or 15 minimi. Morphina. — Morphine, U. S. P. Dosage : 0.01 gm. or 1/6 grain. Morphinae Hydrochloridum. — Morphine Hydrochloride, U. S. P. Dosage: 0.01 gm. or 1/6 grain. , Morphinae Sulphas. — Morphine Sulphate, XT. S. P. Dosage: 0.01 gm. or 1/6 grain. Morrhuae Oleum. — Cod-Liver Oil, U. S. P. Dosage 1 dram to 1 ounce. Myrrha. — Myrrh, U. S. P. Dosage: 0.5 gm. or T% grains. Tinctura Myrrhae. — Tincture of Myrrh, U. S. P. Dosage : 1 c.c. oi 15 minims. Novatophan. — See under Acidiim Phenylcinchoninicum. Novocain. — Novocain Hydrochloride, N. N. R. Dosage : 0.25 gm. or 4 grains In 100 gm. or 3.2 ounces salt solution with 5 to 10 drops of epinephrin solution (1 :1000) as infiltration anesthesia solutions. Nux Vomica. — Nux Vomica, U. S. P. Extractum Nucis Vomicae. — Extract of Nux Vomica, U. S. P. Dosage: 0.015 gm. or % grain. Tinctura Nucis Vomicae. — Tincture of Nux Vomica, U. S. P. Dosage : 0.6 c.c. or 10 minims. Opium. — Opium, U. S. P. Opii Pulvis. — Povpdered Opium, U. S. P. Dosage: 0.065 gm. or 1 grain. Extractum Opii. — Extract of Opium, U. S. P. Dosage : 0.03 gm. or % grain. Tinctura Opii. — Tincture of Opium, Laudanum, U. S. P. Dosage: 0.6 c.c. or 8 minums. Tinctura Opii Deodorati. — Tinctura of Deodorized Opium, TJ. S. P. Dosage : 0.5 c.c. or 8 minims Tinctura Opii Camphorata. — Camphorated Tincture of Opium, Paregoric. U. S. P. Dosage : 8 c.c. or 2 fluidrams. Pulvis Ipecacuanhae et Opii. — Povpder of Ipecac and Opium, U. S. P. Dosage: 0.5 gm. or 7% grains. Oxygenium. — Oxygen, U. S. P. Pancreatinum. — Fancreatin, U. S. P. Dosage: 0.5 gm. or 7% grains. Paraffin urn. — Faraffln, U. S. P. Paraldehydum. — ^Paraldehyde, U. S. P. Dosage ; 2 c.c. or 30 minims. Pelletierinae Tannas. — Pelletierine Tannate, U. S. P. Dosage: 0.25 gm. or 4 grains. Pepsinum. — ^Pepsin, U. S. P. Dosage : 0.25 gm. or 4 grains. Petrolatum, — ^Petrolatum, U. S. P. Petrolatum Liquidum. — Liquid Petrolatum, U. S. P. USEFUL DRUGS 65 Phenol Phenol, U. S. P. Phenol Liquefactum. — Liquefied Phenol, U. S. P. Dosage : 0.05 c.c. or 1 minim. Phenolphthalein. — Phenolphthalein, N. N. R. DosagS : 0.05 to 0.5 gm. or 1 to 8 grains. Phenylis Salicylas.— Phenyl Salicylate, U. S. P. Dosage: 0.2 to 0.5 gm. or 3 to 8 grains. Phosphorus. — Phosphorus, U. S. P. Dosage: 0.5 mg. or 1/125 grain. Physostigma.— Physostlgma, U. S. P. Physostigminae Salicylas. — ^Physoatigmine Salicylate, D. S. P. Dosage: 1 mg. or 1/60 grain. Pilocarpus. — Pilocarpus, U. S. P. Pilocarpinae Hydrochlorldum. — Pilocarpine Hydrochloride, U. S. P. Dosage: 1.001 to 0.01 gm. or 1/6.0 to 1/6 grain. Pilocarpinae Nitras.— Pilocarpine Nitrate, II. S. P. Dosage: 0.1 gm. Or 1/5 grain. Pix Liquida.— Tar, U. S. P. Unguentum Picis Liquidae. — Tar Ointment, U. S. P. Plumbi Aoetas.— Lead Acetate, U. S. P. Dosage: 0.065 ^m. or 1 grain Liquor Plumbi Subacetatis Solution of Lead Subacetate, II. S. P. Podophyllum. — Podophyllum, U. S. P. Resina Podophylli. — Resin of Podophyllum, II. S. P. Dosage: 0.003 to 0.006 gm. or 1/20 to 1/10 grain. Potassii Aoetas Potassium Acetate, II. S. P. Dosage : 2 gm. or 30 grains. Potassii Bicarbonas.— Potassium Bicarbonate, U. S. P. Dosage: 2 gm. or 30 grains. Potassii Bitartras. — Potassium Bitartrate, U. S. P. Dosage : 2 gm. .or 30 grains. Potassii Bromldum. — Potassium Bromide, II. S. P. Dosage : 1 gm. or 15 grains. Potassii Carbonas. — Potassium Carbonate, U. S. P. Dosage : 1 gm. or 15 grains, well diluted. Potassii Chloras. — Potassium Chlorate, IT. S. P. Dosage : Saturated solu- tion may be used as mouth wash or gargle. Potassii Citras. — ^Potassium Citrate, U. S. F. Dosage : 1 gm. or 15 grains. Potassii' Citras Effervescens. — Effervescent Potassium Citrate, 'II. S. P. Dosage : 4 gm. or 60 grains. Potassii et Sodii Tartras. — Potassium and Sodium Tartrate, U. S. P. Dosage : 8 gm. or 120 grains. Pulvis Effervescens Compositus. — Seidlitz Powder, II. S. P. Dosage : One set of two papers. Potassii Hydroxidum. — Potassium Hydroxide, II. S. P. Liquor Potassii Hydroxidi. — Solution of Potassium Hydroxide, U. S. P. Dosage : I c.c. or 15 minims. Potassii lodidum. — ^Potassium IodJ.de, U. S. P. Dosage: 0.3 to 2 gm. or 5 to 30 grains. Potassii Permanganas. — ^Potassium Permanganate, U. S. P. Dosage : 0.03 to 0.06 gm. or % to 1 grain. Protargoi — Protargol, N. N. R., Silver Protelnate. Dosage: 1.2,000 to 1 per cent solutions. Prunus Virginiana. — Wild Cherry, U. S. P. Syrupus Pruni Virginianae.— Syrup of Wild Cherry, II. S. P. Dosage'; 5 c.c. or 1 fluidram. Quinina.— Quinine, II. S. P. Dosage: 0.25 -gm. or 4 grains Quininae Bisulph as.— Quinine Bisulphate, U. S. P. Dosage: 0.25 gm. or 4 grains. Quininae Hydrochlorldum.— Quinine Hydrochloride, U. S. P. Dosage; 0.25 or 4 grains. Quininae Sulphas.— Quinine Sulphate, II. S. P. Dosage: 0.25 or 4 grains. Quininae Tannas.- Quinine Tannate, N. N. R. Dosage: 0.5 gm. or 7V4 grains. 66 USEFUL DRUGS auininae et Ureae Hydrochloridum.— Quinine and Urea Hydrochloride, N. N. K. Dosage : 0.25 gm. or 4 grains. Resoroinol.— Besorcinol, U. S. P. Dosage : 0.125 gm. or 2 grains. Rheum.— Rhubarb, V. S. P. Dosage : 1 gm. or 15 grains. Extractum Rhei.-Extract of Khubarb, U. S. P. Dosage : 0.25 gm. or Tinctura Rhei Aroraatica.— Aromatic Tincture of Rhubarb, TJ. S. P. Dosage : 2 c.c. or 30 minims. . „,. v v xi o x. Syrupus Rhei Aromaticus.— Aromatic Syrup of Rhubarb, U. s. f. Dosage : 8 c.c. or 2 fluldrams. Ricini Oleum.— Castor OU, U. S. P. Dosage : 15 c.c. or 4 fluldrams. Rosa. — Rose. Aqua Rosae.— Rose Water, U. S. P. Saccharum. — Sugar, IT. S. P. Syrupus. — Syrup, U. S. P. Saccharum Lactis.— Sugar of Mill, U. S. P. Salvarsan. — See Arsphenamlne. Santaii Oleum.— OU of Santal, TJ. S. P. Dosage 0.5 c.c. or 8 minims Santoninum.— Santonin, U. S. P. Dosage: 0.065 gm. or 1 grain. Sapo. — Soap, V. S. P. LInimentum Saponis. — Soap Liniment, U. S. P. Sapo Mollis.— Soft Soap, 17. S. P. Scllla.— Squill, U. S. P. Dosage : 0.125 gm. or 2 grains. Tinctura Scillae.— Tincture of Sguill, U. S. P. Dosage: 1 c.c. or 15 minims. Syrupus Scillae. — Syrup of Squill, U. S. P. Dosage : 2 c.c. or 30 minims. Scopolaminae Hydrobromldum. — Scopolamine Hydrobromide, U. S. P. Dosage: 0.5 mg. or 1/125 grain. Senna. — Senna, U. S. P. Dosage: 4 gm. or 60 grains. Fluidextractum Sennae. — I'luidextract of Senna, U. S. P. Dosage: 2 c.c. or 30 ml;alms. Syrupus Sennae. — Syrup of Senna, U. S. P. Dosage: 4 c.c. or 1 fluidram. Serum Antidiphthericum. — ^Antidlphtberic Serum, Diphtheria Antitoxin, V. S: P. Dosage: Immunizing, 500 to 1,000 units; curative, 10,000 units. Serum Antidiphthericum Puriflcatum. — ^Purified Anti4iphtberia Serum, U. S. P. Serum Antidiphthericum Siccum. — Dried Antidlphtheria Serum, U. S. P. Serum Antitetanicum. — ^Antltetanic Serum, XT. S. P. Dosage : Immuniz- ing, 1,500 units; in tetanus, 3,000 to 20,000 units. Serum Antitetanicum Puriflcatum.— rPurlBed Antitetanic Serum, U. S. P. Serum Antitetanicum Siccum.— Dried Antitetanic Serum, U. S. P. Sinapis. — Mustard. Sinapis Nigra. — Blaclc Mustard, U. S. P. Dosage : 8 gm. or 120 grains. Emplastrum Sinapis. — ^Mustard Plaster, U. S. P. Oleum Sinapis Volatile. — ^Volatile Oil of Mustard, 17. S. P. Dosage : 0.008 c.c. or ^ minim. Sodii Arsanilas. — Sodium Arsanilate, N. N. B. Dosage : 0.02 gm. or 1/3 grain. Sodii Arsenas. — Sodium Arsenate, 17. S. P. Dosage : 5 mg. or 1/10 grain. Sodii Benzoas. — Sodium Benzoate, U. S. P. ' Dosage : 1 gm. or 15 grains. Sodii Blcarbonas. — Sodium Bicarbonate, 17. S. P. Dosage : I gm. or 15 grains. Sodii Blphosphas.^Sodium Acid Phosphate, N. N. R. (to be added). Dosage: I to 1.5 gm. or 15 to 20 grains. Sodii Boras. — Sodium Borate, U. S. P. Dosage: 0.5 gm. or 7% grains. Sodii Bromldum. — Sodium Bromide, T7. S. F. Dosage : 1 gm. or 15 grains. Sodii Cacodylas. — Sodium Cacodylate, N. N. R. Dosage: 0.03 gm. or % grain. USEFUL DRUGS 67 ' Sodii Carbonas Monohydratus. — Monohydrated Sodium Carbonate, U. S. F. Dosage : 0.25 gm. or 4 grains. Sodii Cliloridum. — Sodium Chloride, U. S. F. Dosage: 16 gm. or Z40 grains, emetic; i gm. or 60 grains, laxative. Sodii Hydroxidum. — Sodium Hydroxide, tJ. S. F. Liquor Sodii Hydroxidi. — Solution of Sodium Hydroxide, V. S. F. Dosage: 1 c.c. or 15 minims. Sodii lodidum. — Sodium Iodide, U. S. F. Dosage : : 0.5 gm. or TA grains. Sodii Nitris Sodium Nitrate, IT. S. F. Dosage: 0.065 or 1 grain. Sodii Phosphas. — Sodium Phosphate, IT. S. F. Dosage: 2 gm. or 30 grains. Sodii Phosplias Effervescent. — Effervescent Sodium Phosphate, IT. S.- F. Dosage: 8 gm. or. 120 grains. Sodii Sallcyias. — Sodium Salicylate, XT. S. F. Dosage : 1 gm. or 15 grains. Sodii. Sulphas. — Sodium Sulphate, IT. S. F. Dosage: 16 gm. or 240 grains. Sodii Suiphis. — Sodium Sulphite, IT. S .F. Dosage : Applications of 1 in 10 or 1 dram to the ounce. Sodii Thiosulplias. — Sodium Thiosulphate, U. S. F. Dosage : 1 gm. or 15 grains. Staphylococcus Vaccine.^See Vaccine, Staphylococcus. Stramonium. — Stramonium, tl. S. F. Strophanthinum Strophanthin, IT. S. P. Dosage: 0.0003 gm. or 1/200. grain. Strophanthus.— Strophanthus, IT. S. F. Tinctura Strophanthl. — Tincture of Strophanthus, IT. S. P. Dosage : 0.5 C.C. or 8 minims. Strychnina. — Strlchnine, U. S. F. Dosage: 0.0005 to 0.005 or 1/100 to 1/10 grain. Strychninae Nitras. — Strychnine Nitrate, IT. S. P. Dosage: 0.001 gm. or 1/60 grain. Strychninae Sulphas. — Stryclinine Sulphate, IT. S. F. Dosage: 0.001 gm. or 1/60 grain. Sulphonal. — See under Sulphonmethanum. Sulphonethylmethanum. — Sulphonethylmethane, IT. S. P. — Trional. Dosage : 1 gm. or 15 grains. Sulphonmethanum. — Sulphonmethane ,IT. S. P. — Sulphonal. Dosage: 1 gm. or 15 grains. Sulphur. — Sulphur. Sulphur Lotum. — Washed Sulphur, IT. S. P. Dosage: 4 gm. or 60 grains. Sulphur Praecipitatum.— ;Precipltated Sulphur, IT. S. P. Dosage : 4 gm. or 60 grains. Sulphur Sublimatum. — Sublimed Sulphur, IT. S. P. Dosage: 4 gm. or 60 grains. Unguentum Suiphuris. — Sulphur Ointment, IT. S. P. L-Suprarenin Synthetic. — See Epinephrine. Tannalbin. — See imder Acidum Tannlcum. Terebinthina. — Turpentine, U. S. P. Oleum Terebinthinae. — Oil of Turpentine, IT. S. P. Dosage: 1 c.c. or 15 minims: Terpini Hydras. — Terpin Hydrate, U. S. P. Dosage: 0.125 gm. or 2 grains. Tetanus Antitoxin. — See Serum Antitetanicum. Theobromitas Oleum. — Oil of Theobroma, IT. S. F. Theobromina. — Theobromine, N. N. K. Dosage : 0.3 gm. or 5 graJps. Theobrominae Sodio-Salicyias. — Theobromine Sodiimi Salicylate, N. N. -R. — Diuretin. Dosage: 0.5 gm. or 7% grains. Thymol. — Thymol, IT. S. P. Dosage : 0.1 gm. or 2 grains. Thymolis lodidum. — Thymol Iodide, IT. S. P. Thyrordeum Siccum. — Dried Thyroids, IT. S. P. Dosage : 0.06 gm. or 1 grain. Typhoid Vaccine.— See Vaccine, Typhoid. 68 USEFUL DRUGS Tiglii Oleum.— Croton Oil, U. S. P. Dosage: 0.05 c.c. or 1 minim. Tragacantha. — Tragaoamh, U. S. P. Trinitrophenol.— Trinltropbenol, U. S. P. Dosage; 0.03 gm. or % grain. Trional. — See under Sulphonetbylmetlianum. Tuberculinum Tuberculin, N. N. R. Urotropin. — See Hexamethylenamina. Vaccine, Staphylococcus.— Staphylococcus Vaccine, N. N. R. (to be added). Dosage: 1,000,000,000 bacteria. Vaccine, Typhoid.— Typhoid Vaccine, N. N. R. Dosage: 500.000,000 to 1,000,000,000 bacteria. Vaccine, Virus. — See under Virus, Vaccine. Valeriana Valerian, U. S. P. Tinctura Valerianae Ammoniata. — Ammoniated Tincture of Valerian, U. S. P. Dosage: 2 c.c. or 30 minims. Veronal N. N. K. Dosage : 0.3 to 0.6 gm. or 5 to 10 grains. Sodii Diaethyl-Barbituras. — Sodium Dietbyl-Barbiturate, N. N. It. Dosage: 0.3 to 0.6 gm. or 5 to 10 grains. Virus Vaccinum. — Vaccine Virus, N. N. R. Zinci Acetas Zinc Acetate, TJ. S. P. Dosage : 0.125 gm. or 2 grains. Zinci Chloridum. — ^Zinc Chloride, IT. S. P. Liquor Zinci Chloridl. — Solution of Zinc Chloride, II. S. P. Zinci Oxidum. — Zinc Oxide, U. S. P. Dosage: 0.25 gm. or 4, grains. Unguentum Zinci Oxidi. — Ointment of Zinc Ozlde. Zinci Stearas. — Zinc Stearate, U. S. F. Zinci Sulphas. — Zinc Sulphate, U. S. P. Dosage : 2 gm. or 30 grains. Zingiber. — Ginger, XJ. S. P. Dosage : 1 gm. or 15 grains. Tinctura Zingiberis. — Tincture of Ginger, TJ. S. P. Dosage : 2 o.c. or 30 minims. SOME THERAPEUTIC PRINCIPLES INDIVIDUAL TENDENCIES Teachers of therapeutics emphasize the necessity of individualizing the patient but sometimes forget the importance of family tendencies. There is no more doubt that an individual inherits family weakness and family strength or, if the phrase is preferred, family tendencies, than there is that he inherits the features and general physique of his parents and grandparents. These tendencies are often recognizable by the general appearance and physical findings but if not can almost always be developed by a careful investigation into the family history of the patient. THE FAMILY HISTORY It should be the rule of the physician to inquire into the family history carefully with every new patient. Heredity and environment are the two factors that are most prominent in the production of physical and mental health. Environment may improve or mar heredity, but cannot change it. Heredity is therefore the most important factor in raising and developing an ideal race. The importance of good environment for the perpetuation of physical and mental health is so well understood that it requires no discussion. But environment will not eliminate ^ hereditary tendency to disease or to mental or physical insuffipiency. Neither will environment develop perfect mental and physical health when there is an inherited deficiency, although environment can markedly improve deficiency caused by injury or acquired by disease. The environment of. prospective fathers and mothers and their future children. is being constantly improved by the public health advances now being made in all communities but, as has been stated, this will not prevent the ravages of inherited disease (syphilis, epilepsy, insanity, imbecility, physical weak- ness) or of the inherited tendency to disease (tuber- 70 THERAPEUTIC PRINCIPLES culosis, cancer, gout, diabetes, alcoholism, etc.) any more than environment can produce twins, beauty, geniuses or permanent health. In fact, improved environment is doing more for the defectives in all lines than for those of good heredity, who would survive a less improved environment. It, therefore, is of vital importance to the patient that his physician should know and recognize the dia- thesis or predisposition to certain types of disease that he has inherited, so that whatever treatment his pres- ent condition may call for, the tendency to the family weakness niay be at the same time properly combated. UNSCIENTIFIC PRESCRIBING Lack of scientific therapeutic teaching causes a large number of general practitioners to listen to enthusias- tic proprietary detail men and subsequently to use secret proprietary preparations for various conditions, when, in most cases, the active ingredient is a drug which they have long used, but in a simpler and less expensive manner. The physician using such a prep- aration and obtaining good results frequently rushes into print and lauds the preparation or combination of drugs as a cure for that condition or disease, when really it is the principal active ingredient of it that does the work. The thing needed, then, in scientific therapeutics . is more careful instruction in details by the teachers and bedside clinicians, and a willingness on the part of the general practitioner to describe his failures as well as his successes. The general practitioner who writes of his therapeutic successes should constantly bear in mind, first, the trend of troublesome condi- tions to recovery; second, that it is not always the last drug, preparation or treatment that benefited the patient, but that the previous treatment may really have caused the cure; third, that many a new drug or new preparation offered with the enthusiasm of the physician cures a patient by psychic effect, much as does a change of physicians or a change of environ- ment in many cases. RELATION OF THERAPEUTICS 71 THERAPEUTICS MORE THAN MEDICINE The scope of therapeutics and its relation to the practice of medicine are well shown by the accom- panying chart prepared by Dr. Osborne. (Amer. Jour. Med. Sci., 1916.) A disease cannot be correctly treated unless the fol- lowing facts are considered: 1. Can the etiologic factor in a given disease be dis- covered, and can it be removed ? This is the primary treatment. 72 THERAPEUTIC PRINCIPLES 2. What physiologic processes in this patient are disturbed by this disease? The aim of all treatment should be the attempt to correct such disturbed physi- ology, and at the same time not disturb the normal physiologic processes. 3. The pathologic conditions which are the result of the disease should be removed if possible, ameliora- ted if removal is not possible, and never irritated or made worse by any medicinal or physical treatment. Special care should be taken that whateyer treatment is deemed advisable for the patient, it should not aggra- vate or make worse the pathologic condition present. 4. The symptoms and signs of the disease which in their totality determine the diagnosis, and the extent to which the pathology of the disease has progressed, are in their totality of minor and secondary importance in the treatment. On the other hand, individual trouble- some symptoms must be removed or ameliorated, else normal physiologic processes which are necessary to recovery cannot be performed, and toxemias that otherwise need not have occurred may perhaps be the determining cause of the nonrecovery of the patient. PAIN AS A SYMPTOM Of all symptoms, that of pain is the most important and the one from which the patient must have relief. It does not seem to make a great deal of difference whether such pain is pathologically excusable or pres- ent only on account of psychologic mistake, the ner- vous irritability and finally depression caused by it must be taken into consideration and must be treated or, better, managed. At least, pain must be prevented at any cost. This does not mean that the physician should hasten to the use of unneeded narcotics, nor that he should ever use a narcotic without regret and without the extra supervision that should always go with such treatment, but it is the skillful, thoughtful, discriminating physician who can determine the best method of eradicating the symptom of pain in each individual patient. We should remember that it is frequently possible, in making examinations or in treating patients, to secure for them great comfort PAIN AS A SYMPTOM 73 merely by altering the posture. Pain after operation is frequently due to lack of support of the back. Inci- dentally the soothing effects of the warm bath or the warm pack should not be overlooked. The use of olive oil in gastro-intestinal pain is worthy of consid- eration. It is frequently possible by the use of such means to relieve pain without the employment of any narcotic. INFECTIOUS DISEASES MEASLES THE PROPHYLAXIS OF MEASLES Measles is a disease to which practically every indi- vidual who has not already suffered an attack is sus- ceptible. It is one of the most contagious of all dis- eases, ranking in this respect with smallpox and typhus fever. This was particularly shown in the large epidemics of measles attacking our troops during the mobilization on the Mexican border and those which occurred in the cantonments. It seems almost invariably true that one attack of the disease protects against subsequent attacks, though a second, third, and even fourth attack are not uncom- mon. It is probable that when these repeated attacks have occurred, some of them at least were other cutaneous infectious dieases, especially so-called Ger- man measles, or some eruptive but noncontagious disease. It has been observed that children under six months of age are less likely to take this disease than older children, and that extremely old people are also less susceptible. It seems to be a fact that the disease is most disastrous in its effects on infants, on persons who are tuberculous or who have any tendency to tuberculosis, on those who are debilitated from any cause, and on women who are pregnant or who have recently been confined. « Efforts should be made, therefore, t.o isolate children who are suffering from measles in order to prevent the spread of the disease. The contagious material of measles appears to have less vitality and to resist the ordinary measures of disinfection, including sunlight and fresh air, much less strongly than does the contagium of scarlet fever. It seems to exist extensively in the secretions from the PROPHYLAXIS OF MEASLES 75 nose, throat and mouth, and the disease seems to be especially contagious during the period when the catarrhal symptoms are manifest but before the cuta- neous eruption appears. This increases the difficulty of enforcing efficient quarantine. When the disease is prevalent, children who show symptoms of cold in the head should be suspected of having measles and should be promptly quarantined, but at the beginning of an epidemic it is rare that a child will be placed in quarantine before the eruption has appeared. The measures applicable to cases of measles may be briefly summarized as follows : The isolation of the patient in a remote room of the house. The selection of a single immune person to care for the patient. The wearing by the physician of a linen or rubber coat when he visits . the patient, which is removed outside of the patient's door. The destruction of books and toys which have been used by the patient, at the end of the period of quarantine. The disirifection of dishes and clothing before they are removed from the sickroom. At the end of the period of quarantine, which in the case of measles unattended by complications should be three weeks, the bathing and shampooing of the patient and dressing him in fresh clothes. The disinfection of the rootn, after it has been vacated, by exposure of the room so far as possible to fresh air and sunshine.' Sunshine and light are essential to the killing of the germs of all disease, and especially of measles; hence the room of a patient suffering from measles should only rarely be kept dark during the day. The patient's eyes may be efficiently protected from light by blue or smoked glasses. The prolonged cough of measles after the period of quarantine is over should be treated as though the patient had incipient tuberculosis, and then the num- ber of secondary deaths from measles will be cut in half. 76 MEASLES TREATMENT A patient with measles must be isolated. The room must be warm, as these patients should not be sub- jected to cold drafts or cold air. Chilling^ is espe- cially harmful in measles, because of the frequency of lung complications. This does not mean that the air of the room should not be fresh and clean, and the ventila- tion the best possible. Eyes. — Unless the child is very young and cannot wear colored spectacles, the room should not be dark. Sunlight is as essential for the welfare of patients with measles as it is in any other disease. It is absolutely unnecessary, in ordinary cases, to have the room black dark on account of the eyes. If the eyes are inflamed, the child will cooperate and really enjoy using colored spectacles. Of course, when it is time for the child to go to sleep, the room may be dark- ened, and the glasses removed. A saturated boric acid solution may be used as a wash for the eyes, and if it seems advisable, some sim- ple eye-drops may be used, such as: Gm. or C.c. ^ Acidi borici Aquae, camphorae 15 Aquae q. s. ad. 25 25 gr. V flS ivss flSi M. Sig. : Use as eye-drops three or four times a day. If the lids tend to stick together after sleeping, they should be gently washed with warm boric acid solution or plain warm water, and before the child goes to sleep the edges of th^ lids may be anointed with thick white petrolatum. Cough, Etc. — If old enough, the child should gargle several times a day with some simple, warm, alkaline sedative solution. If the child is not old enough to gargle, the throat should be sprayed. The nose should also be sprayed occasionally, if it seems stopped up. It is often well to leave the nose alone in measles. Most nasal douching is inadvisable, as tending to force fluid or secretions into the eustachian tubes. Most of these patients require some simple expec- torant mixture, although many physicians are losing faith in the activity of so-called expectorant drugs. Gm. or C.c. 05 gr-i 3 Si SO flSii 100 flSiv TREATMENT OF MEASLES 11 There is no safe drug that promotes the secretion of the mucous membrane of the upper air passages and bronchial tubes more than does ammonium chlorid. It is of advantage in causing the cough to be less dry, and therefore aiding the expulsion of any mucopuru- lent matter that may be in the trachea and bronchial tubes. If the cough is excessive from irritation, a sedative may be added to prevent the unnecessary coughing. A child 5 years old may receive : B Codeinae sulphatis Ammonii chloridi Syrupi tolutani Aquae q. s. ad M. Sig. : A teaspoonful, in water, every two or three hours, when the child is awake. If the child's cough is not excessive or irritating, the codein may be omitted from the mixture. As soon as the expectoration is more free and there is no excessive amount of coughing, the medicine may be stopped. A child 10 years old should receive twice the amount of codein sulphate, and the ammonium chlorid should be increased to 5 gm., and if deemed advisable, the sour sirup of citric acid may be sub- stituted for the sweet sirup of tolu in amount of 25 c.c. to the 100 c.c. mixture. Because of the frequency of bronchopneumonia fol- lowing measles all lung symptoms should be carefully watched. Bowels. — In the beginning of the disease, the child should receive a small dose of calomel, 0.05 or 0.10 gm. (1 to 1% grains) given with milk; or a dose of castor oil, or some cascara; the bowels should be thoroughly and well moved. Minute doses of calomel frequently repeated should not be given, as such dosage causes irritation. Subsequently the bowels may be moved daily with sorne gentle laxative. Diet. — The food depends on the temperature and should be liquid and simple as long as the tempera- ture is elevated. As soon as the temperature falls to normal, the child should receive good nutritious food, and plenty of it. It is inadvisable to give meat in any form, including broths, as long as the eruption 78 MEASLES is present. If, as has been suggested, the eruption in measles ■ is caused by some irritant circulating in the blood, such as occurs in urticaria, representing a sort of anaphylaxis, the proper diet comprises cereals, milk, and plenty of water. Such little patients are better without fruits, as sometimes even orangeade or lemonade seems to cause more itching and discom-. fort of the skin. Fever. — ^The temperature rarely calls for much treatment. If it is high, however, one or two doses of acetanilid will generally be sufficient to reduce it. Hot sponging will cool the child as much as cold sponging will, and with less disturbance. Cold spong- ing in measles is inadvisable. As often as the child is bathed or sponged for temperature, the surface of the body should be powdered with some bland talcum. ^few.— ^Unless the room is cold and damp, or the patient is otherwise ill, a cotton nightdress will cause less itching and discomfort than would a warmer flan- nel or silk shirt. All through the illness the nurse should recognize that it is the secretions of the nose and throat that cause infection of others, and not the eruption or exfoliation from the skin. This does not mean that it is not necessary to sterilize the child's garments and bedclothing, as such may carry the infection from the nose and throat. Convalescence. — Prolonged, careful convalescence is essential in measles. Measles, like whooping cough, is often a forerunner of pulmonary tuberculosis. Probably no attack of measles ever occurs that does not cause enlargement and more or less inflammation of the bronchial glands. If such glands harbor tubercle bacilli, they are stimulated to cause an acute infection. On the other hand, immediately after an attack of measles a patient is doubtless more sus- ceptible to infection froth tubercle bacilli. Therefore, before the child is returned to school the cough should have ceased, his weight should be normal, and his nutrition should be good. Persistent enlarged glands in the neck or elsewhere, and adenoid conditions or enlarged tonsils, should all be regarded with suspicion. Such conditions are PROPHYLAXIS OF SCARLET FEVER 19 . liable to be accentuated by an attack of measles, and proper treatment should be instituted. A suppurating ear must be treated by a specialist until pronounced cured and the hearing is as near perfect as possible. The physician should remember that most defective ears follow measles, scarlet fever and influenza; that an acutely infected ear, if immediately correctly treated, is generally saved intact; distention and per- foration may occur without pain. Consequently, he should be ever alert to see that the complication of middle-ear inflammation is immediately treated. SCARLET FEVER PROPHYLAXIS OF SCARLET FEVER "Scarlatina," "scarlet rash" and "scarlet fever" are synonymous terms. While scarlet fever may be, and often is, a very serious disease with high tempera- ture, severe sore throat, intense and widely spread eruption, followed by copious desquamation, the fever may be slight or entirely absent, the throat may ;not ^ show more than slight congestion, the eruption, if not entirely absent, may be not very pronounced in appear- ance, not widely spread over the body and of rather transient duration, while the desquamation may be so slight as to be hardly recognizable. Furthermore, it is now generally recognized not only that the very mild cases may be followed by the most serious sequelae which are observed after the severe forms of the disease, and particularly by inflammation of the kidneys^, but also that severe forms of scarlet fever may be, and often are, contracted from patients whose symptoms have been exceedingly mild. A possible explanation of apparent immunity to scarlet fever may be, at least in some cases, that these immune individuals have in their earlier life passed through an attack of scarlet fever of so mild a type that a physician was not called to the patient, or if one was called, he did not recognize the nature of the dis- ease. This, however, probably does not explain' all cases of apjarent immunity. Undoubtedly there, are mariy persons who never contract the disease except -after unusual exposure. On the other hand, it is 80 SCARLET FEVER unjustifiable carelessly or wittingly to expose child or adult to the disease, no matter how mild the t3rpe may be. CONTAGIOUSNESS It was long believed that the contagious element of the disease existed in the scales which occur in greater or less profusion during desquamation. At present we believe that the scales in themselves do not possess the power of transmitting the disease. On the other hand, they may become contaminated by infected secretions; hence it is important to prevent the dis- semination of these scales. The belief has been gaining g.round,that the element of contagion exists actively and abundantly in the secretions from the throat and nose, and also in the discharges from the ear and from the suppurating glands when they are present. Also it is believed that when the disease is transmitted by disseminatio:. of the scales, it is due to the fact that the latter have been contaminated by these secretions. Obviously then, the problem which confronts both family and phytician, as well as sanitarian, is to control the dissemination of these various secretions, discharges and exfoliations. ISOLATION AND DISINFECTION The mastery of the problem embraces first, isola- tion; second, disinfection. The jestablishment of isolation often taxes severely the tact and good judgment of the physician. If the family is large and lives in a small house or apartment and on a limited income, and if the municipality pos- sesses an isolation hospital, or wards of a hospital are set apart for the treatment of contagious diseases, the easiest way is to transport the patient immediately to such an institution. Here he will be under the care of attendants who are accustomed to handle patients with the disease, and whp are trained to exercise all the precautions necessary to prevent the spread of the disease. Most towns have no special provision for taking care of scarlet fever, and in such cases the patients must be treated in their own homes. If the ISOLATION IN SCARLET FEVER 81 family has ample means and lives in a large house, a large room or a suite of rooms must be set apau for the exclusive use of the patient and the special atten- dant, who must be secilreJ to give him exclusive atten- tion. Such an apartment or suite should, if possible, be selected on the top floor of the house or at the end of a hall, so that the other rriembers of the family will have no occasion to go near it. The room should be large and sunny, and all unnecessary articles, such as curtains, upholstered furniture, and ornaments, should Be removed, so that there will be as few articles as possible to which the disease poison . may adhere and which will need to be cleaned or destroyed after the recovery of the patient. The attendant should not invade other parts of the house. Food and other hecessities should be left outside the door of the apart- ment occupied by the patient by another member of the household. Similarly, everything which requires removal from the infected apartment should be dis- infected and placed outside the apartment, and thence carried away. The most important things which are likely to require removal are dishes, clothing, and excreta. These should be disinfected by being placed in suitable vessels and then allowed to soak for an hour in a 2.5 per cent, solution of phenol (carbolic acid). Things which are of little or no value and which are combustible, such as the remnants of food and pieces of cloth or paper which have been used about the room, should be burned. If the nurse finds it necessary to leave the patient's quarters, she should change all her outer garments outside of the patient's room, she should cover her hair, and avoid coming into close contact with anyone. These precautions of isolation should be carried out continuously and strictly until desquamation is entirely completed. During the period of desquamation the patient should be sponged or bathed once or twice a day with hot water (and if there are bathroom facilities the con- valescent should have a daily hot tub bath), and then the skin should be anointed with adeps lanse hydrosus (lanolin) which has been softened with a:lmond (or other bland) oil, and perfumed to suit. Phenol (car- 82 SCARLET FEVER bolic acid) ointments are inadvisable, as any absorp- tion would irritate the kidneys. Sponging with alcohol is contra-indicated. After desquamation has ceased, the patient should remove all -the clothing which he has been wearing, take a warm bath, with soap, and have his head well shampooed. Then he must dress throughout in fresh clothing. The apartment should be thoroughly disinfected. Fumigation after scarlet fever, diphtheria and measles does not seem to pay for the cost and trouble it causes. Proper fumigation with strong 'formal- dehyd, carried out by boards of health, should still be . done for smallpox and tuberculosis, and perhaps for erysipelas, childbed fever and tetanus, especially in hospitals. Spraying with germicides of all the imme- diate surroundings of an infected patient is the method of disinfection now most satisfactory. All washable clothing and bedclothing should be boiled; all other clothing should be baked and put into the sunlight. Carpets and rugs may be thoroughly sunned and aired or washed with antiseptics. Various wash- ing solutions may be used, such as chlorinated lime solutions, 5 per cent., formaldehyd solutions, corrosive sublimate solutions 1 : 500, 5 per cent, phenol (car- bolic acid) solutions, or better, the higher coal-tar disinfectants, as liquor cresolis compositus. The New York Board of Health orders the woodwork and floors scrubbed with hot solution of 1 pound of washing soda to 3 gallons of hot water. Bedding and night clothing are ordered soaked in phenol solutions and then boiled in soapsuds for half an hour. Books and toys should be burned. It should never be forgotten that outside air and sunlight are among the most useful of disin- fectants. When it is possible to carry out such strict isolation as has been described, there is no necessity of quaran- tining the rest of the family but, unfort-imately, such complete isolation is ideal and can rarely be carried out in actual practice. Even when a large family occupies a few rooms, it is essential that one room be selected for the patient, and that he be kept in it con- stantly, and that the other members of the family be kept out of it entirely, except one who is selected to DISINFECTION IN SCARLET FEVER 83 act as the attendant, usually the mother. Under such conditions it is usually entirely impracticable for the attendant to remain constantly in the room -with the patient. She must frequently leave the room, not only, to get things which the patient requires, but also to perform services for the remainder of the family. Under these circumstances it is' desirable and often entirely practicable that such members of the family as attend school, or work in stores or shops, should leave home, and should live elsewhere for six or eight weeks. Those who are obliged to remain at home should avoid as much as possible coming in contact with the attendant. The latter should have several aprons, with sleeves, and large enough to cover all her outer clothing. One of these she should wear con- stantly while in the 'patient's room. Needless to state, she should always wash her hands on leaving the room. It is generally believed by the medical profession that' physicians who use even a moderate degree of caflrtion rarely transport the disease from' a patient to another individual, and when this does happen, the victirn is usually a member of his own* family. He should endeavor to so arrange his calls that he will not go directly from a patient ill with scarlet fever to a family in which there is a child. On entering the room of such a patient he should put on a long cotton, linen or rubber coat. He should avoid sitting on the bed, or allowing the bedclothing to come in contact with his own clothing. On leaving the room he should thor- oughly wash his hands and dry them on a clean towel and remove the gown just outside the patient's door. During convalescence the patient should not be allowed to use books from the public library or the public school, and should use only such books, maga- zines and newspapers as can be burned when he is through with them, or when the period of isolation is ended. Neither should he be allowed to write and send letters through the mail or by messenger to his friends. No drug treatment is known that will certainly prevent persons exposed to the disease from contract- 84 SCARLET FEVER ing it or developing it. Although belladonna has been extensively used for this purpose, and has been believed .by many to have accomplished the prevention of the disease, there is no adequate reason for believ- ing that it has ever produced this result. Although often advocated, and sometimes used, the impregnation of the atmosphere of the room with anti- septics (phenol) and aromatic oils seems to be of no value in killing the germs or in hastening recovery. Various cresol preparations are recommended for this purpose, but their value is small, and the danger of too much absorption of phenol vapor causing kidney irri- tation is ever present. Dogs and cats must be excluded from all patients suffering with contagious diseases, and this is espe- cially true of scarlet fever. The .doors and windows must be screened from flies, if it is the season for them. TREATMENT A. Isolation.— Strict isolation measures, already dis- cussed under other headings, are most importanl^in this disease, and the nurse should distinctly under- stand that it.is. the secretions of the rhouth and nose, and perhaps suppurating complications, that carry infection. The greatest possible care to disinfect or sterilize articles contaminated by such secretions should be exercised, as the infecting germ is persistent and lives for a long time unless killed. The most efficient cleanliness of the patient, nurse, and the physi- cian who handles the case is also essential. B. Diet. — As in the beginning of all diseases, espe- cially the infectious diseases, the bowels should be thoroughly evacuated with castor-oil, calomel, or what- ever the physician deems best; subsequently, they should be moved daily by some gentle laxative, found efficient. If the patient has diarrhea, it is generally caused by a mistake in the diet. Milk is the best basis for the diet in scarlet fever. Intestinal indiges- tion is not frequent. Foods that add products to the blood that during excretion are likely to cause irrita- tion of inflamed kidneys should be avoided. The aim of the physician should be to diminish the inflamma- TREATMENT OF SCARLET FEVER 85 tion and irritation of the skin, to keep it warm, to attempt to keep it moist and promote its secretion, and to give a diet rather low in proteins and without meat, meat extractives or purins. Also, if possible, no drugs shojjld be administered that tend to irritate the kidneys, especially after the first week of the illness. Such drugs are coal-tar products, synthetic products, caflfeins, and any of the drugs that are known as stimulant diuretics. Even drugs that contain salicylic acid should be avoided. The greater the intensity of the disease, the more liquid the diet should be. While milk is the basis, thin cereal gruels are advisable from the start. Malt.ed milk may be added to this diet, and lemonade or orangeade or ■ oranges, as deemed advisable. Later, toasted bread, crackers, and various kinds of cereals, and still later, baked potato, rice, corn starch, and many other cere.al and milk foods, as well as a greater variety of fruit, should constitute the diet. As soon as the convalescence- is established, and ev-en before, if the disease is prolonged, a small dose of iron should be given daily, as on the above diet the blood cannot get this nutriment. A sugar of iron (saccharated oxid of iron) 3-grain tablet should be given from one to three times a day. Sodium chlorid should always be given a patient from the beginning, once or twice a day, in one or more of the feedings. If there is a tendency of the nose and throat to bleed, or there are hemorrhages in any other part of the body, lime-water should be added to the diet, The patient should always receive plenty of water. If • any apparent irritation of the kidneys occurs, it may be well to withhold some of the fruits and to tempo- rarily diminish the amount of food. C. Fever. — -If the temperature becomes very high it may be advisable to give several doses of an antipy- retic, such as acetanilid, antipyrin, or acetphenetidin, always bearing in mind the irritant effect of these drugs on the kidneys. Hot sponging of the body will also tend to reduce the temperature and make the patient comfortable. It relieves itching, and many times is soothing. Cold sponging in scarlet fever is inadvisable. If the fever is excessive,' tepid sponging 86 SCARLET FEVER may be tried. Restlessness and sleeplessness will also increase the fever, and often a few doses of sodium bromid will be of great benefit. It not only causes the patient to sleep, but reduces the irritability of the peripheral nerves. Also, anything that relieves itching or burning of the skin will reduce the temperature and the irritability. Quinin is inadvisable, as it is excitant to the brain and may tend to congest the ears and add one more element that may cause middle-ear compli- cations. An ice cap to the head, unless actual menin- gitis is present and the hair is clipped close to the scalp, is inadvisable. Whether ice caps to the head ever reduce general temperature is open to grave doubt. If there is meningitis, they may relieve the local con- gestion. In this form of treatment the ice cap should be applied vvhenever the patient is sponged with cold water. Ice caps, however, tend to fall to one side or the other of the head and unnecessarily chill the ears, and may become another factor in causing middle- ear inflammation. The value of an ice bag over the mastoid when it is in danger is not under discussion; but an ice cap over an external ear is not called for, and may do harm. D. Care of the Nose. — Antiseptic, alkaline and cleansing gargles and sprays for the throat and nose should be freely used. The cleaner the nose and throat in scarlet fever, the less the secondary infec- tion, the less the toxemia, and the less the danger. Whatever method is used to clean the nostrils, such pressure of the liquid as would tend to force infection into one or the other of the sinuses must never occur. If there is no purulent discharge from the nostrils, it is inadvisable to spray or douche them, as much harm can be done from too strenuous or unnecessary treat- ment of the nose. E. Skin. — Whatever the temperature, hot sponging for cleanliness once or twice a day is of advantage, is soothing and advisable. Whatevef the tempera- ture, sponging with alcohol in any form is inadvisable. Alcohol, unless the solution is so dilute as to represent not alcohol, but only an alcoholic odor, will tend to dry the skin, cause more itching, and more discomfort. Sometimes sponging with bicarbonate of soda in warm THE HEART IN SCARLET FEVER 87 water soothes the irritability and stops the itching. Powdering with some soothing talcum powder often stops itching and quiets the patient. As soon as the acute eruption is over and desquama- tion is about to begin, gentle rubbing into the skin of some bland oil, as cocoanut oil or almond oil or wool-fat, sometimes with a little glycerin and water, hastens the removal of the dried epithelium, prevents scales from flying about (although these scales do not carry the contagium) and is very quieting to the patient, by preventing the irritation and itching. As soon as convalescence is established, a more active massage of the skin and muscles is advisable. The use of mercuric chlorid or phenol solutions of any strength, or phenol ointments, on the skin, is inadvisable. Most of these solutions tend to dry the skin still more; the use of phenol ointment might result in some absorption and therefore is of danger to the kidneys. Also, as it seems to be a fact that contagium is not spread by the skin, there is no excuse far germicidal ointments or applications. Unless the temperature is very high and head symp- toms are present, it is ufinecessary to cut the hair close to the scalp. If the scalp itches, as it often does, a little petrolatum may be rubbed into the scalp and will give relief. A tar soap may stop the itching. Oil of eucalyptus has been recommended and used as a non-irritant application to the skin and scalp. Also, throats have been swabbed with oil of eucalyptus prep- arations, in the belief that eucalyptus oil is especially antiseptic in throat contagions. F. The Heart. — Cardiac stimulation, especially in children, is rarely needed in this disease. The toxin of this disease is not as depressant as is that of diph- theria, and strychnin is generally inadvisable as it causes too much cerebral stimulation, especialy in children. If a long septic process follows scarlet fever, or there is later a septicemia, small doses of strychnin may be of value, and alcohol is of value as not only adding a food, but as tending to prevent a dangerous acidemia. Also, in such septic conditions, as much carbohydrates should be given as the patient can digest. 88 SCARLET FEVER If joint complications occur, there is more likely to be an endocarditis, and perhaps chorea may develop. G. Late Complications. — Middle-ear inflammations should be expected and watched for. The drums should be early punctured if there is pressure, and the services of an expert on diseases of the nose, throat and ears should be early sought by the physician, if any of these complications occur. The glands of the neck are almost always congested and enlarged in scarlet fever, and one or more may tend to suppurate. It often seems that the local appli- cation of a proper-sized ice-bag to a gland, if the patient will tolerate such an application, aborts serious inflammation. However, if such a suspicious gland continues to enlarge, the temperature rises and blood counts show an increasing leukocytosis, there is prob- ably pus formation, and the abscess should be soon opened. The surgeon, however, often decides that he prefers to have warm applications for a short time to cause more rapid breaking down of the central suppu- rating portion of the gland, so that more complete evacuation may occur on incision. The subsequent dressings and treatment of such an abscess are purely surgical. The temperature will generally drop after the evacuation of the pus, unless there is some other localized septic process. Although the percentage of occurrence of nephritis in or following scarlet fever is not great, it occurs sufficiently often to be always looked for and expected. As above urged, all drugs that irritate the kidneys and all foods that cause irritation should be withheld. While it has not been shown that meat will cause nephritis, it is not necessary to add meat to the diet in scarlet fever. Many believe that eggs should not be allowed. The withholding of eggs as a preventive of nephritis hardly seems necessary. Some physicians even withhold salt from the food; this does not seem necessary. In giving fluids, patients may be encour- aged to take larger quantities by supplementing water with citrate solutions or lemonade. This not only aids diuresis but may also be of value in reducing acidosis. If the amount of urine greatly diminishes and albumin appears, there may not be an actual nephritis, but it may be well to attempt to forestall or abort such an CONVALESCENCE IN SCARLET FEVER 89 inflammation. Hot packs or applications to the lumbar region can do nothing but good. Perhaps the best preventive of nephritis is prolonged rest in bed for at least a week after the fever has ceased, as it seems to be a fact that the better the action of the skin, the less likely are the kidneys to become inflamed, and the skin will be warmer, and is likely to be more moist in bed than when the patient is about. Chilling of the body following scarlet fever is an important added cause for the development of nephritis. Also, if the kidneys have been, sufficiently irritated to cause a dis- tinct predisposition to nephritis, an increased use of the muscles, whether by playing, exercise, or work, too soon after the acute symptoms are over, may so increase the excretory substances from muscle metab- olism as to add a very tangible factor to further irri- tation of the kidneys and consequent nephritis. If nephritis develops, the treatment should be as described under that heading. H. Convalescence.- — As just suggested, the patient should remain in bed one week after the fever has ceased, and the subsequent convalescence should be prolonged and carefully watched. During the acute stage of the disease the .urine should be examined daily, to note the first appearance of albumin and how long it persists. During the convalescence the urine should be examined at least every other day for two weeks, and once or twice a week for several weeks more. The diet should be increased and most foods allowed, except that it may be well for at least two weeks not to give meat. During this period the patient should continue to receive iron. A simple bit- ter tonic may be advisable to stimulate the appetite. If the weather is cold and damp, great care must be taken. that the patient be not exposed. Just how long the germ of infection persists in the mouth, and especially in the nose, has not been deter- mined, but secondary cases can occur when the patient, especially if he has a nasal discharge, has been allowed to play with other susceptible children. It was long thought that the desquamating skin was the cause of this late infection of others. 90 SCARLET FEVER /. Use of Vaccines. — As it is conceded that strepto- coccic infection is concomitant with the cause of many of the complications of scarlet fever, vaccine treat- ment with stock vaccines or autogenous vaccines has been suggested and advised to hasten the eradication of left-over, septic processes. The same rules and regulations, and the same frequency of success will doubtless occur in the septic processes following scar- let fever as with any other septic process. Convalescent Serum. — The most recent and certainly a scientific treatment for scarlet fever is the injection of convalescent blood or serum. Reiss and Hertz (Munchen. med. Wchnschr., Aug. 31, 1915) used the mixed serum from several scarlet fever convalescents. They injected it intravenously in large doses, SO c.c. for children and 100 c.c. for adults. The results, they believe, were lifesaving in many instances. The injec- tions were commenced on the fourth or fifth day, and continued as long as needed. The serum was taken from donors in the eighteenth to twenty-fourth day of convalescence, after negative Wassermann tests and the exclusion of tuberculosis and sepsis. Zingher employed convalescent whole blood, aspirat- ing it from the cephalic vein of the donor, citrating it by adding the blood to a 10 per cent solution of sodium citrate in the proportion of 1 ounce of blood to each cubic centimeter of the citrate solution. The needle is not removed from the donor's vein until sufficient blood (from 4 to 10 ounces) has been secured. It is then injected into the patient, best intramuscularly, using the triceps, outer regions of the thighs, the calves and gluteal regions. In young children one-half ounce, in older children and adults one ounce is injected in each place. The injections may be repeated at intervals of four to five days. In early toxic or malignant cases he found frequently a critical drop in temperature, a disappearance of delirium, fading of the rash, improvement of circulation and general improvement occurring rapidly after the injection of the convalescent blood. In later septic cases he found the injection of the whole blood from normal cases to have nutritive and stimulating properties. In septic PROPHYLAXIS OF WHOOPING COUGH 91 cases, when the prognosis is doubtful or poor, the treatment should invariably include the administration of this harmless yet frequently efficient remedy. WHOOPING COUGH THE PROPHYLAXIS OF WHOOPING COUGH The great mortality of whooping cough is indirect. A large number of those infected die of such complica- tions as bronchial pneumonia, capillary bronchitis, tuberculosis and a few from hemorrhages, while chronic debility, anemia, emphysema, and some lesion of the central nervous system are of not infrequent occurrence. In young children and infants, whooping cough causes more deaths than measles, and some statistics show twice as many deaths as measles; 95 per cent, of deaths from whooping cough occur during the first five years of life, and the majority of these during the first two years. It is pretty well proved that the Bordet-Gengou bacillus is the cause of this disease. It seems to be established that the greatest infectivity occurs during the. initial stages of whooping cough, and that even during the active paroxysmal stage there is less lia- bility of infection of others, and in the later stages there is probably no infective agent present. Mallory and Horner confirmed the opinion that the Bordet-Gengou bacillus is the cause of the infection of whooping cough. This is a minute bacillus, occurring in large numbers among the cilia of the epithelial cells of the mucous membrane of the trachea and bronchi. It is stated that the germ does not grow above the larynx, although of course by coughing it reaches these parts. This, germ is a small coccobacillus, and resem- bles the bacillus of influenza. This disease occurs largely in epidemics, and young children and -babies are apparently most susceptible to infection. This may be more apparent than real ffom two reasons: first, because young children, necessarily remaining more in the house, are liable more frequently to come in contact with concentrated infected matter if an infected person comes near them ; and, second, because a large number of older children and the majority of adults have probably had the 92 WHOOPING COUGH infection and have become immune. However, when an adult or elderly person acquires the disease it is almost invariably severe. The muscular strength of adults makes the paroxysmal coughing of much greater danger; they are more liable to emphysema, heart strain and hemorrhage. They are not so liable to have pneumonic complications. Whooping cough, however, even in adult life, is a not infrequent stimulator of a latent tuberculosis. Often an adult, who is in close contact with a whooping cough patient, and who may have had the disease in childhood, develops a mild form of the disease; at least he has the catarrhal symptoms and coughs spasmodically occasionally. Whether the Bordet-Gengou bacillus is present in these cases has not been determined. It is a fact, how- ever, that ordinarily one attack of the disease renders a person immune. The incubation period of pertussis is not definitely known, and may vary from two to ten days ; therefore before it is considered safe for a child exposed to this infection to return to school or to p.lay with other children, at least ten days must have elapsed, and perhaps a better working rule is two weeks. Pathologically, the disease manifests itself by a catarrh of the upper bronchial tubes, trachea, larnyx and perhaps pharynx and nose. The secretion is mostly mucus, with perhaps, later, a mucopurulent discharge from secondary infections. There are con- ditions, moreover, caused by a severe paroxysm of coughing, or by a prolongation of these paroxysms ; in other words, hemorrhages; perhaps more or less emphysema; always cardiac strain, and perhaps car- diac dilatation ; and, if frequent or repeated coughing, anemia and emaciation. Hemorrhages may occur from the nose, in the eyes, or even in the brain. The cough is laryngeal in type, is at first dry, and later becomes spasmodic and paroxysmal, thus differ- ing from that of ordinary colds; that is, the coughs occur in series, more or less periodically, or in showers. With these paroxysms there is more or less closing of the larynx, with the attempt at inspiration through a narrowed glottis, which causes the characteristic whoop. These paroxysms increase in frequency as the disease progresses, and are precipitated by any change TREATMENT OF WHOOPING COUGH 93 in the atmosphere and by suddenly breathing in cold air, as by laughing, and even by swallowing food, and they sometimes occur without any apparent cause, because- of irritation from the germ and its conse- quences. The number of paroxysms in twenty-four hours varies, but there may be as many as fifty. Early in the disease there may be a slight fever. treatmeiStt Unless the patient has considerable rise of tempera- ture, it may not be necessary to put him to bed, but, especially with children, the paroxysms are generally diminished if the child is kept in bed for a time, or at least kept quiet. The more active the child, the more paroxysms. Consequently, even without fever, if a child vomits almost every meal, or if he coughs so severely as to cause hemorrhage, or shows that the right side of the heart is becoming strained (which is the side of the heart most affected), he must be put to bed and remain there. The actual treatment of this disease may be divided into four heads : (1) to prevent the infection of others ; (2) to shorten the disease, if possible; (3) to diminish the severity of the paroxysms ; (4) to treat complica- tions as they occur. The first indication has already been considered. The second indication is met by general hygiene and by drugs. Fresh air and sunshine, without exposure, are among the greatest mitigators of this disease. If the weather is pleasant, the child should be outdoors or on a veranda most of the time. If the weather is such that it is impossible to remain outdoors, he should be isolated in one, or better, in two large rooms, so that while one room is being thoroughly aired and cleansed he may go to the other one. There seems to be no question that the more infected or polluted the atmosphere of a room, the more the child will cough. The Diet. — If the child vomits a meal as soon as he has eaten it, during a paroxysm, in a few minutes he should be given food again, with the probability that the next, paroxysm will not so quickly occur but that the food may remain in the stomach and be digested. A child that receives insufficient nourish- 94 WHOOPING COUGH ment from any' reason should be given food more fre- quently. The character of the food should depend on his condition, and should be that which is found to be less frequently vomited. The best diet is cereal and vegetable, with milk and eggs. The end-products of meat metabolism are likely to raise the excitability and • irritability of any one whose nervous system is irri- tated. For this reason meat should not be given, and no tea or coffee. A patient who is not allowed meat should receive a small dose of iron once or twice a day. Calcium in any simple form may be used as a nervous sedative and a nutrient. Hot baths before going to bed relax the nervous systein and quiet the patient. Also massage is sometimes soothing. Of course, it is always essential to have the bowels move daily. Plenty of water should be given the child, as the more moist the mucous membranes, the less they are irritated, and the less frequent the paroxysms. For this object many inhalants have been devised. Perhaps the most important element of these inhalants, whether sprays or steam, is the water that they con- tain. Sometimes bland petroleum oils atomized and inhaled soothe the irritated mucous membranes. Various antiseptics have been suggested. Antipyrin as a spray and gargle has been much used as a germi- cide in from 5 to 10 per cent, strength, and has been much lauded in this disease. Quinin sprays, though more disagreeable, have been used in the throat as germicides. Various combinations with thymol and eucalyptol, and other mild aromatic antiseptics, have been used as sprays and gargles or inhalants. It is quite probable that a creosote or other antiseptic inhalant may inhibit the growth, of germs in the trachea and upper large bronchi, provided the patient is old enough to cooperate and inhale the vapor into the lungs to that depth. As an application in the pharynx and mouth, hydrogen peroxid solutions, 1 :5, would be •as efficient as anything that could be offered. Man} times, however, these "antiseptic" inhalants or atomi- zing substances cause irritation and paroxysms, and must be abolished, while mild alkaline solutions, well represented by i/4 teaspoonful of sodium chlorid and TREATMENT OF WHOOPING COUGH 95 1/4 teaspoonful of sodium bicarbonate in a glass of warm water, cleanse and soothe the throat without causing paroxysms. ~ There are still many who believe that quinin given internally will shorten the disease. It has not yet been shown that quinin inhibits the. growth of the Bordet- Gengou bacillus. If there is any tendency to secondary infection in the nasopharynx, with congestion of the ears, of course quinin should not be given. Also, to meet this indication and shorten the disease is the vaccine treatment. The exact value of vaccine in this disease has not been demonstrated. Thousands of cases have been reported, and yet there is consider- able doubt as to whether the vaccines are of much benefit. A most carefuly controlled series of cases studied in New York under the Health Department yielded results rather negative in character. • Immunizing doses, to prevent the development of the disease in other children of the family, have been- given in. doses of 20 million bacilli, and the dose repeated four or more times, and the disease has been apparently prevented by such vaccination. Hess, who made a careful study of the vaccine treatment of whooping cough, was disappointed in this treatment, of the disease; but he did find that in a certain per- centage of cases immunizing doses, prevented the development of the disease, although this prophylaxis was far less efiScient than is typhoid vaccine in pre- venting typhoid fever. The third indication, namely, to diminish the sever- ity of the paroxysms, is of great importance. It has already been stated that the more quiet the child, the less frequent will be the paroxysms. Also, if the child lies down as soon as he begins to cough, he is less likely to vomit. An elastic abdominal belt seems to be of value in controlling the vomiting and the paroxysms of young infants especially. In some patients the paroxysms are so severe that chloroform inhalations have been given to prevent the intensity of the spasms. It has been stated that inhalations of chloroform actually lengthen the time between the paroxysms and shorten the disease. Chloroform inhalations may act as a germicide. On the other hand, the frequent 96 WHOOPING COUGH administration of chloroform, even in small doses, is known to injure both heart and kidneys. The most effective of all medicinal treatments, in the opinion of several authorities, is antipyrin and digitalis. A very good rule for the dosage of antipyrin I's 0.05 gm. (about 1 grain) for every year of the child's age. This should be given three or four times a day, depending on the frequency of the paroxysms. It should not be continued indefinitely nor used to excess. Of course this rule is not applicable for higher ages. The frequency should be diminished as the frequency of the paroxysms diminishes. Coinci- dent with the antipyrin should be given digitalis in the form of the tincture, and in the dose proper for the child's age, and determined by its effect on the child's heart and pulse. The heart needs help, both- from the strain of the disease and also as antipyrin might cause some weakening of the heart. The antipyrin acts by causing less irritability of the nervous system and relaxing muscle spasm. Even though the drug has disadvantages^ its disadvantages are much less than the harm caused by the whooping cough paroxysms. The bromids have been frequently given in large 'doses. They act by inhibiting the reflex activity of the nervous system and by more or less dulling the periph- eral nerves in the throat and upper air passages. Chloral has been used in order to depress the nervous irritability. , Atropin or belladonna have been given in large doses, and their value must" be in dulling the peripheral nerves in the irritated .part of the body. Atropin is a stimulant, and cannot have any good effect in this disease, unless the dose is very large, and with such large doses atropin intoxication readily occurs, that is, the pulse becomes rapid, the throat dry, the face flushed, and there is likely to be cerebral excitation and perhaps dilated pupils. Antipyrin is best given to a child in solution, as follows : Gm. or C.c. B Antipyrinae 51 3 iss Aquae menthae piperitae... 100| fli iv , M. et Sig. : A teaspoonful, in water, three or four times a day. ETIOLOGY OF DIPHTHERIA 97 This dosage is for a child 5 years old. It is also available in the form of sweet flavored soft tablets which children will take readily. Various hydrotherapeutic measures are often of value, and the hot bath is always useful in quieting the patient and relieving internal congestions. The fourth indication, namely, to treat complications as they occur, is almost supererogation, as each com- plication _ calls for its proper treatment. However, under this heading the prevention of such complica- tions may be urged. Vomiting may be prevented by quiet, rest for a while after eating, by the abdominal belt and by proper food. Nutrition must be kept up at any cost, and, if necessary, the child given simple liquid nourishment every three hours.. Not infre- quently cod-liver oil is well borne and is an oil-nutri- ment of great value. Anemia must be prevented by iron. If it is seen that the heart is becoming strained, and the face and throat remain congested even after the paroxysm is over, showing that the right ventricle is in trouble, digitalis should be given and such rest as would be given any damaged heart. This treatment also tends to prevent hemorrhages. Even if the child is weak and the circulation is weak, strychnin is inad- visable, as it stimulates the nervous system and causes or allows more paroxysms to occur. If the child has a history of enlarged glands or recurrent colds, or has inherited a tendency to tuber- culosis, or tuberculosis has been present in the child's family, its convalescence after whooping cough should be prolonged, and country or seashore air should be urged wherepossible. Certainly, such a child should not be confined in school until its nutrition has become .as good as before the infection with whooping cough occurred. DIPHTHERIA This throat inflammation has been known for cen- turies, having first appeared in the East and later in Europe, occurring mostly in epidemics. A carrier of this disease may communicate it to persons so widely separated as to make the occurrence of the disease almost unexplainable by any epidemic theory. While nearly all mankind is susceptible to smallpox, and a large majority to scarlet fever, jnany persons seem naturally immune to diphtheria. A closer contact is apparently needed with an infected individual than in these other diseases. This disease has always had a large percentage of deaths; but the death rate since the introduction of antitoxin has been constantly on the decrease, and with a better understanding of the proper dosage of anti- toxin, and with the effort made to diagnose the disease early, the death rate will be more rapidly decreased. Our best sanitarians believe that for every case of diphtheria recognized, at least one sore throat that car- ries the Klebs-Loefifler bacillus escapes ; in other words, there is an equal number of missed mild cases. It has been shown that the normal hydrochloric acid in the stomach inhibits or kills the diphtheria bacilli; therefore it is exceedingly rare to find these germs in the intestines, and very rare to find diph- theritic membrane in the stomach. In the majority of cases the tonsils, one or both, are the parts affected in diphtheria, and with the present methods of treatment, in a large portion of these cases the membrane will be limited to these regions. The soft palate is next most frequently attacked, the pharynx next, and nasal diphtheria, with proper care taken, is not very frequent. Laryngeal diphtheria is not a frequent complication to tonsillar diphtheria ; it generally begins as the original point of attack. CARRIERS These may be convalescents from diphtheria, or may be those who have had contact with diphtheritic patients who may or may not later develop the dis- ease, or the term may be perhaps more properly limited to those who carry the germ for rnonths. Diphtheria germs may live a long time on books or other sub- stances, handled, coughed, sneezed or expectorated on by a diphtheria patient, and may infect persons coming in close contact with such infected material. This method of infection may not be very frequent. Animalsmay carry the infection. It is doubtless a good axiom to -believe that a tonsillitis with exudate is diphtheria until it is proved not to contain the Klebs-Loeffler bacillus. Such a patient should be DIPHTHERIA CARRIERS • 99 more or less rigidly isolated, as streptococcic infection is_, if anything, more readily communicated than is a diphtheria infection. Therefore, there can be no excuse for not isolating a sore throat with exudate or membrane as soon as such a case is discovered. The location of the Klebs-Loeffler bacillus in car- riers who are convalescing is probably most frequently in the throat, though the bacillus may be found in the nose. In those who carry these germs long they are more likely to be found in the nose. Therefore, swabs should be taken from both regions. It is quite probable' that a surface, swab from a tonsil may be negative while a culture obtained from probing into crypts of the tonsils or in the region back of the tonsil might show the presence of the germ. It is culpable neglect to fail to examine a patient thoroughly to ascertain if he is free from the Klebs-LoefHler bacillus. The boards of health vary as to the number of nega- tive cultures that will release a patient from quaran- tine. The safest number is perhaps four negative cul- tures, two from the throat and tonsils, one from crypts or back of the tonsil, and one from the nose, taken on alternate days, at a considerable interval from the use of any antiseptic jvashes, gargles or sprays. This would seem to prove that a patient was free from the Klebs-Loeffler bacillus. . TREATMENT OF CARRIERS Various methods of ridding a carrier of the diph- theria germs have been tried. Local measures vary, and may comprise painting the suspected regions with tincture of iodin or with Lugol's solution, with silver solutions, phenol solutions, or the use of various gar- gles, hydrogen peroxid solutions, etc., and the nasal inhalation of various thymol or iodin inhalants or sprays. There is no question that whatever else is done, some local antiseptic should be applied. Diph- theria antitoxin injection has not been very success- ful. Local applications in the mouth, throat or nose of antidiphtheritic serum have not been proved to be very successful. Vaccinations with dead diphtheria bacilli have been only partially -successful. These various methods are described by Albert. He believes 100 DIPHTHERIA that a local application to suspicious crypts of the tonsils of a "5 per cent, solution of silver nitrate will destroy all bacteria with which it comes in contact." A thorough application of a 10 per cent, solution of silver nitrate he finds will cause some destruction of the epithelium of a crypt and a fibroblastic prolifera- tion with ultimate obliteration of the l^men, which is of course the object desired. Very successful treatment of diphtheria carriers seems to be spraying the nose and throat with pure cultures of Staphylococcus pyogenes aureus. This spray is apparently harmless to the individual, although reports of severe infections have been published. This method was first used by Schipftz, in 1909. Although it is not always efficient, in some instances it has removed the Klebs-Loeffler bacillus and prevented its growth so that cultures were negative to it in a week or less. It has not proved very successful in nasal cases. On the other hand, Womer, after using this staphylococcus spray in forty-two cases of diphtheria carriers, comes to the conclusion that although it is harmless, it does not appreciably lessen the period of quarantine. This leaves the value of this treatment still subject to positive proof. It may certainly be tried. Hektoen and Rappaport {Jour. A. M. A., June 12, 1915, p. 1985) have found that, when properly applied, kaolin in the form of a dry powder removes not only diphtheria bacilli but also practically all bacteria from the nose in the course of from three to four days. For this purpose the kaolin is blown into the nose six or seven times a day at two-hour intervals by means of a rubber bulb attached to a glass tube, the free end of which tapers a little. The instfflation is repeated sev- eral times at each treatment. The success of this treat- ment appears to depend largely on the free and thor- ough distribution of kaolin over the nasal surfaces. . In cases of more or less obstruction of the nasal pas- sages, the removal of bacteria by insufflation is more difficult. In order to secure the most thorough application of kaolin to the mucous membrane of the throat, patients, if old enough, are instructed to swallow as slowly as possible one-third teaspoonful of kaolin four or five IMMUNITY IN DIPHTHERIA 101 times an hour during the day. In the casfe of adults and older children who are anxious to get rid of diphtheria bacilli, this method, which has been selected after trial of several others, involves no special diffi- culty. In the case of small children, it is more difficult to apply enough kaolin, and the plan of mixing the kao- lin with sugar in the form of tablets is being consid- ered. In a number of cases, in some of which there were a great many diphtheria bacilli in the throat, com- plete and apparently permanent removal has been accomplished by the use of kaolin in the way described in from two to four days, the throat to a large extent being freed from all bacteria. They have found also that the, insufflation of kaolin into the nose in cases of rhinitis in scarlet fever appears to improve the condition rapidly and to remove strep- tococci and other bacteria quite promptly. They have not found kaolin to be irritant ; when taken into the mouth it gives rise to a feeling of grittiness. It seeraSj then, that kaolin, and probably also other substances of a similar nature, may prove of value in removing bacteria from various surfaces of the body by virtue of mechanical adsorption. This may prove of advantage, not only in carriers but also in conditions of acute infection. A careful examination of carriers frequently discloses some local condition which allows the bacteria to live and grow and which prevents their being reached by any local application. Friedberg studied such cases before and after removing the tonsils and found that cultures became negative at once or very shortly. Similar favorable results from tonsillectomy have been reported by other clinicians and laboratory workers. There seem to be no contraindications to the operation aside from those obtaining in other conditions. Local conditions in the nose and throat other than those in the tonsils may determine the presence of the bacilli and should be sought and relieved whenever possible. IMMUNITY While it has been long known that infants and many adults seem not to be susceptible to diphtheria, it has only lately been sliown that probably a large propor- 102 DIPHTHERIA tion of adults, stated at 90 per cent., perhaps 50 per cent, of children, and perhaps 80 per cent, of new- born infants have diphtheria antitoxin in their blood and are not likely to become ill with diphtheria. A skin test has been devised, known as the Schick reaction, to determine whether or not an individual is protected against diphtheria, that is, whether he has diphtheria antitoxin in his blood. The reaction seems very positive, and distinctly shows that an indi- vidual is artificially protected or has natural antitoxin against this disease. The test is made with a dilute diphtheria toxin of su£h strength that 0.1 c.c. contains one-fiftieth of the minimum fatal dose for a guinea- pig. This aniount, namely, 0.1 c.c, is injected into the layers of the skin, perhaps best on the inner surface of the arm. A positive reaction should appear in from twenty- four to forty-eight hours, and is evidenced by a slight swelling and localized redness, a reddened papule which remains from seven to ten days. When this papule -^disappears, the skin over it may desquamate slightly, and pigmentation may remain for days an^ even weeks. Park states that the injection rs best given with a small hypodermic syringe with a platinum point needle, that the injection must be into the skin and not subcutaneously, and that immediately after the injec- tion there should be a raised whitish spot, which in twenty-four hours becomes bluish, with a slight edema. Schick's interpretation of the positive reaction, as just described, is that the patient has no antitoxin in his blood, or at least less than' 1/30 unit of antitoxin in 1 c.c. of blood. He declares that all persons so react- ing are susceptible to diphtheria, and Park agrees with him. Park, in his summary on immunity in diph- theria, states that according to Hahn the interval between the injection of vaccine and the development of antitoxin is not less than three weeks, while other investigators think that it may be eight days. Persons who have a natural antitoxin show an earlier increased antitoxin production. Von Behring considers that 0.01 unit of antitoxin per 1 c.c. of blood is sufficient. to pro- tect a healthy individual, arid much less may protect against diphtheria. Immunizing doses of antitoxin to persons who have been exposed to diphtheria, given early, are generally . TREATMENT OF DIPHTHERIA 103 successful in preventing the development of the dis- ease. The immunizing dose for a child should prob- ably be at least 1,000 units. Adults may receive larger doses. TREATMENT A. Isolation. — It should be again. urged that a throat with spots or membrane should be considered as likely to be diphtheritic until a culture has proved it not to be. Such a patient should be isolated in the best room available, looking toward the possibility of the dis- ease being diphtheria and a nurse being required. Other children of the family must be excluded from contact with this patient. If the case is clinically one of follicular tonsillitis, the physician may wait for a positive test before giving antitoxin. If, however, the case is clinically diphtheria, antitoxin should be given without a report being waited for, provided there is nothing in the history of the patient to show that there will he any hypersusceptibility to horse serum. Whether it is follicular tonsillitis, or other strepto- coccic infection, or diphtheria proper, gargles and local- cleanliness of the throat should be immediately inaugurated, and when this is properly carried out, the danger of infection of others is reduced to a minimum. . It is hardly - necessary in this day, in which the advisability of sunlight, a large room, an adjacent bathroom, the absence of all unnecessary draperies, furnishings, rugs, etc., for a proper isolation room are so well understood, to describe again the needs in detail. Instruction should be given the family in the minor details of the prevention of infection of others. A properly trained nurse well understands the necessity for burning wooden tongue depressors, wooden swabs, the gauze and cotton used around the patient's nose and mouth, and washcloths; the use of liquid soap; simple but efifective cleanliness of the patient's face, hands, and body; boiling of all eating and drinking utensils; disinfecting the toothbrush with non-poison- ous germicides; allowing the bed clothing and bed garments to stand in germicidal solutions before being sent to the wash ; frequent washing of her own hands in germicidal solutions; and gargling her own throat with hydrogen peroxid solutions. 104 DIPHTHERIA B. General Care of Patient.— High, fever is not fre- quent in diphtheria, unless the case has been neglected. Consequently, the patient should receive, almost from the beginning, plenty of nutritious food. The exact diet, of course, depends on the age of the patient. Milk, oatmeal gruel, eggs, meat juice well salted, toast, butter, and the whole, or the juice, of one or two oranges, would represent the food needed. With or without meat, it is well to give a diphtheria patient iron, and no preparation is better than the tincture of iron chlorid in 5-drop doses, three times a day, given in fresh lemonade or orangeade, after nourishment. However well the gastric juice inhibits the growth of the bacteria, it is always wise for a patient to gar- gle, or be sprayed, before taking food, so that the mouth and throat will be as clean as possible. The bowels should be moved daily by some simple laxative, if they do not move without such help. While a diphtheria patient should have plenty of fresh air and all the sunlight possible, he should be kept warm. He should not be allowed to become chilled, as the toxins of this disease cause depression and the patient's temperature may be quite low, and the hands and feet easily become cold. Even if the temperature is high, the bathing should be by warm sponge baths. C. Antitoxin. — Recent investigations by Schick show that the dose of antitoxin advisable for ordinary cases of diphtheria can be based on the weight of the individual. Schick finds that 100 units of antitoxin per kilogram of weight is sufficient to combat the toxin in diphtheria in all ordinary cases, and in severe cases 500 units per kilogram is more than sufficient. In other words, enormous doses of antitoxin are not needed. This is especially true if the antitoxin is given early. A kilogram equals 2 1/5 pounds avoirdu- pois, and a child weighing 45 pounds, in an ordinary case of diphtheria, should be given 2,000 units of antitoxin ; while if the case is severe, or in nasopharyn- geal or laryngeal types, 10,000 units would be all sufficient. By the same method of decision as to the dose, an adult of about 130 pounds should receive 6,000 units in a mild case, and 30,000 units if the DIPHTHERIA ANTITOXIN 105 diphtheria is of malignant type, or has aifected parts where the danger of absorption is greater. It seems quite probable that if such doses can be administered on the first day of the infection with the Kkbs-Loeffler bacillus, no more antitoxin will be needed in such cases, and that death from this disease will be reduced to a minimum. Smith and Park have shown that 'when antitoxin is given subcutaneously, ,it takes from three ■ to four days before the maximum amount of antitoxin is cir- culating in the blood. If the antitoxin is given intra- muscularly this period is shortened. From these find- ings, therefore, the conclusion should be made that if the case is urgent and the toxemia serious, anti- toxin should be administered intravenously; if the case is severe and the diagnosis has not been made early, antitoxin should be given intramuscularly; in ordinary or mild cases, and on the first day or two of the disease, it may be administered subcutaneously. The possibility of an anaphylactic reaction should not prevent the use of antitoxin in a patient with diph- theria, even though he has previously received anti- toxin for immunologic or curative purposes. In such persons it is advised to give a small amount (from 0.1 to 1 c.c.) subcutaneously; if no severe symptoms appear after one or two hours, the full dose may be given. Several considerations make it difficult to state the probability of appearance of anaphylactic phenomena in any given case. In addition to individual peculiari- ties which no doubt play a part, the volume of serum injected and the method- of preparation of the serum are important factors. Weaver (Arch. Int. Med.', June, 1909, p. 485) found that when the volume of serum was small (from 1 to 9 c.c), serum disease (urticaria, erythema, arthritis, etc.) appeared in 10.9 per cent. ; with increasing volumes of serum, the per- centage of reactions progressively increased so that in those cases receiving from 80 to 280 c.c, serum dis- ease was noted in 61 ' per cent. The more recently developed methods of concentrating and refining anti- toxin yield serums of high potency, so that the neces- sary amount- of antitoxin units is available in small volume of serum, and the probability of serum disease 106 DIPHTHERIA is accordingly decreased. The removal by tl;e refin- ing process of certain albumiri fractions of the serum decreases the incidence of serum disease. The older statistics, therefore, probably show a higher incideiice of reactions than are being obtained at present with concentrated serum. In persons receiving serum for the first time, serum disease appears in the majority of cases from the seventh- to the tenth day, but,sometimes earlier or much later, and rarely need cause alarm. Of 200,000 per- sons injected with serum, there was but one death from anaphylactic shock (KoUe).. The reactions which follow reinjections of serum (that is, in persons previously injected) may be imme- diate, and in any case are likely to occur earlier than those after first injections (accelerated reactions). The immediate reactions usually present, in addition to urticaria and other symptoms of serurn disease, symp- toms of respiratory disturbance, cyanosis, rapid pulse, etc., and correspond to the anaphylactic shock seen after reinjection of experimentally sensitized animals. Epinephrin and a:tropin have been used with benefit. Even these severe reactions are very rarely fatal. About 50 per cent, of fatal instances of anaphylaxis have occurred in asthmatics, and in some of the latter the fatality followed the first injection of serum. When the reinjection is made within six days after the first injection in man there is practically np danger of ana- phylaxis ; reinjection in from three to eight weeks after the first injection is followed by some degree of ana- phylaxis in about 90 per cent, of cases; reinjection ' after six to nine months is ' followed by reaction in about SO per cent, of- cases (Seidel: Munchen. med. ' Wchnschr., 1915, Ixii, 1210.) With the lapse of years the percentage of reaction on reinjection is further decreased, and usually appears as an accelerated reac- tion. The danger of serum reactions even in previously injected persons is so much more remote than the dan- ger from diphtheria that the physician should not hesitate to avail himself of so potent a remedy as anti- diphtheric serum. D. Care of the Throat. — It would be just as sensible to perform a major operation with the most perfect THE THROAT IN DIPHTHERIA 107 lechnic and yet take no means whatever of preventing infection, as it is to administer antitoxin in proper dose in diphtheria and then to take no proper care of the throat. All odor and all .danger of secondary infection are removed by proper treatment of 'the part affected. Although germicides cannot kill the germs deep in the mucous membrane, or those that are pro- tected by an overlying exudate, a certain large por- tion of the surface bacteria are surely killed by as simple a gargle as hydrogen . peroxid solution. More active and more irritant germicidal gargles or germi- cides that are sources of danger when swallowed, are entirely unnecessary in diphtheria. If the child is old enough to gargle or swash the tonsils, this is the best method of cleansing the throat. If the child is not old enough, thorough spraying of the throat should be done. A solution of one part of the official aqua hydrogenii dioxidi to 3 parts of warm water, freshly prepared each time, should be used as a gargle, every one and one-half or two hours during the day, and every three hours during the night. Three or four minutes after this gargle has been used, it should be followed by some simple alka- line wash, to remove the irritant effects of the hydro- gen peroxid. A gargle that may be used for the sec- ondary, cleansing purpose is a teaspoonful of boric acid added to % glass. of warm water. This will not all dissolve, but ' will deposit on the throat and act as a' mild antiseptic. Also, there is no greater pro- moter of mucous secretion of the throat than boric acid; and the more the mucus is secreted, the quicker will the membrane be loosened. Or,' a simple solution of 14 teaspoonful of salt and ^ teaspoonful of sodium bicarbonate may be added to % glass of warm water. The object of such a gargle and wash is to cleanse the mouth and throat of froth a,nd pieces of membrane, mucus, mucopus, etc., and to socjthe the membrane. It is frequently advisable to insufflate boric acid directly on the masses of membrane or exudate. This should be done by the physician. After the throat has been cleansed all that is pos- sible, it is often of value to apply tincture of iodin to the membrane or exudate. Care must be taken not to touch the healthy membrane with this solution. 108 DIPHTHERIA Lugol's solution may be applied to the parts of the throat that are not affected, which often tends to pre- vent development of more exudate or membrane. If there are pockets and crypts in diseased tonsils, after cleansing such, boroglycerid may be applied to heal and to prevent spreading of infection. As frequent gargling is very tiresome for the throat, svvashing is nearly, if not quite, as efficient, and should be suggested. If the child is too young to gargle or swash, the peroxid should be sprayed on, and the solutions for this purpose should be stronger, namely, 1 part to 2 parts of warm water. The cleansing spray may be used afterward. If the throat and mouth gen- erally are irritated, a soothing gargle is as follows : Gm. or C.c. R Acidi borici 2 Potassii chloratis S Aquae menthae piperitae... 200 gr. XXX 3 iss flSvii M. Sig. : Use undiluted as a gargle, as directed. Gf course, any other flavor than peppermint could be used in this mixture. Whether or not it is advisable to use a weak hydro- gen peroxid sol;ution in nasal diphtheria is a question for individual decision of the physician; generally it is too irritant, even when used weak, and is inadvis- able. Cleansing mild alkaline solutions or boric acid solutions represent the most successful treatment of nasal diphtheria used as sprays or snuffed through the nostrils. Such mild, warm solutions may be poured from a small vial or from a teaspoon into the nostril, with the head thrown back. It is inadvisable to use any of the douches that aire on the market, or any syphon douche, as the pressure is too great, and fluid is often forced up the eustachian tube or into some of the sinuses. Suprarenal extract may be added to these solutions, if deemed advisable, but it should not be used too frequently. Also, the nose should not be sprayed too frequently. As soon as the throat is clean, the frequency of the gargles should be diminished, but it should be several days before the patient is not awakened at night to gargle at least once, or better, twice. GENERAL MEDICATION IN DIPHTHERIA 109 The treatment of the throat advised .for diphtheria is equally applicable to follicular tonsillitis or scarla- tinal throats, and to septic sore throat. E. General Medication. — A diphtheria patient requires very little general medication, unless some complications occur. : In the beginning a small dose of calomel, or a dose of castor oil may be advisable, and subsequently whatever simple laxative is needed to cause a daily movement of the bowels. The tempera- ture does not often call for treatment. If it is high, or there is headache and backache and general aches, two or three small doses of a coal-tar antipyretic may be given. The following combination for a child not under 10 years old is efficient: Gm. or C.c. B Acetphenetidini 1| aagr. xv Phenylis salicylatis 1| M. et fac chartulas v. Sig. : A powder every three hours, if needed. Later, if the temperature is high, tepid sponging is sufficient, but generally, with the ordinary low tem- perature of diphtheria, hot sponging for cleanliness and to increase the activity of the skin, and to remove the, perspiration, should be done once or twice daily. As suggested above, every patient with diphtheria should receive iron, either the tincture of iron chlorid. a few drops in fresh lemonade, or a 3-grain tablet ot eisenzucker, three times a day, ^ or 0.10 gm. (1% grains) of reduced iron, in capsule, three times a day. If there is a tendency for the thr-oat or nose to bleed, it can do no harm to add lime water to the diet, and it may be of value. On account of the nervous depression caused by the toxins of the Klebs-Lodffler bacillus, a smajl dose of strychnin, not exactly as a cardiac stimulant, but more as a nervous stimulant, is advisable, provided the con- dition of the patient seems to require it. For a child 10 years old, 1/60 grain of strychnin sulphate, once in six hours, is generally a sufficient dose. If the child is made nervous by strychnin, it should certainly be withheld. A little coffee or tea may be given a child, as a medicine for the action of the cafFein, and is of value. no DIPHTHERIA F. Care of the Heart. — ^Although it was long con- sidered that heart failure in diphtheria was due to vasomotor paralysis, or to action on the vasomotor center, it has been shown by Porter and Pratt that such is probably not the case: that heart failure is probably due to the action of the toxins on the heart itself. Dr. F. W. White of Boston long ago showed that the heart was frequently affected more or less seriously in diphtheria. White also quotes many other authorities showing that myocarditis is not an infre- quent complication, that valvular disease may roccur from diphtheria, and that even a chronic myocarditis may persist, or a valvular lesion may contmue for months or even years, or for life. The mitral valve is the one most frequently diseased, and if a lesion is caused, it is generally insufficiency. About 60 per cent, of the patients with diphtheria show an irregular pulse, and the younger the patient, the more liable he is to have this heart irregularity. It may occur even in mild cases. The murmur at the apex is doubtless due to a relative insufficiency of the mitral valve, because of slight dilatation of the left ventricle. In this investigation, necropsies showed that endocardi- tis and pericarditis are not extremely rare complica- tions in diphtheria. Clinically, the gallop rhythm, with or without vomit- ing and epigastric pain and tenderness, is a bad symp- tom in diphtheria. This gallop rhythm of the heart is very serious, and if accompanied by vomiting, the prognosis is very bad. Hume and Clegg, after an investigation of 573 cases of diphtheria, declare that . any form of arrhythmia of the heart (except sinus arrhythmia) in diphtheria indicates that the heart mus- cle or nerves are pathologically disturbed. This may occur even when the diphtheria is apparently mild. After a patient is apparently well from diphtheria, if he has been severely ill, and especially if the case has been neglected and a large amount of toxins have been absorbed, cardiac failure may occur any time from the second to the fifth week. Symptoms of late cardiac weakness are often a slow, weak pulse. Such hearts, however, become rapid on the least exertion. Such patients are often very pale, and there are liable to be more or less gastro-intestinal disturbances. THE HEART IN DIPHTHERIA 111 There can be no question that the effects on the he^rt in diphtheria are due to the Klebs-Loeffler bacillus toxins ; consequently, if antitoxin in sufficient dose is given early, the toxic effect on the heart will probably rarely occur. Consequently, cardiac deaths in diph- theria will be less frequent with the early proper administration of antitoxin. , The most important treatment of cardiac complica- tion is rest, and prolonged rest. A patient who has shown cardiac inflammation of any kind, or cardiac irritation during diphtheria, should have a prolonged rest in bed and a very slow convalescence. The small dose of strychnin suggested above as a nerve stimulant . is probably sufficient. If the heart is very rapid, it may be unwise to give even this small, dose. Larger doses do not seem to raise the blood pressure during illness, and strychnin in large doses as a cardiac tonic, in prolonged weakness, is not so successful as has been thought. In an apparently acute failure, a fair-sized dose, 1/40 grain for a child 10 years old, may be given hypodermically ; but to persist in large doses of strych- nin is inadvisable. Digitalis is not indicated, and alco- hol should not be given. Caffein and camphor may be worth while ; but the main thing is absolute rest, small amounts of food, the least possible disturbance for bathing, feeding, defecation and urination, and no prostrating purgatives. G. After Rest. — A patient who has recovered from diphtheria, however mild it rnay have been, should have, for the first two weeks, at least, a carefully watched convalescence. Strenuous exercise should be avoided, and the heart should be carefully examined before the patient is allowed to return to his usual work, school, or play. H. Paralysis. — With the early injection of a suffi- cient dose of antitoxin, diphtheria paralysis will become less and less frequent. The paralysis of the soft palate, which used to be so frequent, is already becoming infrequent. This paralysis occurs early, between ten and twenty days from the beginning of the illness. The treatment consists of tonics, small doses of strychnin, the best of nutrition, fresh air, sunlight, rest, and prolonged convalescence. The gen- 112 LARYNGEAL DIPHTHERIA. eral paralyses, which are now rarely seen, were more serious, and occurred later. They are slow in recov- ery, and besides general treatment, require massage and electricity. I. Diseased Tonsils. — Quite probably diseased ton- sils cause a susceptibility to diphtheria, as they cer- tainly do to follicular tonsillitis. After complete recovery from a diphtheria attack, when the general condition is perfect, and the heart is in good, condition, operations should remove all portions of tonsils that show disease. Whether complete enucleation should be done, or only diseased portions should be removed, and whether or not the capsules should be left, are subjects for an expert decision. LARYNGEAL DIPHTHERIA Membranous croup is laryngeal diphtheria, and as soon as the diagnosis can be made that there is exu- date in the larynx or laryngeal region, antitoxin should be given in large dose, without waiting for a decision from the laboratory that the Klebs-LoeifHer bacillus is present. The only^ safe place for a patient with laryngeal diphtheria is a contagious disease hospital, where expert skill in intubation and, if necessary, in tracheotomy can be quickly obtained. The main dan- ger from diphtheria in this location is suffocation. The toxemia is not great, and the absorption is much less than in nasal, nasopharyngeal, or even in tonsillar diphtheria. The best of nutrition is important, as exhaustion from labored breathing is likely to occur. The atmos- phere of the room is better moist, on acount of the membrane becoming dry and causing more obstruc- tion before it loosens and is coughed up. Just how much local steaming of the throat, or inhalation of various medicated solutions should be given, is to be decided by the individual physician. The main advan- tage is doubtless from the vapor of water. The main requirements to be remembered in laryn- geal diphtheria are the administration of an immediate large dose of antitoxin ; intubation by a skilled operator as soon as indicated ; a trained nurse skilled in intuba- tion cases, if such can be obtained ; the ability to recall SEPTIC SORE THROAT 113 quickly the physician who intubated if the tube is ■coughed up; the immediate removal by the nurse of the intubation tube if it plugs up, and the quick per- formance of tracheotomy by the surgeon, if such a measure is needed. SEPTIC SORE THROAT For some years there have been reported epidemics of septic sore throat, some of which have been dis- tinctly traced to infected milk, and all of which prob- ably develop from that source, or by transmission directly from active cases. In the last few years several cities and towns in this country have suffered from epidemics of thi^ character, which in every instance have been traced to milk from some one dairy, and ultimately to one or more diseased cows. The disease of cows that causes such infection is an inflam- mation of the milk glands, a mastitis, or an inflamma- tion of the udder termed garget. Another possible source for the dissemination of this germ is an infected throat of the milker, or of some one who handles the raw milk. • The germs found in the inflamed udders, in the raw milk, and in the throats of those infected are the same, namely, the Streptococcus pyogenes. The clinical symptoms have been the same in all of these epidemics. The throats generally show intense hyperemia without a grayish exudate. The cervical lymph glands enlarge, and may suppurate; there is extreme prostration, and a tendency^ to relapse. The complications are inflammation of the middle ear, abscess around or about the tonsils,- and erysipelas or other skin eruptions. The most dangerous and fatal complication is peritonitis, and there may be fatal septi- • cemia, with localization in the lungs. Endocarditis, myocarditis, arthritis, and nephritis may occur a.' complications in this septic process. Means of prevention of septic sore throat in epi- demics must include a more frequent bacteriologic examination of the udders of cows and of the throats of those who handle raw milk. Pasteurization of milk prevents the germs from causing infection. The treatment of septic sore throat is not different from that of follicular tonsillitis, namely, application of 114 GERMAN MEASLES dilute hydrogen peroxid solutions 1 :4, immediate sub- sequent washings with mild alkaline cleansing solu- tions, and the local application of a weak iodin solution, as Lugol's solution (too strong iodin prepara.- tions might increase the swelling and hyperemia of the throat). On account of the prostration, the patient should receive plenty of nutriment. The bowels should be moved daily. Pain should be stopped, if it is trouble- some, by codein or morphin, if deemed advisable. High temperature should be treated as seems best, and the complications combated as they occur. Infection of others is prevented by the same methods as those described for diphtheria. GERMAN MEASLES This is a highly contagious disease, most frequently affecting children and youth. It generally occurs in epidemics, but a considerable number of persons exposed to the disease do not acquire it. While the germ has not been -discovered, and though it is not ■ known just how it is transmitted, the probability is that the secretions of the nose and throat are the means of spreading the infection. It is doubtful if the eruption or the- desquamating epithelium carries the contagium. The stage of incubation is apparently long, averaging perhaps frotn about ten days to two weeks. The stage of invasion is rarely seen, as when it is first realized that the patient is ill,' the eruption is present. The eruption is a maculopapular one, reddish, and rarely confluent. The papules are less raised than in measles ; in fact, many points of erup- tion are purely macules. The color is brighter than that of measles. It occurs first on the chest and face, and then gradually spreads over the body, during the first twenty-four hours. Questioning of the per- son attacked often shows that there were slight rigors and some backache or headache or feelings of indis- position. The temperature is generally slight, rarely above 100 F. An occipital adenitis, with swelling of the post-cervical glands, is a frequent accompaniment of the disease. CHICKEN-POX lis ■ Complications are rare. Although the patient should be confined to the house, the infection is simple, and there are not likely to be any consequences. This disease requires, ordinarily, no radical treat- ment. Simple cathartics should be given, the diet reduced, and the patient kept indoors until the eruption has disappeared. If the throat is irritated, an alkaline gargle should be used. Boric acid, 2 per centi to 4 per cent., or Dobell's solution, one-fourth strength, may be used for this purpose. The usual simple methods of preventing the infection of others should be carried out. It is well to isolate the patient from other chil- dren in the family for at least three weeks. The disease should be made reportable, as it is so often confused with regular measles, and rarely has been confused with mild scarlet fever. It is more likely to be confounded with various kinds of intes- tinal or food poisonings that cause eruption. CHICKEN-POX; VARICELLA This simple, acute, contagious disease, generally very mild, and rarely requiring any medication or treatment, need not be mentioned here except that it is frequently confused with smallpox. In chicken-pox : The incubation period is at least two^ weeks. There is no definite history of a pre- vious attack of this disease. A history of successful vaccination within a few years, or a definite history of a previous smallpox causes presuniption that the disease is chicken-pox. There is usually no history of a stage of illness before the eruptive stage. The eruption appears in the first twenty-four hours of the disease, beginning on the back, chest or face, and is most profuse on parts of the skin covered by cloth- ing. The eruption appears in successive crops on siiccessive or alternate days, so that various stages of the lesions may be present at one time. The lesions are round and oval, and the margins are not crenated. The eruption passes through the following stages: 1. Macules lasting a few hours. 2. Soft, superficial papules lasting a few hours. 3. Clear, thin-walled, tense vesicles each lasting a few hours (these vesicles may be readily broken and appear cupped or. pitted, and the weeping vesicle then quickly becomes crusted) , 116 MUMPS 4. The crusts, lasting a shorter or longer, time, depend- ing on the treatment (each crop completes its cycle from macule to crust- in from two to four days). 5. Pitting may occur, but the pits are few, superficial, and often oval.. It is essential that chicken-pox cases should be early diagnosed, and that the patient should be isolated. A laxative should be given; the diet should be simple and without meat; warm baths, and powder to pre- vent itching, represent the only treatment generally required. Older patients should be cautioned, and children should be prevented from picking open the vesicles that occur on the face, thus preventing pit- ting. Young children should wear celluloid mittens. To control the itching of the skin it may be dabbed vvith a weak solution of bicarbonate of soda, one dram to the pint or four grams to 500 c.c. MUMPS This is a highly infectious disease, with a long period of incubation, from two to three weeks. The causative organism is not known, though a diplococcus or strep- tococcus has been found by Laveran, Catrin, Herb and Rosenow. There is more or less of it always present in most cities, and there are likely to be epidemics of it in certain seasons of the year, more particularly, perhaps, in the spring and fall. Children and youth, especially boys and young men, are the most susceptible to it. Infants and adults are not so likely to have it. Possibly adults are less likely to have it because they have^ been rendered immune by unrecognized mild attacks in childhood. While the typical localization of tKis infection is in one or both parotid glands, the submaxillary glands may be coincidently involved, or may be the only glands involved. As simple and harmless as this dis- ease generally is, it may cause very high temperature, sudden cardiac failure, and frequently in young boys and male adults a complication, or metastasis, of orchitis, which is always serious. In girls the mam- mary glands or the ovaries may show metastatic inflammation. A patient with the disease should generally be isolated, and the attack will often be milder if the TREATMENT OF MUMPS 117 patient remains in bed. Although the disease can be serious, it is generally so mild in children that it is' sometimes a question whether other children of the same family should not be allowed to contract it, for the reason that one attack generally confers immunity for all time, and the disease is much more serious in adults, especially in young men, than in children. Of course, an infected child, even though very mildly sick, is immediately sent home from school. On the other hand, doubtless hot a few children with very mild cases are unwittingly allowed to remain at school. TREATMENT The disease is so mild that it may not require any special treatment. Pain in the infected glands is rarely severe, and is modified by dry warmth or simple absorbent-cotton applications, and by any oily appli- cation, the latter to relax the tension of the skin over the swollen gland. For this purpose olive oil may be used, or petrolatum, or an ointment may be made., with 10 per cent, methyl salicylate in petrolatum. It is usually inadvisable to use ice or cold applications to the parotid glands in mumps. The diet should be mild, the bowels kept free, and in simple cases medicinal treatment is not needed. If the fever is very high, one or two doses of antipyrin or acetanilid may be given, with the knowledge that cardiac depression readily occurs in this disease. Hot drinks, as hot lemonade or tea, with perhaps a Dover's powder, for its physiologic action in dilating the peripheral blood-vessels and promoting perspiration, is a satisfactory method of reducing the temperature. Tepid sponging may be of benefit, and hot sponging should be given the patient daily if he is too ill for a hot bath. If a testicle is affected, the lesion is generally an orchitis, or it may be an epididymitis. Warm, moist applications often relieve pain; but if the testicles are kept elevated and surrounded by absorbent cotton, and if perhaps some oil or fat, such as petrolatum, is applied, the inflammation will probably go away as rapidly as by any other treatment. Strapping is inad- visable in this complication. Any massage, or the rub- bing in of any ointment or other preparation in this 118 MENINGITIS kind of orchitis, or to the parotid glands, is inad- visable in mumps. Ichthyol applications in from 10 to 20 per cent, strength, either in petrolatum or in olive oil, or glycerin and water, have been largely used locally in this inflammation. Lead and opium wash has been frequently used; but the less this inflamed gland is manipulated, the better. If the mammary gland becomes metastatically inflamed, the treatment is about the same as that for the parotid. If it is decided that the ovary is inflamed, but little can be done, except absolute rest and the administration of a sedative if there is pain. If there is much pain from any of these inflamed glands, mor- phin or codein may be advisable if it seems unwise to give a coal-tar analgesic. The period of isolation should be about twenty-one days. MENINGITIS This disease occurs in epidemic and sporadic forms, the latter form being often difficult to diagnose. While young children and young adults are most often attacked, it occurs not infrequently in camps, or in other groups of closely associated individuals. The sporadic form is always more or less present in most cities, and so-called "basillar meningitis" is doubtless generally this disease. Some epidemics in cities show a large number of very young children affected by it. Epidemics appear, both in this country and in Europe; most frequently in the winter and spring months, and the greatest number of sporadic as well as epidemic cases occur during March, April and May. The. cause of epidemic cerebrospinal meningitis is the Diplococcus intracellularis meningitidis, also called meningococcus, which was first described by Weichsel- baum, in 1887. These cocci are found in the spinal fluid. It has been found that a second lumbar punc- ture made a few hours after the first or. a drawing of the spinal fluid so as to get some of the fluid from the brain more frequently yields the organisms than tlie first fluid coming from the puncture needle. This indi- cates again that the organism may reach the brain directly from the nasal passages before reaching the spinal cord. In appearance they are very much like gonococci, and lie in pairs either in or near the leuko- CAUSE OF MENINGITIS 119 cytes. These germs are also found in the secretions of the nose and nasopharynx. The meningococcus is of low vitality and is readily killed by sunshine, drying and by freezing; therefore, with ordinary precautions the danger of contagion is slight. As in so many other diseases, carriers of this germ have been found, and they probably play a considerable part in the spread of epidemics and in the occurrence of sporadic cases. From these facts meningococcus cerebrospinal men- ingitis should be made a reportable disease, whether occurring in sporadic or epidemic form, and carriers , should be sought, and when discovered, isolated and treated.. In the first place, it may be mentioned that rarely it has been noted that the disease has attacked an individual more than once. In the second place, carriers have become more or less immune, but it is self-evident that, haying been discovered, although close contact is needed, and though the germ is not sturdy and is readily killed after leaving the body, they must be isolated and treated. Therefore, the persons immediately, surrounding a case of meningococcic men- ingitis should have the secretions of the nose. and naso- pharynx examined for this germ. It has not been shown just what local treatment of the nose and throat of these individuals is advisable, but antiseptic sprays, swabbings and gargles are certainly indicated. All car- riers of the organism should be isolated until free from it. Vaccinations, with dead meningococci, of children who have been directly exposed to the disease, and of the nurse or other persons, who must care for cerebro- spinal fever patients would seem to be advisable in preventing the spread of the disease. It has been suggested that a moderate amount of immunity would be sufficient to prevent this particular infection. How long immunity would last is not known. Vaccination with this germ causes a febrile reaction, with leukocy- tosis. Meningococcus vaccines are now prepared, and can be readily obtained. Meningococcic vaccine has been injected, and antimeningococcic serum has been sprayed into the noses and throats of carriers, with some success. It has not been shown how constantly this treatment is successful. 120 MENINGITIS The symptomatology need not be considered here. It should be remembered, however, that the disease may be systemic with an eruption, as witnessed Dy its old name, "spotted fever." TREATMENT Flexner has given us a specific treatment, and the method to be followed in its administration has been frequently described. If the fluid taken from the spinal canal is cloudy, immediately inject antimeningitis serum, warmed to the body temperature. Inject .slowly. The dose for- an adult is from 20 to 40 c.c, and for infants and children from 3 to 20 c.c; the amount largely depend- ing on the quantity of fluid withdrawn, and the dose should usually be from 5 to 10 c.c. less than the amount of fluid withdrawn. Occasionally in true menin- gococcic meningitis no fluid comes from the canal in spinal puncture, so-called dry tap. In such cases a small amount of the antiserum may be injected, with careful watching of the patient to note changes in pressure as determined by the character of the pulse and respiration. In severe cases the antiserum is injected every twelve hours until there is improvement. In moderate and- mild cases the injection is repeated once a day for four days. The bacteriologic findings of the fluid withdrawn at the last injection, and the condition of the patient, determines whether the anti- serum should be given longer. Usually from four tb six injections are necessary, but more are given if required. On successive punctures and injections the patient is turned first on one side and then on the other, which insures the emptying of the lateral ventricles in rotation. In other words, a patient who lies on his right side for one puncture will be placed on his left for the next. In some instances following injection of serum the patient may go immediately into a condition of shock, with the respiration shallow, the face pale, and the pulse rapid and thready. Artificial respiration is ' resorted to if the breathing has ce^ised, and hypo- dermic stimulation of the heart is given. Large doses of epinephrin may be given intramuscularly. The needle is lowered and the fluid allowed to flow from TREATMENT OF MENINGITIS 121 the canal. This condition of shock does not occur frequently with the smaller doses that are now administered. In some' cases the meningitis becomes a systemic infection, and blood culture shows the, organisms in the blood. In such cases the antimeningococcus serum may be given intravenously in larger doses than are given for spinal injection. .The general treatment of cerebrospinal fever demands the best hygienic surroundings obtainable, and a quiet, cool, darkened room, as in any meningitis. The bowels should be thoroughly moved in the begin- ning, and then, daily, or every other day, the patient should receive a laxative, if needed. As the vomiting is reflex, stomach sedatives are of no avail. As the central condition is improved or the patient becomes more stupid, the vomiting will cease. Food in the early stages should not be pushed, as there is great repugnance to it. Plenty of water, and later simple cereal gruels and milk should be the early diet. The subsequent diet should depend on the height of the fever and the ability of the patient to digest. In the stage of convalescence, food should be pushed, if it is well digested. Through the active illness, starches should be given to prevent acidemia. If the pain is sufficient to require sedatives, much food should not be given, as it will not well digest. A most important symptom of this disease is likely to be pain, and there is no excuse for allowing a patient, because it is a young child, to suffer pain. Morphin or codein represent the most efficient and the safest drugs, the dose, of cciiirse, being regulated according to the age of the patient and the effect. Generally it is better to administer a very small close hypodermically than a large dose by the mouth; the action of the whole dose is obtained, and there is no doubt as to whether or not it is absorbed. Ergot given in aseptic form, intramuscularly, not only seems to act as a sedative to the nervous system and possibly dimin- ishes congestion, but it certainly prolongs the action of any dose of a narcotic. Less morphin,. codein or other narcotic will be required to stop pain and cause rest if ergot is coincidently given. If the blood pressure is low', this is another indication for the administration 122 MENINGITIS of ergot. Generally, if the blood pressure is high, ergot should not be given. Local applications of cold and ice to the head (the hair being cut short) and to the spine, may inhibit the inflammation, and sometimes seem to be of great value. At other times* these cold applications seem to increase the pain. This seems to be especially true if the tem- perature is low. Exactly what these cold applications do to the blood vessels of the parts inflamed is a que,s- tion that has not been determined. Cold sponging of the body is hardly advisable, as it tends to increase the internal congestion. Theoretically, it would seem more sensible, and practically it is often better to use hot applications, as hot sponging, and even hot baths have been advised, for very young children, to relieve the congestion of the central nervous system. Painful joints may be wrapped in cotton and kept warm, much as is done in rheumatism. Conjunctivitis should be treated with a simple boric acid wash. The throat and nose should be cleansed with simple saline sprays or mild antiseptic gargles. There would seem to be no excuse for the adminis- tration of quinin, strychnin, caflfein, or any other cere- bral stimulant. It would also seem inadvisable to administer alcohol in any form. If the. blood pressure is high, hot sponging, small doses of nitroglycerin and more brisk catharsis are indicated. The patient should remain in bed for at least a week after the cessation of the fever, and convalescence should be slow, and the return to activity should be delayed. During convalescence it is well to administer small doses of sodium -iodid, as iodid seems to be effi- cient in aiding the absorption of exudates. Iron and other tonics may be indicated. Stiffening of the muscles and joints may require massage, and, if there are any adhesions in the joints, the orthopedist should be consulted as to whether pas- sive movements or forcible breaking up of these adhe- sions under an anesthetic is advisable. The frequency with which mental deterioration occurs can only be determined by a long, careful study of many cases. Cerebral degenerations and disturb- ances may develop after many years and yet appar- ently have been caused by this disease. ACUTE ANTERIOR POLIOMYELITIS 123 The various complications that may occur have already been mentioned, and their treatment would be that usual for the localized inflammation modified by the general condition of the patient from the cerebro- spinal fever. ACUTE ANTERIOR POLIOMYELITIS DEFINITION It would seem that Flexner's criticism of the long- used names for this disease is justified, because the infection may be present and yet there be no real inflammation of the cord justifying the name of anterior poliomyelitis or infantile paralysis. How- ever, whatever the name, it should be considered an infective, communicable disease that attacks the nose and throat, and causes the usual general symptoms of infection not unlike influenza; that it is likely to, but by no means always does, cause an inflammation of the central nervous system; and that it frequently, but by no means always, causes paralysis. When paralysis is caused, it is distinctive as being almost entirely a motor paralysis. EPIDEMIOLOGY Although this disease is distinctly epidemic, it more or less constantly occurs sporadically. It has occurred in this country in epidemic form for years, but it has become more frequent since 1906, and many, epidemics have been reported since that date. The largest and most fatal epidemic is the recent one of the summer of 1916, when 27,000 cases occurred in the United States, most of them in New York and the adjoining states. Epidemic poliomyelitis seems to be self-limited, the disease dying out in a certain number of weeks. These epidemics occur most frequently in the warm months, June, July, August and September, but just what causes the disease to stop has not been determined. Although cold weather is not apparently conducive to the growth of the germ of the disease, still sporadic cases may occur in any month of the year. In New York City the epidemic of 1916 began in June, and practically ended in October. A winter epidemic 124 POLIOMYELITIS recently occurred in West Virginia. There is no ques- tion that the spread of the disease is stopped by proper quarantine. Children under five years of age are most suscept- ible to the disease, but no age is exempt. About 10 per cent, of a population is ordinarily composed of children under this age, but perhaps only an average of one in every hundred of these children acquire the disease in any one epidemic. In other words, a large number of all children, as well- as most adults, are immune, or are not susceptible to this germ. In the 1916 epidemic in New York City 1.6 persons in every thousand of the population were attacked, as against 2.4 in the rural districts; and in New York City 80 per cent, of those attacked were under five years of age. (Matthias NicoU, Jr., Amer. lour. Dis. Child., Aug., 1917, p. 69). Just what predisposes to a new epidemic cannot be determined. The disease is always sporadically with us. The germs of other epidemic diseases may pre- dispose to the development of this disease. Unhygienic surroundings do not precipitate or pro- mote this infection. The most perfectly housed and cared for children may acquire the disease, while the most neglected, ill-conditioned and unwh'olesomely housed child may escape it. FATALITY- The disease is most fatal in young infants, and is more fatal to boys than to girls. Epidemics show an average of a 10 per cent, death rate, but the New York City epidemic of 1916 had a death rate of 27.2 in every 100 cases, i. e., more than one-fourth of the patients died. Paralysis of the respiratory muscles or of the respiratory center is the most common cause of death. CONTAGION It seems to be proved beyond question that the dis- ease is transmitted by direct or indirect contact, and principally by contamination with the infected secre- tions of the nose, mouth, and throat. Whether infec- tion occurs by direct transmission of the infected mu- cus by kissing, "or by eating or drinking out of common CONTAGION IN POLIOMYELITIS 125 receptacles, or by inhaling droplets . which have been coughed or , sneezed into the atmosphere around a patient, or by inhaling infected dust, the fact remains that, it is transmitted from person to person. While the virus of the infection has been found in the feces, it is not known that it can long live in this environ- ihent. Secretions from inflamed eyes and ears of these patients may transmit the disease. Though the feet of flies or their mouths may carry the infection and plant it where contact can occur,' neither they nor any other insect have been shown to harbor this infection or to transmit it to man. No domestic animal has been shown to have or to suffer from this disease, although the paralytic syrnptoms of the distemper of dogs and horses have suggested the possibility of a relationship. To eradicate the disease, isolation, screening, and strict quarantine of the patient are absolutely essen- tial. The. nurse must sterilize all clothing and utensils used by the patient. All nose, throat, and bronchial secretions should be caught on gauze, if possible, and burned. Feces and urine should be collected in anti- septic solutions, or the diapers should be boiled. The nurse should not come in close contact with others, especially children, and should not prepare food for anyone other than herself and the patient. Though she may be immune, she may be a carrier; and we must recognize that this germ may be carried, as well as is the diphtheria germ, although the carrier may not have had the disease as far as is known. In all epidemics a large number of unrecognized and "missed" cases undoubtedly occur, and account in part for the spread of the disease. Probably the most active period for infection to occur is diiring the first week of the disease, but just how many days longer a patient could give the dis- ease is not known ; a quarantine of three weeks would seem to be protective to the community. A child of youth known to have been exposed to poliomyelitis should be isolated and under suspicion for two weeks. The incubation is from three or four days to two weeks ; perhaps it is generally about one week. How long a carrier continues to be a carrier is not known, or how frequently a cured patient becomes a carrier 126 POLIOMYELITIS is not known. Theoretically a patient cured of an acute attack of this disease has developed enough anti- bodies to cure the infective agent in the nose and throat as well as in the cerebrospinal canal. The germ or virus is not killed ^y ordinary drying ; hence dust may carry this potent poison. The majority of adults and most children over ten years of age, and a goodly number under ten years of age, are immune to this disease. How generally this immunity is natural or inborn, and how often such immunity has been acquired by abortive, undiag- nosed attacks of this disease, cannot be determined. Recovered patients and inoculated and recovered monkeys have in their blood antibodies against this infection. The blood serum of normal adults shows such antibodies, though not of equal amount or of equal effectiveness to the blood serum of one who has had the disease, even many years before. THE ETIOLOGIC ORGANISM OF POLIOMYELITIS An interesting contention has arisen regarding the organism of poliomyelitis. In 1913, Flexner and Noguchi reported the finding of a micro-organism which they described under the term "globoid bodies" and which they stated seemed to bear an etiologic relationship to the disease. More recently, in connec- tion with the epidemic of 1916, Mathers, Nuzum and Herzog, and Rosenow, Towne and Wheeler described an organisni or organisms of a coccal nature and sub- mitted evidence to show an etiologic relationship to poliomyelitis. The publication of this work appar- ently prompted Amoss of the Rockefeller Institute to extend that on the globoid bodies. He points out, moreover, that the globoid bodies have been made to fulfil Koch's law. It shc>uld be pointed out here that the coccus which has been mentioned, when grown in the media in which the globoid bodies are grown, assumes globoid forms ; like the infectious material in poliomyelitic Virus, it is filterable and resists the action of g;lycerin. Bull, another worker in the Rockefeller Institute, insists that . the organism reported by Mathers, Rosenow, Towne and Wheeler, and by Nuzum and Herzog is a streptococcus. He points out ' that the findings of these authors conflict in several ETIOLOGY OF POLIOMYELITIS 127 points with those of previous investigators in this country and abroad, all of which tend -to exclude bacteria as the inciting agents of epidemic poliomyelitis. He insists that the descriptions and pictures of lesions occurring in rabbits and monkeys succumbing to injections with the cocci isolated from cases of poliomyelitis in the published reports of Mathers, Herzog and Nuzum, and Rosenow, Towne and Wheeler, which they identify with the typical lesions present in poliomyelitis ift the central nervous tissue of man and the monkey, are not convincing. Their organism produces lesions which he thinks are of another order from those occurring in human poliomyelitis or in monkeys inoculated with the filter- able virus. It is difficult to analyze the article by Bull in detail since he considers the work of the investi- gators of the coccus without dififerentiating between the results of the various workers. He thus infer- entially makes each responsible for the conclusions of all — ^perhaps a rather unfair method of presentation in view of the differences in the results and conclu- sions of the investigators mentioned. It may be pointed out, moreover, that Bull did not work with cocci isolated from the brain and cord of patients with poliomyelitis. The cocci which he did find in the spinal cord in monkeys dead of experimental poliomyelitis he' regards as secondary invaders. In contrast to the foregoing are articles published simultaneously by Blanton and by Rosenow and Towne. Organisms were found by Blanton in the meningeal exudate covering the cerebrum and cerebel- luin in one case. These organisms were cocci. Some were quite small and appeared in chains, whereas others were seen singly or in pairs. Rosenow and Towne conclude from their recent studies that the small globoid micro-organism which Flexner, Noguchi and their co-workers have consid- ered to be the cause of experimental poliomyelitis has always, in their experience, beeii the result- of the breaking down of large diplococci, which have been isolated from the central , nervous tissues of. each monkey- infected with experimental poliomyelitis. These organisms have not been isolated from other tissues except lymph glands of poliomyelitic monkeys. 128 POLIOMYELITIS nor from any tissue of normal monkeys. The mechan- ism by which the large forms become small has been demonstrated. It appears, then, on the one hand, that the workers of the Rockefeller Institute are unwilling -to grant that the coccus recently isolated by the workers men- tioned from poliomyelitis bears relationship to polio- myelitis in man ; they insist thlat it is merely a strepto- coccus ahd produces lesions which may be produced by streptococci in general. ' On the other hand, Rose- now and Towne claim that these streptococci under proper cultural conditions so modify their characteris- tics as to simulate the globoid bodies described by Flexner, Noguchi and Amoss, which the latter insist is the true causative organism of poliomyelitis. Obvi- ously, the subject demands further investigation and confirmation. Certainly, if the work of Rosenow and Towne is confirmed, the differences in the assertions of the various experimenters will be quite satisfactorily explained. The fact remains that a very interesting coccus has been found in the brain and spinal cord in patients that have died from poliomyelitis — no one can deny that, — but its relation to the disease is not yet determined. It may be a secondary invader or it may have a larger and more direct significance. In any event its discovery appears to be a distinct contri- bution to the bacteriology of the disease or diseases which have been called poliomyelitis. CEREBROSPINAL FJ^UID The cerebrospinal fluid shows early in this disease an increase in the number of cells, from 30 to several hundred per cubic millimeter. Eighty per cent, or more are mononuclears. The globulin content is increased, and the presence of dextrose is demon- strated by the reduction to Fehling's solution. Mild and even abortive cases may show the same spinal fluid changes. "The blood in thepre-paralytic stage does not show a total leucocytic count in excess of what might be considered normal, but as the infec- tion progresses, there js a constant and marked leucocytosis, with an increase of 10 to 15 per cent, of polymorphnuclears, and a decrease of IS to 20 per cent, of lymphocytes." Meningism, syphilis and either EARLY SYMPTOMS OF POLIOMYELITIS 129 tuberculosis or purulent meningitis may be confused with the early stages of poliomyelitis. That . the virus of poliomyelitis travels along the nerve trunks as does. the virus of hydrophobia, is the generally accepted view, and seems to be proved by experiment. EARLY SYMPTOMS The onset of the disease is usually sudden, without prodromal symptoms, with a more or less sharp rise of fever. The fever may or may not become high, but the pulse and respirations are likely to be much, increased. Another constant symptom is pain, more especially in the head and back of the neck, and there may be pain on movement of any part of the body. There is especially likely to be pain down the spine and in the legs; there may be some stiff ening ■ of the spine and the back of the neck. While the patient may be drowsy, the brain is likely to be clear. Instead of drowsiness the patient may be irritable. The throat is generally red, and the tonsils are red. There may be spots or even membrane on the tonsils. The eyes may be congested. These symptoms occurring during an epidemic of poliomyelitis should cause this disease to be suspected, and spinal puncture should .be made for a positive diagnosis. Though most patients are constipated, there may be diarrhea, and there may be vomiting. Gastrointestinal symptoms occurring in an epidemic of poliomyelitis, with an unusual amount of muscle, back, and head pains, should also cause a suspicion of this disease, and spinal puncture should be made. In many instances, the fever of the first day or two is followed by a remission, and then a second attack of fever, and later paralysis; or paralysis may occur on the first day, depending upon the amount of cerebrospinal inflammation. An older patient may complain of dizziness. There may be diminished patellar reflexes, although they are likely to be at first increased. There may be bladder paresis and reten- tion. There may be all kinds of hyperesthesia and vasomotor disturbances, as flushing and blanching of the skin of different parts of the body. Herpetic 130 POLIOMYELITIS eruptions are not infrequent. Kernig's sign is often present. Profuse sweating may occur, and there may be eruptions on the skin of varying types, mostly erythematous. These vasomotor disturbances may also occur in the mucous membranes of the nose and throat, causing them to appear pale. The fever usually lasts only a few days, but it may persist for even as mUch as two weeks. There seems to be no characteristic range of temperature in this disease. The intensity of the beginning symptoms seems to be no indication of future severity or of future paralysis. On the other hand, an attack with mild early symptoms may be followed by serious paralysis and a dangerous condition. Not only is a flexion of the head sometimes combated by the patient on account of the pain, but also flexion of the spine, a symptom of diagnostic importance. DIAGNOSIS The most frequent early symptoms above described, especially if an epidemic is in progress, should suggest the possibility of poliomyelitis. If there is stiffening of the back of the neck and pain on bending the spine,- the presumptive diagnosis is poliomyelitis, and should lead to immediate lumbar puncture for a positive diag- nosis. Careful examination of the extremities may show, even in a young child, a slight difference in the movement of the arms or legs, and such begin- ning paralysis may occur early in the disease. A diagnosis should, of course,- be immediately clinched by lumbar puncture. However, it should be noted that many patients with this infection do not show paralysis, and may not show muscular weakness, and may not show stiffening of the muscles, early in the disease. Also, the temperature may drop in a! day or two, to rise again later. Consequently it should be urged that a patient with the symptoms described, during, an epidemic of poliomyelitis, even without positive diagnostic symptoms, should either have lum- bar puncture made to clear up the diagnosis or should be under suspicion for a week or ten days. If polio- myelitis is suspected, though the symptoms are indefi-' nite and lumbar puncture is not allowed, the patient should be isolated for two weeks. LUMBAR PUNCTURE IN POLIOMYELITIS 131 It may be briefly noted that cerebrospinal feVer is similar in the beginning to poliomyelitis, with per- haps more tendency to vomiting, and with generally an eruption. There is more stiflEening of the neck and less pain, early, in the lower back and legs. Tuberculosis meningitis is never as rapid in its onset as either of the above infections. LUMBAR PUNCTURE When lumbar puncture is made for diagnostic purposes it should be remembered that normal spinal fluid contains not more than 10 cells per cubic milli- meter, and in poliomeylitis the number is increased to 20, and at times to even more than 100. Ruhrah (Amer. Jour. Med. Sci., Feb., 1917, p. 178) states that in the early stage of the disease the poly- morphnuclear cells are found increased, while after paralysis has occurred the chief increase is in the lymphocytes. He states that this increase in the number of cells in the spinal fluid disappears in about two weeks. If the fluid withdrawn is clear, the mononuclear cells will predominate ; if it is opalescent, as it occa- sionally is, the polymorphnuclear cells are increased. Of course if there is an increase of fluid in the cerebrospinal canal there is increased pressure, and the amount of pressure is indicated by the speed with which the fluid is discharged at the time of puncture. The quantity of fluid obtained varies from 10 to 50 c.c. Pain in the majority of cases is relieved by lumbar puncture. Also many head symptonjs are relieved by the evacuation of the fluid which is under pressure. Consequently, lumbar puncture is a therapeutic meas- ure of distinct value. Charles Dana {Jour. A. M. A., April 7, 1917, p. 1017) describes a condition that not infrequently occurs, namely, what may be termed "puncture head- ache." This rarely begins until the day after the fluid has been removed from the spinal canal. It is not serious, and does not last long, but may be quite severe. The pain is diffused over tKe head and even over the eyebrows, or it may be mostly occipital. Dana finds this pain, with various remissions, may last five 132 POLIOMYELITIS to ten days, or even longer. He also finds it is more likely to occur when there is a small amount of fluid in the spinal canal, and heiice low pressure, than when there is high pressure, with extra fluid in the canal. This, of course, is logical, especially as he interprets the condition to be due to the fluid removed from the spinal canal, allowing the water pad of the brain to be diminished so that the brain temporarily rests on the cranial bones and thus causes this headache. Therefore to prevent this "puncture headache" he would withdraw the fluid very slowly, and keep the patient horizontal for three or more days. Zingher (Jour. A. M. A., Mar. 17, 1917, p. 817) states that "the injection of immune or normal human serum into the spinal canal during the acute febrile stage of poliomyelitis causes a distinct cellular reac- tion which is mostly polynuclear in type." He believes these polynuclear cells have a phagocytic action. PARALYSIS As previously stated, when flexing the head and bending the body — in other words, when movements of the spine and consequent irritation of the spinal cord — cause pain, poliomyelitis is frequently the cause. However, without these symptoms paralysis may develop at any time, from even twelve hours to many days, and Riihrah states that paralysis may occur as late as twelve days after the beginning of the disease. It should again be emphasized that the severity of the beginning symptoms seems to bear no relation to the amount of paralysis that may follow ; severe onsets may not be followed by paralysis; mild onsets may be followed by multiple paralysis and death. Severe abdominal pain may occur, even simulating condi- tions that call for operation. There may be trem- blings or tremors of one or more extremities, espe- cially on the attempt to move these parts. The most frequent parts paralyzed are the legs, either one or both. LeBoutillier (Amer. Jour. Med. Sci., Feb., 1917, p. 188) states that in 25 per cent, of all cases one or both legs are involved, in 12 per cent, one or both arms. In the severest cases the muscles of the trunk are involved, even those of the neck,, and EARLY TREATMENT OF POLIOMYELITIS 133 death occui-s from failure of respiration. The most frequent muscles paralyzed, in the order of their fre- quency, according to Ebright (Jour. A. M. A., Sept. 1, 1917, p. 694), are the "anterior foot muscles, quad- riceps, glutei, hamstrings, deltoids, hip flexors, inter- nal rotators of the thigh, and external rotators of the shoulder." He also declares that "a stretched muscle will not regain its tone." It has even been suggested that most cases of scoliosis are due to frank or undiagnosed polio- myelitis. Some statistics from the New York epidemic showed that two-thirds of the cases had paralysis that lasted longer than the quarantine, while about IS per cent, never had paralysis, and about 15 per cent, more had short-lived paralysis. EARLY TREATMENT The early treatment should take into consideration the prevention of the infection of others, even on a doubtful diagnosis, i. e., before the diagnosis has been positively made. In other words, a suspected patient should be isolated, the room screened, all discharges disinfected, and all clothing sterilized. Of course as soon as the diagnosis is made the case should be reported, and all children who have been in contact with the patient should be isolated for two weeks. It should be recognized that the nurse or other attendants may carry the infection in their nostrils or throats and yet not suffer from the disease. They may have become immune from previous attacks, or they may have a natural immunity, and still harbor the infection. The dust of a room in which a patient with the disease has been may carry the infection, and it is even stated that the streets and sidewalks may carry it; hence the spread of epidemics. Bath- ing in pools of water, or in tanks where the water is not frequently changed should be prohibited during an epidemic. While domestic animals have not been shown to harbor the infection, pet animals, as cats and dogs, might cariry the infection in their fur. As peroxid of hydrogen, even ' in weak solutions, kills this virus, it should be used in 5 per cent, solution in warm water as a spray (two or three times a day) 134 POLIOMYELITIS into the nostrils of all children who may. have been exposed to the disease. Also the nostrils of the attend- ants of the patients should be so treated. The throats of young children should be sprayed, while older chil- dren should gargle, a little stronger solution of per- oxid of hydrogen, as 10 or 15 per cent. In three or four minutes after the peroxid of hydrogen solution has been used the parts should be sprayed or washed with a weak (not more than 1 per cent.) solution of sodium chlorid and sodium bicarbonate in warm water. The treatment of the preparalytic stage is the same as that of any other infection. The bowels should be thoroughly cleaned out with the purgative which seems most advisable. Food should be entirely stopped for twenty-four hours, and only water given, or at least only some simple cereal gruel, or milk. The patient should be absolutely at rest, with no mental or physical disturbance. The body should be gently cleansed with hot or warm water sponging, the tem- perature depending on the amount of the fever. Cold water sponging is inadvisable. If there is much pain the patient should be very gently handled, to cause the child the least possible muscle movement, and it may even be necessary, temporarily, to abandon sponging. Acute pain must be stopped with small doses of codein or of the deodorated tincture of opium. The beginning dose may be small ; the frequency should be sufificient to render the child nearly free from pain and to cause some sleep. The lumbar puncture that should be done for diagnostic purposes often becomes a therapeutic measure of value, relieving the .symp- toms of pressure and relieving pain. Puncture for therapeutic purposes may be done every day for sev- eral days, and may- even be done more frequently, if symptoms of pressure are present. Epinephrin has been advised by Meltzer (New York Med. Jour., Aug. 19, 1916, p. 337), as a sub- stance of therapeutic value. It should be injected into the spinal canal once or twice in twenty-four hours, for several days, if there are continued symp- toms of spinal pressure. The amount advised is one or two c.c. of a 1-1000 solution. If this solution is injected at the lumbar puncture it is recommended EARLY TREATMENT OF POLIOMYELITIS 135 that the buttocks be elevated so as to cause gravita- tion of the solution upwards. This treatment has been used with some success. By the second or third day the nutrition of the patient should be carefully watched; the character and the amount of the food depend upon the height of the temperature and upon the ability of the stomach to digest. Some nutrition every three hours in the day- time and once or twice in the night is the best method. If it is not advisable to give meat broths or meat extracts, the child should receive small doses of iron almost from the beginning of the illness. One of the best methods of administering iron is a powdered tablet of the saccharated oxid of iron (Eisensucker) , and a 3-grain tablet once a day is sufficient. If there is much restlessness and sleeplessness with- out acute pain, small doses of bromid may quiet the child, stop the pain and cause sleep. Coal-tar products and synthetic drugs, although they are more or less analgesic, should not be givei^ these young children. Their depressant action is uncertain. Even salol is probably inadvisable. Although iodid of potassium has been recommended, there seems to be no excuse for it, except possibly in very small doses. Iodid of potassium has never been shown to cause absorption of exudate in acute conditions. A very small dose of iodid, whether as iodin, or as iodid of potassium or sodium, as a stimulant to the thyroid will be no more necessary in this infection than in any other infection. On the other hand, it may be advisable in all infections, as it is now known that the thyroid gland is always disturbed by every infec- tion and its detoxicant action in disturbed nitrogen metabolism is increased by a sufficiency of iodin. Acute pain and active symptoms may disappear in from a few days to two weeks after the paralysis. Until pain has ceased, all active measures aimed at .the paralysis are contraindicated. The treatment of the paralyzed parts should be to put them in the. most comfortable position possible by. cushions, sandbags or branbags, so that stretching of paralyzed muscles and ligaments may, if possible, not occur, and that overaction of nonparalyzed muscles may be limited. Sometimes muscle spasm with pain is relieved by a 136 POLIOMYELITIS warm water bag. Very hot water bags should not be used on the child's skin unless they are so covered that the heat is modified. Painful joints may be wrapped in cotton. Hexamethylenamin has been suggested; but it has not been shown that this drug has any germicidal or antiseptic activity unless it meets acid media, as typically in kidney and bladder conditions. As soon as convalescence is established, the nutri- tion should be of the best. Fresh air is important, but rest and quiet for the patient should be continued. Small doses of iron .should be given, and some little bitter tonic may be administered, if the appetite is poor. Small doses of sodium ■ iodid may be advis- able, not more than 0.10 gram (1% grains) twice a day. Calcium in some form may be advisable, unless considerable milk is given the patient. SERUM TREATMENT As it was found laboratorily and clinically by Flex- ner and others that the injection of a serum from an individual who had had poliomyelitis was more or less inhibitive to the advance of this disease and seemed to stimulate the production of antibodies in the individual to fight the disease, it seems advisable to obtain such blood serum, if possible, and to inject it, best intraspinally, and possibly later intravenously, into the afflicted patient. It is found to be more valu- able when given in the early stages, as is true in the antitoxic treatment of all diseases. The serum should generally be given intraspinally, and perhaps only intravaneously when there are signs of a general infection or complications have occurred. It may be given daily, or every two or three days for several doses, and the amount suggested has been from 5 to 30 c.c. The pressure under which the fluid is given should be very carefully watched, and if pressure symptoms occur, the injection ^hould immediately cease, and if necessary some of the fluid must be allowed to flow out of the canal. It may be administered at the time that for therapeutic or diagnostic reasons the fluid of the spinal canal has been withdrawn. SERUM TREATMENT OF POLIOMYELITIS 137 On account of disturbing symptoms and the danger of increased pressure, Draper (Jour. A. M. A., April 21, 1917, p. 1153) cautions that not more than 10 c.c. should be injected into the spinal canal, and then only when a larger amount of spinal fluid has been removed. In other words, increased pressure in the spinal canal must be avoided. He, however, believes that immune serum, when it can be obtained, should be given every child, and the earlier the better, as it seems to have been shown to be of the greatest value before paralysis has occurred. Still, until we have more positive data, during the progress of the disease, even if paralysis has occurred, the serum should be given, as it may cause improvement. It is hardly necessary to urge the necessity of a careful selection of the donor for this serum. The more recently he has recovered from poliomyelitis, the more active in antibodies must his serum be^ How- ever, he may have had the disease many years before and the serum still be of value as a therapeutic agent. Of course he should have no chronic disease. Syphilis must be excluded by a Wassermann or Noguchi test, unless the history of the patient and his family is abso- lutely known. The laboratory care and preparation of the serum for use is beyond the province of this review. Also the value or necessity of preservatives need not be discussed. SPECIFIC HORSE SERUMS Recent reports by Rosenow and by Nuzum and Willy on the treatment of epidemic poliomyelitis describe the preparation of a serum of immunized horses, for which excellent results are claimed. The horses were immunized with the coccus found in the central nervous system in epidemic poliomyelitis, and consequently the question of the exact relation of this coccus to polionfyelitis is again raised. In both reports it is asserted that the serum used has protective and curative powers with respect to the experimental poliomyelitis of the monkey produced by means of poliomyelitis virus, that is, suspensions in physiologic sodium chlorid solution of fresh or glycerinated ner- vous tissue from human beings that have died with this disease, or from monkeys experimentally infected. 138 POLIOMYELITIS While the coccus with which the horses were injected unquestionably occurs in poliomyelitis, and frequently may be present in the so-called virus, its exact rela- tions to the disease have not been made fully clear because thus far it has not been possible to produce poliomyelitis in the monkey by injections of this coccus in undoubted pure culture. But in spite of the lack of this essential link in the chain of evidence necessary to establish that the coccus is the cause of the disease, it must be acknowledged that if the serum of horses immunized with the coccus protects against and even cures poliomyelitis in the monkey, an adequate experi- mental basis for a thorough trial of such serum in the treatment of the human disease certainly has been provided. It is clear, however, that the results of further experiments on the action of the serum in monkey poliomyelitis are required before the claims in favof of its protective and curative powers may . be regarded as fully established. Turning now to a brief consideration of the recorded results from the use of serum produced as indicated, we find that Rosenow treated fifty-four patients with nine deaths, but that six of the patients that died were moribund when the serum was injected, "and hence should not be included as treated cases." This would leave a death rate of 8 per cent. Sixteen of these patients were in the preparalytic stage, and all recovered. Of twenty-three patients in the same epidemic, nine died (35 per cent.). The effects of the serum in the individual case are often striking, at least apparently, because the symptoms soon subside, par- alysis, for instance, being arrested and sometimes dis- appearing completely if in the early stages. As rapid improvement may occur spontaneously in poliomye- litis, as the diagnosis in the preparalytic stage must be difficult (sixteen of the patients treated with recovery are said to have been in this stage), and as it is impossible to form any opinion whether the treated and untreated patients that were the subject of this report are fairly comparable, it evidently is necessary, as Rosenow himself says, that many more patients be treated before conclusions can be drawn as to the exact value of the serum he used. COMPLICATIONS OF POLIOMYELITIS 139 Nuzum and Willy have treated 159 patients, eighteen of whom died (11.3 per cent.). Of 100 untreated patients admitted duri'ng the same period of time to the same hospital, • forty-five died (45 per cent.). We lack, however, a more detailed compari- son as to the ages, severity of attack and general con- dition of the patients composing the treated and untreated groups. We have no information whatever in regard to the principles of selection followed in forming these t,wo groups; consequently it is difficult to determine how much importance may be assigned to the apparently very favorable figures given in this report. These observers also emphasize the rapid gen- era;! improvement commonly seen after the injection of the. serum, there being in many cases a critical drop of temperature. In conclusion, it may be said that the injection of horse serum appears to be quite harmless in polio- myelitis; that the authors of the reports are deeply impressed with the apparent good effects of the serum; that their figures appear to show a great reduction in the death rate, but that the figures are probably not to be accepted without the reservation that they may seem more favorable than is actually warranted. The suggestion ihay be ventured that even if ifeventually should be found that serum produced as described' in these reports has little or no specific effect on the essential cause of poliomyelitis, its use may be followed by favorable results due on the one hand to general nonspecific effects such as follow the intravenous injections of foreign proteins, and on the other hand to its action, specific in nature, on the coccus used in the immunization, which may be a secondary invader of no little importance in polio- myelitis. COMPLICATIONS These hardly need discussion, as each part affected must be treated in the best way possible, as it would be treated were this disease not its cause. A lung complication is very serious, as the danger is very great from anything that interferes with the respira- tion. If the muscles of respiration are more or less 140 POLIOMYELITIS paralyzed, inhalations of oxygen, or artificial respira- tion, may be tried, but they are probably not often, if ever life-saving. Secretions and exudates from any ' complicating inflammation should be thoroughly sterilized, as they may carry the germ or virus of infection. CONVALESCENCE There is a difference of opinion as to whether a paralyzed patient should be long kept at rest in bed or should be allowed soon to begin to walk. There can be no doubt that anything that tends to fatigue is seriously injurious to the paralyzed muscles, and, also, anything that causes Overactivity of the non- paralyzed muscles is not desired. It would seem, therefore, that each patient should be individualized as to the length of time he should remain flat in bed, with such passive movements and such gentle massage as seems advisable. As soon as improvement occurs the patient should probably begin to be about, with such protective apparatus as will prevent deformities and still allow locomotion, and at the same time be not so massive and weighty as to cause much fatigue. From the start, voluntary movements of paralyzed limbs and groups of muscles should be urged, and.even after long months, and even years, of paralysis such voluntary attempts should be made, sometimes result- ing in wonderful improvement. Resistant massage, if the child is old enough to cooperate, is advisable, but the results must be carefully watched and tire pre- vented. Gentle faradism and gentle galvanism, of just suffi- cient strength to cause contraction of the muscles, is probably soon advisable; but electricity should not be used more than from 5 to 10 minutes in any one day. Some clinicians believe electricity is of no value (espe- cially Lovett, Jour. A. M. A., Aug. 5, 1916, p. 421), but the majority of opinion is that, when properly used, it is of value in awakening the activity of muscles and nerves. However, artificial contractions are never of as much value as are even slight volun- tary contractions. CONVALESCENCE IN POLIOMYELITIS 141 Before electricity is applied the part should be heated with warm applications and gentle massage, as the circulation is always sluggish in a paralyzed part and the part is always colder than normal parts of the body. (This massage, by stimulating the circula- tion of both blood and lymphatics, allows the elec- trical reaction to occur with less strength of current. Electric fight heat, as suggested by Lovett, is a valu- able method of heating a chilled, paralyzed limb. It has been suggested that strychnin be injected into a paralyzed muscle during the c&nvalescent stage, and the dose given has been quite large for a child. This may be tried where a miiscle or muscle group is not awakened by ordinary means. One-sixtieth of a grain may be given a child five or more years old,, and even larger doses have been given. Lovett, who has studied this disease very thor- oughly and written many articles embodying his observations, states that it is not generally recognized that the muscles of the back and abdomen become weakened in this disease, causing many deformities, especially if the child too long sits. Deformities in these cases should be prevented by proper jackets or corsets. Skilled muscle training and the advice of an ortho- pedic surgeon is essential in the management of these paralyzed children, even in the convalescent stage. Drop foot, or eversion, or inversion must be, if pos- sible, prevented. Rotation or deformity of the knees must be noted and prevented, if possible. A group of muscles may not be actually paralyzed, but exer- cise with these muscles may show an unusual tire of one leg as compared with the other, or one arm as compared with the other, and such an extremity needs watchful care and treatment. Finally, in this stage of conva,lescence it should be urged that all massage, applications of electricity, and exercise should be done by skilled hands and with skilled advice. Also, the paralyzed limbs, and per- haps the whole body, should be kept extra warm by proper clothing, depending upon the age of the patient, the season of the' year, and the climate. Chilled limbs do not recover as do limbs that are kept thoroughly warmed. 142 POLIOMYELITIS PROGNOSIS The early prognosis as to fatality should be very carefully made, ' even in mild cases, up to the latter part of the first week. The actual death rate varies greatly in dififerent epidemics, perhaps roughly from 10 to 20 per cent., or even higher. While a few patients have no paralysis, . many of these will be found to have weakening of some muscles. Such weakening of muscles and actual paralysis may rapidly recover, even in a few days, but most paralyzed -patients will not recover for several weeks or even months,' while perhaps the majority of those who have suffered paralysis will never again have perfect muscle power. Some patients may . recover without scientific orthopedic or other medical treatment, but the possibility of such recoveries with- out deformity should not be depended upon. There can be no question that scientific, careful manage- ment of the paralyzed patient and of each paralyzed limb may cause progressive and continued improve- ment for months and even years, while any misman- agement, as overexertion, fatigue, or misdirected and overused, measures for improvement will certainly retard recovery or even prevent it. As previously stated, respiratory paralysis is a most common cause of death, and oxygen inhalations, arti- ficial respiration and other artificial respiratory meth- ods may prolong and possibly save life. It has been suggested that turning the patient from side to side may prevent dangerous edema in the vital nervous tissues. It should be remembered that in apparent improve- ment in this disease serious relapses may occur. When the disease attacks an adult it seems to be more seri- ous, and the prognosis not so good. LATE TREATMENT Orthopedic advice should be sought early in the disease, as soon as paralysis occurs, or at least the best orthopedic measures should be taken to prevent deformities. During the stage of convalescence is the period when the orthopedist should either take charge of the patient or should be frequently enough LATE TREATMENT OF POLIOMYELITIS 143 consulted to insure the best possible management of the paralyzed child. The great necessity for rest and yet graded stimulation of weakened muscles has already been emphasized. Proper care at this stage prevents deformities that must be corrected surgically later. It cannot be too often repeated that voluntary effort is of the greatest possible value in awakening paralyzed muscles and groups of muscles. It ha§ been shown that a muscle that is too long over stretched by a mal position of a limb or part of a limb cannot recover its vitality and, strength. Hence such stretched muscles must be relaxed by proper splints or appliances. Although, as previously stated, electrical stimulation is not considered of value by some clinicians, it is urged by others that if a muscle responds to gentle faradism, such gentle daily treat- ments continued but a few minutes at a time will hasten recovery of the muscle. Lov.ett {Jour. A. M. A., April 7, 1917, p. 1018) says that improvement may go on for two years, and even if a muscle shows but a slight trace of power there is still hope, even after several years of- paralysis. He emphasizes the danger from unnecessary braces, and the danger from not properly supporting the para- lyzed muscles. He especially urges that support be given to weak abdominal and weak back muscles. In other words, it requires the best of judgment to decide just what sort of spinal, or other supports, should be used. If a deformity persists after two years or more, surgical orthopedic measures may be instituted, such as the cutting of tendons or fasciae, the stretching of muscles; or more radical measures may be instituted in the way of bone and nerve surgery. When a brace is placed on a child, the mother should thoroughly understand that this is only a pre- vention of deformity, it is not a cure for the paral- ysis, and the child should either be treated at home or taken to some institution for continued muscle treatment. Such treatment may be artificial heat as by electric light; massage; electricity;, voluntary or resistant exercise; and, later, graded exercises some- times termed educational exercises, to re-educate a muscle or group of muscles to do its or their proper 144 HOOKWORM DISEASE work. Heat and warmth to a paralyzed limb is con- stantly essential, as the nutrition of the whole part, muscles and nerves, improves under normal tempera- ture, while, on the other hand, nutrition is at a mini- mum when the part remains far below normal in tem- perature as compared with other parts of the body. In a late communication by Lovett {Jour. A. M. A., July 21, 1917, p. 168) he states that it is a serious mat- ter for a child to attempt to walk on a paralyzed leg before the end of the first year. He finds when the child walks too soon that many times a change from a partial to a total paralysis in the foot muscles occurs. He also notes that a paralyzed right hand recovers sooner than a paralyzed left hand. HOOKWORM DISEASE This disease is found in all tropical and southern temperate zones ; in the United States southward from the Potomac Riyer latitude through to the Pacific coast. The symptoms are laziness, lassitude, weakness, loss of physical and mental ability and vitality, loss of weight and anemia. Children do not properly grow and adults become shiftless, incompetent, and poverty stricken, and they, with their families, become a tax on the community. Hence hookworm eradication is an economic question. The hookworm was discovered in Porto "Rico by Major Ashford, Surgeon of the United States Army, but to Dr. C. W. Stiles of the United States Public Health Service belongs the honor of having found the worm in the southern states and of having shown that it differs generically from the Old World worm, but that it causes the same symptoms. The American type of worm is called Necator americanus. The disease can be discovered by giving the specific treatment in a suspected case and then sifting or wash- ing the stools through cheese cloth, when worms will be found, if present. Billings and Hickey (Jour. A. M. A., Dec. 23, 1916, p. 1208) describe the following simple technic for this purpose : 1. Take a piece of (preferably) formed stool, approximately the size of a walnut, place it in a porcelain cup, and after adding about 60 c.c. of cold water, thoroughly break up the ETIOLOGY OF HOOKWORM DISEASE 145 mass with the aid of a wooden tongue depressor. When the suspension is as complete as possible, destroy the tongue depressor. If the stool is liquid, add an equal bulk of cold water and mix as directed above. 2. After placing over the mouth of the cup two or three layers of wide mesh surgical gauze, strain a portion of the contents of the cup into a centrifuge tube and centrifuge for ten seconds at full speed (which means 2,000 revolutions a minute). The gauze is thrown away and a new piece used for the next specimen. The cup is emptied of its remaining con- tents and thoroughly scalded. 3. Remove the tube from the centrifuge, and without dis- turbing the sediment, pour off the supernatant liquid and refill with cold water to about three fourths the capacity of the tube. 4. Place a thoroughly clean rubber pad over the mouth of the tube, hold in place by the thumb, and shake vigorously. When preparing two tubes at the same time, extreme care will be necessary that the rubber pads are used on their respective tubes at each shaking. 5. Again- centrifuge for ten seconds at full speed. 6. Pour off supernatant fluid as described above, and refill with cold water. Again shake. 7. Centrifuge for ten seconds at full speed. 8. Pour off supernatant fluid, leaving about one-half inch overlying the undisturbed sediment. The specimen is now ready for microscopic examination. The sediment is now removed with a platinum loop or an aluminum wire spatula and placed on a cover glass for examination. The treatment is to give little or no supper, and at bedtime a dose of magnesium sulphate. In the morning, as soon as the bowels have moved freely, one-half the dose of thymol, iri capsules, is given, and in two hours the remainder of the thymol. Two hours later another dose of magnesium sulphate is admin- istered. After movements of the bowels from this dose food may be taken, but only coffee or tea, with- out milk, should be allowed during the period of the' treatment, namely, until the thymol has supposedly all passed out of the body. Absorption of thymol is not desired, as it may cause unpleasant symptoms. Alcohol and oils should not be given either before, during or even soon after the treatment. For one 146 HOOKWORM DISEASE hour after taking the thymol the patient should lie on his right side to hastt.i the passage of the drug and liquid through the pylorus into the intestines. The dose of thymol depends on the age, but is large. Ferrell suggests 4 gm. (60 grains) for an adult dose (that is, from 20 years of age upward). Doses for children and youth may be readily estimated by the following formula, namely: At 15 years, % of the age, % of the adult dose; at 10 years, i/^ the age, 1/2 the dose; at 5 years, % the age, Y^ the dose; at 21/^ years, i/s of the age, i/s of the dose. If the patient is much underweight for his age, the dose should be reduced accordingly. The thymol should be powdered and placed dry in capsules. One-half the dose decided on is given at 6 a. m. If the bowels have been well moved from the dose of magnesium sulphate the night before, the other half of the dose of thymol should be given at 8 a. m., both doses being taken with plenty of water. Ferrell adds sugar of milk in equal parts to the thymol, and says he thinks the drug acts better. In one or two weeks the treatment should be repeated, unless the microscope shows the feces to be free from the parasite and its eggs. Sometimes a third and even a fourth treatment may be needed. The action of the thymol may be hastened by (at the moment of swallowing) uncapping the capsules. Thymol wheii absorbed acts like phenol, but it is slowly dissolved by the gastro-intestinal fluids and hence, is absorbed slowly. Any oil or fatty substance hastens its absorption. Convulsions are probably not often caused by thymol poisoning, but great weakness ' and finally collapse are the gross subjective symp- toms. Objective symptoms of its undesired absorption are albumin and even blood in the urine. Fatty degeneration of the liver and congestion of the kid- neys and lungs are pathologic findings. ' To forestall any possible great absorption of thymol after large doses are administered in hookworm dis- ease, a brisk cathartic (Epsom, Glauber's, or Rochelle salt) should be given and repeated, if free catharsis does not occur within a few hours after taking the thymol. Castor oil, or any other oil, should of course , TREATMENT OF HOOKWORM DISEASE 147 fiot be the cathartic used. If symptoms of poisoning occur, stomach-washing, colon-washing, and sodium sulphate or potassium and sodium tartrate should be the means used to promote elimination. Strong black coffee should be given, and hypodermic injections of atropin, strychnin, and pituitary extract should be administered and the patient should be surrounded by dry heat. Later, any kidney congestion should be treated as an acute nephritis. Except as a specific for hookworm, thymol should probably never be used internally. As a bowel anti- septic it is too dangerous a drug to be used repeatedly, unless the dose is too small to be of any value. Ferrell's dosage for adults for hookworm disease is as follows : Gm. B Thymolis 4| or gr. Ix Fac capsulas siccas 10. Sig. : Take S capsules, with plenty of water, in the early morning, as soon as the bowels have moved. Take the other 5 capsules in two hours. Two hours later take % ounce of Epsom salt, which should be repeated if it does not act in four hours. Owing to a possible scarcity of thymol it is impor- tant to note that investigations of the United States Public Health Service have shown that oil of cheno- ' podium (American wormseed oil) is efficient in this disease. (Public Health Reports, reprint No. 224 Oct. 2, 1914, by M. G. Hotter.), Wormseed oil seems to paralyze or stupefy rather than kill the hookworm; therefore it is very essential that soon after such action has occurred, a cathartic should be administered to cause evacuation of the worms before they can recover their vitality. Unlike male fern and thymol, castor oil may be administered with this drug. It will be remembered that any oil is likely to cause a dangerous amount of male fern and thymol to be absorbed. This is not true of worm- seed oil. The doses of oil of chenopodium suggested in this pamphlet are about 1 drop for every year of age up to fifteen. The drug is well administered in a teaspoonful of granulated sugar, every two hours, for three doses. Two hours later, a child of ten years, for instance, 148 HOOKWORM DISEASE should receive a tablespoonful of castor oil with one- half a teaspoonful of spirits of chloroform. The dose of the castor oil and of the chloroform should vary according to the age of the patient. The routine use of oil of chenopodium was found very satisfactory by Billings and Hickey and many others. The following method of administration was" utilized for adults : Preparatory treatment: At 7 a. m. magnesium sul- phate, saturated solution, 60 c.c, is given. At 7 p. m., sodium sulphate, saturated solution, 90 c.c. The next morning chenopodium is commenced, proceeding as follows : 7 a. m., oil of chenopodium, 15 drops. 9 a. m., oil of chenopodium, IS drops. 11a. m., oil of chenopodium, 15 drops. 1 p. m., castor oil, 18 c.c. ; chloroform, 2 c.c. 1 :30 p. m., plain castor oil, 30 c.c. 2 p. m., a cup of hot tea. DOSAGE OF THE CHLOROFORM-CASTOR OIL MIXTURE Age Dosage c.c. Chloroform, Minims Castor Oil, c.c. From 6 to 7 years From 8 to 9 years From 10 to 11 years From 12 to 13 years From 14 to 15 years Over 15 and under 60 6 8 12 14 16 20 11 12 15 20 25 30 14. 12 8 6 4 The dosage of oil of chenopodium from 6 to 7 years is 5 drops; from 8 to 9 years, 7 drops; from 10 to 11 years, 10 drops; from 12 to 15 years, 12 drops; 16 years and over, and under 60 years, IS drops. A varying amount of the stock solution of chloro- form-castor oil mixture is used, depending on the age of the patient, and sufficient castor oil added to make the total dose 20 c.c. In the second column of the above table is indicated approximately the amount of chloroform per dose in minims. The stock solution contains: chloroform, 2 c.c; castor oil, 18 c.c; one dose is 20 c.c. This dosage is to be used in conformity with apparent age only. PROPHYLAXIS OF TYPHOID FEVER 149 On the sixth day after treatment tKe stool is exam- ined and, if found positive, another course of treat- ment is given and the stool again examined at the end of the second six days. It is not necessary to place limitations on the diet as is the case in using thymol. Possible undesired symptoms from wormseed oil are drowsiness and depression. Such symptoms occurring, rapid purging should be caused by a saline cathartic, and such stimulants as hot coffee or caffein should be given. TYPHOID FEVER GENERAL PROPHYLAXIS OF TYPHOID FEVER Typhoid fever is one of the most preventable of all infectious .diseases. The essential agent in the causation of typhoid fever, Bacill-us typhosus, has been f oiind in the blood, in the feces, in the urine, and in the bile. It cannot always be discovered in the early days of the disease, but in the second or third week it can generally be detected. It may persist for years, even as many as twenty-five or fifty, after a patient has become convalescent, and also in the body, par- ticularly in the feces and urine of individuals who have never themselves, so far as can be determined, suffered from an attack of the disease. These indi- viduals are known as "typhoid carriers." After diagnosing the disease as typhoid, the physi- cian should at once report the case to the health. office. Even should the case be suspicious only of typhoid, the following precautions may well be taken. The feces immediately on being passed should be covered with a 5 per cent, solution of phenol, and the hard masses should be broken up so that the disinfectant will thoroughly penetrate the fecal matter and come in contact with all microorganisms which may exist therein. Other disinfectants may be used, such as chlorinated lime, or liquor cresolis compound, 2 per cent. The utmost cleanliness should be used by the attendants in connection with the movements of the bowels. The skin surrounding the anus should be carefully washed with a disinfectant solution, and the cloths used for this purpose should be put in paper bags and subsequently burned. The attendant also should, after bathing the patient, always wash her hands in a disinfectant solution. In a similar manner 150 TYPHOID FEVER the urine should be discharged into a vessel and mixed with a disinfectant solution. The bacilli can sometimes be found in the sputum, and if the patient has any cough, the sputum should be collected on cloths and burned. All bedding should be soaked in a disinfectant solu- tion and boiled before being washed. The cups, glasses, dishes, knives, forks, spoons, and napkins used by the patient should also be disinfected before being washed. During convalescence, the feces and the urine should be subject at intervals to bacteriologic exam- ination, to determine whether the bacilli are still pres- ent. It has been found that they may be absent at one time, and may reappear later, so that repeated examinations are necessary. The patient should be carefully isolated until repeated examinations have shown entire absence of bacilli, both from the feces and the urine. When these rules have been observed in the care of any patient suffering from typhoid, he, his friends, and the physician, will rest assured that there will be very little likelihood of his communi- cating the disease to anyone else directly .or indirectly. As has been stated, the disease may be carried directly from the patient suffering from the disease, or from a so-called bacillus-carrier. The bacilli may be received directly by a person who does not possess immunity to the disease by handling articles, such as clothing or utensils used in eating, which have been contaminated by fecal matter, urine, or sputum from a typhoid patient. A far more common mode of infec- tion is the indirect method, which embraces infection through water and through various food supplies, especially milk and oysters. Many epidemics have been due to the infection of a water-supply from patients suffering with typhoid. Jordan (Jour. A. M. A., June 6, 1914, p. 1772) states the following rules, for the individual and the community in preventing typhoid ; RULES FOR PREVENTING TYPHOID FEVER For the Individual: 1. Keep away from all known or suspected cases of typhoid. VACCINATION AGAINST TYPHOID FEVER 151 2. Wash hands thoroughly before meals. Do not use "roller towels." 3. Use drinking-water only from sources known to be pure, or if this is not possible, use water that has been purified by municipal filtration or by hypochlorite treatment or by boiling in the household. 4. Avoid bathing in polluted water. 5. Use pasteurized or boiled, instead of raw, milk. 6. Select and clean vegetables and berries, that are to be eaten raw, with the greatest care. 7. Avoid eating "fat" raw oysters and, in general, oysters and other shell-fish whose- origin is not known. 8. Be vaccinated against typhoid in all cases in which any special exposure is known or feared. For the Community: 1. Insist on the hearty cooperation of all persons with an efficient health officer. 2. Require notification and a reasonable degree of isolation of every known or suspected typhoid case. 3. Exercise strict control over the disinfection of known typhoid excreta. 4. Insist on pure or purified water-supplies. 5. Require pasteurization of milk-supplies. 6. Regard all human excreta as possibly dangerous, and control their disposition in such a way as to pre- vent contamination of food or drink. VACCINATION AGAINST TYPHOID FEVER In 1893, Frankel first published his observations on the inoculation treatment of typhoid . fever. In 1896, Wright published his first article on antityphoid inocu- lation. The British first introduced inoculation in the Indian army for the prevention of typhoid fever and demonstrated that the individual was protected by such inoculation for two and one-half years, and partially immunized for five years. In 1900, inoculation pre- vention was used in Germany, also, in her armies, and German and English military camps soon became almost free from typhoid fever by such protective vaccination. With the inauguration of this measure in the United States Army, typhoid fever became greatly diminished in frequency. Vaccination of our 152 TYPHOID FEVER army was begun in 1909, and, in 1911, among 80,000 men only 1 1 cases of typhoid fever occurred, with one death. In 1912 there were 15 cases in the army, with 2 deaths. This shows that occasionally the typhoid inoculation does not protect, but the improvement shown by the diminution in the number of typhoid cases from 9.43 cases out of every thousand soldiers in 1901, to 0.26 for every thousand soldiers, in 1912, compels belief in its efficiency. The death-rate from this disease decreased, per thousand soldiers from 0.64 in 1901 to 0.03 in 1912. The incubation period of typhoid fever is about two weeks. Its duration, when there are no relapses, is about two months. This means two weeks of incu- bation, four weeks of more or less serious illness, and two weeks before the real convalescence. Young adults and youth are most likely to contract this dis- ease, although it may occur at any age. This is the age, then, for the greatest effort to be made to give protective inoculations. All nurses. and members of hospital staffs; students of colleges and seminaries; employees, and those who are interned in work houses, jails, prisons and asylums ; men in lumber camps ; and all those who travel and are therefore subjected to varying water, milk and food-supplies, such as "travel- ing" men, engineers, seamen, tourists, and vacationists, should receive typhoid preventive vaccination. With all the advantages to an individual and to a community conferred by protection against typhoid fever by vaccination, the physician must also carefully consider what constitute contra-indications. It seems to be wise carefully to examine every individual to ascertain his condition of health before vaccination is done. It should not be done if he is suffering from any acute infection however simple, namely, a coryza, a pharyngitis, a tonsillitis, or any acute gastro-intes- tinal disturbance, gonorrhea, syphilis, albuminuria, glycosuria, or the more serious conditions of chronic nephritis or diabetes. The injections should be made in the afternoon, and the active symptoms will gen- erally be gone by noon of the next day. Three injec- tions should be given at weekly intervals. TREATMENT OF TYPHOID FEVER 153 The method of injection is as follows : Paint with tincture of iodin an area about. 15 mm. in diameter at the insertion of the deltoid muscle. Inject subcutane- ously with sterile needles and the best vaccine the dose of killed bacteria decided on. Then paint the region with collodion and allow it to dry. If proper care is taken, no infection will occur, and, as above stated, a temperature reaction is rarely above 100 F., and perhaps never reaches as much as 102 F., even in exceptional instances. A severe reaction could only occur when there is some serious complication in the individual, as perhaps tuberculosis. All slight reac- tions are generally over in twelve hours and even severe ones are generally over in twenty-four hours. The local reaction is greatest after the first dose, less after the second, and least after the third. Typically, there is an acutely inflamed area, varying in size, not hard and indurated like an incipient abscess. The arm may ache, and the axillary glands may become tender. The local reaction is generally af its height in about ten hours, and generally nearly gone in twenty-four hours. Any more severe reaction would be due to. contamination. The dosage for children should be based on the child's weight and not on its age. The recommended adult dose is based on a weight of ISO pounds. It seems to be necessary for continued protection to reyaccinate children more frequently than adults, namely, in about three years. Various preparations are now available. In the vaccination of our troops over one million men were injected with a triple vaccine consisting of 1000 million typhoid bacilli and 750 million each paratyphoid A and B bacilli per cubic centimeter. The first dose is 0.5 c.c. and the second and third doses each 1 c.c. Inocula- tions are made subcutaneously at intervals of seven days. This tremendous experience as well as that of all European nations shows that the adminstration of the vaccine is a safe procedure and it protects. TREATMENT OF TYPHOID FEVER A. General Measures. — Needless to state, the patient ^vith tvphoid fever should be put to bed and kept 154 TYPHOID FEVER quiet. The usual measures, such as the use of a cleansing cathartic, should be instituted and sirnple fluid mixtures such as lemonade or citrate solution may be given. Patients should be encouraged to change the position in bed sufficiently often to prevent the occurrence of congestion of any of the viscera and the development of bed-sores. The hygiene of the mouth should be watched, as mentioned for other diseases, with scrupulous ^care. B. Diet. — Whether we have underfed our typhoid patients or overfed them, it seems that the evidence is very strong that milk alone is not the proper food for these patients. In fact, when we consider the frequent difficulty in its digestion, the large amount of it that must be given to satisfy the system either in calories or in protein, it would seem that we should rule against it as a typhoid diet. These facts imme- diately cause the decision that our old feeding of typhoid fever was wrong, and that we must select a new or modified food in this disease. It can not be .questioned that the high temperature, rapid pulse, delirium, and that association of nervous symptoms called typhoid are not caused by the typhoid germ alone, but by a double infection, and the double or secondary infection is due to toxins or the products of secondary germs absorbed from the intestines. Tympanites is an indication not of typhoid fever, but of intestinal putrefaction and fermentation, and a mistake in the management of the bowels and of the food administered. It stands to reason, then, that primarily such food and arrangement of the movements of the bowels as cause the least tympanites and the least indigestion are of first importance in the managenient of typhoid fever. Secondly, the food which, so far as possible, satisfies the requirements of the body for nutrition and at the same time satisfies the above requirements of -easy and thorough digestion, should be the food of choice. Barker {Journal A. M. A., Sept. 12, 1914, p. 929) suggests the use of a high caloric diet which has been shown by Coleman, DuBois and others to be theo- retically adequate and practical. The amount of food DIET IN TYPHOID FEVER 155 necessary to meet the needs in typhoid fever is large. The carbohydrate intake is most important; when not contra-indicated for some special reason, it should make, up, Coleman thinks, a half of the calories given. The carbohydrate may be given partly as bread or toast (with butter), and partly as lactose added to milk or cereals. Coarse cereals with cellulose residue are to be avoided. Dry toast or- zweibach buttered, if thoroughly chewed by the patient, may be used with- out harm. Lactose is a very important article of the diet. It is easily soluble, is- not very sweet, and can be given in large amounts without the appearance of sugar in the urine. Examples of some of Coleman's milk, cream, and lactose mixtures are: For 1,000 calories a day: Calories Milk, 1 quart (1,000 c.c.) 700 Cream, 1% ounces (50 c.c 100 Lactose, 1% ounces (50 gm.) _ 200 This furnishes eight feedings, each containing: Milk, 4 ounces 80 Cream, 2 drams 15 Lactose, 6 drams 24 For 2,000 calories a day : Milk, 1% quarts 1.000 Cream, 8 ounces (240 c.c.) 500 Lactose, 4 ounces (125 gm.) 500 This furnishes seven feedings, each containing: Milk, 7 ounces 150 Cream, 1 ounce °0 Lactose, 18 gm '^ For 3,000 calories a day: Milk, 1% quarts J.OOO Cream, 1 pint (480 c.c.) . .- 1.000 Lactose, 8 ounces l.""0 This furnishes eight feedings, each containing: Milk, 6 ounces • 120 Cream, 2 ' ounces •' 120 Lactose, 1 ounce (30 gm.) 1^0 The following is a sample diet for a day in which 3,910 calories are to be given : Hours Total Calories Milk, 6 ounces 9 a. m.; 1, 3, 7 p. m. 1,260 c.c. 860 Cream, 2 ounces 10 p. m.; 1, 4 a. m. 420 c.c. 840 Lactose, 10 gm 70 gm. ^ 1.980 156 -pifPHOID FEVER At 11 a. m.: Calories At 5 p. m.; Calories Egg, 1 80 Egg, 1 80 Mashed potato, 20 gni 20 Cereal, 2 tablespoonfuls ISO Custard, 4 ounces 2S0 Cream, 2 ounces 120 Toast (or bread), 1 slice 80 Apple sauce, 1 ounce 30 Butter, 20 gm 150 Tea ■. ■ ■ ■•• Coffee Cream, 3 ounces 180 Cream, 2 ounces 120 Lactose, 20 gm 80 Lactose, 20 gm 80 - — 640 78" ^ . ■ At 7 a. ra.: Calorics Egg, 1 .- 80 Toast, 1 slice SO Butter, 20 gm 150 Coffee Cream, 2 ounces 120 Lactose, 20 gm 80 510 Lactose lemonade may be substituted for the milk mixture at 3 o'clock. A liberal amount of fat in the diet will send the cal- ories up, but not all patients bear fat well, especially early in the disease. Fat may be tried in the form of cream, of butter and of yolk of egg. Coleman has been able to give as much as 200 or 250 gm. of fat per day without causing digestive disturbances. The fat content of ordinary milk is of course considerable, and milk in amounts of from 1.5 to 2 liters per day can be given to most patients without difficulty. Fruit juices, to which lactose has been added, may be given, as long as there is no diarrhea, but they should be discontinued should diarrhea develop. It must be remembered, however, that patients on the high-calory diet ordinarily have from two to four stools a day. It should be continually borne in mind that indi- vidual patients may not thrive under such a high- calory diet. Should tympanites or other digestive dis- turbances begin to appear, it is well to modify the diet at once and especially to restrict the intake of milk and of lactose. If, on the high-calory diet, examina- tion of the stools shows that undigested food is pass- ing through, the diet should be reduced. A good mixed diet for twenty-four hours, suitable for an ordinary adult ill with typhoid fever, is repre- sented by one pint of milk ; two eggs, or the whites of three eggs; one cup of thoroughly cooked, thin oat- meal gruel; the juice expressed from a pound of chopped round steak; a small cup of cofifee, in the DIET IN TYPHOID FEVER 157 morning; a small portion of wine, orange, or lemon jelly made from gelatin ; and enough salt and sugar in the above to make them palatable. The "milk may be administered, hot or cold, with or without salt, with or without Vichy, with or without lime water, in two or three doses, as. deemed best in the individual instance. Sometimes koumys makes a valuable substitute for ordinary milk. Sometimes but- termilk may be used, ^nd this in large quantities. The eggs may be given raw, beat up with a little milk, or given with lemon juice on cracked ice, may be poached, or, if the temperature is not high, soft boiled or in the form of boiled custard. The oatmeal gruel should generally be made with milk, and thoroughly cooked, strained, and salted to suit the taste. Meat juice is best prepared by just covering the chopped steak with water, and allowing it to stand for aii hour and a half. The water and juices are then expressed out of the meat. This watery extract will then contain, besides the blood of the meat, actual inuscle serum, which is a decided tonic, especially to the heart. This expressed fluid is then kept on the ice and administered, properly salted, in two or three doses. If the patient is not too ill, the food may be made more agreeable by allowing the patient to chew the meat, but not swallow the fibrous portion. While gelatin is generally pleasant to most patients, it also has some nutritive value, and possibly tends to aid normal coagulation of the blood, and perhaps pre- vent capillary bleedings from the inflamed intestines. A patient who is accustomed to his morning coffee need not be deprived of that pleasure because he has typhoid fever, unless there are meningeal symptoms, or meningitis is actually present. Experience seems to teach that it is best to adminis- ter nutriment to the typhoid patient in small amounts at three-hour intervals. It should, however, be arranged that the patient has normal rest. In other words, he should not be awakened from a comforta- ble~sleep because it is time to do something to him 'or for him, and at regular three-hour feeding intervals should be the periods at which he is to be disturbed for 158 TYPHOID FEVER • - other treatments. During the night, if he is not seri- ously ill, he should not be disturbed as often as every three hours. With the treatment outlined and, with proper care of the mouth, the patient's tongue is rarely badly coated and should be moist, there should be no nausea, and there should be no tympanites. C. Colon Enemas. — It has been lately shown that fecal deposits, seeds or other food debris may become lodged in the lower corner of the ascending colon, the cecum, and may cause inflammation or symptoms of appendicitis, and may even be a subsequent cause of appendicitis. Hence it may be found to be good treat- ment, in the first few days of typhoid fever, to give colon enemas of from one to two quarts of warm water, the patient lying on his right side, to aid in washing away the possible accumulations in the cecal region. Such colon washings can certainly do no harm in the first days of typhoid, and may be of marked benefit in the future course of the disease. In other words, the more thoroughly the pathologic process in the intestines, in typhoid fever, is considered from a surgical standpoint, with the aim to keep these ulcers and the inflamed intestinal mucosa- as clean as possible, the less will there be secondary infection, the less will there be tympanites, the less will there be deep ulcera- tions, hemorrhages and perforations, the less high the fever, and the better the whole prognosis. D. The Fever. — Hydrotherapeutic measures have become so universal in the treatment of the fever in typhoid patients that it is unnecessary to describe these measures in detail. E. Medical Treatment. — Not only should the bowels be cleared at first, but subsequently, the bowels should be moved daily. This is best done by administering, every other day some gently acting saline laxative, which cleans the upper part of the intestines, tends to drain the portal circulation, to keep the liver, our Pasteur filter, in a healthy condition, and to cause an easy watery movement. Any tendency to a diarrheal condition or to too many movements from sUch a laxative may be stopped by the administration of 1/10 grain of morphin. The bowels are thus cleaned and MEDICAL TREATMENT OF TYPHOID FEVER 159 subsequent excessive peristalsis inhibited, and the patient is genprally at rest for the remainder of the day. . On the alternate day a small glycerin enema, administered with a glass syringe, consisting of a tablespdonful of glycerin and a tablespoonful of water, will cause within ten minutes a movement of the bowels that will at least empty the descend- ing colon and cause the expulsion of gas. Such management of the bowels seems contra-indicated only by intestinal hemorrhage, signs of perfora- tion and great prostration. Such treatment also prevents secondary infections that keep the tempera- ture high. In other words, less antipyretic measures are needed, if the abdomen is flat, tympanites is not present, and the patient's bowels have moved daily artificially, and the movements are not caused by diar- rhea due to irritation from the disease. The best antiseptic to the upper part of the intestines seems to be salicylic acid in some form, and one of the best forms is the combination with phenol, viz., phenyl salicylate (salol), which may be given in capsules with- out any disturbance of the stomach, as it is there undissolved and breaks up in the duodenum. A small dose of this drug (0.25 gram or 4 grains) every six hours may be given continuously through the disease, unless there is a diminished execretion of urine, or albuminuria develops, or the urine shows darkening from the phenol, which would be very rare from this size dose. Even the non-believers in bowel antisep- tics must admit that whether the co.lon bacilli or typhoid bacilli come to the upper part of the intestine by migration, or reach these regions through the blood stream, it would not be so healthy for them provided salicylic a:cid was present in the upper intestine as though it were not present. Thus far sour milk treatments, lactic acid germs and the administration of yeast have not been mentioned. Certainly bowel infections of most kinds are made bet- ter by the administration of yeast. The value of sour milk treatments in typhoid fever must be_ determined by experience. A patient, however, who is not doing well on the diet above suggested should be put on the sour milk treatment. One of the principle objections 160 TYPHOID FEVER to such treatment is that the patient's stomach soon objects to any one diet that is to be long continued, although for a few days he might accept the soured milk. On the other hand, most patients do not object to the sour drink produced either by a tablespoonful of upper brewer's yeast in a glass of' water, or by the solution of a five-eighths inch cube of a compressed yeast cake in a glass of water, given two or three times a day. F. Vaccine Therapy.- — It is difficult to arrive at a just estimate of the value of vaccines in the treatment of typhoid lever, because the evidence for and against their use is derived from two widely different sources. From a theoretical standpoint, such a procedure has little justification. It is well known that there is an extensive invasion of the blood by the infecting organ- ism early in the course of the disease, and it seems reasonable to assume that these invading organisms furnish sufficient antigenic stimulus to cause the maxi- mum antibody formation. On the other hand, if this antibody formation is delayed early in the course of the infection, vaccines may be of value in stimu- lating such a response. In the field of clinical medi- cine", many observers have reported striking results from the use of vaccines, and it is the common opinion of these clinicians that they are efficacious in the treat- ment of typhoid fever. The type and dosage of the vaccine have had no apparent influence on the results obtained. Sensitized vaccines have been strongly advocated by Besredka, Metchnikoff, Garbat and others, and on theoretical grounds such vaccines would be favored; but the majority of investigators have had good results with suspensions of dead bacteria prepared according to Wright's method. Sensitized vaccines are made by exposing suspensions of bacteria, for example, typhoid bacilli, to the action of the corresponding immune serum which has been heated in order to destroy the complement. The excess of serum is removed by cen- trifugation, and the bacteria suspended in salt solution. Sensitized vaccine may be prepared with living as well as with dead bacteria, but in the case of typhoid vac- cine it would hardly be justifiable to use living sen- VACCINES IN TYPHOID FEVER 161 sitized bacteria. There would be a possibility of either infecting the individual or causing him to become a carrier, notwithstanding Besredka's assertion that the sensitized living typhoid bacilli used by him are wholly harmless, and especially as it has not been established that any kind of sensitized vaccine has any greater value than plain vaccine. It is true that advantages are claimed for sensitized vaccine, but there does not as yet seem to have been sufficient experience to war- rant any definite conclusions. Although autogenous vaccines generally have been preferred, stock vaccines prepared from organisms selected for their high agglutinogenic power have been efficacious in the hands of many. Reports have been so uniformly favorable with all preparations, that it seems as if the type used is of secondary importance. The observations of Elmer {Jour. A. M. A., 1915, Ixiv, p. 5 18) indicate that vaccines will not prevent the attack, once infection has begun. It seems probable that their use early in the course of the disease modifies the duration and intensity of the attack. Furthermore, in complications, especially localized typhoid infections such as cholecystitis, and in the treatment of typhoid carriers, vaccines are of limited value. In local infec- tions in which there is a secondary invading organism, as iu' pneumonia and otitis media, typhoid vaccines ' are probably contraindicated. G. Convalescence. — The patient should be kept in bed until the pulse regains its normal rapidity, and the amount of exercise that he is allowed to take should not be such as will increase the action of the heart beyond the normal rate. The patient should be allowed to sit up in bed. If this results in a marked increase in the heart rate, he should not be allowed to get up. It is also important that the nervous system should not be subjected to unusual irritation, and he should avoid cares and worries as far as possible'. Any anemia should be treated as mentioned in connection with other infectious diseases. Protracted rest and a simple diet are essential features of this protective treatment. Before releasing the patient from observation the stools and urine should be examined repeatedly for the presence of typhoid bacilli. 162 RHEUMATISM RHEUMATISM The average case of rheumatism presents usually a history of repeated attacks of acute or chronic tonsil- litis. "Sore throat" is also not uncommon in these cases. In other words, a thorough search will usually reveal a focus of infection in the body and experi- mental work has shown undoubtedly as confirmed by clinical experience the relation of these foci to the joint disturbance. TREATMENT In acute conditions, provided the focus of infection is in the tonsils, it is not always advisable to remove these tissues at once. In mild cases or chronic cases this may be done at once and is usually followed by marked benefit. A case which is acutely ill should, of course, be managed like other cases of acute infection. The bowels should be carefully watched as to their condition. The use of salicylates in rheumatism should be gov- erned by observation of the effects of the quantities administered. Miller {Jour. A. M. A., Sept. 26, 1914), after a thorough investigation of the effects of the salicylates in rheumatism, concludes: "As salicylic acid after absorption circulates and appears in the tissues as' a salicylate, it ' cannot act as a germicide unless the increased carbonic acid tension in the joint; the result of inflammation, reconverts it into salicylic acid. Statistics show that patients receiving salicylate are free from pain much earlier than those not treated. As the treated patients much more frequently relapse than the untreated, however, the total duration of pain in the treated and untreated patients may not be materially different. The period of stay in the hospital of patients' receiving salicylate and of those receiv- ing other forms of treatment is the same. Cardiac complications are not less frequent since the use of salicylates. In rabbits the prophylactic use of salicyl- ate is of no value in preventing arthritis after intra- venous injections of hemolytic streptococci." The salicylates may be given in doses of from 5 to 10 grains every two to three hours continuing the treatment for PAIN IN RHEUMATISM 163 perhaps a week after the patient seems to be free from symptoms. But one case has been found in medical literature of a patient with toxic symptoms following aspirin. This was in a woman who had taken 10 grains twice daily for seven years. Jadek, a foreign observer, after a considerable experience approves salicylic acid as most desirable. Wood (Abstr. Jour. A. M. A., June 13, 1914, p. 62) advises the use of acetates and citrates which are oxidized in the body into carbonates and therefore act as systemic antacids. The potassium salts, he believes, are slightly more active as diuretics than the corresponding salts of sodium and increase the com- pleteness of the oxidative process in the body, thereby lessening the amount of uric acid to be excreted. From 20 to 30 grains of the salt should be given every two or three hours, or until the urine becomes alkaline. PAIN For the relief of pain a small amount of morphin is better than a large amount of coal-tar product. This is always true when pain is constantly recurring. The repeated administration of any coal-tar preparation is inadvisable in acute conditions. The most important measure is immobilization and protection of the inflamed joint. Measures should be employed which increase hyperemia, such as wrapping in cotton batting, hot applications and counter irri- tation. The care of the individual joints which are inflamed cannot be dogmatically dictated. The joint and limb should be placed in the position that gives the patient the most comfort. If several joints of a limb are involved, and especially if there tends to be more or less troublesome muscle contractions, or an inadvertent movement causes excruciating pain, a splint may be devised to keep the limb at rest. Whether cold appli- cations or warm applications are the best for other joints, depends on the feelings of the patient. Too continuous cold is perhaps best not applied, as tending so to deteriorate the circulation of the part as possibly to do harm. Generally, warm, moist applications, and perhaps nothing better than alcohol fomentations (one 164 RHEUMATISM part of alcohol to 3 or 4 parts of warm water; a towel or napkin soaked in this and then wrung out just suffi- ciently not to drip, and this wound around the joint and then covered with oil silk) will probably give as much comfort as any application. These should be changed as frequently as they are cold. Sometimes dry cotton around the joint causes as much comfort as any application. The official methyl salicylate may be applied, or oil of wintergreen, but probably neither is more valuable than the above alcohol dressing. Later when" the acute inflammation in the joint has subsided, but the inflaihmation tends to persist in cer- tain joints, ichthyol applications are much used and seem at times to be efficient in hastening the absorption of exudates. Ichthyol may be used in from 10 to 25 per cent, mixture with glycerin, or with olive or other bland oil. When there is acute rheumatic inflamma- tion in the joint, counter-irritation is contra-indicated, but when a subacute inflammation persists, either fly blisters or the actual cautery may be advisable. Anemia which so often follows rheumatism is per- haps frequently due to abstinence from meat and the prolonged administration of salicylates and alkalies. The constant administration oi iron throughout the disease and a not too long use of salicylates and alka- lies will generally prevent this condition. The convalescence following rheumatism should be prolonged until the patient is thoroughly able co attend to his work. If there is a cardiac complication, such a recommendation is positively necessary. It can never be determined how much endocardial inflammation was present, how much valvular inflammation and thickening will be permanent, or how perfect the repair of the heart may be. Also, even when auscul- tatory evidence of cardiac complication has not been discovered, there may have been some inflammation which should call for prolonged rest. The adminis- tration of small doses of an iodid, best sodium iodid, from 0.10 to 0.20 gram (from U/^ to 3 grains) three times a day, is often advisable. Such treatment has frequently seemed to hasten or aid in the complete recovery of endocarditis. Not every endocarditis from rheumatism leaves valvular lesions. VACCINE TREATMENT IN RHEUMATISM 165 Meat does not cause rheumatism, and prolonge'd abstinence from meat is generally inadvisable, still but a small amount of purin foods should be taken for some time. Eggs, green vegetables, and cereals should constitute the main food; later, fish or meat once a day may be allowed. VACCINE TREATMENT Greeley (Abstr. Jour. A. M. A., July 4, 1914, p. 62) treated patients suffering from rheumatism with vac- cines made from streptococci isolated from the joints, the pharynx, the blood or the urine. He found uni- versal improvement after the use of such autogenous vaccines. No case should be given a vaccine during an exacerbation, marked by acute joint swelling, pain or fever. In a large series of cases studied by Billings he found that the final results in two groups was quite as satis- factory without as with vaccine. His experience is that of most observers. NON-SPECIFIC PROTEIN INJECTIONS In acute rheumatism, but more particularly in chronic infectious arthritis, markedly good effects have in some cases followed the injection intravenously of various non-specific protein antigens. Miller (Jour. A. M. A., Sept. 8, 1917) reviewing his experience with 130 cases treated by this method says that the chief difficulty is the violence of the reaction following the injection of the protein. The nature of the reaction has not been determined and it may be due solely to the temperature reaction and the various agencies of immunity excited by it. It is too early to state whether it is going to be a regular therapeutic procedure but it would seem that it cannot be entirely discarded. The chief objection to it is the danger of grave or fatal reaction. Carelessness must be specially guarded against. It must be considered still in the experimental stage and not generally employed without careful con- sideration of the possible dangers. If used the toxicity of the particular vaccine must be determined and the patient carefully searched for cardiovascular pathologic conditions. Thomas, writing in the same issue, gives 166 CHRONIC ARTHRITIS his experience with eighty-six cases. As these were mostly of the chronic form the further consideration of the subject will be given in the next article. COMPLICATIONS Circulatory weakness during rheumatic fever may be combated with strychnin, with , camphor, with aro- matic spirits of ammonia, rarely with alcohol, some- times with caffein, and exceptionally with strophan- thus or digitaHs, the latter provided that there has not been prolonged high fever and there is no acute endo- carditis present. In the treatment of this disease, it should be urged that the heart be watched daily by stethoscopic exam- ination, to note as soon as signs of endocarditis occur. This complication is so insidious that it may not cause symptoms appreciable to the patient. There may, how- ever, be an increase of temperature, as there may be cardiac pain or distress. While it is not the object of this article to describe the treatment of endocarditis, it may be stated that an ice bag over the heart may inhibit the inflammation, that the salicylates should be stopped if endocarditis occurs, and that rest and con- valescence after complications should be prolonged. CHRONIC ARTHRITIS Chronic arthritis develops not only as a result of long continued bacterial infection but also on a basis of metabolic disturbances, gastro-intestinal derange- ment, etc. The blood carries to the joints "chemical products of bacterial growth, products derived from the gastro- intestinal tract, metabolic products of organ activities, and drugs, such as lead." Bacteria may locally infect a joint and produce substances that are irritant. Mechanical injury to the joints whether irri- tation, pressure, overwork, or insufficient circulation from some old injury or anything that disturbs the nutrition of a particular joint or set of joints may become causes of chronic arthritis. The following localities deserve attention as being the possible sources of toxins in such cases : the teeth, tonsils, naso- pharynx, bronchial tubes, bronchiectatic cavities, infec- tions of the gall bladder, appendix, seminal vesicles or fallopian tubes. TREATMENT OF ARTHRITIS 167 TREATMENT "The main problem," says Billings (abstr. Jour. A. M. A., Oct. 10, 1914, p. 1325), "is to get rid of the systemic infection." Primary rest is necessary as long as motion causes pain. The etiologic factor must be sought and removed if possible. The metabolism of the patient should be studied thoroughly, and the analysis should include repeated examinations of the excretions. Worry, nervous frets and mental irrita- tion should be avoided. In the treatment of individual joints, the measures mentioned under rheumatism should be borne in mind. Hyperemia about the joints may be produced and body baking may be of value in more generalized affections. In varying time, from four to six weeks, according to Billings, passive motion with gentle massage may be begun. The amount of passive exercise must be gauged by the effect on the individual. The patient, always more or less nervous, tires easily. To these patients tire is painful. Day by day the exercise must be increased. The rest, restorative measures (food, etc.), should improve the general nutrition and blood circulation. The passive exercise will gradually improve the local blood circulation and oxygen supply to the infected tissues. In due time active exercise is added. This must be systematically and regularly performed. Usually a nurse or masseuse should teach the patient the lighter forms of calisthenics. These measures, namely: rest, restorative food, pure air, environment of optimism, graduated passive and later active exercises will overcome the debility, malnutri- tion and poor general circulation. They will also help to restore the local circulation and oxygen supply to the infected tissues. By these measures the natural defenses of the body are improved, the infected tissues become richer in oxygen and consequently a poor cul- ture medium for the invading micro-organism. Finally the destructive progressive metabolic changes of the tissues cease. Gradually one may note favorable changes in the joints. Atrophied, contracted muscles increase in bulk and functionate. But one dare not relax the control of the patient. Daily systematic passive and active exercises increased gradually mu.st 168 CHRONIC ARTHRITIS be continued until a relative restoration occurs. Other- wise a relapse is apt to occur because of neglect of one or more of the above important factors relating to nutrition, general and local blood supply, etc. Autogenous vaccines made up of the dominating strains of streptococci obtained from the tissues and exudates of the focus of infection have been used by Billings but as has been noted without any marked advantage. It is Billings' opinion that the general measures of management and treatment are absolutely necessary to succeed in helping these patients. To this management may be added autogenous vaccina- tion without fear of harmful results. The use of vac- cines in the treatment of chronic deforming arthritis ■without attempting to find or remove the dominating etiologic focus of infection and without a systematic hygienic management is irrational and most unjust to the patient. NONSPECIFIC PROTEIN INJECTIONS Thomas (Jour. A. M. A., Sept. 8, 1917) describes his experience with the use of these injections in eighty-six cases. A large percentage of the patients were subacute and chronic cases with begining and advanced joint changes, hard working, ill fed and poorly cared for persons who sought the hospital as a last resort. Rest in bed and search for an elimination of the focus of infection was insisted on in all cases excepting those where immediate relief from suffering was imperative. The following possible sites of infec- tion were kept in mind: tonsils, teeth, gums, sinuses, ears, eyes, urethra, prostate, gallbladder, heart, gastro- intestinal tract, and female pelvic organs. In a few of the cases there was no demonstrable focus. In sub- acute and chronic cases of ostearthritis Thomas says that one will make no mistake if he prescribes fifty million typhoid vaccine intravenously and if the reac- tion is only moderate cautiously raises the amount at intervals of two or three days to a hundred and fifty million bacteria at an injection. In the eighty-six sub- acute and chronic cases treated he has seen no harm done nor any alarming symptoms from the treatment. Indirectly he has heard of several fatal cases but these were, he believes, acute cases with alarming coexisting TREATMENT OF ARTHRITIS 169 illness. Moderately advanced heart and kidney dis- eases have not been considered contraindications, but only as demanding care in the preparation of the patient; seeing that the stomach is empty for some hours before the treatment and the use of a small initial dose gradually increased but only after all the disagreeable symptoms that previously existed from the last dose have passed away and appetite has returned. The immediate effects following injection are a more or less uncomfortable feeling accompanied by a chill, rise of temperature and emesis. Protocols of two cases are given. The practically cornplete relief from all joint pains and optimism of the patient a few hours after the vaccine are most striking in virtually all cases. After from twelve to twenty-four treat- ments over a period from one to two months they are able to leave the hospital as cured. The relief of pain, however, has not been permanent in over 30 per cent., but the remaining percentage has done better than after any other treatment that he has used and he therefore considers this method superior. Before forming any final judgment it will be well to bear in mind the question asked by Theobald Smith in another connection : how much energy does a reac- tion of this sort cost the patient, and is the final result worth the cost? Medicinal treatment, except such treatment as is aimed to promote digestion, proper bowel activity, proper circulation, and proper character of the blood, is of little value. If there is thought to be hyper- acidity of the secretions or at least decreased alka- linity, alkalies may be of value, but certainly alkalies should not be pushed to the point of interfering with stomach digestion. Salicylates are of but little value in chronic joint disturbances. lodids in large doses will produce waste, and may be what a fat patient needs. Small doses of iodid . stimulate the thyroid to extra activity, promote general metabolism, and may be of value in the individual case. Colchicum in chronic arthritis is probably of little value except as it may increase intestinal activity. All of the various lithia salts, and all of the various laxative and alkaline waters have no specific action, but if combined with 170 ARTHRITIS DEFORMANS increased muscular activity increased activity of the skin, increased drinking of water in proper selected cases, a regulated diet and a regulated life, in other words, proper regime, they may be of apparent benefit. It is the regime, however, and not the particular kind of lithium or other salt that works the cure. ARTHRITIS DEFORMANS The etiology of this disease is only now being worked out. The relation of infection elsewhere in the body to this disease has been emphasized, espe- cially by Billings and cannot easily be overestimated. The changes in the joints are not due to the absorption of toxins from the focus alone, but to actual localization of the bacteria themselves. The difficulty in obtaining the causative organism is great, owing to chronicity; by special methods Rosenow succeeded in isolating peculiar streptococci from the excised lymph-glands draining the involved joints, from contracted and dis- eased muscles, and from excised portions of tTie diseased capsule of the joint itself, and recommended the use of a vaccine prepared from organisms thus isolated rather than from the streptococci in the focus. The use of even these vaccines, however, is quite futile unless the focus is removed. The peculiar character of the changes, in which there is a proliferation of endothelial cells in the blood-vessels about the involved joints with a" consequent anemic necrosis, makes it clear that no matter what vaccine or other 'remedial agent is used, cure in advanced cases will be exceed- ingly difficult. Removal of the focus, the judicious use of autogenous vaccines in small doses prepared not from the focus but from the adjacent lymph-gland or tissue itself, together with rest, good air, passive motion and forced feeding comprise rational proce- dures and yield substantial results. It is important to consider the special needs of each. In one instance important joints may have become ankylosed in unusable positions, or their motion interfered with by marginal exostoses. Appropriate surgical treat- ment will be of service in such cases. Other joints are benefited by immobilization with splints or adhesive tape. Continued infection, pain, ajid interference with CAUSE OF TETANUS 171 locomotion may have resulted in partial invalidism, with attendant anemia, poor appetite and sluggishness of function of various organs of the body. With the removal of infection and all possible mechanical correc- tion of deformities should go attention to nutrition by giving a virell balanced general diet. Tonics containing iron may be of benefit. There is no drug therapy specific for this condition. Outdoor life and such moderate exercise as is consistent with the policy of rest for affected joints, will help to build up the general tone of the patient. TETANUS . The occurrence of thousands of cases of tetanus in the great war and the cases in our own country follow- ing Fourth of July injuries and other wounds, make the prevention of tetanus a most important subject.- The anaerobic organism responsible for this disease is, it has been said, widely prevalent in the soil of . France and Belgium, the chief field of military opera- tions, due to the intensive cultivation of the soil in these countries. The incubation period of acute tetanus is from one to ten days, and of subacute tetanus from ten to twenty days. Fifty per cent, of all cases develop between the sixth and ninth day, the majority appar- ently on the seventh day after infection. Acute tetanus lasts from one to ten days, and subacute tetanus from ten to twenty days. Not until the patient has lived until the tenth day of the disease is there an equal chance for life. After the tenth- day the patients chances of recovery increase day by day. There is probably always more or less leukocytosis in tetanus, and Hill found the average count to be 13,000. The eosinophils seem to be diminished in number. The tetanus bacilli is a cylindric rod, larger at one end than the other, and is an anaerobic germ. It is constantly present in the dirt of cities and on most country roads, as well as in barns and pastures. Noble has recently shown that this bacillus occurs in the intestines of otherwise normal animals, and he found the germ in the feces of eleven of sixty-one horses examined. Further examination of these 172 CAUSE OF TETANUS infected animals showed that the germ could disappear in a few weeks, but could also remain present as long as four months. Such animals become tetanus^ car- riers, and are a constant menace to other animals which may receive injuries, and to their drivers and hostlers, who may have slight wounds on their hands. These tetanus-carrying horses infect the dirt of the fields or streets on which they work or travel. . This bacillus gains entrance to the system almost always through a wound or abasion, and, as has long been recognized, the most frequently infected wounds are contusions and crushing or lacerating wounds, especially those that occur from sliding, grinding and ■ friction injuries in the streets and from lacerating wounds acquired in warfare, explosions. Fourth of July injuries, etc. At £rst the infection is a local one, and it is stated that the bacilli do not often wander from the point of infection; but they soon produce their toxins, which cause the general disturbance. SYMPTOMS The beginning symptoms of poisoning from this germ are aches and pains in the muscles, with a gen- eral lassitude, some "headache, and soon some stiffness of the muscles of the back of the neck, face and jaw. The wound or source of infection may show no change; in fact, may apparently be healed. The more or less permanent contraction of some muscles and the convulsions of tetanus are too well understood to need description. Spasm of the sphincters may make urination and defecation almost impossible. The mind generally remains clear, unless there is very high tem- perature, which is one^ of the causes of death. Death may occur during a convulsion from spasm of the dia- phraghm or spasm of the laryngeal muscles, or it may occur from exhaustion. THE PREVENTION OF TETANUS For convenience the important points in the prophy- laxis may be summarized as follows : 1. Carefully and thoroughly remove every particle of foreign matter from the wound, laying it open, if necessary, under anesthesia. PREVENTION OF TETANUS 173 2. Dry the wound thoroughly, and paint it and the surrounding parts as carefully as possible with iodin, or else cauterize it thoroughly with a 25 per cent, solu- tion of phenol (carbolic acid) in glycerin, or alcohol. 3. Apply a loose wet pack, using a solution of some such antiseptic substancfe as boric acid or alcohol. 4: As soon as possible inject intravenously or sub- cutaneously 1,500 units of antitetanic serum and con- tinue the injections if indications of possible tetanus arise. 5. In no case close the wound. Allow it to heal by granulation. Remove the dressings and packing each day and apply fresh ones. Ritter, on the basis of observation of 60,000 wounded in Bavaria, believes that our ordinary meas- ures are not sufficiently severe; 0.7 per cent, of the wounded died and 0.4 per cent, of the deaths were caused by tetanus. Even prophylactic injections of serum were not always able to ward off the disease. Freidrich makes a practice of excising the wound all around for 1 cm. into sound tissue, both at the surface and in the depths. This method is the ideal, Ritter declares, but it is not always applicable. Another method is to apply hyperemia according to Bier's stasis technic. This washes out the wound from within on account of the higher blood pressure in the tied-oflf limb. He urges a trial of this measure on a large scale. Copious application of Peruvian balsam or its equiva- lent checks the production of hard crusts behind which the secretions can accumulate. Painting with tincture of iodin is a step in the right direction, he reiterates, but it does not go far enough. THE TREATMENT OF TETANUS ANTITOXIN The use of full doses of antitetanus serum given as soon as the earliest symptoms appear is the measure of greatest importance in the treatment of this disease. Irons (abstr. Jour. A. M. A., Oct. 14, 1914, p. 1505) analyzed the results of 225 cases of tetanus treated with various measures. Irons believes that the delay of treatment until the second or third day of symptoms, and the small doses 174 CAUSE OF TETANUS (1,500 to 3,000 units) which a number of these patients received, go far toward explaining the failure of these methods to reduce the death-rate in this series below 50 per cent. The unfortunate fact that often patients do not apply for treatment until the second or even the third day of symptoms can not be used as an argument against a method of treatment which offers a reasonable hope of success if instituted early in the disease. Magnesium sulphate was given intraspinally in eighteen cases which also received serum. Four cases, two acute and two chronic, recovered, giving a mortality for the group of 77 per cent. In two cases death occurred shortly after the injection, with symp- toms of respiratory paralysis. Irons emphasizes that it is important that the full effect of the antitoxin should be obtained immediately and this may be accomplished by giving 3,000 to 5,000 units intraspinally and 10,000 to 20,000 units intra- venously at the earliest possible moment after symp- toms of tetanus appear. On the following day the intraspinal injection may, be repeated. The blood remains strongly antitoxic for several days. On the fourth or fifth day 10,000 units should be given sub- cutaneously to maintain the antitoxin content of the blood. If only a small amount of antitoxin (3,000 to 5,000 units) is available it should' be given intra- spinally. Intraspinal and intravenous injections should be given with all the precautions usually employed for these methods. Nicoll {lour. A. M. A., June 12, 1915, p. 1982) determined by animal experimentation in the Research Laboratory of the Department of Health of New York, in conjunction with Dr. William H. Park, and also by clinical experience, that from 3,000 to 5,000 units of antitoxin should be injected into the lumbar region of the spinal canal as soon as tetanus is diagnosed. This injection should be done under an anesthetic, to inhibit any possible convulsion during the injection. The volume of the fluid injected should be "brought up to 10 to 15 c.c. by the addition of sterile normal saline, the exact amouqt being regulated according to the age of the patient and the amount of spinal fluid with- drawn." At the same time he advises the injection of TREATMENT OF fETANUS 175 10,000 units of antitoxin intravenously. The spinal injection dose should be repeated in twenty-four hours, and a subcutaneous injection of 10,000 units should be given three or four days later. Nicoll finds that the death rate has been reduced by this method of treatment of those who already show symptoms of tetanus. Subsequent injections of antitoxin, especially when given intravenously, can cause anaphylaxis, sometimes severe; and Simon thinks that injections later than the tenth day become dangerous from the standpoint of being likely to produce anaphylactic shock. The prophylactic dose of tetanus antitoxin sh6uld be about 1,500 units, given subcutaneously, preferably in or about the region of the injury, and this should be given whenever the character of the injury or the region in which the injury is received presents any pos- sibility of tetanus infection. This dose can be repeated in a few days if deemed advisable. The serum may also be perfused into the open wound, but the anti- toxin powder applied to the wound can probably not be relied on as an effective prophylactic. An antitoxin impregnated pad is described by Robertson (Jour. A. M:^., Aug. 28, 1915, p. 793). As in administering diphtheria antitoxin, it should be ascertained if the patient is susceptible to emana- tions from horses or stables; if he shows hay fever and asthma symptoms from such emanations, it is unwise to administer horse serum, especially as a prophylactic for something that may not occur. This use of antitoxin in no respect replaces other necessary recognized non-specific methods of treat- ment in tetanus. Surgical treatment of the site of infection should be instituted at once. The patient should be placed at rest in bed in a quiet, darkened room, and should receive sufficient sedatives to con- trol convulsions, together with adequate supply of fluid nourishment, and attention to the elimination by kidney and bowel. The necessity for large and con- tinued doses of sedatives such as chloral or chlorbu- tanol should not blind the physician to the possible danger of giving an overdose. The condition qf the 176 CAUSE OF TETANUS patient should be carefully watched, and a revision of the standing orders for sedatives made whenever symp- toms suggest the decrease or increase of dose. MAGNESIUM SULPHATE When tetanus is once installed, according to Wein- traud, who observed numerous cases among the Ger- man wounded, little can be hoped from serum treat- ment but we have an important symptomatic aid in the Meltzer and Auer's magnesium sulphate treatment. The dosage when given subcutaneously should be 15 or 20 c.c. of a 20 per cent, solution or 12 or 16 c.c. of a 25 per cent, solution. Eunike {Milnch. med. Wchnschr., Nov. 10, 1914) . injects 10 c.c. of a 10 per cent, solution of magnesium sulphate intraspinally. This drug more or less suc- cessfully inhibits the convulsions. If active symptoms recur in two or three days, he gives another dose of 8 c.c. of the 10 per cent, solution. Certainly the intraspinal injections of magnesium sulphate should be given only in very severe cases. The dosage suggested by Eunike is not large; very much stronger solutions have been injected. The danger lies in causing paral- ysis of the respiration. Schiits has shown that mag- nesium sulphate diminishes heat production, and he thinks that the intensity of its action may be deter- mined by the temperature curve. Injections of magnesium sulphate into the system, and especially into the spinal canal, are always more or less dangerous, and it would seem that in serious convulsive conditions, while waiting for the antitoxin to have its effect, inhalations of chloroform would be safer in quieting and controlling the patient than injec- tions of a substance whose activity passes beyond the control of the physician. OTHER DRUGS The serotheraphy by no means does away with the necessity for chloral or morphin. The dosage must be proportional to the age of the patient and the severity of the tetanus. Some clinicians give very large doses of chloral, but Permin thinks it is wiser to keep below the maximum dose and supplement the TREATMENT OF TETANUS 177 chloral with morphin, keeping the patient in a quiet, darkened room. It is of the utmost importance that the patient should get adequate nourishment as the resisting powers depend to such an extent on this. Fluid foods are best and with extreme lockjaw it may be necessary to pull a couple of teeth to permit the introduction of a rubber tube through which fluid nourishment can be poured into the mouth, or better still, if possible, nasal feeding by a tube may be tried. Daumsler, chief physician of the French army, administers 6 gm. of chloral every six hours until the patient is in a state of torpor and all hyperexcitability is abolished. Sainton injects subcutaneously twice a day 40 or SO c.c. of a 2 per cent, solution of phenol — the Baccelli method. The patients are isolated in semi-darkness, and twice a day given an enema consisting of 6 or 8 gm. of chloral, one or two yolks of eggs and 250 gm. of milk. The phenol injections were kept up more than a month in two cases, one receiving a total of 48 and another 88 gm. of phenol. The doses of phenol given by Sainton do not approximate the fatal dose, which is in most cases as much as 15 gm. (I/2 ounce). It should be remembered that tetanus is an extremely fatal disease, and all forms of treatment employ heroic doses of the remedies used. The doses given by Sainton are about SO per cent, above those recom- mended by Baccelli. Baccelli thinks thkt patients with tetanus are extremely tolerant to phenol. The dose of chloral is considerably above doses which have proved fatal in exceptional cases, but the chloral in tetanus is probably largely counteracted by the convulsive condition of the patient. While the minimum fatal dose of chloral has been put at from 1.5 to 2 gm. (20 to 30 grains), much larger doses have been used in tetanus without serious results. In a case of tetanus, 93 gm. or 3 ounces were given in twenty-four hours without causing death. This is, of course, exceptional. Anders recommends chloral to be given by rectal injections, 2.59 gm. or 40 grains, at a dose. Other methods of treatment include the injection of hydrogen peroxid directly into the wound, expos- 178 , CHOLERA ing the wound to a continuous stream of oxygen, and the blowing into wounds of a powder composed of one part chlorinated lime and nine parts bolus alba (Kao- lin), and the use of a dressing of powdered antitoxin. CHOLERA Cholera, which is infrequent in the United States, has been more widely spread recently in Europe, due to the traveling of large bodies of troops. It is re- grettable that serum prophylaxis in this disease is not so efficient as in typhoid. PREVENTION Rosentfial gives the following outline of the prophy- laxis: Each person can effectually protect himself against cholera by extreme cleanliness and avoiding unboiled water and uncooked foods. The most im- portant general prophylactic measure is the isolation of the sick. The disease starts almost always with diarrhea, and although the patient may still feel quite well yet he is already scattering germs in his numerous stools. A soldier with profuse diarrhea should go at once to the hospital and stay there. Even before it is possible for bacteriologic examination of the stools, the leukocyte count and blood-picture may reveal the presence of cholera infection and permit the discharge of the men as having harmless diarrhea. Even direct exposure to cholera does not necessarily cause the disease unless the system is depressed, and he urges for this reason restriction of the use of liquor, avoidance of physical excesses, raw fruit, etc. Before eating and especially before preparing food the hands should be thoroughly cleansed with soap' and water, The face and particularly the mouth should not be touched by the hands. All fluids should be boiled before drinking. If water has to be taken raw, the danger of infection can be materially reduced, he says, by adding a little acid, a knife-tip of citric acid to half a liter, or 20 drops of liquid phosphoric acid. The army corps should have a supply of each. He insists that it is unnecessary to use a disinfectant for the hands, and that spraying the rooms and clothes with a solution of phenol does no good whatever and merely TREATMENT OF CHOLERA 179 serves to lull into false security. Disinfectants are of no use for the desired purpose except in the privies, and even here chlorinated lime is preferable to phenol and much cheaper. The linen and the dejecta from the sick require, of course, thorough sterilization. There is no transmission of cholera, typhus or dysen- tery through the air. In Bulgaria he used to see persons extremely punctilious in singeing their dishes with alcohol and toasting all their bread, and yet they would eat raw fruit and drink unboiled water. TREATMENT Measures to alleviate disagreeable symptoms should be adopted. Diarrhea should be checked but castor oil may be given to govern the bowel movements and bismuth subcarbonate to sooth the intestine is useful. Morphin is useful in alleviating cramp. Brachio, in a recent severe epidemic in Europe, (Abstr. Jour. A. M. A., Oct. 3, 19.14, p. 1236) found iodin extremely effective, the best method being an intraperitoneal injection of a mixture consisting of iodin 14 graiii; potassium iodid i/4 grain, distilled water, 20 m. In almost all cases the treatment was supplemented with a free use of epinephrin, dropping the solution on the tongue. Naame has shown a strik- ing analogy between the cholera syndrome and the symptoms from defective functioning of the supraren- als. He injects epinephrin subcutaneously in doses of 4 to 6 gm. in twenty-four hours, over several days, supplemented by saline infusion. Recognizing that the loss of fluids from the tissues through vomiting and copious evacuations in the acute stage constitute the chief danger in this disease, Rogers has recommended rectal injections by the drip method of physiologic sahne solution. This is kept up until the kidneys act freely. If the blood pressure is low this may be given intravenously. PNEUMONIA Pneumonia is today the most serious acute infec- tious disease confronting the physician. Second only to tuberculosis among the acute infectious diseases as a cause of death, it attacks suddenly and kills quickly 180 PNEUMONIA Occurring usually in endemic form, it also appears frequently in epidemic form, and has become one of the most threatening of the diseases that attack sol- diers. No better evidence of this is needed than the list of causes of death of soldiers in our expeditionary forces and the large number of cases in our canton- ments, several of which have already suffered severely from epidemics occurring secondary to measles and other infections as well as in the primary form. DEFINITION In outlining a plan of procedure to follow in the prophylaxis and treatment of pneumonia it is essential to have clearly in mind the causation and natural course of the disease. Pneumonia, or inflammation of the lungs, includes acute lobar pneumonia as well as various forms of atypical and bronchopneumonia. THE INFECTING ORGANISM Acute lobar pneumonia is due to infection by the pneumococcus, usually runs a rapid course, and is characterized by a diffuse exudative inflammation of large parts of one or more lobes of the lungs. Bron- chopneumonia, on the contrary, may be due to a variety of bacteria, but is usually associated with streptococci. Most cases of pneumonia which follow or complicate contagious diseases are due to strepto- cocci, i. e., are septic pneumonias. Mathers studied a series of cases of pneumonia of atypical types, occurring during and following attacks of grip in 1915-1916. The clinical and pathologic pic- ture was that of a streptococcus bacteremia ' with metastases in the lungs, joints, kidneys, serous sur- faces, gallbladder and appendix. The prominent gross pathologic lesions were extensive hemopurulent pleuritis and pericarditis, marked hyperplasia of the lymph glands, parenchymatous degeneration of kid- neys, liver and myocardium. The lungs were usually only partially consolidated, very heavy and pliable. Often most of an entire lung was involved. In almost all cases hemolyzing streptococci were present in the sputum and lung. These cases correspond to those often observed in association with diphtheria, scarlet CAUSE OF PNEUMONIA 181 fever, measles, etc. It is likely that the cases of pneu- monia occurring so extensively in connection with epidemics of measles in our training camps are in large part of this sort. While we have been in the habit of saying that lobar pneumonia is caused by the pneumococcus, recent studies have shown that strains of pneumococci which are alike so far as cultural properties are concerned are still widely separated in their biologic qualities. When the study of pneumonia at the Hospital of the Rockefeller Institute was undertaken, a large number of races of pneumococci were isolated and studied as to their 'immune reactions. Animals were immunized to each strain, and the blood serum of each immune animal was then tested as to its power to agglutinate each of the strains and also as to its power to protect mice from infection by each strain. As a result of these studies the strains of pneumococci grouped themselves into four classes or types. The serum produced by immunizing with each member of a group acted in a similar manner on all the strains of the group, agglutinating the bacteria and protecting mice against infection. On the contrary, the serum produced by immunizing with a member of one group had no such power over the strains of the other groups. The four groups of pneumococci are spoken of as Types I, II, III and IV. Type I is found in 33 per cent, of cases of lobar pneumonia; Type II in 29 per cent. ; Type III in 13 per cent., and Type IV in 20 per cent. The pneumococci found in normal mouths belong to Type IV. These studies have a very important bearing on the prophylaxis and specific treatment of lobar pneumonia. Making use of the serum of animals which have been immunized against cultures of the four types of pneu- mococci, it is possible to test the strain from each case of pneumonia and to place it under the type whose corresponding serum causes it to be agglutinated. This is very important if immune serum is to be used, as the only cases of pneumonia which are benefited by serum are caused by organisms of Type I. Ill 448 cases studied in the Hospital of the Rocke- feller Institute, 145 were of Type I, 148 of Type II, 182 PNEUMONIA 55 of Type III and 100 of Type IV. Of these cases, pneumococci were found in the blood in 136 instances. The mortality when the organism was found in the blood was 55.8 per cent., whereas in the 312 cases with negative blood cultures, the mortality was only 8.3 per cent. This shows that the presence of the pneumococcus in the blood during lobar pneumonia indicates a severe infection and a bad prognosis. GENERAL CONSIDERATIONS Although pneumonia has been considered a self- limited disease tending to recovery, this can hardly be said to be generally true. The sthenic type of pneumonia which does tend to recovery, with one or more lobes distinctly involved, is now not so frequent as a less circumscribed pneumonia, or an asthenic type with a low temperature and without much tendency to self-limitation and, as the statistics show, not a great tendency to recovery. The crisis which should intro- duce recovery means, according to Hektoen, the destruction of the pneumococci in the lungs and blood. This, he says, is accomplished by phagocytosis and by extracellular digestive processes. Therefore, the great- est defense against pneumonia is a production of leuko- cytosis and of antibodies in the blood. Such patients as rapidly die of a toxemia have this blood defense in insufficient amount. When this defensive process has been produced in sufficient amount rapidly to destroy the pneumococci, the recovery is by crisis; when it is in sufficient amount to destroy them only slowly, the recovery is by lysis. The latter form of recovery is the one that we now see most frequently. PREVENTION It has generally been considered that many persons harbor the pneumococcus in the throat, and that it is thus ever ready to attack the person who becomes debilitated, and especially to add its attack to that of the influenza bacillus or to follow a streptococcal infec- tion of the throat or nose. It is no doubt true that exposure and a weakening of individual resistance do play a prominent part. Recent studies of the incidence of the various types of pneumococci in the throat of PREVENTION OF PNEUMONIA 183 normal persons, in the throats of those suffering with pneumonia, in healthy persons in contact with cases of pneumonia, as compared with those not in contact, and in the dust of rooms in which lobar pneumonia had not occurred, as compared with, the dust of roorris in which cases of pneumonia had occurred, all show that pneu- monia, in a considerable proportion of cases at least, arises chiefly by infection from without. It was shown definitely that pneumococci of Types I and II are prac- tically never found except in the environment of per- sons ill of the disease or in the environment of carriers. It seems advisable, therefore, henceforth to regard every case of pneumonia as a focus for the spread of the infection, and the same measures should be insti- tuted as have been found efficacious in other communi- cable diseases. These include primarily (a) isolation of the patient as far as is possible and convenient, (b) collection of the sputum in special containers and its disinfection, and (c) sterilization and prevention of contamination from utensils, bedclothing; personal clothing, handkerchiefs, and other material in close contact with the patient. The physicians, orderlies or nurses in attendance on patients with pneumonia should practice the greatest care in order to avoid transmitting the disease to others. This involves the wearing of a clean gown when attending patients, the thorough cleansing of the hands by soap and water before and after attend- ing each patient, and, as has been suggested by Weaver, the wearing of a simple protective face mask when in attendance on patients. This not only pre- vents the physician or other attendant from becoming infected, but also prevents the patients from becoming infected through their attendants with secondary infec- tions with organisms which they do not already have. The room in which the pneumonia patient lies should be cleansed daily to avoid dissemination of dust, and after the patient's recovery it should be thoroughly aired, washed and sunned to dispose of any remaining organisms. Cases of the common contagious diseases, as measles and scarlet fever, in which secondary pneumonia occurs should be isolated and not allowed with uncom- 184 PNEUMONIA plicated cases. Those attending such cases may have the protection offered by gauze masks, as recommended by Weaver. In a recent editorial by Victor C. Vaughan on "Measles and Pneumonia in Our Camps," the principles involved in preventing the spread of pneumonia are clearly stated. He says : "Valuable as improvements in the determination of the types of the pneumococcus and the development of curative serums are, the prevention of infection and the limita- tion of its spread are far more important." CARRIERS Finally, a search should be made for pneumococcus carriers of the organisms of Types I and II especially, and these carriers should be instructed as to prevention of the spread of the organisms. They may also be pro- vided vi^ith a disinfecting mouth wash or gargle, and should use it persistently until the organisms have disappeared from the throat and the sputum. Kolmer and Steinfield refer to the studies of numer- ous observers who have shown the high pneumococ- cidal activity of ethylhydrocuprein hydrochlorid and of quinin preparations. They studied the possibility of disinfecting the sputum and the mouth with such preparations. The results indicated that 1 : 10,000 dilutions of ethylhydrocuprein hydrochlorid or quinin bisulphate, quinin hydrobromid, and other cinchonics in a 1 : 10 dilution of liquor thymoHs constitute mix- tures that may readily be used as mouth washes or gargles. Such a gargle may be used at least twice daily by those in contact with pneumonia cases, as well as by persons with pneumonia. Similar dilutions in Dobell's solution may be used for spraying the nose. For washing the mouth and gargling, a solution is conveniently prepared after the following formula: Gm. or C.c. IJ Ethylhydrocuprein hydrochlorid or quinin bisulphate O.OOS Liquor thymolis 5.0 Distilled water to make 50.00 Liquor tjiymcjlis, which is used in the Philadelphia Polyclinic Hospital as a substitute for liquor antisepticus, is prepared after the following formula: benzoic acid, 64 grains; boric acid, 128 grains; thymol and menthol, each, 16 grains; oil of eucalyptus, oil of wintergreen and oil monarda, each, 4 drops; alcohol and glycerin, each, 4 ounces; water sufficient for 16 ounces. VACCINATION AGAINST PNEUMONIA 185 PROPHYLACTIC VACCINATION Prophylactic vaccination against pneumonia with Ifilled organisms has been studied on a large scale by numerous observers. The results of these studies have been carefully analyzed by the workers in the Rocke- feller Institute. They . believe that the results of studies on animals indicate that the employment of • this method would result in a great saving of human life. Studies on the production of immunity in ani- mals suggest strongly that more efifective and rapid immunity may be produced by the frequent injection of small amounts of vaccine than by the infrequent injection of large amounts. Lister, who recently studied an epidemic in South Africa, concluded that "three subcutaneous inoculations, at seven days' inter- val, should be employed; each dose should consist of 6,000 million cocci of each . group against which - immunity is desired." He found that his own serum still contained agglutinins and opsonins against the types of organisms injected eight months after the last inoculation. TREATMENT 1. Rest. — The patient's rest should be as near per- fect as possible. Not only should the room be situated for the best possible fresh air, but it also should be as quiet as possible. Friends and relatives should not disturb the patient. Sleep and a quiet heart are more essential in pneumonia than in almost any other dis- ease. Perfect rest does not mean that the patient should not be turned frequently, or that he should not have at times several pillows. The point should be emphasized that the circulation in the lungs should be changed by alterations in position. A patient with pneumonia should not lie flat all the time. Hypostatic congestions readily occur with pneumonia, especially if the heart's action is impaired. It is most desirable that such patients receive hospital care and attention. If transfer to a hospital is to be made, the patient should not be allowed to stand, but should be moved with the least possible exertion to himself. It is questionable whether sufficient value attaches to baths to justify too frequent disturbance of the patient for their application. 186 PNEUMONIA 2. Fresh Air. — It has now long been demonstrated that a pneumonia patient has less fever, a slower pulse, a better blood pressure, and breathes less frequently in cool, clean air than in close house air, and this whatever the season. Wards on the roof are very valuable for hospitals in the treatment of pneumonia as well as tuberculosis. The balcony, veranda, or even tent treatment of pneumonia is advisable at certain seasons of the year with certain types of patients, when such facilities are obtainable. It is always essen- tial that the room of a pneumonia patient should have more than one window — the more the better — and that these windows should be open, except when the patient is being bathed or his clothing is being changed. Under no circumstances is it wise to have a draft of cool or damp air blowing directly over the patient's face, but screens can modify the direction of the wind or Isrisk air. Very young children and old persons should not be subjected to severe cold atmos- phere, while older children and strong adults may not only endure cold, but may even thrive in it. The fresh air or outside air treatment of pneumonia is subject to the modification of common sense. If a patient's body and extremities become cold or chilled when properly covered, the fresh air treatment is too severe. 3. Diet. — The food should represent something of all the elements required for nutrition. This means protein in the form of eggs, meat juices, properly made meat broths and milk. The eggs may be in any form desired, except fried. The milk should never be sufficient in amount to cause intestinal gas, or gastric indigestion. The next necessary element for nutrition is starch, and it should not be forgotten that many a seriously ill patient may die of acidemia from carbohydrate starvation. Egg albumin and milk do not represent the proper food for patients more than a few days. The starches can be presented in cereal gruels, rice, oatmeal, malted milk, toast, crackers, and even by potato soup. Ice cream, custard, chocolate, and a small amount of "sucrose or lactose are all of value. The patient should be allowed plenty of water, as, however valuable a deprivation of water may be in aborting an acute cold or acute bronchitis, it ' is not DIET IN PNEUMONIA 187 advisable to withhold water in pneumonia. Unless there are edemas from a failing heart or from kidney insufficiency, water will increase the amount of urine and therefore remove more products of waste metab- olism from the blood, thus tending to prevent the toxemia which is to be feared. Water promotes the secretion of the skin, which is desirable, and also renders the exudate in the lungs less tenacious and more easy of expectoration. Elements of nutrition which must not be forgotten are: sodium chlorid, iron when meat juices are not given, and lime when little milk is given, and especially if there is much blood in the expectoration. The sodium chlorid can be given by properly salting the patient's food, especially his gruels, and even at times his milk. The iron may be given as a saccharated oxid of iron, 3-grain tablet, crushed at the time of taking, or crushed by the patient's teeth, and administered twice a day. The lime may be given as lime water in tablespoonful doses in milk or in water, three or four times in twenty-four hours ; or it may be given in a capsule as calcium glycerophosphate, in 0.3 gm. doses. The whole question of the diet is also subject to common-sense modification to fit the patient. There are enough suggestions in the foregoing to fiirnish sufficient nutrition while meeting almost any patient's desires. The main object is (1) to avoid starving the patient on any element that he requires to promote metabolism and keep up nutrition, and (2) to avoid gastric and intestinal indigestion. If the tongue is heavily coated and the patient is so seriously ill that he does not digest properly, 5 drops of dilute hydro- chloric acid in water, directly after his protein meals, will aid the stomach digestion and often clean the tongue. It may also stimulate intestinal digestion. If there is much intestinal gas, the diet should be closely studied to ascertain which food is causing it. Pro- vided the blood pressure is not too high, the heart not too irritable, and the patient not too nervous and rest- less, coffee morning and noon, or coffee in the morn- ing and tea at noon, or tea both times if the patient prefers, is advisable ^and often beneficial. Tea and coffee should be considered, as representing caffein, and if the action of caffein is desirable, these beverages 188 PNEUMONIA may be given; They should not be given in the late afternoon or evening, as they tend to prevent sleep. 4. The Bowels. — ^The bowels should move daily. Constipation should be prevented, but a diarrheais not desirable. A cathartic may be given in the beginning of the disease, the one preferred by the physician. Later, his preferred laxative, whether a cascara mix- ture or some other combination, should be given. An occasional enema of glycerin and water, 1 ounce of each, will be found valuable. It will empty the colon and prevent the necessity of giving large doses of a laxative or a cathartic. Such treatment will aid in preventing tympanites. Diarrhea will weaken the patient and add one more element to cause weakness of the heart. If it occurs, the bowels should be cleaned out with a laxa- tive, castor oil if it can be taken, and then movements should be prevented by %o grain of morphin. Saline cathartics are likely to increase the amount of gas in the intestine, and hence are generally contraindicated. Bismuth is likely to remain too long in the bowels and promote the growth of germs and the absorption of toxins, which will add one more danger in the pneu- monia toxemia that is constantly feared. Phenyl sali- cylate (salol) in 0.25 gm. doses, in capsules, may be given, four or five times in twenty-four hours, for a few days, to stop excessive fermentation. 5. Abdominal Distention. — The routine use of a daily morning enema of soap suds has been suggested to prevent this complication. If abdominal distention occurs, milk should be temporarily eliminated from the diet. Compresses soaked in olive oil, 3 parts, mixed with turpentine, 1 part, may be applied. These should be covered with flannels wrung out in hot water, the heat being retained by covering with a thick pad. The hot flannels must of course be renewed frequently, as needed. These may be continued until relief occurs Following the application of the stupes, medicated enemas may be employed. The following has been suggested : Oxgall 4 gra. Oil of turpentine *. . . . 8 c.c. Asafetida 12 gm. Soap suds 2 pint? CARE OF SKIN AND MOUTH IN PNEUMONIA 189 This is followed in an hour by an ordinary soap suds enema. ' Frequently pituitary solution 1 : 10,000 in doses of 0.5 c.c. given hypodermically may be effective. 6. Care of the Skin and Mouth. — It is rare, with the proper diet, the proper treatment of the bowels, and with plenty of fresh air, that the temperature in pneu- monia is so high as to require sponging with cold water. Even when the temperature is very high, with a cerebral complication, tepid sponging in a warm room is as severe treatment as should be tried. Ordi- narily, then, sponging once or twice a day with hot- water is advisable, both for the comfort of the patient and to remove perspiration and keep the skin active. The temperature is more or less reduced by the warm sponging, the blood vessels of the surface are slightly dilated, the circulation is equalized, and the normal activities of the skin, which are essential, are increased. Also, warm sponging tends to relieve the tension of blood in the head, and many times aids in promoting sleep. If the patient's temperature is low, hot- water sponging is certainly advisable, and hot-water bags should be used around the extremities and even around the body. Such a condition is often seen in pneumonia in alcoholics. Profuse, cold, clammy perspiration should never be allowed to remain on the patient's, body. Warm alcohol sponging in such conditions is advisable, that is, sponging with pure alcohol. A dash of alcohol in a basin of water has no therapeutic or physiologic value, and represents nothing but a fad. Cleanliness of the mouth, teeth and tonsils is very important. The patient may have infected himself from his own tonsils or his own gums ; such possibili- ties should be remembered, as well as the necessity of keeping the mouth as clean as possible during the ill- ness. The sputum, being as likely to communicate disease as is that from tuberculous patients, or even more so, should receive the same antiseptic care as does that of tuberculosis. The patient's mouth, excretions from the nose, and the nurse's hands and contaminated clothing or gauze should be treated in the manner so well understood in tuberculosis. 190 PNEUMONIA VACCINE TREATMENT Vaccines during acute pneumonia are of doubtful utility and perhaps sometimes absolutely harmful. They have been tried so extensively under favorable circumstances with such uncertain or unfavorable results that there seems no good reason for continuing their use. SERUM TREATMENT As has' been stated, workers in the Rockefeller Insti- tute have prepared antipneumococciis serums. The serums against infection with Type I organisms appear to have produced especially good results, and to be highly effective in treatment of cases of pneumonia due to its type of organism. The serum of Type II is much less efficacious and, indeed, it has not yet been thor- oughly demonstrated whether it has any valuable effect on the outcome of the disease. The serum for Type III organisms has apparently but slight thera- peutic power, and has not been considered worthy of use in infections with this organism; the same is true of infections with Type IV pneumococcus. Commer- cial preparations of these serums are available and also polyvalent serums. These polyvalent antipneumo- coccus serums are of extremely doubtful value. It has been suggested that polyvalent serum be given until the type of the organism is determined, and that fol- lowing this, the specific serum for Type I or Type II may be utilized if the infection proves to be of that character. With pneumococci, at least as regards the first three types, the immunity reactions appear to be specific, and for this reason the workers in the Rocke- feller Institute do not advise the routine manufacture of polyvalent antipneumococcic serums. In fact, they suggest that for the present, the production of anti- pneumococcic serum should be confined to Type I. It has also been suggested that every pneumonia patient receive, immediately after admission to a hospital, a large dose of antipneumococcic serum of Type I, with the idea that the case may prove to be of that char- acter, and considerable time will be gained. While cases caused by other types of pneumococci than Type I are not benefitted by serum, it is quite likely that they may be harmed. The intravenous SERUM TREATMENT OF PNEUMONIA 191 injection of a hundred or more cubic centimeters of horse serum can hardly be devoid of harm and is certainly not to be used except when very decided benefit may be expected to follow its use. Hence the first thing is to determine the sort of bacterium caus- ing the pneumonia in the individual, and if it is a pneumococcus to determine the type to which it belongs. If it is a Type I pneumococcus, serum treat- ment may be undertaken. The value of the serum in the treatment of pneumonia is uncertain, but the results reported are sufficiently convincing to warrant its further trial under suitable conditions. It should be used only when correct diagnosis of the type of infecting organism has been determined. Under pres- ent conditions this can hardly be done, of course, out- side of a hospital or in a laboratory which has specially trained workers. The serum may then be used, except in very young children who appear but little intoxicated by the injection, or in adults mildly ill and already showing signs of decreasing fever and intoxication. Before administering the serum, patients should be questioned as to previous injections of immune serums for diphtheria, meningitis or for tetanus infections, and also concerning previous symptoms suggesting asthma, hay-fever, or special sensitivity to proteins, including those in serum. They suggest also the use of the intradermal skin test, injecting first 0.02 c.c. of sterile diluted horse serum, diluted with salt solution 1 : 10, with injection of a simple salt solution as a con- trol, to learn whether or not the patient is especially sensitive to the serum. If sensitivity is present, the injection of the serum produces a large urticarial wheal surrounded by an area of erythema. It becomes evident when one views critically the present status of the serum treatment of pneumonia,, that it can be properly carried out only in institutions where it is possible to make accurate bacteriologic diagnoses and differentiations of the types of pneu- mococcus, and where facilities for the intravenous administration of large amounts of horse serum with safety are at hand. Even at best a limited number of cases are suitable for treatment with immune serum, a large proportion of lobar and the very large 192 PNEUMONIA group of atypical and bronchopneumonias not being susceptible of attack by these measures. Technic. — The serum is injected into a convenient vein, usually at the bend of the elbow, the skin being previously cleaned with iodin and alcohol. If there are facilities for making blood cultures, blood may be first withdrawn for this purpose. The serum is injected into the vein with a syringe, or by the gravity method, the injection being done steadily and slowly, the injec- tion of the first 10 to 15 c.c. occupying from ten to fifteen minutes. During this time the patient is care- fully watched for symptoms of reaction, such as increased rapidity of the pulse, difficulty of respiration, cyanosis or urticaria. If no symptoms arise, the remainder of the injection may be completed in from ten to fifteen minutes. Dosage. — The amount of serum necessary will vary in individual cases. It is generally, believed that the initial dose should be large, perhaps from 90 to 100 c.c. of the standard serum." The specific serum treat- ment having been begun, it should be continued until a definite favorable result has been obtained, and the serum may be given every eight hours in doses of from 90 to 100 c.c, unless there are contrary indi- cations. The average total amount of serum required in cases in the hospital of the Rockefeller Institute was about 250 c.c. In many cases an elevation of temperature follows the injection of the serum within from twenty minutes to an hour, and this in turn is followed by a marked fall. If the temperature continues low and the patient's condition is good, no more serum is admin- istered. The temperature is taken every two hours, and if it rises within twenty-four hours to 102 F. or over, a second dose of serum is at once administered. If no fall of temperature occurs following the first dose, or if it does not fall to 102 F. within eight hours, a second dose of serum may be given. The same rule governs the administration of the third or subsequent doses. MEDICINAL TREATMENT We are past the stage when any dogmatic advice can be given in regard to the use of drugs in pneu- DRUGS IN PNEUMONIA . 193 monia. The physician who has charge of a pneumonia patient must decide whether a .drug is needed to com- bat a condition or symptom and which drug is the best for the object aimed at. The following are sug- gestions of drugs that have positive value for certain conditions, "and brief descriptions of the pharmacologic action expected of them: . Morphin or Codein. — If the pain is acute in the beginning of pneumonia, one of these sedatives should be given. Acute pain is depressant and should not be allowed. Strapping of the chest is inadvisable in pneu- monia. * An ice bag over the painful region of the chest does not abort pneumonia and is generally not desirable, and on account of the generally high fever at this time, hot-water bags are not advisable. • A cough that is frequent and unproductive, as it may be in the first stage of pneumonia, will be quieted and the pain alleviated by codein sulphate in doses of 0.01 gm. (Yq grain) every two, three or four hours as is necessary. Acetanilid and Antipyrin. — Acetanilid, Q.l gm. (2 grains) every three hours for four or five doses, or antipyrin, 0.5 gm. (7i/^ grains) every four hours for two or three doses, may be of advantage in lower- ing the high temperature in the first stage of this dis- ease. _ These drugs also will lower the blood pressure and quiet the heart. Such an action may be needed in the very acute first stage of pneumonia, provided the heart is normal. At this stage the lowering of the blood pressure produced by these drugs is often beneficial. Later in the disease, even if there is high temperature, such coal-tar products are contra- indicated. During the administration of the specific serum, drugs affecting the temperature should not be given, as this is the best guide to the value of the serum, necessity for repeated dosage, etc. Ammonium Chlorid. — If the expectoration is very adhesive and cohesive, scanty in amount and hard to raise, ammonium chlorid acts satisfactorily and is indi- cated. The dose should be 0.25 gm. every two hours, given in a sour mixture, or in lempnade ; and if there is much pain or if there is ineffective, frequent cough. 194 PNEUMONIA it may be combined with codein sulphate. Ammonium carbonate, with its irritant, nauseating action, has no tangible cardiac stimulant action; therefore it should not be used. Digitalis. — If the patient does not die of the acute onslaught of the germ by incombatable toxemia, or by exhaustion from a later general toxemia, or from a migration of the pneumococci to the meninges, his sur- vival or death depends on the ability of his heart to withstand the disease. Porter, Newburgh and others have stated, ^on the other hand, that the heart muscle is not vitally mjured in pneumonia. Respiration ordinarily fails before cir- culation. The heart in pneumonia may be influenced by digitalis in the same way as in normal persons, as shown by Cohn. The workers in the Rockefeller Insti- tute suggest the use of some form of digitalis as a routine in these cases. They use digipuratum, but any other standardized form available may be satisfactory. Its use should be commenced early so that the patient is partially digitalized when necessity arises. Patients are given 0.5 gm. a day by mouth, if seen early. If, on being seen later, they appear quite ill, 1 gm. may be" given. When digitalis effects appear, the drug is dis- continued as long as the patient's condition indicates that its use is not necessary. Strophanthin. — This drug, in recently made sterile ampules and injected directly into one of the veins in the elbow, provided digitalis has not been recently administered, is often efficient in tiding a patient over a shocked condition. It should rarely be repeated. Strychnin. — This is a drug that has been very much overused. Clinically, strychnin often does very good work and even seems to tide our patients over critical periods. In a sluggish, inefficiently contracting heart, when digitalis is contraindicated, strychnin may be of benefit. The rule for strychnin should be, when indi- cated as shown by this discussion, to give to an adult not more than %o grain, hypodermically, if deemed advisable, once in six hours, and such a dosage should not be long continued. As soon as there is improve- ment, it should be given by the mouth instead of hypodermically. DRUGS IN PNEUMONIA 195 Camphor. — Laboratory findings and some hospital reports have not shown that camphor is of value in heart failure. On the other hand, clinical experience at the bedside not infrequently shows that hypoder- mic or intramuscular injections of a sterile preparation of camphor and oil improves the pulse as to its regu- larity and volume, causes the surface of the body to be warmer, and often relieve a cardiac dyspnea by thus equalizing the circulation. When there is cardiac dyspnea, when the pulse is small, and especially when it is slow and weak and the surface of the body is cold, and when there is cold perspiration, that is, a partial collapse condition, camphor given hypodermi- cally every three or four hours may be of benefit. Caffein. — The administration of this drug as coffee- or tea has already been discussed under diet. Perhaps no drug, except epinephrin, the action of which is very fleeting, so frequently raises the blood pressure in serious conditions as does caffein. In emergencies it may be administered hypodermically, or it may be given by the mouth several times in twenty- four hours. It should not be forgotten that it is a cerebral stimu- lant and not a sleep producer. Its action on the heart is almost always for good, except in some few patients who show an idiosyncrasy to it, the heart becoming irritable from any form of caffein. Oxygen. — This has been used by inhalation, but observers have not agreed as to the effects. S. J. Meltzer (The Journal A. M. A., Oct. 6, 1917, p. 1150) has recently recommended its use by insufflation. Sufficient data is not at hand to admit of any opinions as to its value. Venesection. — In some cases, with the right heart, distended with blood, venesection gives great relief. Nitroglycerin.— "^htn pneumonia occurs in a full- blooded, sturdy man, especially if he is of the age when his blood pressure is a little high, small doses of nitroglycerin, as %oo to %oq grain, every four to six hours, tends to dilate the peripheral vessels and relieve the internal congestion. It also slows and quiets the circulation. By bringing more blood to the surface of the body, it also tends to promote loss of heat and a reduction of temperature. It will never weaken a 196 ERYSIPELAS heart as long as the blood pressure is high ; it should not be used if the blood pressure is low. Hypnotics. — It is hardly necessary to name the dif- ferent hypnotics. As stated above, in very weak con- ditions the only safe, hypnotic is morphin. In delirium and in insomnia it may be well to use some other hyp- notic than morphin. Almost any one of them causes some subsequent cardiac depression. The best hyp- notic is perhaps chloral, although there is prejudice against its use. Probably an eflfective dose of chloral is no more depressant to the heart than is an effective dose of any other hypnotic. Ethylhydrocuprein Hydrochlorid. — This drug, when first advanced, was reported to have a specific bacteri- cidal effect on pneumococci both in vitro and in vivo. Extensive studies have been made as to whether or not it has a curative effect in pneumonia. In general, no definitely beneficial effects have been observed, and, in fact, it has been found that its routine use internally may involve danger of the drug's producing injury to the eyes. Because of its proved effect on the organism, the use of the drug or of quinin, of which it is a deriv- ative, in mouth washes or gargles, seems justifiable. I CONCLUSION There is no specific cure for most cases of pneu- monia. The resources of the physician will be taxed and his judgment put to a severe test by many a case of this disease, but a successful outcome in many apparently hopeless cases will reward his efforts. As- stated at the outset, a restful, quiet room, a sen- sible, efficient nurse, a sufficient amount of fresh air, and a suitable diet and proper care of the bowels will prevent high temperature, heart failure, low blood pressure, insomnia, tympanites and toxemia in very many cases, and prevention is far better than the treat- ment of these serious conditions. ERYSIPELAS ETIOLOGY In the majority of cases of the facial type the point of entrance of the infection is through the nasal mucosa following a coryza. In others there may be TREATMENT OF ERYSIPELAS 197 abrasions of the scailp or face, and in many instances, the infection may begin in an operative wound. Leg ulcers and wounds are the usual origin of infection in the extremities. ONSET AND COURSE The attack usually begins with chills, general malaise, headache and a rise of temperature, which precede the appearance of the local lesion by from twelve to twenty-four hours. In many cases, however, the burning and redness of the skin are the first symp- toms noted. Typical facial erysipelas which starts at the bridge of the nose and spreads in butterfly pattern rather symmetrically over the cheeks, may remain thus limited, but in many cases it proceeds to involve the ears, the forehead, the scalp and the neck, down to but not beyond the collar-line, except in the small percentage of cases which are of the migratory type. "Erysipelas which starts on the face or trunk and spreads to the extremities," says Erdman (Jour. A. M. A., Dec. 6, 1914, p. 2048), "usually travels down both arms or legs with remarkable symmetry from day to day." DIAGNOSIS The diagnosis should be made from the character- istic skin appearance, the fever, bleb formation and desquamation. TREATMENT Internal medication should consist of such sedatives, stimulants or cathartics as the symptomatology may indicate. On the affected part, continuous cold compresses of boric acid solution may be of value. In migratory cases ichthyol may be applied or the areas may be painted with picric acid, solution. Rondet {Lyon Med., 1915, 124, No. 9) calls attention to his successful use for thirty years of a 1 .'40 solution of silver nitrate applied to the erysipelatous area every three hours, day and night, for seven days at least, never more than nine days. The skin is first cleansed with hot soapy water. The beneficial action is so pronounced in twelve or twenty-four hours that one is tempted 198 TYPHUS FEVER to suspend 'the treatment. But any cessation of the applications is followed by exacerbation of the ery- sipelas; to avoid surprises of this kind the treatment must be- kept up systematically for nine days. The fluid should be swabbed all over the area and for two fingerbreadths beyond. Erdman found vaccines of no value in shortening the disease, decreasing the mortality or preventing recurrence. TYPHUS FEVER The recent developments in our knowledge of the etiology and transmission of this disease have been largely due to American investigations. These ad- vances have resulted from the clinical observations of Brill and the experimental work of several scientists, notably Ricketts, Anderson and Goldberger. Typhus fever is doubtless of microbic origin, but the infective agent has not- yet been determined with certainty. Studies by Plotz indicate that it is a minute bacillus, and while these studies have been generally accepted some European observers (Nicolle) are still inclined to doubt that the organism he describes is the one which causes the typhus which they have observed. While the etiology of the disease has just been determined, its mode of transmission has been worked out so that we are able to take reasonably efficient means for its prevention. It has been well demonstrated that the disease is communicated by the body louse and probably also by the head louse. This observation explains many puzzling features, for example, as McCrae remarks, the decrease of the danger of infection when the patient was removed to a hospital and the great danger to attendants in epidemics, to which Murchison drew attention. The transmission of the disease to monkeys has enabled it to be made the subject of exact experi- mental work. Typhus fever formerly was very preva- lent in epidemics, and also as sporadic cases, being known under the names of jail fever, camp fever, ship fever, etc., terms which indicate its close associa- tion with overcrowding and filth. With the progress of sanitary science, the prevalence of the disease decreased until it appeared to have vanished with the march of civilization, especially in this country. PREVENTION OF TYPHUS 199 In the United States the disease, in its typical form, has been found usually in ships coming into our sea- ports. A mild form of the disease has been discovered even in our farthest inland cities. It is important that the existence of this mild form should be borne in mind not only as explaining many puzzling cases but also as the possible source of epidemics when the organism may assume unusual virulence or the oppor- tunity for transmission be unusually great. The epidemic form, according to Brill, usually begins rather suddenly with a chill or chilly sensations, though it may occasionally be preceded by two or three days of malaise and general body pains. Head- ache rapidly supervenes and fever immediately appears. These symptoms are quickly augmented, so that by the second or third day the fever may have reached its fastigium of 104 or 105 F. As the disease progresses it is marked by profound toxemia, signs of intense blood infection, marked involvement of the nervous system manifested by delirium, excite- ment and tremor, and somnolence, stupor, coma vigil, and an unusually severe involvement of the muscular system as well, with the tremor and physical exhaus- tion which were so often manifested. Epidemic typhus fever is a disease of the winter months and is highly communicable. The endemic or mild form of typhus fever and the epidemic typhus fever are alike in their onset, in the first stage of the eruption, in the critical decline and both are terminated, not followed, by relapses. In all other respects they differ. The eruption in the mild form (Brill's disease) rarely goes to the hemorrhagic stage; it is always an ery- thema. There is no profound involvement of the nervous system; there may be a slight delirium, but it is mild in type, appearing only at nighf. The patient is never, or rarely, stuporous, never seized by maniacal excitement, never goes into coma vigil, and has no muscular tremors, subsultus, or carphology. Involuntary discharge of urine and feces are not seen in the mild form of typhus fever. In the mild form the headache, instead of diminishing about the eighth day as in the epidemic form of the disease, becomes progressively more intense even up to the end of the s 200 MALARIA illness. The mortality of the mild form is less than 0.25 per cent. The prevention of the spread of this disease is a comparatively simple problem, although, as experience in the present war shows, it may be very difficult of accomplishment. It consists essentially in the destruc- tion of vermin. This involves, of course, at the same time the removal of filth, the cleaning of the inhabi- tants, and the prevention of accumulation of waste. The treatment should be symptomatic following the suggestions made for other infections. MALARIA Malaria, an infectious disease caused by the hem- ameba or Plasmodium malariae is a disease marked by chill, fever and sweating periods and by its response to quinin. While comparatively rare today in most parts of the United States it still takes large toll of the population in Italy, Russia and the tropics generally. ORGANISM The organisms are the tertian which requires 48 hours for development and causes a paroxysm on each third day; the quartan, developing in 72 hours and causing paroxysms on each fourth day; the estivo- autumnal, irregular in development and causing the severer types of the disease. The organisms may be sought for in fresh blood on a warm stage, but if such is not available it is possible to detect them in dried or fixed specimens using -Wright's, the Romanowsky or other common stains. PREVENTION The notable work of the United States Army and Public Health Services have shown that this disease may be completely eliminated in any community by the proper measures. It is carried by the female anopheles mosquito. These lay eggs in marshy places, and from these eggs the larvae develop in warm weather after two or three days. The larvae are air breathers and are therefore easily destroyed by plac- ing petroleum on the surface of the water. Better TREATMENT OF MALARIA 201 still is the draining of marshes and breeding places. At the same time human habitations should be screened and while the work of draining and preven- tion is under way prophylactic doses of quinin should be administered to those likely to be affected. TREATMENT The general treatment of the patient with malaria should be that given to equally severe symptoms in other infectious disease. It includes bed rest (con- tinued through the interval periods of apyrexia) ; care of the diet, the bowels, the skin, etc. During the chill the patient asks for warmth which should be given by the supplying of hot drinks in profusion, hot water bottles to the feet, warm cover- ings and similar measures. In the stage of fever the patient receives cool sponging, cool drinks, lighten- ing of the coverings on the bed, alcohol rubs and similar physical . and hydrotherapeutic measures. If there is headache it may be relieved by cold applica- tions to the head or if intense by administration of a small dose of morphin. When prespiration begins the patient may be kept dry. by rubbing with dry towels. Cooling drinks may be administered to aid in sustaining him. QUININ There are numerous methods of administering quinin to these patients and practically every physician who has treated these conditions extensively will describe special methods which he uses. Ochsner (Jour. A. M. A., March 17, 1917) describes a technic of quinin administration with which hundreds of patients were cured in a com- munity in which he visited. Some of them had been deemed almost incurable as they had not yielded to other methods. He mentions first twelve facts which are to be borne in mind during the treatment as guides to the physician: 1. Quinin will kill the adult Plas- modium malariae. 2. Quinin will not kill the Plas- modium in spore form. 3. Quinin will prevent spores from developing into adult forms. 4. Quinin, if given continuously, will consequently keep malaria spores in the body, which will later cause a recur- 202 MALARIA rence. 5. Quinin must be absorbed in order to be effective. 6. Quinin must be kept constantly in the circulation, at least for forty-eight hours, in order to kill all Plasmodia which belong to the one, two and three day type. 7. Quinin taken by mouth will not be entirely eliminated in three hours. 8. Quinin taken by mouth may all be eliminated in six hours. 9. It is consequently necessary to give quinin night and day at sufificiently short intervals to keep fresh quininjn the blood for at least forty-eight hours con- tinuously. 10. The alimentary canal must be in a con- dition suitable for the absorption of quinin. 11. Hot water in large quantity should be given with each dose of quinin in order to insure solution and absorp- tion. 12. The use of quinin should be completely interrupted for a sufficient interval after all adult Plasmodia have been killed to permit the spores to develop sufficiently to be killed by quinin, but not long enough to permit new spores to form; that is, the iiiterval should be less than seven days. He then gives the following rules for treatment based on these facts: 1. Give an exclusive diet of hot soup for ten days treatment. 2. On the evening of the first day give 2 ounces of castor oil in fruit juice or beer foam. 3. At 6 a. m. of the second day begin giving a 2 grain capsule of quinin (preferably bisulphate) with cover taken off, with one half pint of hot water, every two hours night and day for thirty doses, being absolutely sure not to miss a dose, in order to keep fresh quinin in the blood constantly. It is important to insist on waking the patient at night in order that the intervals shall not exceed two hours at any time. 4. The following six nights and five days give absolutely no quinin, but give a pill contain- ing 1/50 grain of arsenious acid, with one-half pint of hot water at 6, 9, 12, 3 and 6 o'clock. 5. Give castor oil as in Rule 2 on the evening of the fifth day. 6. At 6 a. m. following the sixth night, again begin to give 2 grains of quinin precisely as under Rule 3. 7. After that give general tonic and simple nourish- ing food. 8. Avoid reinfection by the use of screens and remaining away from locations where infected mosquitoes abound. LA GRIPPE 203 It may be mentioned that in severe cases, inasmuch as malaria is an infection of the blood, intravenous injection of the specific remedy may be the best method of administration. Jeanselme and Manaud (Presse med.. May 31, 1917) recommend for this purpose the dihydrochlorid of quinin which is soluble in less than its own weight of water and does not produce more than an opacity with blood serum in the test tube. A solution of the concentration of 1 : 100 may be used and the volume of liquid intro- duced about 100 c.c. This is introduced slowly and evenly by the gravity method. As quinin is anti- pyretic and as there may be marked idiosyncracy to it in some cases the intravenous method may be used only when it seems absolutely necessary and when previous inquiry has elicited the fact that there are no contraindications. LA GRIPPE The remarkably widespread acute epidemic types of this disease represent a different condition from the sporadic cases of a somewhat milder condition which are well termed grip, as distinct from an ordi- nary cold or bronchitis. Mathers {Jour. Infec. Dis., July, 1917) found that the prevailing organism in the small epidemic of 1915-1916 was the strep- tococcus viridans. The small blood-vessels all over the body seem to dilate and produce capillary conges- tion, especially of the mucus membranes, the most frequent result being coryza, a pharyngitis, a laryn- gitis or a tracheitis. The congestion in the larynx causes the harsh, dry, metallic cough which is. quite characteristic of this type of influenza. The conges- tion and swelling of the mucous membrane of the trachea causes a peculiar oppressed feeHng with more or less pain, referred to the upper part of the sternum. The great amount of sneezing which occurs with a typical attack, almost similar to hay-fever, is due to congestion of the mucous membrane of the nostrils. The conjunctivae may also be injected, caus- ing pain in the eyeballs and often a serious conjunc- tivitis, another typical symptom of influenza. In some seasons there seems to be a special tendency to middle- ear inflammations. At other times there frequently 204 LA GRIPPE occurs a congested drum, with sometimes a hemor- rhagic bleb or vesicle on the drum, a very painful though easily remedied condition. The almost constantly present lumbar backache at the onset of this disease is probably due to congestion of the kidneys, and albumin is frequently found in the urine of such patients, and occasionally blood cor- puscles. A menorrhagia or a metrorrhagia may occur from the same tendency to dilatation of the blood- vessels. There may even be nosebleed, and occasion- ally a slight hemoptysis without any other assignable cause and without any. subsequent development. With this disease, although the fever may be high, the skin is likely to be moist, and there may be a profuse per- spiration. The pulse may be slower than we normally expect from the height of the fever, and the blood- pressure is generally lowered; all of these conditions are due to the tendency of the blood-vessels to dilate. The heart is generally weak from start to finish in this disease, and even collapse turns can occur. Rather an infrequent type of the disease is the bowel type; this can occur without respiratory catar- rhal symptoms. Patients so afifected have diarrhea, with more or less intestinal irritation, apparently the greatest amount of dilatation of blood-vessels in these cases occurring in mucous membrane of the intestinal tract. These various types, the catarrhal, the nervous and the abdominal, may be interwoven, and a patient may show symptoms of all three. The future of every case of influenza is prostration, nervous and muscular debility, with more or less cir- culatory weakness ; in other words, there is exhaustion. The patient's resisting power is reduced, and any defect or diseased condition that he may have is aggra- vated by an intoxication with this germ. If no complications occur, the convalescent patient should rest as much as possible, should not be sub- jected to expoure and should be given tonics, and, if necessary to cause restful sleep, for a short period at least, some hypnotic or some physical method of caus- ing sleep. The most frequent complication is pneu- monia, and the type of pneumonia that the influenza germ seems to cause most frequently is the lobular or bronchial pneumonic type ; pneumonic congested areas PROPHYLAXIS AGAINST LA GRIPPE 205 may be found in different parts of one or both lungs. Not infrequently, however, true lobar pneumonia occurs. The next most frequent complication, as suggested above, is the middle-ear inflammation. The various sinuses in the region of the nostrils may become affected; all types of indigestion may occur, and not only sleeplessness and meningismus, but also a very serious meningitis, and even insanity can be caused by these germs and their toxins. Mental depression is a common occurrence, following severe attacks of grip. Pericarditis and endocarditis occur as complica- tions of influenza. It is thus seen that this disease should always be taken seriously, and every possible n;eans used to pre- vent contagion, as it is one of the most highly con- tagious diseases. It spreads with great rapidity, but only by contact, although it may doubtless be trans- rnitted by infected clothing, and perhaps even by let- ters, as when the last epidemic first reached Anierica, the first persons affected in many cities were post- office clerks. PROPHYLAXIS While no season is exempt from this disease, it occurs most frequently in cold weather, and in the colder climates, and in moist climates. Perhaps the more sunshine, the less frequent the disease. While one attack may protect a person for that season, he seems more susceptible to subsequent attacks in fol- lowing years. There are doubtless many carriers of this disease who may have a persistent and continued subacute or chronic catarrhal infection and very likely are distributors of the disease to others. When one case occurs in a household, other members of the family become readily infected. The same is_ true in schools and in stores or buildings in which an infected person is closely associated with others. Many an office with one employee affected will soon, on investi- gation, show every other employee to be more or less seriously affected. While almost all persons are sus- ceptible to this disease, a few seem to be immune. It is the most frequent of all definite infectious dis- eases. 206 LA GRIPPE TREATMENT It having been determined or suspected that a patient has influenza, it is much more important^ that he remain in bed, or at least in the house, than if he has an ordinary acute cold. Also, it is more essential that he be more or less isolated or that measures be taken that he does not spread the disease by spraying from coughing or sneezing,- and that he does not use the same towels, napkins, drinking-cups and eating utensils as other members of his family. The patient should be prohibited from fondling and kissing chil- dren. If the patient is a young child in close contact with the mother or nurse, all possible precautions to prevent contagion should be taken. In a word, each family should be taught that grip is an infection, that it is contagious, that it spreads rapidly, that it may have serious complications and that it frequently leads to pneumonia, which has become in many regions of this country the most fre- quent .cause of death. Therefore, even an apparently mild case of grip or influenza should be treated actively and energetically. As previously stated, whether a schoolchild begins with an acute cold or an influenza, he should be sent home and remain there until he is well, or at least almost well. As a grip patient is liable to have a chill, or at least feel chilly or have cold sensations up and down the back, anything that makes him warm improves his condition. He may be given hot malted milk, hot tea or hot lemonade, at more or less frequent intervals, until his chilliness has ceased. The patient may be given a hot tub bath and then put into a warm bed in a warm room as an efficient means of making him comfortable and relieving his internal congestions. Hot water bags at the feet and extra coverings to the bed are often needed. A quickly acting stimulant is aromatic spirits of ammonia, given in half teaspoon- ful doses in hot water or hot lemonade, at intervals of three hours, for three or four times. The various methods suggested for aborting an acute cold may be used in this disease. Much greater care must be exer- cised, however, if the patient has the influenza infec- tion than if he has a simple cold, as to when he can TREATMENT OF LA GRIPPE 207 return to his work or occupation, or be subjected to exposure to cold or dust, either in a house, building or outdoors. As soon as the patient feels warm, the temperature may rise quite high, associated with severe headache, backache and irregular pains in other parts of the body. At this time a drug such as acetanilid, antipyrin, acetphenetidinum, or acetylsalicylic acid will be of benefit, provided that the patient is not ambulatory, and that he is not to be subjected to exposure. With this depressing infection such treatment is not wise unless a patient is in bed, or at least remains in the house. The proper dosage of these drugs has already been suggested, and no one of them should be long con- tinued. The most depressant is undoubtedly acet- anilid, and perhaps the least depressant is acetphen- etidinum. Should depression occur after one of these drugs has been administered or from the disease, cir- culatory stimulants such as aromatic ammonia, cam- phor or caffein should be given and the patient sur- rounded with dry heat. A hypodermic injection of •strychnin sulphate, 1/30 grain, may be given to stimu- late the nerve centers. Cyanosis has not infrequently been caused by acetanilid, but an amount of this drug large enough to cause such a condition should never be given. The following prescription may be suggested: Gill. IJ Acetanilid! OISO gr.viiss Sodii bicarbonatis 1 1 gr. xv M. et fac chartulas 10. Sig. : One powder, with water, every two hours, except when the patient is sleeping. Gm. IJ, Acetphenetidini 1|S0 Phenylis salicylatis llSO aa gr. xxv M. et fac chartulas 5. Sig. : One powder every three hours. A combination of aspirin, camphor and Dover's powder will sometimes be found of value: Gm. or C.c. IJ Ac. acetyl, salicylic 6 Pulv. camphorae ._. 1 Pulv. ipecac et opii 4 M. et fac chartulas 20. Sig. : One powder every three hours. 3 iss gr.x 3i 208 LA GRIPPE Where there is much irritation of the throat, gargles of salt solution and mild alkaline solutions are advised. Thus a mixture of hydrogen peroxid, alcohol and glycerin may be prescribed in ^fce ' following combina- tion: Gm. or C.c. IJ Aquae hydrogenii dioxidi ... . Alcoholis Glycerini Aquae cinnamotni aa SO 3 ii M. Sig. : Use as gargle diluted with four or more parts of water. When there is pain or headache suggesting involve- ment of the nasal sinuses, sprays containing epinephrin 1 : 10,000 will often give relief by allowing the escape of retained secretions. It should be remembered, as previously noted, that it has been shown that an alkali like sodium bicarbo- nate may inhibit the undesired action of coal-tar drugs on the heart ; also, that caffein does not protect a heart from undesirable activities of the coal-tar drugs; in fact, it has been shown to intensify such activity. In making a diagnosis of the infection present it is well to remember that some of these drugs, and salicylic acid in any form, may cause eruptions on the skin, either erythematous or urticarial. But Jittle food is needed during the first twenty- four hours of grip, and it should not be pushed even on the second day, if food is repugnant to the patient. He should have plenty of water and such simple liquid ■ nourishment as he desires. As soon as the appetite returns, food should be pushed. The various catarrhal conditions should be treated as suggested under coryza, pharyngitis and bronchitis. Also, while the patient is kept warm, he should have good fresh air in his room. This is essential with all infections, and especially with infections of the nose, throat and lungs. The bowels should be treated as indications call for. Simple laxatives may be given, if needed, or the sooth- ing bismuth subcarbonate, if there is intestinal inflam- mation. Phenyl salicylate (salol) may be given, if there is much fermentation in the bowels, or the Bulgarian form of lactic acid bacilli may be given for a few days. ETIOLOGY OF TUBERCULOSIS 209 As soon as the patient begins to convalesce, he should be given_ tonics and if there is no inflammation in the ears, quinin is valuable. Some form of iron should generally be given, and possibly a bitter tonic before meals. If the patient is .not nervous, a small dose of strychnin three times a day is good treatment. On the other hand, it should be urged that strychnin stimulation is overdone, and a patient who cannot sleep should not be given strychnin or quinin later than the noon meal. Sometimes the sleeplessness following influenza is benefited by the administration of one-half to one teaspoonful of good fluidextract of ergot, taken an hour before bedtime. These patients should never be allowed tea or coffee after the noon meal, as they are very susceptible to cerebral stimulation by caffein and are likely to remain awake for hours from such stimulation. All disturbances or diseased conditions left over by grip must be treated energetically, else they tend to be prolonged. There are few germs that seem to be so tenacious and persistent, at least in their unpleasant results, as is the influenza bacillus. All persons are susceptible to serious consequences from influenza. , TUBERCULOSIS Under the general title of tuberculosis are included the various pulmonary forms, abdominal forms, tuber- culosis of the bones, glands and other organs of the body. This is a disease of civilization and hence due to the congregation and crowding of mankind into small regions, as cities. Thousands of persons suffer- ing from pulmonary tuberculosis are walking, our streets and expectorating billions of tubercle bacilli daily. ETIOLOGY The discovery of the tubercle bacillus by Robert Koch, in 1882, and the proof that this bacillus was the cause of tuberculosis, changed the established belief that tuberculosis was hereditary to the belief that it must always be acquired. This is of course a most constant fact, but the part that heredity plays in the development of tuberculosis, in furnishing proper ground in which the bacillus may grow, or in oflfering 210 TUBERCULOSIS a condition of low-grade immunity against this disease, is progressively becoming more prominent. A human fetus can be born with tuberculosis,"but comparatively few such cases have been recorded. If one were roughly to estimate the number of such authentic in- stances it might not be far from one hundred, and in most of these the mother was the tuberculous parent. Tubercle bacilli have rarely been found in the milk of an infected mother. Therefore, direct infection from this source is improbable. It is possible, how- ever, that toxins from the tubercle bacillus or from a secondary infection of the mother may be eliminated in the milk and cause, in the child, gastro-intestinal disturbance, fever and emaciation. It is improbable that the milk could furnish any substance that would render the child immune to tuberculosis. The thera- peutic conclusion is positive that a tuberculous mother should not nurse her child, not only for the child's sake, but also for her own, as the mother rapidly grows worse through the nutritional loss caused in producing the milk. Statistics show that the person who is underweight and has a family history of tuberculosis is more likely to develop the disease than one who is underweight without a family history of tuberculosis. On the other hand, a person of full weight or overweight, whatever the family history, while not precluded from the possi- bility of developing tuberculosis, is much less likely to have it than one who is underweight. Also, one who is underweight is more likely to develop tuberculosis than a person of normal weight. Whether or not, the majority of underweight persons harbor tuberculosis germs and such a condition predisposes to underweight has not been demonstrated, but it is quite possible. As is apparently true of most germ diseases, a race that has but recently acquired the disease is more sus- ceptible to its inroads, and has the disease more actively than a race that has long suffered from it. Also, a change from outdoor life and a dry, clean air environment to indoor or to city life, or to a region where the air is damp or dust laden, predisposes to the development of tuberculosis. These bacilli almost invariably gain entrance to the system by one of two ways: by inhalation, as occurs ETIOLOGY OF TUBERCULOSIS 211 in the majority of cases, or by swallowing. A germ that is so constantly present in almost every com- munity of civilized peoples must be breathed and swallowed by most persons. Something in the in- dividual must tend to kill these germs before they acquire a home, that is, before they congregate in suf- ficient numbers to perpetuate themselves. Nothing probably tends more to prevent the acquirement of this disease than general good health, which especially means health of the upper-air-passages and throat, the absence of bronchial catarrh, healthy tonsils, a normal digestion and healthy intestines. The evidence that the tonsils may be a portal of entry Ravenel believes is very conclusive. The tubercle bacillus probably cannot find a living chance unless there is some dis- ease, injury or chronic disturbance in one of the parts of the body mentioned, and unless-a sufficiently large number of them are inhaled or swallowed at once, so as almost to overwhelm the person's ability to destroy the germ. Of course, it is possible and perhaps prob- able that, although this disease gives no immunity, a patient in whom the disease has been arrested or in whom the disease once active is now chronic or more or less latent, may produce, or have already circulating in the body-fluids, enzymes that may destroy the tubercle bacillus more readily than is possible in one who has never had the disease. Perhaps many conditions that we have termed causes predisposing to tuberculosis may really stim- ulate to activity latent tuberculosis or a tuberculous focus harbored and concealed somewhere in the patient's body. Whichever of these two suppositions may be correct, we recognize that a patient is likely to acquire, or having acquired, at least may develop an active tuberculous process when he is anemic; when he is under weight; when he is continuously overfa- tigued; when he has a tendency to recurrent colds, especially to recurrent bronchitis; when he does not quickly recuperate from any simple acute infection, whether it be grip, measles or whooping-cough, etc., or when he has suffered from a -more serious acute infection, such as some prolonged septic process or 212 TUBERCULOSIS typhoid fever, and especially when he does not recover quickly from a pneumonia or a pleurisy with effusion. Pleuritic effusions are considered as perhaps generally tuberculous in origin. None of the surrounding pre- disposing causes, such as unsatisfactory housing and occupations that are dangerously dusty, need to be con- sidered here. A child is considered predisposed to the development of tuberculosis, or perhaps already has a latent tuber- culosis, if he is pale; has a tendency to eczemas, or has enlarged tonsils or postnasal adenoids, and especially if he has enlarged cervical glands. Caries of the teeth is also perhaps a predisposing cause, as decayed teeth may harbor all kinds of germs. Therefore to allow caries of a child's first teeth to persist, because they will soon be lost with the eruption of the second teeth, constitutes serious neglect.- An enlarged cervical gland probably always shows that an infection entering through the tonsil has invaded the next fortress of protection, namely, the cervical glands. If the infection is tuberculosis, the gland may be actively tuberculous, and evident tuberculous adenitis is the condition. Much more frequent and not evident, but often found by good roentgenograms of the chests of children, is the involvement of the bronchial glands by the tuberculous germ having perhaps first gained entrance through the tonsils, and this without any involvement of the cervical glands. In fact, it has been repeatedly demonstrated that perhaps the major- ity of children affected with tuberculosis, have the initial lesion in the tracheobronchial and hilus glands. The bovine tuberculosis is frequently transmitted to children through milk by way of the intestine has for some years been thoroughly established, and it has been shown that many instances of glandular tuber- culosis are due to this type of bacillus. General tuber- culosis rarely, but udder tuberculosis almost always, infects milk with tubercle bacilli. The frequency with which bovine-tuberculosis-infected milk causes tuber- culosis in children is still more or less a subject of dispute. Many experiments have shown that the gas- tric juice does not necessarily, if ever, kill the tubercle bacillus. PREVENTION OF TUBERCULOSIS 213 MEASURES THAT WILL CAUSE A DECREASE IN THE INCIDENCE OF THIS DISEASE These may be enumerated as, primarily: 1. General instruction in hygiene and iri the con- ditions that predispose to this disease. 2. Tenement-house laws to prevent overcrowding. ,3. Sunlight. '4. Open windows, verandas and roof-gardens. 5. Municipal breathing-spaces; parks, playgrounds, etc. 6. Proper ventilation of all churches, theaters, halls, and assembly rooms. 7. Open-air schools, or open-window schools. 8. Laws prohibiting spitting on the streets and in buildings. 9. Better factory sanitation; better methods of cleaning public buildings and public conveyances. 10. Special laws against the dissemination of dust in factories, foundries and all occupations in which it may be inhaled. 11. Better hygiene and improved buildings for all general hospitals, prisons and jails. 12. Better laws for the more scientific control of tuberculous cattle, and compulsory cleaning and im- proving of cow-bams and farms used for producing public milk-supplies. 13. Certification or pasteurizitag of all milk used for infant-feeding. Personal preventive measures are: 1. Compulsory report of every case of tuberculosis. 2. Careful instruction of the family in the care of the tuberculous person, if he is to remain at home. 3. Careful personal instruction of the patient, if he is at an age to receive it, as to the possible methods of communicating the disease to others. 4. Sanatoriums for incipient cases of pulmonary tuberculosis. 5. Isolation hospitals for advanced tuberculosis patients whose home surroundings are inadequate. 6. Skilled dispensary care of ambulatory cases and visiting nurses for "follow-up" work. 7. Sanatoriums or rest-hospitals for joint and bone tuberculosis; these are of special value when located 214 TUBERCULOSIS at the seaside. (The value in glandular tuberculosis of seaside sanatorium or veranda rest-cures should also be recognized.) 8. Careful instruction to reduce the morbid fear of other members of the family, and for the mental com- fort and happiness of the patient. This should be given, both by the board of health and by the attending physician, to the effect that the disease is not contagi- ous, and that if the instructions urged are properly carried out the probability of acquiring the disease from the patient is practically nil. 9. It has long been known that pregnancy in a tuber- culous woman is a dangerous complication. Though she may appear to have better health during the pregnancy a fatal issue may follow rapidly after par- turition. Knopf and many others who have recently considered this subject believe that there should be a maternity sanatorium or special wards^ in existing sanatdriums where prolonged antituberculous treat- ment . may be given to the tuberculous women who wish to, bear children. PRETUBEECULOUS SYMPTOMS The earlier we recognize the signs of probable or even possible tuberculosis, the better, as prevention is far easier than cure, though a cure is probable all through the first and second stages, and possible even in the third stage of the disease. The conditions which predispose to this disease have already been enumerated. Besides correcting these conditions, we should use every means to build up the general system by tonics, outdoor life, change of clim- ate, and by proper tepid or cold water sponging in the morning which causes the skin so to react that colds are not readily acquired. At a very early stage there may be no lung signs, and it may be impossible to determine whether or not the bronchial lymph-nodes are enlarged or diseased. There are loss of weight, more or less gastric disturb- ance, pallor, lassitude and vasomotor disturbances shown by cold hands and feet; or the latter may be intermittently very hot and dry. There is generally a history of progressive loss of weight, irregular chest TUBERCULOUS SYMPTOMS 215 pains, shallow breathing, dry cough, especially on deep inspiration, and, most important symptom of all, an afternoon or evening rise of temperature, not explain- able by any tangible cause (although it must not be forgotten that occasionally such & temperature can be of nervous origin). Gastric indigestion, with loss of appetite, is often an early symptom of pulmonary tuberculosis. An anal fistula is generally secondary, and is not often primary to the lung lesion, and the discharge from it may contain tubercle bacilli, as well as staphylococci and streptococci. There may be some other chronic suppuration present, as a" middle-ear catarrh. While anemia is generally an early symptom, in the early stages there may be aji increase in the number of the red-blood corpuscles. Amenorrhea, even without anemia, in girls and women is generally an early symptom; but women can complete one, or even two pregnancies while tuberculous. While we are studying every symptom, and the lung symptoms are so few, to ascertain whether the patient really is tuberculous, a personal history of much sickness, especially colds, enlarged glands, ghronic joint and tendon swellings or recurrent diarrheas, even if there has been no actual pulmonary consumption in the immediate family, renders the tendency, and hence probability of tuberculous infec- tion, much greater. In making the physical examination it should be remembered that it has long been decided that the flat, broad chest, contrary to previous belief, is less likely to be tuberculous than the rounded, barrel-shaped chest. Also, the chest circumference in the nipple line should measure anatomically half the height of the person. The expansion, unless the patient is abdominally obese, should be from 3 to 5 inches; 2 inches is too small an expansion for a young adult. The in- spection of the chest may show a lagging of one side during expansion, which may, however, be most notice- able with the finger-tips placed under the clavicles. This sign is very suggestive. The typical impaired percussion-note, imperfect breeziness of the inspir- atory murmur, lessened depth, slight jerky inspiration, slightly prolonged expiration, slightly increased vocal 216 TUBERCULOSIS resonance and localized rales, either dry or moist, with increased muscle resistance over a diseased area, with pleuritic pains in the upper part of the chest or be- tween the shoulder-blades, are all too well understood to require elaboration. Very suggestive is the axillary, dripping perspiration during examination. Also sug- gestive is the little dry cough during the required in- creased inspiratory eilfort. This dry cough, hardly noticed by the patient, has probably been observed for weeks, if not longer, by the patient's family. A study of the temperature of the suspected person is important; the temperature should be taken every three hours during the day for several days, or at least at 8 o'clock in the morning, at 4 in the afternoon, and at 8 in the evenirig, if not more frequently. A recur- rent rise of temperature in the afternoon or evening, without any assignable cause, is almost pathognomonic of a latent tuberculosis becoming active. Some patients who show no temperature at rest will have quite a rise of temperature on the least exercise. Temperatures taken under the tongue are not so accurate as when properly taken in the axilla. Many a patient whose temperature is normal by the mouth will be found to have a higher temperature in the axilla. Of course", the most accurate is the rectal temperature, but this is rarely necessary for the diagnosis. An increased pulse-rate, over a. hundred, with or without rise of temperature, is very suggestive, and if the pulse-rate is higher than the temperature would call for, the like- lihood of tuberculosis is increased. A slight hemorrhage of arterial blood always causes the laity to suspect phthisis, and the suspicion is quite generally correct. Hemorrhages can occur from the blood-vessels of the throat and larynx, although they are generally very small in amount, and most fre- quently venous, and many a patient has been con- demned to treatment for tuberculosis on account of a perfectly simple throat 'hemorrhage. The occurrence of typical night sweats, that is, cold sweats toward morning, is a frequent and suggestive symptom of tuberculosis; but patients who have been weakened by illness, overwork, or overexertion may have this symptom for a short time, although it should always create suspicion. TUBERCULOUS SYMPTOMS 217 A rarely noted symptom of tuberculosis, which may occur early in the disease or not until later, is atrophy of the mammary gland on the afifected side; also, the hand and foot may be colder on the side affected, or if they are hot and dry, may be warmer than on the other side of the body. Conjunctivitis, blepharitis and an inequality of pupils, with dilatation of the pupil on the same side as the affected lung, have been noted. The skin of the tuberculous- patient is often dry, and may be rough and sallow ; there may be increased pig- mentation, especially around the nipple on the diseased side, and there may be chloasmic spots. Bright red spots on the cheeks, and the glistening eyes occurring in the late afternoon, with the hands dry and hot, are almost pathognomonic. At other times of the day there is pallor, with the veins prominent all over the body; the face looks sad, and there is languor and a rapid, collapsing pulse. These are all signs that may occur at an early period. Before deciding that the sputum of a suspected patient, or a patient who has incipient tuberculosis, is free from tubercle bacilli, several examinations must be made. The sputum may be found free from bacilli on several days, and then on the last day of the exam- ination found to be loaded with them. The number of bacilli found has no great bearing on the prognosis of the disease. On the other hand, if large numbers of tubercle bacilli continue to be present after consider- able periods, probably cavitation is either present or developing. The prognosis can hardly be made from the character or appearance of the tubercle bacilli, although it has been thought that large numbers of the smaller tubercle bacilli show greater activity of the disease. A fluoroscopic examination of the chest will often reveal, even before clouding of any portion of the lung occurs, a diminished excursion of the diaphragm on the affected side. This is very suggestive of tubercu- losis. Roentgenograms may show areas of beginning lung trouble as well as diseased bronchial glands. Be- sides the skin tuberculin tests, the conjunctival test and the interdermal test, all of which are more or less reliable, a positive diagnosis can generally be made by injecting the original tuberculin subcutaneously. 218 TUBERCULOSIS A number of substances can produce a reaction in tuberculous patients similar to that from tuberculin. Nucleoproteins, cinnamic acid and some alkaloids can do this. The tuberculin used in making the test for tubercu- losis is a purified extract prepared from tubercle bacilli. The details of its preparation need not be described here. Its. injection causes a leukocytosis and stimulates the production of ferments, especially in the cells and tissues immediately surrounding the tubercles. These ferments then act on the poisons that have been produced by the tubercle bacilli and have acctunulated in the tubercles. The fever reaction is due to the toxins set free from the tubercles and to the action of the enzymes on these toxins. If some form of tuberculin is used for cur- ative purposes, the reactions will become less and less, as more of these sealed-in toxins are set free. Also, reaction may be less as the system becomes less sensi- tive and hence immune to the irritation of these toxins. It can readily be seen that if too large doses of tuber- culin are administered either as a diagnostic test or as a curative treatment, such a large amount of these toxins might be liberated as to cause an intense fever reaction, to the disadvantage of the patient. Also, it is quite possible by such treatment to liberate live tubercle bacilli and cause general infection. Hence the greatest possible care should be exercised in using tuberculin, either as a test or as a treatment, and the first doses should be of minimum amounts. As tubercle bacilli are not readily killed by leuko- cytes, the latter surround the mass of bacilli and disin- tegrating and caseous material ; the resulting lesion is called a tubercle. The fight, then, of enzymes and toxins goes on between the two opposing factions. Some of the leukocytes and some of the bacteria die, with the production of toxins and enzymes. If these are liberated by the local inflammatory process the fever reaction and the other concomitant symptoms occur in the person if sufficient amount of the toxin circulates in the blood. Every tubercle that breaks down and is evacuated into the bronchial tubes and expectorated, is a step toward recovery. This satis- factory process, however, cannot go on without a TUBERCULOUS SYMPTOMS 219 general disturbance of the patient, with loss of appe- tite, loss of weight and emaciation, and it becomes a question whether the person can stand the disease until the tubercles are evacuated, and whether or not such evacuation will produce cavitation. The object of a tuberculin treatment is to aid the patient slowly to eliminate his tubercles when the disease in him has come to a standstill, and he shows no tendency to re- covery, even if he is not growing worse. The theo- retical object, then, aimed at by treatment is the elimination by the patient jof most of the tubercles, or the permanent encapsulation of those not eliminated by such fibrous and calcareous material as will cause them to be forever outside of the body, as far as any relationship to the blood and lymphatic circulation is concerned. On the other hand, if too many tubercles are broken down at once, too persistently or too continuously, the prognosis is bad, and tuberculin is ordinarily not indicated. Our conclusions as to the subcutaneous tuberculin test may be as follows: 1. It is a reliable test, and is pathognomonic in children and young adults. In older adults, if the test is positive, it may be relied on as showing a tuberculous focus- somewhere, but if the test is negative it is not so reliable as in children. 2. It should not be used carelessly, though perfectly safe if the beginning dose is small. 3. The tuberculin test is unnecessary when a localized pulmonary lesion has been discovered by. physical examination. 4. When we recognize that a patient is tuberculous or is liable to become so, although we find no physical lesions, the tuberculin test is unnecessary, as our preventive treatment should be the same whether reaction is posi- tive or negative. 5. In doubtful bone, tendon or joint inflammations, or when for any reason a decision must positively be made, the tuberculin test should be used- Although a reaction from tuberculin has occurred in cases of carcinoma, syphilis and actinomycosis, still, these instances are so rare that there is the probability that such patients had a latent tuberculosis, and hence the test may be considered positive. In advanced cases of tuberculosis, however, the test may be negative on account of a tolerance to the toxins already described. 220 TUBERCULOSIS The beginning dose of "old tuberculin" for diagnos- tic injection is 0.1 mg., the second dose should be 1 mg., the third may be 3 mg. and the fourth 5 or 6 mg. Of course, a reaction occurring with any dilution would prevent the necessity or advisability of giving another injection. A suspected patient not, reacting to 5 or 6 mg. should be considered free from tuberculosis. If a physician desires, he may receive direct from the serum and bacterin firms the "old tuberculin" properly diluted for the diagnostic test. Tuberculin triturates and, tuberculin vaccines have been administered by the rnouth as a possible treatment of tuberculosis, but such administration is as yet purely experimental. The tuberculin injection test should be used only with a patient who is at rest and does not have a morn- ing rise of temperature as shown by a series of ob- servations. The injection should be given at about 9 p. m., and if there is a rise of temperature in the early morning, it should be considered a positive reaction, and- if there is pain-, swelling or heiat discovered at an external suspected area, as a joint, or if there is con- gestion or moist rales are discovered in a suspected area of lung-tissue there is a "focal reaction." If there is a marked reaction at the region of the injec- tion (the "local reaction"), even if there is no general reaction, the patient probably has tuberculosis, and it may often be unnecessary to continue the injection of higher dilutions. The "intradermal" tuberculin test for the diagnosis of latent or concealed tuberculosis (first described by Mantoux and Hutinel, Bull, de I' Acad, de mM., Paris, Oct. 27, 1908), has been recently revived and recom- mended by Jeanneret. (Rev. MM. de la Suisse ro- mande, 1913, No. 5, p. 3/3). The advantage of this test over the von Pirquet and the Moro skin tests is that a known amount of tuberculin is injected between the layers of the skin. The reaction is a local one, and there is no general disturbance like that occurring with the subcutaneous tuberculin test. Another diagnostic test is the determination of the presence of albumin, and its amount, in sputum. Al- bumin is generally present in all sputa of tuberculous origin, and it has been said that persistent absence of GENERAL MEDICATION IN TUBERCULOSIS 221 albumin from sputum shows that its source is non- tuberculous. Albumin is also present in sputum of bronchitis, pneumonia and other conditions, so that it probably is of slight diagnostic import. GENERAL MEDICATION IN THE TREATMENT OF TUBERCULOSIS In the first place, drugs, as such cannot cure, and are not antidotes to this disease. On the other hand, much can be done, with proper medication, to aid the physiologic process. Ccdcktm.—^t has long been thought that patients suffering from tuberculosis have previously become demineralized. This means especially that they have lost their calcium, and perhaps phosphorus, equilib- rium. It is also true that tuberculous lesions heal by more or less calcification. Also, patients are more likely to have hemorrhages, if their calcium blood- content is diminished. Certain it is that patients, especially children, often improve with increased amounts of calcium in their food or as a medicament. One of the great values of a proper amount of milk for tuberculous patients is probably the calcium and phosphate content. On the other hand, many patients improve by the administration of a calcium salt. Galliot (Arch, de med. d. enf., 1913, 16, 289) ad- vises the following combination for children who are suffering from tuberculosis: calcium carbonate and calcium phosphate, -each from 20 to 30 eg. (from 3 to 5 grains) ; magnesium chlorid from 10 to 20 eg. (from 1^ to 3 grains) ; magnesium oxid from 5 to 10 eg. .(from about % to U/^ grains). This he administers two or three times a day. Creosote. — Creosote has been long recommended and much used, and its action in tuberculosis has been lauded by able medical men. There is a great difference of opinion among clin- icians as to the value of creosote in pulmonary tuber- culosis. Many physicians never use it in this disease, and others push it to such an extent that the patient is practically saturated with it, and his room and almost the whole house reeks with the odor of creosote. It 222 TUBERCULOSIS seems to be true that many patients have improved appetite under its stimulant or irritant action in the stomach. It may also, for a time, improve digestion, and the patient often adds weight. During this period there is frequently a lessening of the bronchitis, and therefore a decreased expectoration, and with this decrease of the secondary (streptococcic) infection, there is likely to be less fever and therefore less sweat- ing. It is so rare, however, for a patient to take creo- sote and not adopt the rest cure and other measures that go toward improving his condition, that it is not fair to attribute such iniprovement to the creosote. Creosote is also more or less of an intestinal antisep- tic, and hence bacteria-laden sputum that may be inad- vertently swallowed may be rendered harmless in the upper part of the intestine. Be that as it may, it is a fact that good bowel activity, an improvement in the intestinal digestion, and the prevention of fermentation or putrefaction in the intestine, by' many so-called bowel antiseptics, will all cause an improvement in the tuberculous patient. Unfortunately, as frequent aftermaths of the good action of creosote the pancreas becomes oyerst^mu-. lated by the drug and does not furnish its secretion properly; there is intestinal indigestion; the liver is disturbed; there are stomach indigestion and loss of appetite, and the patient will lose weight faster than he gained it under the creosote treatment. Too much creosote will also irritate the kidneys, and may cause albuminuria. In other words, it generally does not seem wise to recommend creosote, as such, internally in pulmonary tuberculosis. As an ingredient of an inhalant mixture it may be of value, as a positive anti- septic to the upper air-passages and the trachea and large bronchial tub'es. If there is fetid, purulent ex- pectoration such inhalations may be of advantage. Guaiacol frequently in the form of a benzoate of guaiacol has been used for tuberculosis, but guaiacol has no advantage over creosote in the treatment of tuberculosis. The exponents of the creosote treatment believe that the drug should be begun in small doses and gradually increased to the point of the patient's tolerance. Tolerance means that the appetite is not GENERAL MEDICATION IN TUBERCULOSIS 223 interfered with, that there is no nausea or vomiting, and that the urine does not become dark and show albumin. The symptoms of creosote poisoning are similar to phenol poisoning. From its overaction the patient not only has gastritis and intestinal disturbances, but also dark urine, perhaps nephritis, and dizziness and sweat- ing. Ichthyol. — The internal administration of ichthyol in tuberculosis seems to have its only advantage in acting as a bowel antiseptic. In this mariner it may do some good, but as patients generally eructate it, it is exceed- ingly unpleasant treatment. Cod-Lizfer Oil. — This oil is a food, and as such has its advantages. A small dose of cod-liver oil is as easily taken as a large dose of some emulsion which contains but little of the oil. In other words, if one desires to give cod-liver oil, it may be given; but, as previously stated, other oils and fats are of as much advantage, particularly butter, and it certainly is not wise to load the system with large amounts of bile- salts. There is no difference in the effect of Nor- wegian cod-liver oil and the oil prepared on our own shores. The Hypophosphites. — There is no chemical, physi- ologic or specific excuse for giving the hypophosphites ; the success of treatment of lung conditions with hypo- phosphites is. a fallacy. It is not intended to state that- some phosphorus and some calcium-bearing prepara- tions and foods containing these elements may not be of value, but one is not justified in expecting results from any hypophosphite combination of these or other elements. Arsenic. — Arsenic has been advised for years in many lung conditions. It has been stated that the arsenic eaters of France and Switzerland have been more or less immune from tuberculosis. It has beeil stated that patients breathe more freely and better un- der the influence of arsenic. However this may be, in the treatment of pulmonary tuberculosis the value of arsenic is very slight. It seems to stimulate the production of blood-corpuscles, both red and white, and in small doses it may stimulate the appetite. In 224 TUBERCULOSIS any large doses arsenic is harmful, tending to cause secondary destruction of red blood-corpuscles, to irri- tate the kidneys, to upset the digestion, and when pushed, may cause multiple neuritis. In other words, arsenic is a poison, and should not be administered to a patient unless there is a tangible, positive indication. lodm. — For many years this element in some form has been given frequently for various kinds of tuber- culosis, especially glandular tuberculosis. It was re- cently lauded for pulmonary tuberculosis by Boudreau. {Abstr. Jour. A. M. A., Feb. 14, 1914, p. 577.) He gives the French tincture (1 part of iodin to 12 parts of 90 per cent, alcohol), and commencing with small doses runs it up to IQO drops a day, administered in various beverages. After ten years of trial, he finds such treatment of value not only in pulmonary tuber- culosis, but also in renal tuberculosis. Ritter asserts that he has marked success with this method of ^treatment. J Although there are no other reports concerning this treatment, harm has been done in pulmonary tubercu- losis by the administration of an iodid. It seems to be a stimulant to the tubercles, not unlike tuberculin, and may cause a lighting up of a quiescent tuberculous , process or a serious exacerbation of a slow-going in- fection. The stimulant action on glands is well known, and tuberculous glands may be overstimulated to the •harm of the patient. In other words, iodids should not be used carelessly in pulmonary and glandular tuber- culosis. This does not militate against the possibility of small, very slowly increasing doses of iodin doing the same good that graded doses of tuberculin do, but the treatment should be most carefully watched. Chemotherapy. — The success of salvarsan in syph- ilis has stimulated similar experiments with regard to tuberculosis. These include the use of methylene blue and compounds of arsenic copper, various dyes and other substances. Most prominent has been the work with cyanocuprol by various Japanese investigators and most optimistic claims have been made for this substance. None of the numerous substances studied, however, as yet warrants the hope that a specific treat- ment has been found. Certainly these drugs should HELIOTHERAPY IN TUBERCULOSIS 225 not be tried in the human until they have been thor- oughly tested by the usual experimental methods. Tuberculin. — Tuberculin is not holding the position which was accorded to it after its recovery from the depression due to its early incautious use. It is not in itself curative, but it is, at most, a stimulant to the curative efforts of the organism. Some observers are still of the opinion that it is of value in selected cases of tuberculosis. The potency of tuberculin for harm is recognized by all. Its administration requires care- ful selection of the case, close observation of the patient and appropriate regulation of the dose. Pa- tients should be treated in a hospital, or, if the remedy is administered to ambulant patients, a strict control should be exercised. The results are frequently good in the forms of localized tuberculosis called surgical, such as afifect the skin, bones, joints and lymph-nodes. Tuberculosis of the lungs, when strictly localized, would appear to indicate its use, but the different character of the tissue involved seems to render the results less favorable. Heliotherapy.- — Treatment by the direct rays of the sun has been applied by RolHer of Leysin, especially in cases of pulmonary tuberculosis complicated by local tuberculosis of the bones, joints or glands. It is seldom used iti ordinary cases of pulmonary tubercu- losis. It should be limited to incipient cases and applied with caution, where there is fever or a ten- dency to hemoptysis. The treatment is best carried out in connection with the tonic af>plication of cold at high altitude. It consists in graduated exposure of the body to the light of the sun for increasing periods daily until the resistance developed permits a long stay in the open air. The treatment is said to be well borne by children. During the treatment the head should be protected and the room should be comfort- able for the patient. Gauvain (Brit. Jour. Tuberc, 1916, 10, 111) believes that sunlight is an important adjunct in treatment of tuberculosis. He summarizes the action of sunlight as follows : On the local lesions it has at first a direct effect. Superficial micro-organisms are destroyed or inhibited by the sterilizing action of the light waves, 226 TREATMENT OF TUBERCULOSIS and this action is assisted by the inflammatory re- sponse which results from a reasonable exposure to strong sunlight. The author has formulated a number of rules which must be observed when this treatment is given: 1. The patient's head must always be pro- tected. 2. The patient must never be allowed to become too cold or too hot. 3. On the first day the legs to the knees may be exposed hourly for five min- utes. If this is tolerated well, exposure of the knees may Jast for ten minutes hourly. On the third day exposure of the thighs for ten minutes hourly, and on the fourth day, similar exposure for fifteen minutes may be attempted, On the fifth day exposure of the thighs for fifteen minutes and of the body for five minutes is desirable. On the sixth day exposure of the thighs for fifteen minutes and of the body for ten minutes hourly may be attempted. If the patient is pigmented, the periods of exposure may be gradually increased, until the patient may be completely exposed for periods, and, when pigmentation is fully e'^tab- lished, continuous exposure may be undertaken 4. Blistering must be carefully avoided. 5. If the tem- perature exceeds 100 F., the patient should not be exposed the following day, unless special or/3ers are given. 6. Sinuses should be exposed and any puru- lent discharge from them should be immediately swabbed. 7. A nurse must be on duty during the whole time. TREATMENT OF SYMPTOMS Fever. — Nothing tends to diminish the temperature more than the rest, quiet and fresh-air treatment already outlined. The patient who has high fever should not be given too much food at any time of day, even if the disease is tuberculosis; and most of what he does receive should be given during an afebrile period if possible. If he is suiifering from acute tuber- culosis, the nutrition should be much the same as for any other serious fever. .Sponging with hot water will often give these pa- tients comfort and, if they have profuse sweats, it keeps the skin clean. The frequency of such sponging will, of course, depend on the height of temperature and its continuance. Antipyretics are rarely indicated. COUGH IN TUBERCULOSIS 227 The following points should be observed in the treat- ment of fever: First and foremost, absolute rest in bed, preferably out of doors; artificial pneumothorax in selected cases; a trial with autogenous vaccines, especially when there is copious purulent expectora- tion ; the cautious use, if at all, of tuberculin, and then only after other measures have failed; hydrothera- peutic measures suited to the condition and comfort of the patient; and ample diet, but not necessarily "forced feeding," and the judicious use of medicinal antipyretics. Cough. — The treatment of the cough depends on whether it is dry or moist, and whether expectoration is easy or difficult. If the cough is dry and hacking, much of it may be prevented by the will-power of the patient. It should not be forgotten that many dry, irritating coughs are due to a lingual tonsil or throat irritation. Soothing, alkaline gargles, non-irritating inhalations of simple steam or steam medicated with some non-irritant drug, as a small amount of pine oil, will give relief. Many coughs of this kind are relieved by swabbing the lingual tonsil with boroglycerid. These dry, irritating coughs should be relieved with- out giving medicine by the stomach. If there, is considerable bronchitis with insufficient expectoration, or the cough is frequent without expec- toration, the following cough mixture is soothing: Gm. or C.c. Q Codeinae sulphatis Ammonii chloridi 5 Syrupi acidi citrici 2S Aquae q. s. ad 100 20 gr. iv 3 iss flSi flSiv M. Sig. : A teaspoonful, in plenty of water, every two, three or four hours, as needed. Heroin may be used in place of codeiu if desired, but codein is the best sedative preparation of the opium series to meet the indication. The action of all other expectorants is inferior to that of ammonium chlorid, and ammonium chlorid as prescribed above is not disagreeable. The dose may be taken in Vichy or other sparkling water if desired. None of the multi- ple sweet, sickish, syrupy preparations offered by pro- prietary firms should be used in the bronchitis and 228 PAIN IN TUBERCULOSIS catarrh of tuberculosis, or in any other kind of bron- chitis. It is not necessary to cause nausea or vomit- ing because a patient has a cough. The success of some of these syrups of malt preparations in dry cough is due to the fact that they soothe the throat and lingual tonsil. Such irritation can be allayed without the patient swallowing a mixture. If the cough' is loose, and if the expectoration is profuse, the stimulating efifect of ammonium chlorid and the seda- tive effect of codein are not needed, and terpin hydrate becomes the best drug to use 'as an expectorant. To meet this indication of profuse bronchorrhea.it will not ordinarily be necessary to combine it with either codein or heroin. It should never be given in solu- tions, as not enough of it to be of advantage will be dissolved in any solution. It may be given in tablet, powder or capsule, and the usual dose is 30 eg. (5 grains), given with plenty -of water four or five times in twenty-four hours. If there are cavities in the lungs, the patient should occasionally, by lying over the edge of the bed, allow gravity to aid him in expectorating the fluid and pus. Elevation of the foot of the bed is often of advantage. Sometimes inhalants containing creosote, oil of pine and perhaps benzoin are valuable. When there are large cavities which continue to fill up and cause septic fever, with the debility and loss of "appetite that go with it, or when there is danger of serious hemorrhage, it may be wise to inject air or nitrogen into the pleural cavity and compress the diseased lung. Such treat-, ment should be given only in hospitals or sanatoriums, and then by an expert, as very unpleasant symptoms may occur; the heart may be unpleasantly pressed on, with a serious outcome. On the other hand, the treat- ment is sometimes very satisfactory. Pain. — Pain in the chest is most frequently due to localized pleurisies, but it may be a neuralgia, or referred pain caused by disturbances of the more deeply seated nerves. Nothing is of more advantage in easing such pain than temporary strapping of the part of the chest affected. This is especisilly true of pain in the lower part of the thorax. Sometimes a hot-water bag will ease the pain ; rarely a yedative may HEMOPTYSIS 229 be indicated, but generally it is not needed. Mild counter-irritation by a liniment or ointment is some- times advisable over these regions of pain; blisters are rarely expedient, though the thermocautery may be used. Dry cupping may give relief. •Hemoptysis. — Blood-tinged sputum or very slight pulmonary hemorrhages as evidenced by small clots or streaks of blood require no special treatment. Ex- pectoration of pure blood, or coughing up a little blood repeatedly requires attention. Such a patient should rest, and should undergo no exertion. The diet should be light, and hot soups or hot drinks should not be taken for a day or two, until the hemorrhage ceases. For this kind o'f bleeding little other treatment is necessary.' If the bleeding is more severe, the patient should immediately be placed in a semirecumbent posi- tion, with loosened clothing and should be assured that there is no danger, as there rarely is danger from hemorrhage during all the early stages of pulmonary tuberculosis. In the late stages, with cavities, a large blood-vessel may rupture and the hemorrhage be fatal. It is well to have the patient lie on the side which is bleeding. This tends to prevent the blood from flow- ing into the brojichi of the other lung. Besides reassuring the patient, it is often well, if there is a troublesome, irritating cough, to administer a hypnotic of morphin in just sufficient dose to quiet the irritability of the bronchial tubes and larynx so that the cough will be only sufficient for expectoration. (It is unnecessary to give a large dose which later. will cause prostration ; hence from 1/10 to 1/8 of a grain will be sufficient.) The more rest the bleeding part has, the quicker will the blood coagulate in the bleeding vessels, but as above stated, mere capillary oozing should not be taken seriously. With a real hemorrhage from the lungs, the .rest must be absolute ; the patient should not even Speak, at least not above a whisper. For some hours he should receive no food or drink. It is exceedingly doubtful if an ice-bag over the region of the bleeding is at all efficacious. The long-used remedy of eating salt may reflexly, by irritation,, increase the vasomotor, tension and thus may occasionally stop a hemorrhage. 230 TREATMENT OF ' HEMOPTYSIS but most of the remedies used and said to be satisfac- tory in hemorrhage from the lungs are drugs that increase the blood-pressure more or less, which is undesirable. As the blood-pressure is lowered, the hemorrhage will generally cease, usually without med- ication, so that whatever has been given has been supposed to be the cause of such cessation. If the patient becomes faint, blood-pressure is lowered, coag- ulation in the open vessel or vessels takes place, and the unpleasant syrnptom is cured by Nature's meth- ods; therefore we should aid the natural cure of the condition by giving the patient nitroglycerin to lower the blood-pressure. Amyl nitrite is very frequently advised, but its action is so sudden, and for a few minutes so intensely disagreeable, that it is hardly advisable to use this powerful drug. Nitroglycerin on the tongue or hypodermatically will act as efificiently and almost as rapidly without causing the faintness . and throbbing head that amyl nitrite will cause. It is a mistake to give ergot, caflfein, suprarenal prepara- tions, or digitalis, as these tend to increase the heart activity and raise the blood-pressure. If there is a tendency to repeated, more or less serious hemorrhages, the daily administration of cal- cium in some form, either as lime-water or calcium lactate, and the feeding of gelatin are indicated. Also, if there seems to be a general tendency to the oozing of blood and to hemorrhage, injections of aseptic horse-serum is advisable; one or two subcutaneous injections will generally be sufficient.. Inhalations of steam impregnated with some astringent such as tannic acid may be of value, if there is oozing of blood from the larger bronchial tubes, but such inhalations are of no value in bleeding from deeper portions of the lungs, as the astringent could not reach the region of trouble. The patient should generally remain in bed for a week after a real hemorrhage. If the heart is impaired and some dilatation exists, if the expectorated blood is venous, and there are other signs of passive congestion of the lungs and of cardiac weakness, digitalis may be the best treatment for the condition ; but for ordinary hemorrhages in pulmonary tuberculosis it is tetter, as above stated, to administer nitroglycerin in sufficient TREATMENT OF HEMOPTYSIS 231 amount distinctly to lower the blood-pressure tempo- rarily. It has been repeatedly noted that constipation increases the tendency to hemorrhage in pulmonary tuberculosis, and that the higher blood-pressure caused by constipation is readily lowered by the administra- tion of even simple laxatives. Because of this, it has been recommended (Bly, Jour. A. M. A., Dec. 20, 1913, p. 2207) that when pulmonary hemorrhages occur, the patient should receive a dose of magnesium sulphate as well as nitroglycerin. Such immediate treatment of hemorrhage from the lungs seems hardly advisable. It might cause vomiting, and the mere increased exertion caused by bowel movements at this time, might cause more bleeding. The fact remains, however, that in pulmonary tuberculosis the patient should ,not be allowed to become very constipated. If the hemoptysis occurs late in the disease and is dangerous in amount, the patient may quickly suc- cumb,, whatever the treatment adopted. A most efficient treatment of this serious condition is to place elastic bandages high up on the legs, or even on all the extremities, to shut off their blood from the general circulation. It would be inadvisable, even -if the hem- orrhage was severe, to transfuse immediately, as any- thing that raises the blood-pressure will be likely to cause a return of the hemorrhage from the open ves- sel. Later, after the hemorrhage has ceased and suf- ficient time for thorough coagulation has passed, the extremities, one at a time, may be released and the blood contained in them allowed to return to the general circulation. Continued bleeding from the lungs (especially when cavities exist and a serious hemorrhage has taken place, or seems likely to occur) is one of the most important indications for the use of lung compression. Other indications, as previously suggested, are the presence of pus in a cavity in the lungs, and bronchi- ectasis. For either of these conditions lung compres- sion is becoming more and more popular with specialists in tuberculosis. - It is also wise, perhaps, to compress a lung wh'en, in spite of some weeks of proper treatment, the disease continues to spread in it, the other lung being normal. 232 NIGHT SWEATS IN TUBERCULOSIS The gases that may be injected into the pleural cavity are nitrogen, oxygen and nitrogen, oxygen and air, or air and nitrogen. If only temporary compres- sion is desirable, air, or a gas rich in oxygen seems indicated, as its absorption is more rapid. If a pro- longed compression is desired, nitrogen should, . per- haps, be used, as it is less readily absorbed, and therefore the compression is longer continued. A mixture of air and nitrogen is perhaps a good com- bination when a brief compression is desired, and being more rapidly absorbed than nitrogen, will allow a decision as to the ability of the patient to stand this compression before using the longer compression by nitrogen. It has also been urged that air compression is safer than By nitrogen from the fact that if gas bubbles enter the circulation, the air bubble is more quickly absorbed than the nitrogen bubble. Good technic with proper instruments, however, should preclude such an accident. If compression is once done and its continuance is desired, more gas should be injected before all of that previously injected is absorbed, as after an injection has once been made, and the pleural surfaces have come together, they become more or less adherent and it is difficult to inject the gas again "into this pleural cavity. Night-Sweats. — This debilitating symptom is very characteristic of tuberculosis, and may occur even without much afternoon or evening fever ;■ generally, however, it follows such increase of temperature. Therefore, the rest and fresh-air treatment that pre- vents a rise in temperature will also ameliorate or prevent the night-sweats. If, however, typical cold night-sweats occur, nothing in the way of medication more successfully prevents them than atropin, 1/200 to 1/100 of a grain, given dry on the tongue at bedtime. The hydrotherapeutic measures already advised, that is, the warm water, and later cold water morning spongings are of value as preventives. If the patient is at rest and is getting no exercise, good massage followed by an alcohol rub is an excellent method of stimulating a more healthy circulation in the skin and muscles, and diminishing the tendency to profuse perspiration. The avoidance of constipation, a healthy DYSPNEA IN TUBERCULOSIS 233 circulation and good activity of the kidneys, all pre- vent night-sweats and the accumulation of toxins in the blood. If there is much circulatory weakness, several doses of strychnin sulphate a day, or digitalis, may also prevent night-sweats. Diarrhea. — Simple diarrhea occurring in tuberculosis patients generally means either that the patient becomes chilled, or that the diet is incorrect. Correc- tion of these conditions will soon stop such diarrhea. Tuberculous diarrhea, i. e., a diarrhea due to tuber- culous disease of the intestine is a serious complication not only of pulmonary tuberculosis, but also of any other form. It often occurs in the last stage of the dis- ease. Rest in bed and a carefully selected diet should be the treatment. Whether the diet consists of milk alone, or of a little meat and eggs with milk, should depend on the patient. Generally, vegetables, fruit and even much cereal should be temporarily withheld. Bismuth subcarbonate may stop the diarrhea, but bismuth should not be long continued. Lime-water may be of benefit. . If the kidneys are normal and there is no albuminuria, phenyl salicylate (salol) is good treatment. At times, one of the creosote com- binations is valuable. The administration of opium in some form may be necessary before diarrhea can be checked, and in the last stages of tuberculosis diarrhea may not be prevented. Colon washing with warm physiologic saline solutions is. sometimes . markedly sedative and of value. The bowels should always be kept especially warm, and the patient with diarrhea should not be subjected to intense cold. Dyspnea. — If the patient is in the last stages of pulmonary tuberculosis and must soon die, there is no excuse for not preventing the air-hunger, and morphin administered in properly selected, small doses will often relieve the dyspnea. In the very last stages, if the patient cannot be out of doors to get an increased amount of oxygen, he may be given oxygen inhala- tions. But oxygen inhalations as a curative procedure are useless and inay even do harm. The Pneumonic Type of Pulmonary Tuberculosis. — Such a condition is likely to occur as a part of acute miliary tuberculosis, but it may develop in a lung as an 234 LARYNGEAL TUBERCULOSIS acute exacerbation of a chronic tuberculosis. The disturbance may be ushered in with a chill, high, irreg- ular temperature, frequent, short cough, considerable dyspnea, at first without physical signs of gross con- solidation, but later showing in a part of a lobe, or even the whole lobe, the usual pneumonic signs, even with rusty sputum. The rusty expectoration soon disappears, however, and yellowish, greenish sputum, perhaps blood-streaked and loaded with tubercle bacilli, occurs. The prognosis is very serious, but the acute exacerbation may cease. The treatment is not dissimi- lar from that of an ordinary pneumonia. Laryngeal Tuberculosis. — The prognosis of this con- dition has, up to recent years, been considered very bad indeed, but with more skilful treatnient by throat specialists, with the added rest-cure arid with tuber- culin treatment, many such cases are aborted and the lives of the patients saved. The instances of tuber- culosis of the larynx are rare in which, preceding or subsequent to the beginning of the laryngeal disease, some portion of the lungs will not be found affected. The exact local treatment of a tuberculous larynx depends, of course, on the location of the ulcer or ulcers. If they are so situated that swallowing is very painful, anesthetizing sedatives must be used. Various preparations of silver, lactic acid and menthol are used by different clinicians to aid in healing the ulcers, but the tuberculin treatment, properly used, is probably always advisable. Tuberculous Peritonitis. — This condition uncompli- cated with tuberculosis elsewhere must, of course, be differentiated from many abdominal conditions. If there is fluid, other causes of ascites, as inflammation of the liver, serious cardiac insufficiency and ovarian cysts must be excluded. Tuberculous peritonitis may appear in several forms: the miliary form which causes ascites, the fibrocaseous, the fibro-adhesive and that which causes tumor masses. The range of tem- perature' (although in chronic tuberculous peritonitis there rnay be no increase of temperature, and it may even be subnormal), the localized tumor masses and fluid confined to one portion of the abdominal cavity by adhesions, will aid in the diagnosis. In tuberculous peritonitis there may be more fluid on the left side of TUBERCULOUS PERITONITIS 235 the abdomen than on the right, as the diseased mesen- tery retracts and draws the bowel to the right. As frequently tuberculosis is not present in other organs, the diagnosis is often difficult, and a tuberculin test is indicated. The fluid in the abdomen in tuberculous peritonitis does not contain pus, unless there is a mixed infection, as the tubercle bacillus does not produce pus. The drawn serum very frequently does not show tubercle bacilli, but a guinea-pig inoculated with the serum will, in due time, develop tuberculosis, if that is the infection from which the patient, is suffering. If the exudate found on laparotomy or withdrawn for examination is bloody, it shows the disease is active. Tuberculous peritonitis may originate from infected . mesenteric glands. Much false membrane is formed, which causes many adhesions of the intestines. A patient may apparently be very well and. still suffer from tuberculous peritonitis, and the prognosis is rather favorable if ^such a patient is operated on. It is not advisable to operate for tuberculous peritonitis if tuberculous infiltration is already in the lungs. At times, withdrawal of fluid from the abdomen by aspira- tion, tonic treatment, rest and the exposure of the abdomen to the rays of the sun will cause a cure.. Matiy sanatoriums are installing the necessary equip- ment for giving heliotherapy, or sun baths. The direct rays of the sun are thrown on the chest or abdonien. The electrochemical action of the roentgen ray has also been tried, but its value has not been well proved. If the ascites tends to recur, or remains, laparotomy should be done, and sunlight let into the abdomen. Laparotomy may cure tuberculous peritonitis when there are simply, tuberculous masses or tumors, but no fluid in the abdomen. It has been thought that small doses of mercury administered for a long period, especially in the form of corrosive sublimate, was of advantage in tuberculous peritonitis. The results of operation may be summed up about as follows : There is slight danger from the operation itself. Temporary improvement may almost always be expected. Fatal cases usually terminate in a few months after the operation; while not far from one- third of all cases seem to recover in about one- to two 236 CERVICAL GLAND TUBERCULOSIS years after the operation. Antiseptic injections or continuous drainage after operation are not indicated and are useless. Tuberculosis of the Genito -Urinary Tract. — Tuber- culosis of the bladder and prostate is rarely primary, and often has gonorrhea as an antecedent. Tuber- culosis of the testicle is by no means infrequent. Removal of the testicle is of course advisable, and operative interference in the bladder and prostate may be indicated. A tuberculous kidney should be removed as soon as it is diagnosed provided the other kidney is normal. The general treatment is the same as in all tuberculosis. Tuberculosis of the Cervical Glands. — Although this subject has already been quite largely discussed, it should be urged that while surgical removal is neces- sary, and very frequently indicated, every gland that is needlessly removed weakens by just so much the ability of the system to protect itself against all infec- tions. Roentgen-ray treatment, while lauded by some men, seems unsatisfactory to many clinicians. While infected or broken-down glands are being removed, the dissection should be very carefully done, lest the sur- rounding parts be infected with liberated germs, or if not locally infected, lest the bacilli be absorbed into the lymph circulation and cause general infection. While a gland should not be removed merely because it is enlarged, at the same time it is a serious mistake to allow enlarged glands to cause such inflam- mation of the surrounding tissues as to render it neces- sary to remove parts of muscles, to say nothing of the danger of such chronic inflammation necessitating, during operation, injury to important blood vessels and nerves. Glands shduld be removed before they cause injury to the patient or the surrounding tissues. The tuberculin treatment of tuberculosis of the glands, especially in children; is now much in vogue, and if the tuberculin is used in carefully graded doses the results seem to be satisfactory. Caseated glands should be eradicated or curetted, however, as the tuberculin treatment will not cause resorptioti. Also, the exact value of the tuberculin treatment for tuber- culous glands cannot be determined, as fresh air, good food, iron tonics, and medical supervision are active BONE AND JOINT TUBERCULOSIS 237 aids in the cure of this condition. Too large doses of tuberculin may overstimulate the diseased glands and cause general infection. Also, one does not know how many concealed diseased bronchial glands will be stim- ulated by the tuberculin injections ; hence a very care- ful study of focal reaction should be made through- out the treatment.' Bier's hyperemic treatment is probably inexcusable. Bone and Joint Tuberculosis. — In tuberculosis of these parts of the body, according to Fiske, there may be a slight leukocytosis of not far from 12,000, while in osteomyelitis the leukocytosis is generally not far from 16,000. Children who have bone tuberculosis frequently do well at sanatoriums or in hospitals espe- cially arranged for their out-door or veranda treat- ment. They 'do especially well at the. seashore, and direct sunshine makes a valuable addition to the treat- ment of this kind of tuberculosis. Tuberculosis of the glands and bone and joint tuberculosis, do especially well under treatirient by sun baths^ both general and local, in combination with the invigorating effects of cold at moderately high altitudes. Rollier of Leysin and other practitioners at sanatoria in the Alps and at a few places in the United States have secured particu- larly good results by this form of treatment. Such treatment can be given at home by the institution of simple arrangements at first in the patient's room, later on a veranda and finally when the surgical condition will permit, by free movement in the open air. Tuberculous Meningitis.- — Meyers (Amer. Jour. Dis. Child., May, 1915) classified the etiologic factors, symptoms and signs of 105 patients with tuberculous meningitis. As to sex, they were equally divided. The ages varied from 5 months to 11 years, with about one third of the patients between the ages of 2 and 3, while over half were between the ages . of 2 and 5. The greatest number of these cases occurred in Jan- uary and' March (in Boston). The variations in the number of cases occurring in the different, months would probably change somewhat with the region and the climate investigated ; therefore a monthly analysis is of but little value. Meyers found that 38 per cent, of these children had had no previous diseases ; in the 238 TUBERCULOUS MENINGITIS remaining 62 per cent, measles had occurred more fre- quently than any other disease. The average duration of the disease from the time of the beginning of symp- toms was seventeen days. Meyers thinks the disease is not so rapidly fatal as it once was on account of lumbar puncture being now more frequently done, thus preventing early deaths from cerebral pressure. Lumbar punctures were done from once to seven times to a single patient. He finds that lumbar punc- ture prevents convulsions, which become rare in the clinical history of the disease thus treated. Meyers believes that the advantage of lumbar puncture is not only in relieving pressure, but also in eliminating a certain amount of toxin. He has not found unpleasant symptoms to occur from the withdrawal of even a con- siderable amount of spinal fluid, even though, it was not under high pressure. The rule of Meyers is to allow the spinal fluid to drain until it runs at. the rate of from 10 to 12 drops per minute, and to draw off from 20 to 30 c.c. of fluid, depending on. the pressure. Eighty per cent, of the cases showed increased pressure but varying, of course, in degree. If the child lived, lumbar puncture was done once every forty-eight hours. If the fluid removed at the first puncture did not show the organism caus- ing the meningitis, the later punctures usually did, and tubercle bacilli were found in 21.5 per cent, of these 105 cases of tuberculous meningitis. When there was no increase of pressure in the cerebrospinal canal, there were almost no disturbances of the reflexes, and there seemed to be no relation between the amount of pressure and the presence of convulsions, bulging fontanel or retraction of the head. The fluid of this disease was never found really tur- bid, and was generally absolutely clear. The cell count of the fluid varied from 24 to 960 per cubic millimeter, with an average of 198. This cerrebrospinal fluid cell count seems to vary with the leukocyte count of the blood : the greater the leukocyte count, the greater the number of cells in the spinal fluid. The prevailing type of cell in the spinal fluid was the small mononuclear, ranging from 90 to 100 per cent, in 67 per cent, of the cases, and from 80 to 90 per cent, in 20 per cent, of the cases. A fibrin clot was found in 70 per cent, of the TUBERCULOUS MENINGITIS 239 cases, and a positive globulin test in about SO per cent. The globulin content seems to vary directly with the cell count The first part of the spinal fluid with- drawn at each puncture has a different cellular con- tent from the last part that is withdrawn, the first part giving the greater number of cells. One fourth of the cases showed a leukocyte count of the blood between 10,000 and 15,000; the lowest count was 8,509, ^"^ the highest 48,000. Absence of eosino- phils, as in some other diseases, is considered an unfavorable symptom. In those tested for the von Pirquet reaction, 63 per cent, were positive. Twenty-five per cent, of the cases gave a history of definite exposure to tuberculosis. Thirty per cent, of the cases showed lunig involvement, and had more or less cough. In 71 per cent, the eye reflexes were abnormal, but in 29 per cent, the pupils were equal, and reacted normally to light. Thirty per cent, showed nor- mal patellar reflexes, and in 21 per cent, the reflexes were absent. There was a positive Babinski in 21 per cent. Fifty per cent, of the cases gave the Oppenheim sign. Ankle clonus was rarely present. Kernig's sign was present in 27 per cent, of the cases. Forty-three per cent, showed some signs of paralysis, with stra- bismus as the most frequent form. Seventy per cent, showed some rigidity of the neck, and, late in the dis- ease, there was definite stiffening of the limbs. While 39 per cent, of the patients had a history of convulsions before, entering the hospital, as stated above, spinal puncture seemed to relieve or prevent convulsions. The subjective simptoms were drowsi- ness, indifference, and sometimes irritability. Eighty- five per cent, had vomiting as an initial symptom. This vomiting had no relation to the food taken, and in no case was there projectile vomiting as is so frequently seen in meningococcic meningitis. Pain was a frequent symptom. In 18 per cent, of the cases the urine showed acetone, and sometimes slight traces of albumin. Before death, pulse, temperature and respiration in about half of the cases became higher. Early in the disease the pulse was slow and irregular ; later in the disease it became soft and rapid. In 64 per cent, of 240 ACUTE MILIARY TUBERCULOSIS the cases there was a remission, with a drop of pulse and temperature ;. but this was apparently not a sign of improvement. Also, a patient, who may have been comatose, may brighten up and answer questions from twenty-four to thirty-six hours before death. Forty- two per cent, of the cases showed terminal bronchial pneumonia. In no case in this series was there recovery. The treatment tried was sodium benzoate in large doses, and inunctions of mercury, Hexamethylenamin was used in large doses, but even with these large doses there was never a trace of formaldehyd found in the spinal fluid. This seems again to disprove the value of this drug in cerebrospinal inflammations. Enough cases are now on record to show that recov- ery from tuberculous meningitis is possible, so that the prognosis is not absolutely hopeless, although very dire. If the child is suffering pain, codein or some form of opium should be administered in doses found sufficient for the individual, but not large enough or so frequently repeated as to produce coma; that is, if coma occurs it should be known that it is caused by* the disease and not by the drug. The little patient should not be compelled to suffer severe pain. If food is refused, forced feeding may be advisable, but if the child is thirsty he will generally drink milk. Acute Miliary Tuberculosis. — This, occurs in several forms; one in which all the organs of the body are attacked, others in which only certain organs are dis- eased. In another form the tubercles may be larger and show degeneration. The disease is always serious, generally fatal, and clinically -occurs in the meningeal form just described or as a general acute bronchopneu- monia of both lungs, or as the typhoid type. In the lung form the sputum is loaded with tubercle bacilli and the diagnosis is readily made. In the typhoid form there may be no cough, and no' real lung signs, although lesions may be found in the lungs on necropsy. It may be difficult at first to distinguish this form from typhoid fever, but the temperature is likely to be very high in the evening with considerable of a drop in the morning, and profuse sweatings. Such morning remissions occur early in the disease as dis- tinguished from typhoid fever. The pain and tender- THE PROGNOSIS IN TUBERCULOSIS 241 ness in the abdomen, and the joint and cerebral symp- toms, will soon make the diagnosis positive. Diarrhea generally does not occur with acute miliary tubercu- losis; in fact, the patient is generally constipated — another symptom different from most cases of typhoid fever. The treatment is similar to that of any acute infec- tion with the exception that great care should be exer- cised to sterilize every excretion from the body. Tuberculous Rheumatism.— Poncet and others have described cases of pain and swelling of the joints due either to the circulation of tuberculous toJtins in the blood or to the presence of a small number of tubercle bacilli in the affected joints. It is probable that a con- siderable number of. cases of ordinary rheumatism are due to tuberculosis. An almost positive sjgn of such cases is the occurrence of focal reactions (pain ind swelling) in the joints after injection of old tuberculin subcutaneously. PROGNOSIS In the first place, as to the probability of cure of tuberculosis, it should be remembered that statistics of necropsies show that from 30 to 35 per cent, or more of patients who have died from causes other than tuberculosis show evidence of that disease, either healed or latent. In general, the prognosis of pul- monary tuberculosis is modified by the family history, by the causes which have allowed the tuberculosis to develop, by the whole general condition of the patient, and by the amount of lung tissue involved. A tuberculous process that begins in the lower part of the lung, following a pneumonia, gives a bad prog- nosis. A generally debilitated and anemic condition will necessarily slow or preclude a cure. An associated laryngeal or intestinal complication makes the prog- nosis very serious. When a patient is first seen, the prognosis should be guarded, as it is only after weeks or months that the decision can be made as to how much this patient may improve, for even a person who looks otherwise well, except for the fact that tuberculosis is discovered; may develop an acute form' of the disease. The physician should individualize the patient, not only as to his sur- 242 THE PROGNOSIS IN TUBERCULOSIS roundings and his occupation, but also as to his men- tality. His disposition should be studied. It is a mistake to send a patient to a sanatorium who will be restless under sanatorium restrictions, or who will be so seriously homesick as to lose his appeite, or who will not at all obey instructions. Therefore, the men- tality, the individuality and the willingness to coopier- ate of the patient is of great importance in the prog- nosis. According to Combe (Le Nourrisson, 1916, 4, 202), the opinions qf pediatricians differ as to the pjognosis of tuberculosis in infants. While most declare that, when diagnosed clinically it is absolutely fatal, others affirm that they have seen infants survive tuberculous disease. Combe is of the opinion that the prognosis of tuberculosis in infants is very grave, but not inevit- abl5r fatal. He thinks the outcome depends on a number of factors. The age of the child ait the time of infection is the first point to consider. The younger the child is at this time, the less capable he is of defending himself and the greater is the tendency of the tuberculosis to become generalized. The virulence of infection and the opportunity for reinfection are important factors. Contact with open tuberculosis offers this opportunity for reinfection. It is usually admitted that infection from the mother is more dan- gerous than that from other members of the family, and that the danger is the result of reinfection. The clinical form of the disease is most important in prognosis. If when the diagnosis is made the tuber- culosis is . still localized in the glands, a less serious prognosis can be given. If the glandular barrier is broken down and there is mediastinal and hilus infil- tration, the case must be regarded as very serious, although the author affirms that he has seen symptoms "recede and apparent recovery result from tuberculin therapy. If signs of generalized tuberculosis are present and the roentgen ray confirms the diagnosis of miliary tuberculosis or of acute caseous pneumonia, the case must be regarded as desperate. Chronic, surgical tuberculosis is the only form which offers a good prognosis and is caused by a spontaneous auto- tuberculin therapy from the slow progressive penetra- tion of tuberculin into the general circulation. THE PROGNOSIS IN TUBERCULOSIS 243 It is a question whether asthma, which was long sup- posed to protect against tuberculosis, really does so. Certainly an asthmatic patient could have tuberculosis. It seems to be a fact that persons who suffer from heart-disease, especially if there is a sufficient loss of compensation to cause more or less dyspnea and pul- monary passive congestion, do not have tuberculosis so readily. This subaeration may interfere with the growth of tubercle bacilli. Tuberculosis~of the cervical lymph-nodes may be due to an auto-infection. In other words, bacilli may be contained in the patient's own sputum, infect the tonsils and be from there carried to the cervical glands. A more or less continuously rapid pulse gives a bad prognosis. A temperature that is not greatly lowered by rest gives a bad prognosis. Of course, the case is serious as long as there is a morning fever. A patient whose temperature is normal or subnormal in the morning, even if there is considerable rise in the after- noon and evening, may not only improve, but may recover. Any sexual excess, and even any sexual act during tuberculosis will aggravate the condition. A slight gain in weight, while desired and looked for, and generally an indication that the patient is improv- ing, is not necessarily a positive indication that the prognosis is absolutely good, as many instances occur in which the patient gains weight for a time, under proper treatment, but the disease progresses. There- fore, a slight but steady gain in weight should be con- sidered satisfactory, but should not cause too favorable an opinion of the outcome to be given. It is considered a good prognosis when the lympho- cytes in the blood are increased in number, showing that the nutrition is improving. It has also been con- sidered that a normal number of eosinophils gives a good prognosis, while an absence of eosinophils gives a bad prognosis. Whatever the condition, however, it should constantly be borne in mind that pulmonary tuberculosis is curable in the first and second stages, and a cure may even take place in the third stage, or when there are cavities. Pregnancy in a tuberculous patient makes the prog- nosis bad, and should call for a consultation to decide as to whether or not abortion should be produced. 244 ARRESTED TUBERCULOSIS ARRESTED TUBERCULOSIS A patient who has even a temporary return to health must generally go to work, and the question of vital importance is, What shall the work be? There is no light outdoor work suitable for such recovered patients; hence, unless the occupation is one that is a menace to his health, a patient should return to his previous work. The education received during his cure should have taught him how to live to keep his health. The next important rule for him to follow is to return to his physician for observation and advice at frequent intervals, depending on his condition. DISEASES OF THE RESPIRATORY TRACT COMMON COLDS Colds far surpass in frequency any other disease condition. There is no immunity acquired by surviving a coryza, a pharyngitis or a bronchitis; in fact, or- dinarily, the person is at least temporarily more sus- ceptible to taking or developing a fresh cold. This may not be quite true of ah influenza or grip cold, because many persons have a real or pseudogrip attack early in the fall or winter and are then more or less immune from acute attacks during the rest of that season ; but there seems to be no doubt that the influ- enza bacillus leaves a patient temporarily, at least, more susceptible to other more dangerous germs, as the pneumococcus or tubercle, bacillus. Consequently, be- sides the immediate debility that an acute cold causes, the possibility of opening the way for the entrance of more serious disease should cause every cold to be considered seriously and treated energetically. Acute colds are always due to germs of some kind. A too dry atmosphere, which is the condition in so many houses today, may so irritate or- congest the nostrils as to allow the least irritant to cause at first a simple inflammation of the mucous membrane, which congested area may. later pick up and harbor, or cease to kill, germs. It seems to be an established fact that good outdoor air does not predispose to colds as much as indoor air, and it is a fact that persons whose occu- pation is indoors are more liaTile to have colds than those whose occupation is outdoors. Chilling, whether indoors or outdoors, certainly predisposes to colds. It is quite probable that chilling of the surface of the body congests the inner organs and possibly the mu- cous merhbranes of the air passages. If the mucous membrane of the nose is congested, it more readily becomes inflamed. Acute nasal inflammation, often called a "cold in the head," is of frequent occurrence in some regions, espe- 246 BACTERIOLOGY OF COLDS dally near the seacoast, and occurs repeatedly in cer- tain persons who seem to have a susceptibility to in- flammation in the nose. Some persons cannot be exposed to a single draft on any part of the body without an acute coryza starting. It is supposable, however, that while most acute nasal inflammations are due to infectious germs, more or less chronically hypertrophied mucous membrane and more or less sluggish circulation in this membrane may allow simple noninfectious inflammations to occur when irritation of any kind is applied. Other persons who do not have this susceptibility may become chilled, may be subjected to violent cold, damp winds, and may even get wet and still never develop a nasal inflammation. Just as large tonsils more readily catch germs and become diseased, or more readily harbor germs and have recurrent inflammations, so hypertrophied mucous membrane, of the nostrils becomes susceptible to reinfection or to reirritation. Frequent acute colds, more or less con- stant subacute inflammations, or chronic inflammation may result from such a condition. BACTERIOLOGY Tunnicliff (Jour. Infect. Dis., 1913, 13, p. 283) in the acute and chronic forms of rhinitis, isolated an anaerobic gram-negative bacillus, which she named the Bacillus rhinitis. In a large percentage of cases this organism was found in pure culture. It was also found in about 90 per cent, of the cases of chronic rhinitis in which there was a mucoid discharge. That this organ- ism was the etiologic factor in acute rhinitis was shown by the production of the condition after experimental inoculation and by recovering the organism in pure form from those infected by the inoculation. Kruse, (MUnchen. med. Wchnschr, 1914, 61, p. 1547) working along the same lines, was able to demonstrate that when the secretions from the discharge in cases of acute rhinitis were taken and diluted even as much as twenty times, and then filtered, the filtrate inoculated into the noses of healthy people produced typical cases of acute rhinitis. As a result of this he concluded that the acute rhinitis was caused by an invisible and filter- able virus, since the filtrate when cultured remained sterile. PROPHYLAXIS OF COLDS 247 More recently Foster, {Jour. A. M. A. April 15, 1916, p. 1180) repeated Kruse's experiments and ob- tained similar results. He, however, went further, and using Noguchi's method for growing the parasite, of rabies and the organism of poliomyelitis, was able to obtain from the filtrate an organism which, when inoculated into the noses of seven soldiers, produced a typical condition of acute rhinitis in all of them. Cultures made from the nasal secretions of these also showed the same growth on mediums. Foster, exam- ining the growth under the dark-field microscope, states that there/ are "myraids of extremely active minute bodies occurring singly, in pairs and in agglomerations of varying magnitude. These did not stain satisfac- torily with the usual stains." PROPHYLAXIS The preventive measures consist of proper bathing to keep the skin in good condition; proper clothing, depending on the region, season and exposure ; proper heating and ventilation of living rooms, bedrooms and buildings in which persons are" employed, and in the case of the child, proper heating and ventilation of the schoolrooms. Too severe exposure of young chil- dren and babies to dampness and winds is inexcusable and does not increase their resistance against catching cold, and often precipitates more serious conditions. Any person who has a tendency to nasal or pharyngeal colds should not suffer undue exposure at night. Too many windows being open iriay cause too much direct draft over the face. Fresh air sleeping should be gov- erned by common sense. Cold daily sponging of the child's face, neck and chest, followed by quick friction, is a splendid means of decreasing the likelihood of catching cold or Jjecoming chilled. Older persons may take cold showers or cold plunges in the morning, if it is advisable in individual cases. Children especially should not be subjected to unnecessary infection by being taken into prowded cars, stores or into various assemblages, where it is impracticable to avoid close contact with coughing or sneezing persons who do not properly protect the sur- roundiag atmosphere by using handkerchiefs. 248 TREATMENT. OF COLDS As so many' times urged, a child or adult who has repeated colds should be examined and properly treated medically or surgically by a nose and throat specialist. The family should also be taught that the exchange of handkerchiefs and the use of the same towels when one member of the family has a cold or sore throat is inexcusable. Direct contagion by this method is probably very frequent. During all colds the nasal and throat secretions or excretions should be received into paper handkerchiefs, or pieces of cheese- cloth, and either immediately burned or deposited in a paper bag for burning -later. If handkerchiefs are used, they should be washed separately and soon. A too dry indoor atmosphere can harm the mucous membranes of the upper air passages as it leaves the membranes unprotected, and the first irritant that attacks them may cause an inflammation. TREATMENT Acute coryza having begun, an attempt should be made to abort it. There are various methods of reliev- ing internal congestions, and the general principles are the same in all cases, wherever the localized inflarrima- tion may be. These general methods are some means to reduce an increased . temperature, some means of bringing the blood to the surface of the body and increase perspiration, some means to produce free catharsis and thus to deplete the blood-vessels and lower- the blood-pressure to relieve indirectly the ten- sion in the region of congestion, and some means to prevent the development of the second stage, or stage of secretion, if possible. Methods used to meet one of these indications will many times meet one or more of the others ; hence the treatment is often very simple. If the patient is first seen in the morning, or before the middle of .the afternoon, the best treatment is a saline purge of some description, as exemplified by the Seidlitz powder or by the effervescing magnesium cit- rate or Rochelle salt, or castor oil if that is preferred. If the patient is seen first in the evening, a less quickly acting cathartic is advisable, and none is better than a small dose of calomel, as from 0.05 to 0.20 gm. (about 1 to 3 grains), depending on the age of the individual, combined with 0.5.0 to 1 gm. (7l^ to 15 grains) of TREATMENT OF COLDS 249 sodium bicarbonate. Or, 1 grain of calomel may be given with an ordinary compound aloin pill or tablet. The old-fashioned Dover's powder is still given by many physicians and often works well, but may cause considerable nausea. Also, opium, or morphin in any form tends to inhibit free action of the bowels, which is undesirable. One of the best treatments is one of the coaltar products, such as antipyrin, acetanilid or acetphenetidinum. Any one of these may be given in one fair-sized dose or in two medium-sized doses, or in several small doses. One gm. of antipyrin would be a full dose ; 0.50 gm., repeated in five or six hours, would be a medium dose ; 0.30 gm. of acetanilid. would be a large dose, and 0.10 gm. might be repeated at three- hour intervals for three times. A satisfactory method is a combination of acetanilid with sodium bicarbonate, and a .prescription similar to the following is often very valuable : Gm. IJ Acetanilidi 0125 or gr. v Sodii bicarbonatis 2|S0 gr. xl M. et fac chartulas 5. Sig. : One powder every two or three hours. A similar combination may be given in tablets, if preferred.. It should be remembered that caffein has been shown not to protect the heart from depression causd by large doses of a coaltar product; therefore, there is no object in adding caffein to such a prescrip- tion. When these coaltar products are ordered, it is well to give coincidently hot lemonade. Perspiration is more readily caused by this means. Provided the patient is not soon to be subjected to exposure, a hot bath is another efficient means of relieving internal congestions, and can be used coinci- dently with the other treatment. Acidum acetylsali- cylicum (aspirin) is now more largely used than almost any other drug to abort colds. The laity, on account of the instructions which they have received of the dangers of acetanilid and similar drugs, now all buy and use this drug with too great freedom. Rhinitis tablets are sold everywhere to the laity, and are largely used by physicians. These ar^ various combinations of morphin, atropin, strychnin and aconi- tin. The minute dose of aconitin ordered probably 250 TREATMENT OF COLDS generally has no action. If one desires the activity of aconite, it is best to give it in a tangible form and dos- age, namely, the tincture of aconite, a drop perhaps every half hour or hour, until the pulse shows the activity of the drug. However, this treatment ordi- narily requires that the patient be seen within a certain number of hours by the physician, to ascertain whether or not the aconite should be stopped, unless the doses are limited in number. The old aconite treatment of colds has mostly given place to the newer treatments described above. The whole rhinitis tablet combina- tion probably represents principally the action of atropin with some help from the morphin, both of which will dry up the secretions of the nostrils and throat. The small amount of strychnin probably is not very active. Sometimes minute doses of quinin enter into these combinations, but that probably is not active. In other words, a small dose of atropin sul- phate, given frequently, acts as well as one of these rhinitis combinations. There is no question about the drying up of secre- tions by morphin, if this drug is pushed. Rarely is such treatment needed. Quinin sulphate has been used for years as an abor- tive treatment of colds, and the laity, until more recently adopting acetylsalicylic acid, have always resorted to this drug. Small doses would probably not have .any very decided action; large doses are inadvisable at this stage of the cold because of the tendency to congest the middle ear. Spraying or snuffing solutions into the nostrils at this stage is inadvisable. The throat may be gargled with warm physiologic saline solution, which is roughly represented by 14 teaspoonful of salt to half a glass of warm water. If the patient has been known to be exposed to some acute throat or nasal infection, more active antiseptic gargles and sprays may be used ; but an acute coryza will rarely be aborted by local treatment. If the inflammation is not aborted and the second stage develops, that of profuse mucus and some muco- purulent^ discharge, then cleansing of the nose and throat becomes urgently needed. At this stage all of the foregoing abortive measures should cease. A TREATM'ENT OF COLDS 251 patient who has been more or less deprived of food, except a small amount of liquid nourishment for from twenty-four to thirty-six hours, may now resume his normal diet. The more or less purulent discharge from the nos- trils should not be allowed to remain blocking up the passages. Consequeiitly, atomizing with warm saline and alkaline solutions should be more or less fre- quently done. Various compound solutions or tablets for solution are offered, but there probably is no advan- tage in these combinations over more simple ones. The simplest cleansing solution is one made from y^ teaspoonful of salt and % teaspoonful of sodium bicar- bonate to a glass of warm water, or half these amounts for half a glass of water. To be properly soothing, the solution should always be warmed. The same solu- tion may be used as a gargle. If a mild antiseptic is needed, saturated solutions of boric acid or borax are efficient. If stronger antiseptic solutions are required or advisable, hydrogen peroxide is valuable, as 1 part of the official aqua hydrogenii dioxidi to 4 or 5 parts of warm water for a gargle, or 1 part to 7 or 8 parts of warm water for a nasal spray. Nasal spraying and proper cleansing of the nose protects the adjacent sinuses from infection. Cleansing the nasopharynx by snuffing back a solu- tion from a teaspoon or a Small vial, or snuffing back a spray, or gargling and then throwing the head for- ward and washing the nasopharynx, protects the eustachian tubes from infection. Two cautions should be suggested : first, that douching of the nasal passages should not be done with the nostril blocked, or with a high placed douch reservoir, as the pressure is likely to be sufficient to send fluid into the eustachian tubes or into the sinuses, and cause inflammation of such parts. Most of the patented douch apparatus are inad- visable. The second precaution is that it is not well to cleanse the mucous membrane of the nostrils too thor- oughly of mucus before the patient goes into the out- side air, especially if that air is dust-laden. The proper time to spray is when the patient is to remain in the house for a short time; or if he is sprayed and then must go out of doors, he may receive a non-irritant oil spray to furnish coating for the mucous membrane, 252 TREATMENT OF COLDS this is to be used after the alkaline spray." Or small plugs of cotton may be placed in the nostrils. It may be well at this time to use a camphor-men- tholoil mixture either as drops or as a spray. The fol- lowing may be suggested : Gm. or C.c. IJ Menthol Camphor Liq. petrolatum SO 25 S If 'the secretion from the nose is tenacious and hard to dislodge by blowing the nostrils, ammonium chlorid may be a drug of value. It has been used as a stimu- lant to the upper air passage mucous membrane as well as to the bronchial mucous membrane. It may be given in a simple preparation as : Gm. or C.c. 3 iss or flSi flSiv B Ammonii chloridi S Syrupi acidi citrici 25 Aquae - q. s. ad 100 M. Sig. : A teaspoonful, in water, every three hours. If the coryza tends to become subacute and pro- longed, tonic treatment is required; a small dose of quinin and a small dose of iron, with or without arsenic and strychnin, are advisable. The following tonic capsule may be used, and the doses may be modi- fied for a child : Gm. or C.c. 5 Arseni trioxidi Strychninae sulphatis ' Ferri reducti 1 Quininae sulphatis 2 M. et fac capsulas siccas 20, Sig. : A capsule three times a day, after meals. Spraying with suprarenal solutions is sometimes of advantage, but sometimes is followed by more conges- tion. Some nose and throat specialists use suprarenal preparations constantly.- Such treatment certainly many times is efficient in temporarily relieving conges- tion and giving comfort. This discussion of the treatment of common colds would not be complete without reference to the vaccine treatment. While the exact value of such treatinent has not been determined as an abortive treatnfent or as a treatment that shortens the course of the disease, the 04 04 aa gr. % or gr. XV gr XXX ACUTE PHARYNGITIS 253 enthusiastic recommendation of such treatment by some writers should be recognized. The large majority find no value in vaccines either for prophylactic or curative purposes. When there is sinus infection, auto- genous vaccines would seem indicated. ACUTE PHARYNGITIS The abortive treatment of this inflammation is the same as that described for acute colds. With a simple pharyngitis, soothing alkaline gargles, as previously described, should be the treatment. A very simple, pleasant and efficient gargle is as- fol- lows : Gm. or C.c. Acidi borici 2 Potassii chloratis 2 Aquae menthae piperitae. . . .200 3ss 3 iss flSvii M. Sig. : Use undiluted as a gargle, every three hours. COUGHS DEFINITION Coughing is an expiratory effort caused refiexly by some irritation. The muscles of the lower part of the cKest are most engaged in the act of coughing ; hence in severe, prolonged or frequent coughing muscle tire occurs in the lower part of the chest, both anteriorly and posteriorly. The abdominal muscles all take part in this expiratory efifort, and the erector spinae mus- cles, the serratus, and the quadratus lumborum are all utilized in a strong expiratory cough. The mus- cle contractions compress in all directions the lower part of the chest, and the air in the bronchial tubes is forced upward, and, if there is no obstruction, is expelled through the glottis. If there is obstruction, or even partial obstruction, the upper portion of the lungs, especially the apices, become dilated, and tem- porarily, or in severe cases, permanently, emphysema- tous. CAUSES Cough can be caused by irritation of any of the mucous membranes of the air tract, by irritations of the nerves in the lung tissue, by irritations of the pharynx, by reflex irritation of the vomiting center, 254 . TYPES OF COUGH and by any irritation that can reach, through the pneumogastric nerve, the center in the medulla. From any of these reflex causes efferent impulses are trans- mitted, and the result is a cough. Irritation in the nose and ear may cause cough. Pain and muscle tire from prolonged coughing, besides occurring in the lower part of the chest, occur in the sides, low down, perhaps in the region of the insertion of the diaphragm, and also in the back even down in the lumbar region. These strong contrac- tions of the abdominal muscles during coughing also aid in temporarily diminishing the capacity of the thorax by pushing upward the abdominal organs. At the same time there is a considerable force exerted downward, which may tend to cause uterine displace- ment, hemorrhoids and even involuntary urination. Before this forcible expirationT or cough there is generally a deep, quick inspiration; then the glottis is partially closed and the air is propelled upward for- cibly, causing friction which tends to expel anything on the walls of the mucous membrane of the bronchial tubes and trachea. Even in simple bronchitis, if there is much coughing, there will be found increased resonance in the apices of the lungs, as there is prob- ably always a temporary emphysema. Nasal irritations may produce cough as frequently as they cause asthma. Irritations of the nasopharynx and pharynx proper frequently cause coughing, which is very likely to be accompanied by retching and even vomiting. An elongated uvula may tickle the epiglottis and cause spasmodic, quick expiratory coughing. This cause, however, is rare compared with the frequency of cough caused by an enlarged lingual tonsil, whether the tonsil is hypertrophied, contains dilated blood- vessels, or is inflamed. Any disturbance of this gland or lymphoid tissue may cause a tickling in this region sufficient to produce a very irritating and disturbing dry cough, which comes on sometimes in paroxysms, until a certain amount of mucus is literally scraped off. The very intensity of the cough so irritates the part, like scratching a spot on the skin that itches, as to stop the tickling sensation for a time. Irritations of the larynx almost always cause cough. Hence no TYPES OF COUGH 2SS examination of a patient who coughs is complete with- out a throat and larynx observation. TYPES OF COUGH The dry bark of spasmodic croup is very character- istic. The noise is low pitched, and is a bark. If it is husky there is mucus or membrane present. The cough of bronchitis can be of all descriptions; it may be dry, may be non-productive, and may be moist and productive. Pain in such cough (the same is true of grip) is referred under the sternum, and is due largely to the vibrations of the air causing pain to the inflamed mucous membrane of the trachea and per- haps larger bronchi. The cough of pneumonia is at first somewhat pain- ful, and the pain is referred to the side, near the nipple. This cough may be at first dry, but is soon productive and generally should not be discouraged. The eough of pleurisy is non-productive and unde- sired, and is never loud. It causes pain referred to the side, and is repressed by the patient. There is nothing to expectorate, and it should be discouraged and stopped. The cough in the first stages of tuberculosis is often ,dry and catchy ; it is a hack. There is no great inten- sity to this cough, and no necessity for it, and it should be discouraged. As soon as there is much local bronchial catarrh the cough should, as it is then pro- ductive, not be discouraged, except at meals, and in the presence of others; that is, such patients should be taught when to cough. In laryngeal tuberculosis the ulceration of the cords produces usually a peculiar croaking cough. The cough of asthma is a wheezing affair and accompanied by all sorts of rattlings; the same type occurs in a stuffy, asthmatic bronchitis. This cough is generally not harsh. Nervous cough usually consists of a single effort often repeated from time to time with monotonous regularity. The coughs of different individuals vary. Some always cough with great intensity, and others easily and lightly. Older persons seem to raise muciis and pus from the bronchial tubes with difficulty. It takes 256 ACUTE BRONCHITIS a great many coughs to raise the sputum for expecto- ration. Young children generally cough easily, but generally swdllow their sputum. Very weak patients will hardly expectorate at all. In such cases the foot of the bed may be raised at night ; also when they cough while in bed, they should turn, onto the side or stomach in order to raise the sputum, or they should lean over in order to have gravity aid as much as possible the expulsion of the mucus, etc. The cough of pertussis occurs in showers or paroxysms, and at the height of the disease the glottis closes during inspir- ation, and the air is sucked in through a more or less narrow slit, giving the characteristic "whoop." Persons coughing very hard, as typically in whoop- ing cough, but also in emphysema and in the severe bronchitis of strong, sturdy men, will cause a great deal of cardiac disturbance by retarding the flow in the large vessels of the thorax, thus increasing the work of the heart, especially of the right side» Such coughing can force backward the blood in the large veins thus congesting all the organs, notably the eyes, face and head, and whooping-cough can cause a cere- bral hemorrhage or a hemorrhage into the eyes. These patients may not infrequently have nosebleed, and even vomit blood. ACUTE BRONCHITIS There is no question that, whether bronchitis occurs in an adult or in a child, the patient will recover more quickly if he remains in bed for one or more days. The prophylactic treatment is the same as for an acute coryza, and these treatments will more or less relieve the congestion in the bronchial tubes and pro- mote expectoration, if the disease is not aborted. The cough is at first non-productive, but as soon as mucus begins to be plentifully secreted the cough is pro- ductive, the tightness of the chest is relieved, and the patient feels better. One of the best promoters of a free mucus secretion is ipecac, and a few drops of the syrup of ipecac, given every hour, unless nausea is caused ; or from 0.03 to 0.05 gm. (about % to 1 grain) of the powdered ipecac may be given every two hours. The ipecac should never he pushed to the point of causing uncomfortable nausea. The dose should, therefore, as suggested, be very small. ,• Gm. or C.c. 20 gr. IV 5 3iss 2S flgi 100 flSiv TREATMENT OF BRONCHITIS 257 In the second stage of bronchitis there is no expecto- rant that seems to work so well as ammonium chlorid, and the dose should be about 0.25 gm. (4 grains) every two hours. The bad taste of this drug. may be well covered up by giving it in a sour mixture, as the syrup or citric acid and water. If the cough is excessive and more than the secretion calls for, there is possibly no better method for its control than to give small doses of codein sulphate. This may be combined with the ammonium chlorid in a sour mixture, as : IJ Codeinae sulphatis Ammonii chloridi Syrupi acidi citrici Aquae q. s. ad M. Sig. : A teaspoonful, in water, every two or three hours. This prescription is for an adult, but may be readily modified according to the age of the child. If the codein is not desired, it may be omitted. If it is desired to give the ammonium chlorid less frequently, the dose may be made larger. If a sweeter mixture is preferred, the syrup of tolu may be substituted for the syrup of citric acid; or both the syrup of citric acid and the water may be omitted and the syrup of wild cherry substituted. If the larynx is inflamed, the inhalation of simple steam, or various other inhalants, may be of value, but a patient with laryngitis of any type should be under very careful observation by a physician. The steam for inhalation may be modified by adding to the boiling water oil of eucalyptus, 5 minims to the pint, or compound tincture of benzoin, 1 dram to the pint. If the expectoration becomes more profuse and seems not to stop readily, terpin hydrate seems to be of value. The dose is 0.30 gm. (5 grains) about four times a day. This may be given in tablet or in powder ; solutions are unsatisfactory as it is very insoluble. If deemed advisable it may be combined with codein or heroin in small doses. There is, however, no real advantage in heroin over codein. If the coughing persists longer than a week, the sputum should be examined to determine what germs 258 ASTHMA are present. If it proves to be a simple bronchitis, but prolonged, sodium iodid in small doses may be of value, especially if the patient is at all asthmatic, or should he be an elderly person. Fresh air, good food and iron are always of value in curing all kinds of bronchitis. If the patient is a child and the nutrition is poor, plenty of good food rich in fats should be sup- plied. A bronchitis that will not stop must be treated as a pre-tuberculous stage of tuberculosis, and the patient should receive climatic, or open air rest cure treatment. It should be emphasized that a patient with bron- chitis is not properly supervised unless the tempera- ture is taken, and this more or less frequently. A patient with a fever should remain at home, if he wishes to avoid complications that readily occur from an acute bronchitis or grip. The district nurse or the medical inspector should always take the temperature of a coughing child. If a child has any fever, it should be sent home and the family physician summoned. ASTHMA In the first place, the disease asthma should be disso- ciated from conditions which are termed asthmatic. A patient may be asthmatic from various causes, but the term asthma should be limited to the disease or condi- tion itself, i. e., periodic attacks of bronchial spasm. More or less continued dyspnea, with or without whistling rales, and with or without acute attacks of asthma, may be caused by cardiac disease, cardiac asthma; by renal insufficiency, renal asthma; by pleth- ora, causing attacks of acute hyperemia of the lungs; by arteriosclerosis ; emphysema ; diabetes ;. thyroid dis- turbances, and by the various anemias. Spasmodic asthma may be caused by bad heart attacks ; by acute toxemia from renal insufficiency; by exacerbations of gout, probably due to a toxemia from nitrogenous mal- metabolism; by acute indigestion, and by gastrointes- tinal irritants causing a swelling of the mucous mem- branes of the bronchial tubes, really an urticaria. This swelling of the mucous membrane of the bronchial tubes has been caused by injections of horse serum. CAUSES OF ASTHMA 259 CAUSES The diseased condition, or neurosis, termed true asthma, is often due to irritation of the nose and throat, and sometimes of the ear; is frequently due to chronic bronchitis, often is concomitant with acute dis- turbances of the mucous membranes of the upper air passages, as when caused by irritations from pollen, such as hay fever, rose fever, and by various dust and drug irritants. Asthma, however, is frequently a sim- ple respiratory neurosis. An attack of asthma generally occurs at night, and may be preceded by hea,dache, some symptom of indi- gestion, mental depression or nervous irritability. There is at first some slight dyspnea and a short dry cough. The dyspnea and consequent cardiac distress increase, and the agony suffered by these patients can not be understood unless one has seen them suffering from an attack of this terrible disease. The agony is almost as great as that of acute cardiac dyspnea; although there is not much mental anxiety. The patient may be pale or almost livid, and the expression of the face shows the suffering due to attempts to inspire, and then to expire, through the contracted bronchial tubes. The muscles of inspiration being stronger than the muscles of expiration, for a time more air enters the lungs than can get out, and little by little there is increased chest distention. Percussion shows hyper-resonance. The greatest amount of wheezing, as shown by the stethoscope, is in expiration, and the expiration is prolonged in the attempt to empty the lungs and prepare them for the next inspiration. If the bronchial secretion begins, as it generally does, moist rales may also be heard, and, after a series of spasmodic efforts, the cough brings up white glairy mucus. The length of these attacks of acute asthma, if unre- lieved, varies from an hour or two to all night, and sometimes an attack may last several days. Occasion- ally the attacks last for many hours, or even days, in spite of all treatment, and any temporary relief given by powerful drugs may not prevent the resumption of the asthmatic spasm the moment the patient is out of the influence of the drug. ^The amount of dyspnea 260 GENERAL TREATMENT OF ASTHMA that the patient has, and the amount of suffering and the seriousness of the attack, do not bear a close rela- tion to the amount of wheezing that is heard. A patient may not suffer greatly from dyspnea so long as he is sitting upright, and yet be wheezing like a decrepit old horse. The longer the paroxysm lasts and the more intense it is the greater the danger of permanent injury to the heart and the greater the danger of the distention of the chest so injuring the lung tissue as to make the emphysema permanent. Even after repeated attacks most patients have no cardiac injury and no lung injury, but this is doubtless because most of those who suffer from acute asthma are young; the older patients do have more or less lasting bronchitis, heart debility and more or less constant dyspnea and often emphysema. It is rare for a patient to die during an attack of acute asthma, but the condition should always be considered serious, as it could never be decided how much future disability was caused by the pro- longation or repetition of such serious disturbance of the vital functions of respiration and circulation. Acute attacks of asthma may occur every night for a series of nights, and then not for a long period, or after one attack there may be no more for some time, or they may occur more or less periodically, or they may recur only at certain periods of the year or in certain places. These last are likely to be due to nasal irritations. The attacks may also occur more or less frequently for several years, or even for a lifetime. GENERAL TREATMENT The opinion is gaining ground that asthma is a form of anaphylaxis. The physician should endeavor to ascertain what type of hypersensitiveness each case presents. The treatment of this troublesome disease, or condi- tion, will never be a success unless the cause has been determined, and, if possible, removed. Hardly any patient with any disease should receive a more careful general examination than the asthma patient. The lungs must be carefully examined for bronchitis and emphysema, and more serious conditions found or eliminated, and the blood pressure taken. The diges- SENSITIZATION IN ASTHMA 261 tive ability of the stomach and intestines should be investigated, the urine should be examined, and all pos- sible reflex causes sought in the throat, nose or ears. If all tangible causes of the asthmatic attacks have been eliminated, a careful analysis of the excretion of the various salts and solids in the twenty-four hours' urine, on a known diet, should be made. Even careful examinations of the feces, on a known diet may give conclusive evidence of the cause of the toxemias that give rise to asthma. Finally the response to cutaneous sensitization tests with various food substances pre- pared as vaccine for this purpose may be thoroughly studied with a view to finding some substance to which the patient has an idiosyncrasy. SENSITIZATION According to I. Chandler Walker (Jour. A. M. A., Aug. 4, 1917) bronchial asthmatics who are sensitive to specific substances have the onset of their asthma early in life, are not usually subject to chronic bron- chitis nor to cardiorenal disease. Those not sensitive have asthma after 40 years of age and have the two complications mentioned. The sensitive patient will usually be found to respond with a positive skin test to one of the following kinds of protein: horse dan- druff, staphylococci, wheat, pollens, cat hair and a few very common foods. The skin test is made as follows : "A number of small cuts, each about one-eighth of an inch long, are made on the flexor surfaces of the fore arm. These cuts are made with sharp scalpel, but are not deep enough to draw blood, although they do penetrate the skin. On each cut is placed a protein and to it is added a drop of tenth normal sodium hydroxide solution to dissolve the protein and to per- mit of the rapid absorption. At the end of a half hour the proteins are washed off and the reactions are noted, always comparing the inoculated cuts with nor- mal controls on which no protein is placed. A positive reaction consists of a raised white elevation or urti- carial wheel surrounding the cut. The smallest reac- tion that can be called positive must measure O.S cm. in diameter. 262 MEDICAL TREATMENT OF ASTHMA DRUGS IN ASTHMA Perhaps the most frequently successful drug in pre- venting the recurrence of asthma is an iodid, and this is probably because most asthma is due to affections of the air passages, and this drug is specifically a stimu- lant to the mucous membrane of the nose, throat and bronchial tubes. If any chronic disturbance is located in these mucous membranes the iodid tends, first, to increase the exudate from these membranes, then to make the mucus more liquid, and, while at first appar- ently irritant, soon relieves congestion of these mem- branes, and often, sooner or later, cures a chronic con- gestion and causes the membrane to become healthy. Hence the frequency of success from iodid simply emphasizes the necessity of a careful examination for, and the removal, if found, of any nasal obstructions or irritations. After such removal, a sensible treat- ment to prevent the recurrence of attacks would be the prolonged administration of iodids, and very large doses are seldom needed, or if the history of the attack shows long standing of the disease, the treatment of the neurosis by bromids is advisable, and here again the dose should not be large. We should not produce debility either with iodids or with bromids. Arsenic, a so-called alterative drug, seems at times to have a specific action. In chronic bronchitis, in asthma, in catarrhal conditions of the air passages, arsenic, when given for a long period, is sometimes of considerable benefit. The respiratory ability and free- dom from colds and coughs of the arsenic eaters of France and the Alps is well known. A local cause in the upper air passages having been removed, if there was any such, besides treatment either by iodids or bromids, if either one is deemed advisable, anything that will improve the general health of the individual should be utilized. An occupation in which there is an atmosphere of dust or other irritant should be changed for one more suitable. Perhaps indoor work should be changed for outdoor work, per- haps the climate or location should be changed. Any indigestion, gastric or intestinal, should be corrected; constipatiop should be prevented; anemia should be treated, and insufficiency of the thyroid, if present, should be noted and modified. DRUG TREATMENT IN ASTHMA 263 If asthma occurs at certain periods of the year as does hay fever, the preventive treatment is the same as for hay fever. Anything that will reduce the nasal irritations and congestions will relieve the asthma, and any change in location that will prevent the hay fever will generally prevent the asthma. To just what local- ity or climate an asthmatic patient should be sent is difficult to determine. Also it is impossible to predict that, because one patient is benefited by a sojourn or residence in one particular place, that place will be beneficial to the next patient. Theoretically, regions free from dust and vegetation should be the regions to prevent attacks of asthma. Sea voyages are some- times beneficial and sometimes not. The decision as to whether or not benefit will be derived from certain regions may often be determined by a careful investi- gation into the condition of the patient's mucous mem- branes and the condition of his circulation. Anything that would tend to make the circulation better in the mucous membranes of the upper air pas- sages and diminish congestion and tumefaction of the mucous membranes of all the air passages will tend to prevent recurrences of asthma. Cardiac insufficiency, of course, should be properly treated, and whether the heart needs digitalis or the arteries need nitroglycerin or nitrites continuously, or whether the general good effect of ergot on the circulation is needed (and asthma may sometimes be prevented by ergot) must be deter- mined by a careful study of the individual patient. Insufficiency of the kidneys as a cause of asthma should be treated by the proper diet and the preven- tion, - if possible, of nitrogenous toxemias. Such asthma is an indication of nitrogenous poisoning. The asthma due to gout is often best combated with thyroid, and when there is insufficiency of the thyroid in young individuals, which may be recognized by well-known signs, such as amenorrhea or scanty menstruation in women, an unusual and undesirable increase of fat, a dry condition of the skin, and a tendency to nitrogen- ous poisonings, the asthma will be benefited by small doses of thyroid, perhaps, coiricidentally administered with small doses of iodid, as iodid has been shown to be the most active stimulant of the thyroid gland. 264 PAROXYSM IN ASTHMA TREATING THE PAROXYSM The best treatment of the paroxysm of asthma must be decided by a careful study of each individual patient. There is no one best treatment for the asthmatic attack. The drug that most frequently is suc- cessful in rendering the patient comfortable and short- ening the paroxysm is, of course, morphin, but before the physician begins the treatment of the asthmatic attaqjcs with morphin he should have exhausted his other resources, as he is not sure that he can cure the asthma, even if he removes the reflex cause, and such patients readily acquire the morphin habit. If a given patient is incurable under the surroundings and condi- tions in which he must live and no other drug will relieve his suffering, he doubtless has the right to receive morphin, even if he does form the habit. In endeavoring to abort or shorten the attacks we may have recourse to narcotics, which relieve the paroxysm by inhibiting the reflexes and dulling the receptive centers. Such drugs are morphin, bromids, chloral, and chloroform by inhalation. We may use drugs that dull the peripheral nerves and prevent their susceptibility to the irritation from which they are suffering and thus abort the paroxysm. Such drugs are mostly of the atropin group, as bella- donna, stramonium and hyoscyamus. The effective action is atropin action, and doubtless atropin, and per- haps scopolamin (hyoscin) will do all the good that the crude drugs can do, although inhalation of the fumes from burning stramonium leaves has been used with success for centuries. We may consider the treatment with such drugs as cause muscular relaxation by prostration. Such are emetics, and nicotin with patients who are not used to its action. The next group of drugs whose action we consider in the treatment of asthmatic attacks are vasodilators. These drugs not only dilate the peripheral blood vessels and therefore relieve congestion in the mucous mem- branes of the respiratory tract, but also are preventers of muscular spasm. Such are, of course, the nitrites in the form of amyl nitrite, sodium nitrite, and nitro- glycerin. The iodids will also cause lowered blood pressure, but are hardly of value during the attack. INHALATION IN ASTHMA 26S Many times quite the reverse of this dilating, relax- ing treatment is indicated in an asthma paroxysm. The vasoconstrictors are indicated, and if used in these instances will abort the attack. The best are solutions of epinephrin sprayed on the mucous membranes of the nostrils or throat, or into the larynx, or an epineph- rin preparation in tablet form may be dissolved and absorbed in the mouth. The action is of course imme- diate, and sometimes so is the relief. For the nos- trils epinephrin spray solutions of from 1 to 10,000 to 1 to 5,000 (diluting with a mild alkaline solution) may be used. In the throat and larynx a strength of 1 to 3,000 may be used. Digitalis is sometimes of advan- tage in these attacks even if there is no cardiac lesion or cardiac debility. Intramuscular injection of an aseptic preparation of ergot is also sometimes efficient treatment in stopping the paroxysm. Citrated caffein, or strong coffee, or strong decoc- tions of tea are of benefit during the asthmatic attack in some individuals. The favorable action of caffein must be due to the cardiac stimulation and possibly to stimulation of the respiratory center. Strychnin given hypodermatically has been much rec- ommended for the asthmatic attack. While it generally fails, it sometimes does a great deal of good to patients who have bad heart action. A combination of strych- nin, morphin, and atropin given hypodermatically sometimes seems to act better than when the strychnin is omited. INHALATIONS Almost from ancient times paroxysms of asthma have been treated by the inhalation of fumes from burning medicinal substances. For this purpose the medicated substance may be in the form of cigarettes, powder,^ cones, or papers. Sometimes the fumes of these burning powders are directly inhaled, or the patient's bedroom is allowed to become filled with the fumes. Sometimes the attack is relieved by the inhala- tion of steam, or the vapor of boiling water in the room of the patient adds some relief. Sometimes liquid medicaments are added to boiling water in vari- ous apparatus for inhalation. Most popular, however, 266 INHALATION IN ASTHMA and most frequently used are the powders or papers, or pastils that are burned and inhaled directly. Probably nearly all the powders or papers ordered by physicians for inhalation for asthma and almost all of the patented preparations and nostrums contain niter (saltpeter) and stramonium, or belladonna, or other atropin-containing drug. The action of the niter, i. e., potassium nitrate, fumes is to cause relaxation both of the blood vessels and of the bronchi. Papers are saturated with solutions of potassium nitrate, and when dry may be rolled in the form of a cigarette and smoked, or may be burned in any other form, and the fumes are beneficial to some patients. The addition of potassium nitrate to other medicinal powders causes them to bum more readily and give off their fumes. Stramonium (leaves) is the most frequent form in which the alkaloid atropin is administered by inhala- tion. The action of the atropin thus locally applied is to dull the irritability of the peripheral nerves in the nose, throat and larger bronchial tubes, and thus by relieving irritation tends to relieve spasm. At the same time the atropin acts as a circulatory stimulant. Various combinations of drugs are used for inhala- tion for asthmatics, many of which are nostrums (but have been analyzed) and have more or less efficiency in relieving the attack, because of the potent drugs often recklessly employed. The asthma nostrum ven- dor is looking mainly for immediate results, and he cares little what the danger to the patient may be or how strong a dose he gives; consequently, he orders used sufficient amounts of the drugs to. cut short the asthmatic attack. Therefore, the prescription which a physician is willing to write may not be so successful in a certain case as the nostrum temporarily may be. One form of asthma cigarette contains the following ingredients : Belladonna leaves 5% parts Hyoscyamus leaves 2% parts Stramonium leaves 2% parts Extract of opium Vs part Cherry laurel water A sufficiency The dried leaves are cut small, mixed well, and moistened with the opium which has been dissplved in PROTEIN IMMUNIZATION IN ASTHMA 267 the cherry laurel water. A small amount of potassium nitrate is added in order that the cigarettes may burn readily. Arsenical cigarettes also have been used by asth- matics, sometimes beneficially. Yeo says that- "these are made by dissolving 15 grains of arsenite of potash in half an ounce of distilled water and saturating unsized paper with it. This is afterward dried, cut up into twenty pieces, each of which is rolled up into a cigarette. The smoke from the cigarette must be drawn into the bronchial tubes by a slow inspiration." It certainly is not obvious how arsenic can shorten an asthmatic attack. The administration of arsenic in small doses for some time may prevent the develop- ment of asthma, and chronic bronchitis is sometimes benefited by the prolonged use of arsenic. PROTEIN IMMUNIZATION Walker found that asthmatics who were sensitive to proteins in horse dandruff or cat hair were relieved of attacks during a series of subcutaneous injections with these proteins. Treatment was begun with a dilution of the protein next higher than that to which the patient reacts, sometimes as high as 1 : 100,000. The strength of the dilution is then slowly and grad- ually increased waiting for a subsidence of response following each infection. The largest number of doses required was forty-two, the average number was eleven. The protein extracts are injected intramuscu- larly with all of the precautions that accompany any surgical procedure, including thorough cleansing of the skin, sterilization of the syringe by boiling, and absolute surety that the injection is not being made directly into a blood vessel. Oxygen inhalations have sometimes been used by asthmatics, and with relief. This, however, is not very dissimilar to breathing the outside air, and will, of course, partly relieve the oxygen starvation. A patient who must go to the window and gasp for breath should, perhaps, have an oxygen tank in his room to use when he needs it. Xi we were to Siim up the best treatment for the paroxysm of asthma we must say morphin and atropin hypodermatically, the administration of nitroglycerin 268 HAY FEVER by the mouth, or epinephrin into the nostrils or throat, or tablets containing epinephrin dissolved in the mouth, fumigations with potassium nitrate and stra- monium, and cocain applications and sprays, if must be. HAY-FEVER This troublesome condition is most frequent in the late summer and early fall months,-but it may occur at other times of the year in different climates, depending on the susceptibility of an individual to various pollen-beariiig plants. While bacteria may increase the intensity of the disease, or may cause a patient to become susceptible to it, still hay-fever is probably always caused by irritating pollen. The disease is present only in regions where pollen- rich plants predominate, and occurs only when these plants have reached the stage of disseminating the pollen, or when the pollen is artificially introduced into the nostrils of a susceptible person. When a patient is removed from all source of pollen, or when the offending weeds are destroyed in the region in which the patient lives, hay-fever does not occur. Hay-fever is no respector of persons, and may occur at any age, in both sexes and in any civilized race. It is more frequent, however, in males, and more fre- quent in the white race than in the colored race. The age of greatest susceptibility, or the age at which most cases develop, seems to be in the decades from 10 to 40. This age of greatest incidence and the rea- son that males are more affected than females may sigfnify the age and sex most exposed to pollen. Scheppegrell, president of the American Hay-Fever Prevention Association, finds that hay-fever may be artificially produced at any time in hay-fever subjects. If the inoculation of the irritating pollen, which he finds to be the male elements of the flowering plants, is given to the patient at another period of the year than the hay-fever season, the length and degree of the attack may be accurately controlled. This is because, unlike micro-organisms, the male elements of these pollens cannot reproduce themselves. The reaction from these pollens he divides into the direct and indirect effect. Some produce the reaction by the local mechanical irritation, and this perhaps PREDISPOSITION TO HAY FEVER 269 even in persons not susceptible to hav-fever. In insusceptible subjects, the reaction ceases as soon as the pollens are discharged. The indirect effect occurs in susceptible persons who are poisoned by absorption of some to^albumin contained in the pollen. While the pollen of many plants may cause hay- fever reaction when applied directly to the nostrils, it is only the wind-borne pollens that need to be consid- ered in hay-fever. Scheppegrell states that it is char- acteristic of hay-fever weeds that they have no attrac- tive flowers or perfumes, and these hay-fever plants are "the ragweeds, wormwoods, cockleburs, careless weeds and grasses." In the United States, the spring type of hay-fever is caused by the grasses, while the fall types are caused more by the ragweeds, the cockle- burs and the wormwoods. While it seems to be a fact that goldenrod is a cause of hay-fever, Scheppe- grell doubts that it is a frequent cause. SUSCEPTIBILITY AND PREDISPOSITION There can be no question that a susceptibility to hay- fever must exist since so few persons (1 per cent., according to Scheppegrell) in a locality overrun with these weeds are subject to the. aifHiction. Cook, Flood and Coca (Jour. Immunol., 1917, 2, 217) after careful investigation of the subject of sen- sitization, sum up thus: 1. Hay-fever is the clinical symptomatic expression of local hypersensitiveness. The active pollen substances are not toxins. 2. The hypersensitiveness is established spontaneously and never by immunologic process. This has been shown in two ways : first, by the observation that individuals may be sensitive to pollens of plants that are indigenous in foreign countries and with which they have never come in contact; and second, by the observation that individuals who are naturally sensitive to one protein only cannot be artificially sensitized to another protein, either animal or vegetable. 3. The sensitization is not directly inherited, although the tendency to spontaneous sensitization is inherited as a domi- nant character. 4. The antibody-like substances of human sensitization are not demonstrable in the blood of sensitive persons by any of the immunity reactions. They are present in the cells of the 270 SUSCEPTIBILITY TO HAY FEVER sensitive tissues. They cannot be increased artificially by the usual process of immunization. S. The mechanism of the alleviating effect of specific, that is, pollen extract therapy, is the same as that of desensitiza- tion in experimental anaphylaxis. The freedom from symp- toms lasts as long as the respective "antigenic" substances remain in combination with the antibody-like substances in the tissues. Persons who are attacked by hay-fever may be pre- disposed by some other cause than a peculiar hyper- sensitiveness of the mucous membrane of the nose. These patients, many times, are found to have ana- tomic malformations, such as hypertrophic turbinates or deviated septums, or other obstructive or irritative conditions in the nostrils, and many of these patients are cured by the removal of these abnormal condi- tions. In other instances more or less incurable pathologic changes may be present in the mucous membrane of the nose and adjacent sinuses. Further- more, a neurotic^ individual may be more hypersensi- tive to this irritation than other persons without any assignable physiologic, pathologic or anatomic excuse. On the other hand, as shown by Strouse and Frank {Journal A. M. A., March 4, 1916, p. 712), persistence of a hay-fever attack rnay well be due to an associated bacterial acute or subacute infection. An associated infection may allow more of the pollen irritant to become absorbed, and the disease is then intensified and is more difficult to cure. True hay-fever due to pollen should be differenti- ated from similar conditions caused by emanations from animals, such as the horse, cat or dog, and from odors from certain fruits, flowers, and from ipecac and musk. Sneezing, lacrimation, coughing and asthma may occur in some persons, who have such peculiar idiosyncrasies. Bronchial asthma may occur as a separate entity, or be associated with or follow hay- fever; hence its treatment often is the same as that of the hay-fever. The symptoms of an attack of hay-fever may begin immediately on inhalation of the pollen, or they may be delayed for a few hours; but sneezing, congestion of the nostrils, reddening and itching of the eyelids or of the inner canthi of the eyes, irritation of the GENERAL TREATMENT OF HAY FEVER 271 roof of the mouth and throat, and soon more or less spasmodic attacks of sneezing are the primary symp- toms. Later rhinitis may occur, with more or less conjunctivitis, pharyngitis and bronchitis. There may be temporary increased temperature, but soon there is depression, more or less weakness, and often sub- normal temperature. GENERAL TREATMENT 1. All predisposing causes should be ascertained, and if possible, removed. (a) Hypertrophic and sensitive mucous membrane of the turbinates should be removed. An obstructive and deflected septum should be corrected. An infected sinus should be cleaned. (b) All infected areas in the mouth and throat should be removed. (c) Meat and purin bases should be removed from the diet. Although the diet should be nutritious, it should contain no irritating substances, such as mus- tard or other condiments. Tea, coffee and, of course, alcohol are contraindicated. Fish, strawberries, and any other food that is likely to cause anaphylactic irritability should not be allowed. (d) The bowels should be carefully regulated so that toxic intestinal substances are prevented from entering the circulation and adding to the disturbing elements already present in the blood. (e) Alkalis should be administered to decrease any possible hyperacidity of the system. There is no bet- ter alkali than sodium bicarbonate, which should be administered for a few days at least in a dose of 1 gram (15 grains) every three hours. It is pleasantly given' as an effervescing salt, or it may be given in combination with a small amount of bismuth sub- carbonate, as : Bismuth subcarbonate S gm. Sodium bicarbonate 20 gm. Mix, and make 20 powders Take a powder, with water, every three haurs. This small amount of bismuth may prevent the slight irritation of the mucous membrane of the stomach that may occur frotn.the sodium bicarbonate. 272 GENERAL TREATMENT OF HAY FEVER If preferred, potassium citrate may be the salt administered. The dose should be 2 gm., given in wintergreen water, and administered four times a day. There is no question that alkalis many times diminish the irritability caused by anaphylaxis, and it has long been recognized that alkaline sprays in the nostrils are of benefit, and alkaline gargles are soothing, in hay-fever. (/) Calcium is often of value in hay-fever, as it is in hives, in angioneurotic edema, and in some forms of asthma. Calcium may be administered as calcium lactate, or as the more irritant calcium chlorid. If the lactate is used, and especially if the chlorid is used, it should be administered after food has been taken, and then largely diluted. (g) An associated bronchitis should be treated as though the hay-fever were not a factor. (h) A weakened heart should be strengthened. The persistent sneezing and the frequent coughing in hay-fever always more or less weaken and tempo- rarily, at least, dilate a heart, and a hay-fever patient generally is improved by digitalis. Of course, if the heart is sturdy, if there is arteriosclerosis and hyper- tension, digitalis may not be indicated, and nitro- glycerin may be of value. Strychnin is generally inadvisable, on account of its increasing the general nervous irritability. 2. If possible, all pollen-bearing weeds in the imme- diate neighborhood of the patient's home should be destroyed ; otherwise the patient must migrate to some pollen-free region. 3. The symptoms should be ameliorated. Most patients certify to the relief obtained from simple alkaline sprays in the nose and throat. Such treat- ment is well represented by alkaline tablets, consisting essentially of sodium bicarbonate and borax, dissolved in 60 c.c. (2 fluidounces) of warm water. Epi- nephrin sprays, in solution of 1 : 10,000, are used, and are frequently of value. It may also be used as an ointment of 1 : 1,000, and a small portion placed in each nostril. Some persons, while getting immediate relief from epinephrin solutions, later have increased congestion and extra speezing, but the majority of SPECIFIC TREATMENT OF HAY FEVER 273 patients are benefited. -Sometimes a weak menthol, or menthol and camphor, oil spray or ointment benefits the patient. While cocain may be used by the phy- sician in his office, if he thinks it advisable in an indi- vidual case, such solutions should not be given to the patient, and should not be used frequently by the physician. Boric acid washes and eyedrops will gen- erally relieve the itching of the eyes and eyelids and will be soothing in conjunctivitis. If the nasal dis- charge is very profuse and watery, atropin sulphate in a dosage of 1/500 grain every two hours may be given until there is a dryness of the throat. If there is much asthma and the patient wheezes and has hard work to get his breath, and the bronchial secretion is not sufficient, sodium iodid in a small dose to cause an increased secretion may be good treat- ment, although it will almost invariably increase the nasal secretion. 4. The only drugs that have proved of much value in hay-fever are quinin and antipyrin, and these are not very efficient. Large doses of quinin have been found successful in some cases. Antipyrin in large doses has also modified the attacks, much as it may modify the paroxysms of a whooping cough; but the doses must be large, and during its administration the heart should be protected by digitalis. Arsenic and strychnin have been advocated, but have not been proved of much value. SPECIFIC TREATMENT Preventive. — Before it is decided to use a pollen extract, it is advisable to ascertain the particular pollen to which the patient is susceptible. The skin test is safe and generally satisfactory; the eye test is hardly justifiable. Various dilutions of different pol- len extracts should be tried in this test. The arm is generally employed for this purpose. Several scratches through the epidermis are made, and a drop of the pollen extract, beginning with a well diluted solution, of first one hay-fever weed and then another, is used to note the sensitivity. A patient sensitive to an extract soon shows local irritations at the point of absorption. As soon as the pollen that causes reaction 274 SPECIFIC TREATMENT OF HAY FEVER is found (the reaction occurring in from five to fifteen minutes), various dilutions of this particular pollen may be tested to determine the dose correct for this particular patient, and the first dose of injection should be the dose which fails to excite a skin reaction. The first subcutaneous injection should not be given until after all symptoms of the local skin test reaction have subsided. , Turnbull (Boston Med. and Surg. Jour., 1916, 175, 931) has demonstrated something that seems to be of practical interest: He found that some of these hay- fever patients showed a cutaneous reaction from the proteins of wheat, barley, oats, corn and rice, and some even showed a reaction, especially to wheat, on the respiratory tract. Therefore, he believes that hay-fever patients should avoid bread and boiled cereals, and use only the dry, prepared cereals, and he finds that patients so arranging their diet are more quickly cured of their hay-fever. As it is not always feasible to test out the individual pollens as described above, the stock preparations of mixed spring or fall pollens may be used. Full direc- tions for the use of these pollen extracts for diagnostic purposes, for immunization, and for curative purposes, come with the package. The preventive treatment of hay-fever should be begun about eight weeks prior to the season in which the patient is susceptible. Ordinarily from ten to fifteen injections are required, and they should be given at two or three day intervals, depending on the amount of reaction. If symptoms of anaphylaxis or hay-fever symptoms occur, the dose should be smaller and less frequent. If the patient, from such injec- tions, is immune for that year, he may be immune to the hay-fever pollen the following year; but it seems to have been shown that this immunity is only weak and rather ineffective by the third year. However, sufficient statistics have not yet been offered to. show how long an immunity may last; also failure to pro- duce immunity must be expected. The theory of this treatment is that a person sensitive or sensitized to a certain pollen may be desensitized by exhausting from the body cells the specific proteolytic enzymes by the pollen protein injection. SPECIFIC TREATMENT OF HAY FEVER 275 Curative. — Theoretically and practically there can be no antiserum prepared to treat pollen infection or hay- fever. Rarely, perhaps, the hay-fever may be aborted, after it has begun, by a few injections of a pollen extract; but not enough data have been pre- sented to show the value of the vaccine treatment during the active process of hay-fever. The symp- toms could easily be aggravated and perhaps become serious by a large dose of pollen extract. Consequently, only very small doses should be tried, at first, to see what reaction the patient shows, and with gradually ascending doses the susceptibility can be ascertained and the pollen curative treatment tried. It would be inexcusable, however successful in indi- vidual cases the pollen treatment might prove to be, to omit the therapeutic suggestions already mentioned. It would also be inexcusable to depend on possible immunization for the following year by means of pol- len extracts and to omit a careful study of the patient to eliminate, if possible, all predisposing ~ causes of hay-fever disturbances. DISEASES OF THE GASTRO INTES- TINAL TRACT HYGIENE OF THE MOUTH AND TEETH The things to be remembered in the care of the mouth and teeth may be summed up as follows: 1. Theoretically water should follow the milk of bottle-fed babies. 2. A soft cloth should be thoroughly moistened with a mild alkaline wash and frequently applied over the first little teeth of the infant. 3. No candy, or at least but little, should be given to young children, and as soon as their teeth have erupted they should have the more crunchy or granular cereals, and not so much of the soft, gelatinous cereals. 4. The teeth should be regularly cleaned by a den- tist, at least once in six months. 5. All cavities, even small, should be filled, at least with temporary filling, so that the first teeth may be preserved as long as possible in order to develop the jaws properly, so that the second teeth need not be crowded. 6. The teeth of children and adults should be thor- oughly brushed at least twice a day, better three times, with a proper brush, and, at least in the morning, with a tooth powder that is not too soapy, and at night with an alkaline mouth wash. 7. All persons, growing children or adults, should have all the tartar that may become deposited cleaned from their teeth once in three months, and examina- tions of the teeth once in every six months will disclose cavities before they have become large ones. 8. If the teeth tend Ito Regenerate and cavities quickly form, the trouble is getierally with the nutri- tion, and the person is often deficient in bone-forming salts. Such patients should receive lime salts, phos- phates and iron. The best iron preparations for this purpose are: tinctura ferri chlorid, 1 or 2 drops in a wineglass of MOUTH INFECTIONS 277 water or fresh lemonade, three times a day, after meals; ferrum reductum 0.05 gram (1 grain), in capsule, three times a day, after meals; ferri oxidum saccharatum tablets, each 3 grains, 1 three times a day, after meals. If the teeth are delayed in eruption and do not grow properly in young children, the dried extract of the thymus gland may be of value. One of the tablets is given three times a day ; it is best taken between meals, crushed with the teeth and swallowed with water. If the child as a whole does not grow well, even if not a cretin or if he is in any way like a cretin, small doses of thyroid extract (glandulae thyroidse siccse) in' dose of 0.03 gram (y2 grain) once a day, is of value, and this dose is sufficient. 9. The care of the mouth during severe illness should be on the lines previously described. 10. The proper care of the teeth will prevent pyor- rhea, one of the most troublesome and painful things that can happen to the jaws, meaning a retraction of the gums and exposure of the dentine of the teeth. 11. The treatment of pyorrhea alveolaris must be strenuous and persistent. There is no excuse for its presence, and it can be eradicated. The treatment is persistent cleanliness and antisepsis, the same as in ozena. There is no excuse today for the horrible stench perpetrated by patients who suffer from ozena. The same is true of the nastiness of the breath of these pyorrhea patients, to say nothing of the danger to themselves of infection from germs harbored in the mouth. The elementary features of the treatment include a frequent use of a mouth wash of 1 part of peroxide of hydrogen solution in 4 or 5 parts of warm water, and then the persistent use of an anti- septic alkaline mouth wash and tooth paste or tooth powder after the peroxide of hydrogen has eradicated and removed the pus. MOUTH INFECTIONS Only of late years has the part played by Ae mouth and its adjacent structures in the production of a great many pathologic processes been demonstrated. The mouth, including the teeth, gums and tonsils, affords a 278 MOUTH INFECTIONS broad surface and readily accessible means of entry for various pathogenic micro-organisms. It is not always essential that visible evidence should be pres- ent in the mouth of the focus producing a systemic infection, to prqve that the portal of entry was in the mouth. The focus may be discovered only by careful examination with the roentgen ray. A portal of entry may be present and not directly demonstrable in any way, for example, when the bacteria enter the lymph or blood stream by way of the tonsils. That a focus does exist in the mouth and that it is directly responsible for the pathologic condition has been repeatedly proved by removing the source of infec- tion or by treatment with a proper autogenous vaccine made from bacteria isolated from the pus at the site of the focus. Such treatment often causes the disap- pearance of the systemic pathologic condition. Within the mouth there are various channels through which bacteria may enter the system: the tonsils, gums, roots of the teeth, and by way of the esophagus to the stomach and intestine. That the ton- sils play an important part in various infections has been demonstrated by many. In this connection, the work of Rosenow has proved that many ulcers of the stomach are associated with tonsillar infections. He obtained streptococci from some of these ulcers, and after injecting cultures of these organisms into animals, he was able to observe gastric ulcers in them. Stone pointed out the rela- tion between enlarged cervical glands and foci of infection of the tonsils, even though the tonsils may not be hypertrophied or inflamed. The short and direct communication between the tonsils and the lymphatics is responsible for this. In this way there may also result tuberculous adenitis. Perhaps equally common as a source of infection are the teeth. The open, exposed, ulcerated or decayed tooth is not always the worst in this respect. More harm may be done by the heavily crowned, capped and bridged teeth, under the poorly fitted mar- gins of which the bacteria flourish and manage either to enter the lymphatics or to send their toxins into the system. There may also be a tiny abscess situ- ated deep down at the root of the tooth. In these MOUTH INFECTIONS 279 cases local manifestations of a focus in the teeth may be entirely lacking, and may be demonstrable only by the roentgen ray. These so-called "blind-abscesses" may remain dormant a long time. Ultimately they open into the mouth by way of the sinus. Often they lead into larger abcesses in the bone, in which toxins are produced, giving rise to septic conditions. It is probable that, depending on the nature of the organ- ism in the abscess, there may result any of the com- plications so often resulting from tonsillar affections. Rosenow states that these foci are common in patients who for years have suffered from arthritis, neuritis, appendicitis, ulcer of the stomach, goiter, etc., and that persons with perfect health are, as a rule, free from sources of infection in relation to the teeth. The treatment of the complications secondary to the focus within the mouth consists first of all in remov- ing the mouth infection. Careful examination should be made of the tonsils and teeth, and if the tonsils are found to be hypertrophied or inflamed, even with- out visible signs of any abscess, they may be removed. Often the abscess may be located deep in one of the crypts. If any visible pus is present, it would be advisable to obtain a culture of the bacteria contained in it. Normal tonsils should not be removed. When the tonsils appear normal, even though there inay be no history, of tooth involvement, the teeth, neverthe- less, should be carefully examined. Poorly fitting crowns should be taken off, and often underneath them may be found the cause of the trouble. Many cases of arthritis have been cured by a correction of the dental work of the mouth, removal or filling of ulcerated areas, and insertion of proper bridge work. Roentgenograms may. locate a blind or apical abscess when least suspected. When such has been found, the tooth should be extracted. Rarely it is possible to drill into the abscess and in this way offer drainage for the pus. In this way also the tooth may be saved. This, however, can best be left to the judgment of the dentist. Besides the removal of any foci, a mouth wash may be indicated. There are many mouth washes on the market under various trade names. Many of these contain the same ingredients and vary but slightly in 280 PREVENTION OF MOUTH INFECTIONS their composition from those described in either the Pharmacopeia or the National Formulary. The best mouth washes are those that are alkaline, antiseptic and astringent. Some of the simpler antiseptic and astringent mouth washes are strong solutions of glycerin or of alcohol. Hydrogen peroxid, one part, to three parts of water is a good wash. For ordinary cleansing purposes sodium bicarbonate, in water, will serve the purpose. A list of good mouth washes appears in a later article. Cleanliness of the teeth plays an important part in the asepsis of the mouth. By regular and frequent brushing of the teeth with a good, fairly stiff tooth- brush and a simple tooth powder or tooth paste, the accumulation of tartar on and between "the teeth may be to some extent prevented. In conjunction with this brushing of the teeth, gargling with a mouth wash will aid in cleansing the mouth. Equally if not more important in the care of the teeth is the periodic visit two or three times a year to a dentist, that tartar may be removed, that caries of the teeth may be early treated, and that the condition of the gums may be noted and pus pockets early discovered. PREVENTION Prevention of suppuration or other infection in the mouth is of the greatest importance all through life. The following suggestions for preventive measures may be of value: / 1. There should be inspection of children's teeth in schools. 2. Every infected area in the mouth must be treated and eradicated if possible as soon as discovered. 3. The public should be taught that a bad tooth or a diseased gum or tonsil is serious, and neglect of such a condition may cause an incurable disease. 4. The mouth of every patient should be examined as part of the physical examination. 5. Roentgenograms of suspected gums or jaws should be taken, and if advisable, a culture from the pus or secretions of the infected region should be made. ' FOUL BREATH 281 6. There should be cooperation of the physician with the dentist to decide on what is best for the correction of mouth defects, whether certain teeth should be filled or pulled, or otherwise treated, and just what is the best treatment for a diseased gum or tonsil. Neither physician nor dentist is infallible, and both should recognize that cooperation is best for the patient. FOUL BREATH It is rarely excusable for a person having once dis- covered that the breath is offensive to neglect its prevention. Perhaps the most frequent cause" pertains to the teeth. There may be cavities, or there may simply be lack of cleanliness from an insufificient use of the tooth brush and the proper tooth powders, tooth pastes or mouth washes. It is also necessary to remove with a toothpick particles of food which may have become fixed between closely set teeth. All cavities should be filled and tartar deposits should be regularly removed, not only because of their likelihood to cause disagreeable odor to the breath, but of the possibility of allowing germs to develop and be swallowed. If the stomach is not in a healthy condition and the gastric juice not normal, such germs may not be killed. The proper tooth powder should be determined by the ease with which the teeth are cleaned, some requiring more friction in the powder, and others requiring more soap. The choice of the powder and the frequency with which the teeth should be brushed is determined by the results. They must be kept clean, and the cleansing must be done at least twice a day — in the morning and at bedtime. If there is any tendency .to alveolitis, or if purulent alveolitis is present, then antiseptic, followed by alka- line, mouth washes should be frequently used until the condition is cured, but if it tends to recur, then such mouth washes should be used once a day, continuously. For a time weak peroxid of hydrogen solutions are beneficial, especially if the acid, which is formed after its oxidizing action, is quickly washed away with an alkaline solution. If gums are spongy a 5 per cent, solution of potassium chlorate makes an efficient mouth 282 FOUL BREATH wash. One of the best local astringents and local anti- septics is a dilute solution (perhaps one part to five) of alcohol in water. The teeth not being the cause of the odor of the breath, the tonsils should be examined, and not infre- quently little calcareous deposits will be found in one or more crypts, or there may be a pocket of caseous deposit back of the tonsil. These should, of course, be removed and the crypts treated with some antiseptic solution and a cleansing antiseptic gargle given. Another frequent cause of bad breath is postnasal or nasopharyngeal infection. If this is a chronic condition the treatment is tedious, and unless the patient thor- oughly cooperates, results will be unsatisfactory. The proper treatment of nasal and nasopharyngeal infection can only be determined by a study of the individual condition. A warm cleansing solution is, of course, always important, and the frequency of its use can only be determined by the rapidity with which the secretion forms deposits. Tn atrophic rhinitis the odor- is terrible, and, unfor- tunately, the condition is generally incurable; but there is absolutely no excuse for such a patient pol- luting the atmosphere of the rooms in which he works or lives. The odor can be prevented by the proper use of mild antiseptic and cleansing solutions, such as Dobell's solution. This solution is as follows : Gm. or C.c. 5 Phenolis 1 m. xv Sodii bicarbonatis 3 Sodii Boratis 3 or aa gr. xlv Glycerini 10 flS iiss Aquae ad 200 ad flS vii M. Sig. : Use as an antiseptic gargle or as a nasal anti- septic spray. Other catises of disagreeable breath are constipation and dyspepsia. The cause of these conditions should be treated, and as the tongue becomes clean and the pharynx less congested the breath will become better. Laryngeal and bronchial inflammations and catarrhs, of course, are other causes of bad breath. If the condi- tion is acute or subacute, it can soon be improved by proper treatment. If the condition is a chronic one, MOUTH WASHES AND GARGLES 283 mild antiseptic inhalations will largely prevent the fetid condition. Gm. or C.c. IJ Creasoti 1 m. xviii Olei pini silvestris 10 or flS iii Tincturae benzoini compos- itae q. s. ad 100 ad flS iv M. Sig. : To inhale a teaspoonful from boiling water, one, two, or three times a day. MOUTH-WASHES AND GARGLES There are perhaps fifty mouth washes on the market. They are all more or less similar in their composition, more or less multiple in their constituency, and more or less expensive, and represent more or less enormous profits to their owners. A number of pharmacopeial and National Formulary preparations have been devel- oped to meet the need of mouth washes and also to imitate some of the proprietary preparations. Such polypharmacy as this is absolute nonsense. As in many pharmaceutical preparations, the value of the really useful ingredients is obscured by the useless camouflage which surrounds them. As antiseptic for the mouth and throat we cannot improve on the carefully localized applications of the tincture of iodin or of weaker solutions of iodin ; when deemed advisable, of a strong solution of nitrate of silver carefully applied locally; or of local swabbing with strong hydrogen peroxid solution, or the more generalized washing or spraying with dilute solutions (provided that hydrogen peroxid is not applied to a deep ulcer or sinus where it can possibly cause disin- tegration of tissue). Strong preparations of glycerin and strong solutions of alcohol are other pleasant anti- septics, and the latter is decidedly astringent. When a strong antiseptic is used, after it has acted for a few minutes, soothing washes or sprays should be used. Also it should be remembered that any simple cleansing wash (than which perhaps nothing is better than simple salt solution in so-called physiologic strength, 0.9 per cent., or % teaspoonful of salt to about half a glass of warm water to which may or may not be added another 14 teaspoonful of sodium bicar- bonate) is of value on an inflamed mucous membrane. A.fter such cleansing of the membrane, the antiseptic 284 MOUTH WASHES AND GARGLES may be directly applied, if such is indicated, or the cleansing and soothing gargle or mouth-wash just men- tioned may be all that is needed. It is not the par- ticular preparation that is used, or the particular ingredients in the mouth-washes and gargles, but it is efficient washing and gargling that is of benefit. The value of boric acid, not only in being mildly antiseptic, but also in promoting mucous secretion and therefore causing the easy removal of follicular exu- dates and membrane, should not be forgotten. Many times the insufHation of boric acid powder directly on the region involved is most efficient. At other times gargling of a solution in which boric acid is suspended is of value. While boric acid will dissolve in water only to about 4 per cent., a large surplus of boric acid should be left undissolved in the bottle. The bottle should be shaken, and the patient then gargles a boric acid solution which will deposit boric acid crystals on the throat, and will often be of as much value as though the powder were insufflated. Perhaps the most pleasing pungent taste to the majority of patients is peppermint, and there is no reason for mixing this up with several other aro- matics. If peppermint is disagreeable to a particular person, wintergreen may be substituted. The following are formulas of a few simple solu- tions for mouth and throat washes : 5 ss or 3 i flS VI Gm. or C.c. IJ Acidi borici 2 Potassii chloratis. . . ._ 5 Aquae menthae piperitae... 200 M. Sig. : Use as a gargle or mouth-wash, diluted or undi- luted, as directed. Gm. or C.c. IJ Sodii chloridi Sodii boratis aa 2 Glycerini 50 Aquae gaultheriae . . . q. s. ad. 200 M. Sig. : Use as a gargle or mouth-wash, diluted or undi- luted, as directed. Gm. or C.c. IJ Acidi salicylici 2 Glycerini 25 Aquae menthae piperitae q.s. ad 200 M. Sig. : Use as a gargle or mouth-wash, diluted or undi- luted, as directed. 3 ss flS iss flSvi gr. XXV flSv flSvi MOUTH WASHES AND GARGLES 285 The value of dilute alcohol washes, such as one part of alcohol to four or five parts of water, should not be forgotten. Alcohol is astringent, cleansing and antiseptic. Sometimes potassium chlorate solutions, though very disagreeable, are most healing when the whole mucous membrane of the mouth is more or less inflamed. If there are no pockets in which hydro- gen peroxid may form bubbles and cause an exten- sion of ulceration, there is no mouth-wash more antiseptic and more efficient than diluted hydrogen peroxid solution, and one part of hydrogen peroxid solution to three or four parts of warm water. Imme- diately after the use of hydrogen peroxid solutions a mild alkaline solution should be used to wash off the froth caused by the peroxid action and also to remove the acid irritation caused by such action. If the mouth is dry during illness, some slightly pungent substance may be taken, to be either chewed or swallowed, such as some effervescing water, ginger ale, some pungent mint chewing-gum, or even a simple peppermint lozenge. Of course the value, in such conditions, of vegetable sours such as lemonade, orangeade or a piece of orange is well understood. These will increase the mouth secretions and prevent drying of the mucous membrane, which is such a frequent cause of ulceration. Various preparations of glycerin diluted with water, with or without boric acid or borax, or boroglycerid, or milk of magnesia, are all valuable in preventing or aiding in the healing of a sore mouth. If the tincture of iodin does not heal an ulcer or fissure, one or two applications of either the stick nitrate of silver or a 25 per cent, solution, applied by means of a -swab, will generally cause healing. If the patient is too ill for strenuous or perfect cleanliness of the mouth, as soon as convalescence is establislj^ed extra care should be given the mouth and teeth. It should not be considered that a patient has been thoroughly examined until the condition of the mouth has been investigated. As before stated, too many chronic diseases have their source and continuation from diseases of the gums or from neglected, decayed teeth, to say nothing of diseased tonsils. A fetid, bad 286 CARE OF TEETH breath should always be investigated, as it is generally due to chronic inflammation in the mouth. While a large portion of adults over 40 have more or less pyorrhea alveolaris, a large number of these patients may have the conditions entirely prevented, and by various methods to-day many patients are cured of what was long considered an incurable condition. The foregoing of course are only suggestions, and each physician should order the mouth-wash that he desires for his patient as carefully as he would write any other prescription. There is nothing wonderful or mysteriously curative in any of the formulas described, and simple" home remedies will often be as effective as an expensive proprietary preparation, unless an antiseptic is required. Even simple starch water makes a very soothing gargle. CARE OF THE TEETH It has too long been believed that a serious illness caused of itself degeneration of the teeth, either cavi- tation or actual loss. While there are many of the elements of nutrition that are needed for the teeth to remain healthy, neglect of the mouth and teeth is probably the larger factor in their degeneration. Tartar forms, inflammation begins and pus-pockets develop around the teeth when they are not properly cleansed and the gums are not properly cared for. If the patient is so ill that he cannot allow brushing of the teeth either by himself or by the nurse, the gums and teeth should be cleansed by rubbing or spraying with the liquids selected. A great source of cleanliness for the teeth is chewing, which is more or less in abeyance during serious sickness, but we are learning that in most of the prolonged acute diseases the patient is able and willing to chew such a simple thing as dry toast. This alone cleanses tl»e teeth, starts the saliva, and normal mucous flow, and fre- quently offers a better food than the constant swallow- mg ot even nutritious liquids. If the ordinary simple cleansing lotions are not sufficient to prevent the forma- tion of pus or ulcerations, various applications to the regions of trouble should be made, and perhaps none PYORRHEA ALVEOLARIS 287 is better than the tincture of iodin, or, if that is con- sidered too severe, a modified solution of iodin as follows : Gm. or C.c. B lodi 1 gr. XV Potassii > iodidi 3 or gr.xlv Glycerini 30 flS i M. Sig. : Use externally as directed. Gies found that so-called antiseptic mouth-washes and alkaline washes did not wash off or dissolve the adherent mucin, and therefore are not effective in pre- venting decay of the teeth. He believes that the vege- table acids, such as diluted vinegar and the fruit juices and their acids, are the most successful cleansing sub- stances that can be used on the teeth. He also believes that starches and sugars should never be eaten alone, but should be certainly followed by some acid substance, as some of the acid fruits or some of the vegetable sours. After most meals, therefore, it is good sense to eat a little fruit, and on going to bed perhaps the most successful cleanser of the teeth is a little sour fruit or diluted fruit vinegar. Children and patients should also be taught to brush the gums as well as the teeth, and when it is needed a patient should be taught to massage the gums. The use of wooden toothpicks to remove particles between the teeth that cannot be _^ removed by the toothbrush should be approved. Many patients' teeth are so close together that par- ticles of food remain lodged between them and cannot be removed in any other way. Dental floss should certainly be used occasionally, or frequently, if pos- sible. If inflammation actually occurs in the gums or around a tooth, the advice and care of a dentist are needed. PYORRHEA ALVEOLARIS GENERAL CONSIDERATIONS The occurrence of pyorrhea alveolaris varies among different classes of people. At present the care of the teeth has an important place in the daily routine of the better educated people^ and although cases do exist among them, they are less frequent than among those who are strangers to the toothbrush and to mouth cleanliness. Bass and Johns state that they 288 PYORRHEA ALVEOLARIS found pyorrhea in 95 per cent, of the cases examined by them. It is possible that their cases were collated from the poorer classes of people and from those suffering from tooth affections. By pyorrhea alveolaris is meant a condition in which pus to a greater or less degree is present at the gingival margins affecting the peridental membrane and ulti- mately exposing the bone. As a result, pus pockets, from which pus escapes freely or may be easily expressed, occur. Predisposing factors are bad crowns, careless fillings, improper bridging, and, in all classes, neglect of the care of the teeth. Bacteria find a lodging place in the tartar deposited on the teeth or under a cap, and set up an inflammation. The gums become painful and tender, and there is a tendency to bleed easily from the slightest touch. Gradually the gums recede until pockets form between the teeth and gums in which the bacteria grow and thrive unchecked. Unless the disease is stopped, the teeth lose their firm support jn the alveolar processes and become loose. Pyorrhea alveolaris seems directly responsible for a large number of body ailments, produced by the entry into the lymph or blood stream of -the bacteria from the infected gums. Their toxins also produce systemic disturbances. It is also true that general systemic infections, by lowering the resistance of the gums, may be the starting point of pyorrhea alveolaris, which will continue, after the general infection has been cured. Removal of the pus may cure the asso- ciated condition. It is also probable that the pyor- rhea, through its micro-organisms and their toxins, reduces the physical resistance of the body to such an extent that it is readily susceptible to other inva- sions. There has been considerable difference of opinion as to the causative micro-organism producing pyor- rhea alveolaris. Fully ISO different organisms have been isolated from the gums and described. It has been assumed by many using vaccines that the real offender was a streptococcus, and that if such were obtained from the deep recesses of the pus pocket, it could be used for the manufacture of an autogenous vaccine in the treatment of the condition. Hartzell TREATMENT OF PYORRHEA 289 and Henrici found streptococci in cases of pyorrhea alveolaris and dental abscess associated with arthitis deformans, acute articular rheumatism, endocarditis, pernicious anemia, gastric ulcer, and acute iritis. Vac- cines were used with varying results, but these authors cannot positively state that vaccines have a definite value in these cases. They also found other organ- isms present with the streptococci. Barrett and later Bass and Johns recognized the ameba or endameba as the specific micro-organism of pyorrhea alveolaris. Barrett, however, also considered that pathogenic bacteria played an important part in the condition. There seems to be but little doubt that Endameba bucealis is a common invader of the tissues within the mouth, particularly the gums. This has been known for many years, the special strain of endameba around the gums having been called the Endameba gingivitis by Gros, in 1849. A contrary view of the action of the endameba has been held by Chivero, of the University of Rome, who, after a careful study of the mouth pr6tozoa, stated that he had found the Endameba bucealis in the pus in all cases of pyorrhea,- but that he thought them beneficial, claiming that they fed on pathogenic bacteria. Perhaps the best proof of the relation of the enda- meba to pyorrhea alveolaris is furnished by the action of ipecac or emetin, a specific amebicide, on the enda- meba. Such treatment often results in improvement of the pyorrhea, alveolaris. Emetin treatment, how- ever, without additional measures, such as removing the offending bridge, crown or tooth which may have caused the pus pocket, will not suffice in effecting a cure, as pockets still persist and invite further accumu- lation of tartar and pus. TREATMENT Treatment of pyorrhea alveoralis with emetin may be applied locally, or it may be given hypodermically, Bass and Johns giving doses of O.S gm. emetin hydro- chlorid hypodermically each day for from three to six days, the duration depending on the case, and also on the stage of the disease. They found that the enda- mebas disappeared from all lesions in 90 per cent, of their cases after a one to three day treatment, and in 290 TREATMENT OF PYORRHEA ■ 99 per cent, of the cases after at most six days' treat- ment. With the disappearance of the endameba, they also found that the pain and soreness disappeared, and that there was no further tendency of the gums to bleed. They found no indication in any of their cases for the space between the root and the alveolar process to fill up with periosteum or other tissue. On this account a pocket was left that provided a place for fur- ther pyorrhea. This would mean constant injection of emetin, which would, for various reasons, be imprac- ticable. On this account there is offered good oppor- tunity for recurrences. Reinfection may be prevented by daily local application of fluidextract of ipecac to the gums. It has been found that this, even when diluted 200,000 times, will kill the endameba. The fluidextract may be diluted ten times with alcohol and applied by means of a toothbrush, care being taken to force the ipecac between the teeth. Even with this prophylaxis, relapses have occurred, and on this account it is suggested that courses of injections lof emetin be repeated every three or four weeks. With the emetin treatment there is also essential the treatment of the teeth, such as removing the tartar, cleaning, and removing any dead tissue -from the pus pockets. With such treatment the pus pockets should also be irrigated with a weak solution of the fluid- extract of ipecac. * Levy and Rowntree report two cases of poisoning from emetin, in one of which the patient died. In both cases there was diarrhea, and in the fatal case signs of kidney involvement. The employment of iodin on the gums is both anti- septic and stimulating to the tissue of the gums which becomes firmer under its use. Talbot describes this use of iodin as follows: A mixture which he calls iodoglycerol consisting of zinc iodid, IS, water, 10, iodin, 25, and glycerin, 50, is applied with cotton wound around wooden applicators to the gum margins above and below. The lips and cheeks are held away from the jaws until the iodin has dried. These applications should be made every day and continued until the patient is dismissed. Most important in ridding the patient of pyorrhea are the services of a good dentist. Whatever the EXAMINATION OF STOMACH CONTENTS 291 local or systemic treatment, the dental management of the retracted gums and eroded and diseased teeth is of primary importance and any treatment will fail unless the dental care is also successful. During such treatment Talbot suggests friction and stimulating methods be employed by the vigorous use of a "gum massage brush" to stimulate the gums, such a brush, he says, should be so shaped that it will reach the festoons between the teeth. It should be made of the stiflfest unbleached bristles that can be obtained. The brush should be inserted into the mouth, the mouth and teeth closed. When the tissues of the mouth have become revitalized, deposits from the alveolar process on the roots of the teeth will cease to form. As a gum wash for the patient to use in connection with gum massage he suggests a zinc car- bolate mixture originally recommended by Whitslar: Zinc sulphocarbolate 60 grains Alcohol 1 ounce Distilled water 2 ounces Oil of wintergreen 8 minims The patient should use the gum massage and gum wash at least three times a day. But let it Be again emphasized: The importance of adequate dental assistance in the treatment of pyorrhea cannot be overestimated. THE EXAMINATION OF STOMACH CONTENTS Test Meal. — The object of the test meal is to show the state of digestion. For this purpose a meal con- sisting of ordinary food is most appropriate. It has recently been suggested that gastric secretion is suf- ficiently stimulated by ordinary water and in this way the gastric juice can be secured in a state of great purity, especially fit for chemical examination. While this is true such a meal does not indicate how the stomach deals with ordinary food. For the latter purpose the test breakfast of Ewald has long been used and has proved itself very serviceable. It should be used as a routine. It consists of bread and tea or bread and water. The amount of bread should be from 35 to 50 gm. No butter, sugar, milk or spices are used. The amount of bread can be supplied by 292 EXAMINATION OF STOMACH CONTENTS two slices of bread, a roll, or five ordinary soda crack- ers. The amount of tea should be two ordinary cups approximating 400 c.c. or a pint. The meal should be taken on an empty stomach, before breakfast or in place of the noon meal. The latter time has the advantage that in case of motor insufficiency remains of the breakfast may be found in the stomach contents. In this case it is well for the patient to eat some article of food for breakfast that can be easily recognized. The test meal should be tastefully prepared and tastefully served. Such table accessories should be furnished as will make it as attractive as possible. Preparations for the removal of the contents should be made without attracting the attention of the patient. The time for removing the contents should be reckoned at one hour from the time of beginning the meal. In some cases this time may prove too long because the' lack of acid perhiits the contents to leave the stomach prematurely and no contents are brought back through the tube. In such a case the meal should be given again and the contents removed at the end of forty-five minutes or even a half hour. Removal of Stomach Contents. — ^The technic of removing stomach contents is simple. The patient should be covered with an apron to protect the clothing ; the physician may also find it advantageous to wear a gown. A shallow basin should be provided to receive the contents; a better arrangement is a stout glass jar known as a celery jar which should be placed in a larger basin. It is well to suggest to the patient to hold the basin with his hands. This serves to keep the hands occupied and tends to lessen the tendency of the patient to pull out the tube. The patient should be assured that the operation will not hurt; at the same time it is best to. admit that it will be disagree- able and especially that it is apt to give a sensation of difficulty in breathing, but that this will disappear if the patient breathes regularly through the nose. The tube to be used is a simple tube with one lateral opening and one at the end. To the upper end a short piece of jrubber tubing is attached by a connecting short piece of glass tubing and the shorter tubing is attached by a piece of hard rubber to a strong walled EXAMINATION OF STOMACH CONTENTS 293 bag like a PoUitzer bag. This serves as an aspirator to remove the contents by suction. The tube is introduced by the hand of. the operator holding it like a pen. It is not necessary for the hand to enter the mouth. The operator should stand partly behind the patient and may steady the patient's head with the left hand. When the tube has entered the stomach the contents may flow spontaneously; if not the flow may be stimulated by moving the tube up and down which excites some nausea. If the contents are not easily obtained the aspirator should be emptied of air and attached. When it is allowed 'to expand the contents will flow into the bag and can be emptied into the receptacle provided. The temptation will sometimes arise to facilitate the removal of contents by injecting water. This defeats the object of the removal as the contents obtained are practically worth- less even for qualitative tests. At the termination of the process the patient should be warned against spitting in the dish containing the contents. He may spit in the outer basin. Examination.. — The stomach contents should be measured. The contents ordinarily secured varies from fifty to one hundred and fifty cubic centimeters ; a quantity above 150 c.c. is indicative of one of two things : either there has been a retention of food rem- nants on account of motor insufficiency or a hyper- secretion of the gastric juice has occurred. The chemi- cal examination will usually determine this question. The macroscopic examination of stomach contents is perhaps of more importance than the laboratory investigation. For this reason the physician should remove the contents himself. The contents should be poured into a clean basin and poured back again into the original dish. The color should be noted. A greenish color may indicate admixture with bile; it is also sometimes due to a growth of mold or other fungi. Mucus will be recognized by the stringiness of the contents which is readily seen as the liquid is poured from one vessel into the other. Mucus may be swallowed from the throat or possibly from the chest. Such mucus is light and frothy, or in lumps which float on the surface; stomach mucus clings to the vessel and is intimately mixed with other contents. 294 EXAMINATION OF STOMACH CONTENTS Blood may be readily recognized, but is of minor sig- nificance; it is frequently shed by the mucosa which has been injured by the tube. The mucosa is espe- cially liable to suffer such an injury in achylia gastrica. The condition of digestion is easily observed by the appearance of the remnants of the roll. If digestion is good the gluten of the flour is digested and the starch sinks to the bottom as a fine sediment. If the digestion is imperfect the roll is coherent and in case of total lack of acid the bread appears as if it had just been swallowed or it may be enveloped in glairy mucus. Occasionally small pieces of mucous membrane will be found which have been stripped off by the tube. Having noted these striking characters one should proceed to the chemical examination. Usually it is not necessary to filter the contents. A piece of congo paper may be dipped into the contents ; if free acid is present the red paper changes to blue. A piece of tropeolin paper will turn brown if free hydrochloric acid is present and on drying this at a gentle heat the color will change to violet. This is usually sufficient to demonstrate the digestive power of the mixture. One proceeds at once to the titration of acids for which a determination of the free hydrochloric acid and the total acidity are sufficient for routine examinations. 10 c.c. of the contents are measured, most conveniently in a 10 c.c. graduated cylinder and poured into a small beaker glass. It is well before reading the amount in the cylinder to remove any mucus floating on the top by means of a pair of small forceps and fill up to the mark with clear fluid. After emptying the cylinder it may be rinsed with distilled water and the rinsings added to the fluid in the beaker. This is then titrated for free HCl by running in from a burette decinormal sodium hydroxid solution with dimethyl-amino-azoben- zene as an indicator until the red liquid becomes orange yellow (not lemon yellow). The reading of the burette is then taken and one or two drops of solution of phenolphthalein are added to the liquid in the beaker. The alkali solution is then run in until the liquid shows a distinct tinge of pink after stirring. This gives the total acidity; both readings are taken from the zero point and the figures multiplied by ten EXAMINATION OF STOMACH CONTENTS 295 to get the amount of alkali required to neutralize acid in 100 c.c. of stomach contents. These figures are customarily used in reports and are designated as the degree of free and total acidity. The tests described above consume little time (not more than fifteen minutes for one accustomed to the work) and may suffice for the examination in the majority of cases. Some other tests ordinarily de- scribed, are not needed in ordinary clinical work because their results can be predicted from the results pf tests already made. Among these may be included the following. Tests for the digestive action of the saliva are unnecessary because we may assume with fair certainty that starch digestion will be poor in the presence of high acidity, fair with normal acidity, and very good with low acidity. Tests for the presence of pepsin are unnecessary unless there is no free hydrochloric acid. In the absence of hydrochloric acid the presence and amount of pepsin should be tested for. Tests for lactic acid are quite unnecessary when there is free hydrochloric acid. When hydrochloric acid is very deficient or absent lactic acid should be tested for. Kelling's test for lactic acid may be used: Add a few drops of 5 per cent. Fe CI3 solution to a test tube of distilled water sufficient to produce a faint yellow color. Divide this into two parts. Keep one for comparison. To the other add a few drops of the gastric juice. A distinct canary yellow color appears if lactic acid is_present. If the total acidity is as low as 8 the probability of achylia gastrica may be assumed. Microscopic Examination. — For examination with the microscope a drop of the contents is placed on a slide and examined with a low power. It can advan- tageously be stained with a weak Lugol's solution. Starch is colored blue,' proteins yellow, and some bac- teria blue. The objects of interest are Oppler-Boas bacilli, long bacilli often bent on themselves, sarcinae masses of cocci aggregated in groups of eight with divisions between the individual cocci which cause the mass to look like a fleece of wool, yeast cells and starch granules. 296 EXAMINATION OF FECES EXAMINATION OF FECES The examination of feces is of little value so far as the diagnosis of indigestion is concerned unless a definite diet is prescribed so that one may know what appearances the residues of the food should present under normal conditions. The original test diet of Schmidt was devised so as to conform to German dietetic customs and is ill adapted to American habits. Several modifications of this diet have been proposed, among them the following menu by Dr. M. M. Scar- borough. Breakfast: — One soft boiled egg, 2 slices of toast with butter, 1 bowl of oatmeal with sugar and cream, 1 glass of milk, and 1 cup of coffee. If coffee is not desired, another glass of milk may be substituted. Dinner: — A quarter pound of finely chopped round steak (very slightly broiled so that most of it is rare), 14 pound of mashed potato, 2 slices of white bread or toast, plenty of butter, and 1 or 2 glasses of milk. Supper :^Same as the breakfast. A patient is put rigidly on the above diet for three or four days. At the beginning of the diet he is given a tablet or capsule containing 0.30 gram (5 grains) of pure willow charcoal. This dose of charcoal is repeated at the end of the diet. The consequent black stools from these two doses of charcoal will mark the beginning and end of the period of special diet. The length of time it. takes the charcoal to go through the intestines will determine their activity and whether the food is delayed or not in its passage through the alimentary tract. The second dose of charcoal is use- ful only to determine whether the activity of the canal has changed during the rigid diet. The stool which is to be taken for examination should be at the end of. the third 24-hour period of the diet and before the administration of the second dose of charcoal. The stool desired may be collected in a wide mouthed jar or what is more convenient for the ordinary examina- tion, a sample may be transferred to a glaSs ointment jar and transmitted to the laboratory for examination. The examination may be divided into macroscopic, microscopic and chemical. EXAMINATION OF FECES 297 Macroscopic Examination. — Macroscopically, under normal conditions, we find a soft-formed stool, light- brown in color and of uniform consistency. A liquid stoc^ usually denotes a too rapid passage of food through the tract ; a tarry stool indicates blood coming from the stomach or high up in the intestine. Flakes of mucus, blood, pus, etc., are pathologic. Next a piece of feces the size of a walnut is ground up in a mortar with a Uttle water and then spread out on a glass plate in a thin layer. The plate should be placed over a sheet of paper half of which is white and half black. The normal feces appear perfectly homogeneous except for here and there small broken, brownish points of cellulose from the oatmeal eaten. In this prepara- tion may be seen food remains which are abnormal. Firm, whitish or yellowish strings of connective tissue, and small brown-colored rods of muscle fibre, appear- ing like splinters of wood, may be seen here and there, denoting improper indigestion of the meats. Starch granules in the form of glassy transparent globules like sago grains, may be present and must be distin- guished from shiny, ragged flakes of mucus. Microscopic Examination. — The microscopic exam- ination is very simple. A small mass of feces is pressed out in a thin layer on a slide by means of a cover glass. A little water may be added if necessary. Normal excrement from the test-diet appears as a- fine detritus of granules, globules and bacteria interspersed here and there with fragments of muscle fibers, small, irregular, yellowish flakes of calcium salts and less numerous skeletal remains of potato cells, besides the chaffy particles from the oatmeal. On a second slide a small piece of feces is stirred*up with two drops of - a 35 per cent, solution of acetic acid, heated over a flame until bubbles arise, and then set to cool. The process causes a liberation of the free fatty acids which flock out on the surface of the preparation, giving a rough index to the amount of fat in the stool. On a third slide an iodin solution (liquor iodi com- positus, Lugol's solution), diluted with equal part of water, is used, which stains the starch, yeast and other fungi that may be present. The microscopic examination may reveal the following pathologfic com- ponents: fragments of muscle fibres large in size and 298 EXAMINATION OF FECES in good state of preservation; clusters of undigested starch grains; numerous needles and crystals of _ fatty acids and soaps; and occasionally various fungi. Chemical Examination. — ^The chemical tests are very simple. The litmus reaction is taken; normal stools are faintly alkaline or at least feebly acid. Next a little of the stool is mixed virith a strong bichlorid solution (a saturated solution of corrosive sublimate in water, which is, in cold water, not far fropi 7 per cent.) ; normal feces give a red reaction, while feces that have passed through the tract so rapidly that the bile has not been reduced to give a greenish color. The greenish color is abnormal and shows that unchanged bile pigments have passed entirely through the intes- tinal tract. The last test is the amount of gas that the stool will give off. An acid stool with an excess of carbohydrates will ferment if kept warm and give off considerable carbon dioxid; on the other hand a stool which gives an alkaline reaction and contains much unabsorbed protein will readily undergo putre- faction and evolve ammonia and hydrogen sulphid. The gas from decomposing feces can be collected by filling a large test tube with diluted feces and invert- ing the tube over water in a shallow dish and placing in an incubator for a day or two. Pathologic Findings. — The significance of pathologic findings are briefly as follows : Mucus in the stool means inflammation of the colon or rectum. Rarely it may come from the small intes- tine. A green color with the bichlorid test indicates a very rapid passage of intestinal contents. Absence of bile pigment dendtes complete obstruction of the biliary duct. The pigment may be obscured by excess of fat, which should be removed by ether before a final opinion as to the absence of biliary pigments should be expressed. The finding of meat remains is of great significance. Connective tissue never appears in the feces after the test-diet unless there is disturbance of digestion in the stomach, a diminished gastric juice. Muscle fibers are not digested in the stomach, but in the intestine. Even in complete achylia gastrica the muscle fibers may be completely digested leaving the connective EXAMINATION OF FECES 299 tissue skeleton of the meat unaffected. The presence of muscle fibers in a good state of preservation always means trouble in the small intestine, due to one or more of the following conditions : the pancreatic juice may be insufficient; or the active enterokinase of the secretions of the small intestine may be absent; or finally, there may be a marked hypermotility, too rapid peristalsis, of the small intestine, thus not allowing time for digestion of these elements. A method for the investigation of the exact cause of intestinal indi- gestion of meat fibers has not yet been satisfactorily worked out. However, as the nuclei of tissue cells are digested only by the pancreatic secretion, Schmidt has devised his nuclei test which consists in giving a small cube of meat placed in a small porous silk bag. The bag almost always contains remains of the tissue after passing, through the gastro-intestinal tract. If undi- gested nuclei are present, it is safe to conclude that there is an unsatisfactory functioning of the pancreas. The presence of starch elements indicates its incom- plete digestion in the small intestine and shows a dis- turbance of the pancreatic secretion and of the intes- tinal juice. Insufficiency of starch digestion is further confirmed by the fermentation test and by the finding in the stool of organisms that stain blue or violet with iodin. In the feces of constipated persons, as a rule, there are few food remnants, few bacteria, and water has been largely absorbed rendering the feces dry and hard. Digestion in the constipated may be said to be too good. DIAGNOSIS AND TREATMENT The diagnostic findings and the indications for treat- ment may be summed up as follows : 1. If the charcoal is slow in passing through the alimentary canal, i. e., more than thirty-six hours after ingestion, intestinal peristalsis is sluggish. 2. If the fecal matters are very dry, there is too great absorption of liquid fAjm the intestines. 3. If the stools are very liquid, there is generally too rapid peristalsis. 4. If the fecal matters are distinctly or very acid, there is an imperfect intestinal digestion. 300 EXAMINATION OF. FECES 5. If there is much gas in the feces, there is maldi- gestion- of some kind ; it may be purin maldigestion or carbohydrate maldigestion. Whichever it is deter- mined to be, that particular kind of food should be limited. 6. If there is undigested connective tissue found microscopically, the trouble lies in the stomach, which should then be studied by means of the test breakfast and examination of the stomach contents withdrawn an hour after the test breakfast has been taken. If there are undigested muscle fibers present, there is insufficient pancreatic secretion, and meat should be diminished or temporarily withdrawn from the diet. 7. If there is a large amount of undigested starch particles, the pancreatic juice is deficient, at least in its starch digestion properties; consequently the starch in the diet should be diminished. 8. If the bile pigments are absent,, of course the bile is not secreted (or excreted) into the alimentary tract. If there is a large amount of fatty acids, or if there is a large amount of fat in the stool, it shows defi- cient bile secretion, and the amount of fat ingested should be greatly diminished. 9. Abnormal bacteria, or an abnormal amount of bacteria, or specific bacteria would suggest various diets, bowel antiseptics, purgings, and various sys- temic treatments, depending on the findings. 10. Much mucus or pus would suggest the treat- ment, depending on the region from which it was sup- posed to come; colon washings or colon treatments, if the colon was at fault. 11. If there is blood in the stool, evident or occult, it must be determined, if possible, from what part of the tract it comes. THE FINDING OF PATHOLOGIC OVA Fauntleroy and Hayden {Abstr. Jour. A. M. A., Feb. 13, 1915, p. 620) have devised a method which consists essentially of staining the fecal matter with anilin gentian violet. This solution stains everything on the slide except the eggs. It does not pene- trate the membrane about the eggs and they are SYMPTOMS REFERABLE TO THE STOMACH 301 therefore left in a natural state. None of the other ordinary colored stains will do this. The entire slide with the exception of the real eggs is stained violet. This method of examination has been used in the exam- ination of over a thousand stools with uniform success. All eggs, hookworm and others, stand out very clearly and beautifully. About 2 gm. of the fecal material are thoroughly mixed with 5 c.c. of a 2 per cent, aque- ous solution of compound solution of cresol in a cen- trifuge tube. The specimens are centrifugalized at high speed for one minute, the supernatant liquid is then decanted and fresh compound cresol solution added and mixed with the sediment in the tubes. This operation is repeated three times. On completion- of the centrifugalization process a small portion of the bottom sediment is removed with a clean pipette and placed on a clean slide, a small drop of anilin gentian violet mixed with the sediment, and a clean cover- glass placed on it. See also description of methods under "Hookworm." INTERPRETATION OF SYMPTOMS REFERABLE TO THE STOMACH There is perhaps no group of symptoms regarding which there is more misapprehension among physi- cians than symptoms arising from the stomach or felt in the region of the stomach. INDIGESTION Indigestion is a much abused term commonly used to cover all forms of stomach disease. Strictly it means the non-digestion of food. This is a rare event among those who are not seriously ill. That digestion may fail in the stomach or in some other part of the alimentary canal or that some parts of the food may escape digestion is common enough, but the human organism is provided with compensating mechanisms so that if one organ in the digestive system fails to perform its duty another is usually capable of taking its place. As a rule in adults, even in the case of those who complain of trouble with the stomach or bowels, only a minimum of the food ingested escapes digestion or fails to be absorbed. The test of diges- 302 SYMPTOMS REFERABLE TO THE STOMACH tion is found in the state of the bowels; if the bowels act normally or are constipated as a rule the digestion is complete and may indeed be too good. If there is diarrhea it may be assumed that digestion is imperfect, although there may be no lesion of the stomach or intestines. We may repeat that indigestion is not a common symptom in the ordinary chronic affections of the stomach and intestines. As a corollary of the above we may affirm that digestive ferments are not often lacking and there is rarely a rational indication for prescribing artificial ferments to supply a lack in the normal action of these organs. Such drugs should be prescribed only after their deficiency has been shown by the proper tests. THE IMPORTANCE OF STOMACH DIGESTION It is not desirable to over-rate the importance of the processes going on in the stomach in the final process of digestion. The stomach is a preparatory digestive organ. It is a reservoir which reduces the food to a fine state of subdivision and renders it suit- able for the subsequent action of the secretions of the liver, pancreas, and intestines. Its work is seldom complete. The organ may be removed or fail to perform its functions without any serious disturbance in nutrition. Nevertheless one cannot deny that changes in the utilization of food may occur in the absence of the correct functions of the stomach which, in the long run, may seriously affect metabolism and nutrition. In this connection we may note s.ome peculiarities of the motor action of the stomach which have important bearings on treatment. The stomach does not absorb water and hence in case a liquid which needs no digestion is taken, even at meal time, a special channel is formed along the lesser curvature by which the liquid is conveyed to the intestine with- out mingling with more solid undigested contents of the stomach. The taking of liquids at meal time does not, therefore, dilute the gastric juice as was formerly taught. Such an event may happen, how- ever, when the stomach is atonic and allows water or other liquid to flow into the lower part instead of conducting it into the intestine in a normal manner. SYMPTOMS REFERABLE TO THE STOMACH 303 RELATION OF THE STOMACH TO OTHER ORGANS It should always' be borne in mind that the stomach has important nervous connections with other organs by which it reflects like a mirror events taking place in other parts of the digestive system. Symptoms apparently arising in the stomach may, in reality, depend on disease of the liver, gall-bladder, appendix, or lower bowel. Neighboring organs not connected with the process of digestion or even remote organs may produce a reflex disturbance in the stomach. A very large part of the disturbances of the stomach are of psychic origin. The physician should always interpret the symptoms presented by the patient who thinks there is something wrong with his stomach in the light of possible disease of other organs or of mental disturbances. Even in the presence of proved organic disease the possible influence of emotion in producing symptoms should not be forgotten. THE MAJORITY OF STOMACH CASES FUNCTIONAL While the existence of serious organic disease should never be overlooked it is well to understand that only a small proportion of patients who come to the physician complaining of the stomach or of digestive disturbances have ulcer or cancer. The physician should not make or suggest a diagnosis of serious disease until he has proved its existence by appropriate physical and laboratory examinations. SYMPTOMS NOT CHARACTERISTIC Diagnosis on the basis of the patient's recital of symptoms without physical examination or the anal- ysis of a test-meal or of the feces is much too com- mon. It may be said at the outset . that there exists scarcely a symptom that is characteristic of any definite stomach disease. This may explain the readi- ness with which practitioners resort to such terms as indigestion, dyspepsia, catarrh of the stomach or the indefinite term "stomach trouble" -to explain their diagnosis to the public. Relying on the symptoms, they cannot have exact knowledge of the condition present. In many cases it may be said that a stomach 304 SYMPTOMS REFERABLE TO THE STOMACH specialist could do no better. Specialists have often been mistaken in their impressions- gathered from the recital of the symptoms and assumed the existence of a hyperchlorhydria only to find on exact examination a total lack of acid in the stomach contents. The importance of laboratory diagnosis is thus clearly shown and it may be assumed almost as an axiom that a diagnosis of stomach disease based on the symptoms alone is little better than guess-work. THE RARITY OF FERMENTATION IN THE STOMACH Formerly it was a favorite custom to explain the belching of gas from the stomach and the flatulent distention of the organ, as also the "sour" stomach, by saying that these symptoms arose from the fer- mentation of the food. Such an explanation gave rise to attempts to suppress fermentation by giving a host of antiseptics, some of powerful and some of feeble germicidal power. This explanation and the practice based on it arose from the application of a chemical theory without sufficient regard for the actual condi- tions prevailirfg^ in the stomach. The contents of the stomach are at times subject to fermentation with the production of a certain amount of gas. Lactic acid may be formed by fermentation, but usually no gas is formed with it; butyric acid may occur in the stomach contents, and its formation is accompanied by the evolution of some gas; yeast fermentation forms gas at times. However, if one will watch one of these fermenting liquids he will find that ordinarily the formation of gas is slow and quite insufficient to account for the belching that many patients experi- ence. These occasional sources of gas account for its accumulation only in rare cases. In the majority of cases the gas present in the stomach consists of swallowed air. As a rule, even in cases in which much distress is produced by flatulence or belching, there is no fermentation in the stomach. The swallowing or air may be a habit of voluntary origin or it may arise from the forcing of air through an atonic cardiac orifice by the force of expiration. The acid present in the stomach contents is seldom the result of fer- mentation but is produced by oversecretion of the gastric juice. It is well, therefore, to ascertain the ACUTE DYSENTERY 305 true origin of these symptoms before attempting to prevent them by the administration of injurious anti- septics. ACUTE DYSENTEEY Acute dysentery or colitis is an inflammation of the large intestine, throughout either the whole or a por- tion of its extent. Sometimes the lower part of the small intestine is coincidently inflamed. The disease may be due to various irritants of microbic or parasitic origin, giving essentially similar symptoms but requir- ing different treatment addressed to the cause of the disease. As Mathieu remarks, we should not speak of dysentery but of "dysenteries," as there are several kinds of dysenteric colitis. It is, however, convenient to discuss the symptoms and general treatment in common for the different varieties and then take up the specific treatment of the different forms. The disease is characterized by mucus, blood and purulent discharges from the rectum, accompanied by much straining, colicky pains and tenesmus. The fol- lowing classes of dysentery may be noted: bacillary dysentery, amebic dysentery, balantidium dysentery, and dysentery arising from some unknown infection. The disease is, therefore, infectious, and may be trans- mitted by the discharges or articles contaminated with them. It occurs in epidemics and also sporadically. When dysentery occurs sporadically it is generally more amenable to treatment. SYMPTOMS The general symptoms of acute dysentery are mild fever, a variable pulse, at times rapid or weak from exhaustion, with a tendency to collapse turns; the movements are frequent and exhausting. The nearer the rectum the inflammation is, the more intense is the tenesmus and the more constant the desire to strain, with resulting small movements and but little relief. The higher up the inflammation is in the large intes- tine, the more frequent the griping and abdominal pain. The stools consist of large masses of niucus mixed with feces, and later mucus, more or less blood- streaked, perhaps without any fecal matter at all. Later, slight hemorrhages occur, depending on the 306 TREATMENT OF DYSENTERY amount of ulceration or erosion of the membrane, and finally pieces of membrane are passed similar to diph- theritic membrane. The tongue is coated, but gener- ally moist, unless a large amount of fluid is lost. If the progress of the disease is unfavorable, the tem- perature is likely to rise high, otherwise it remains low. If the disease long continues and the movements are frequent and profuse, a typhoid state develops. GENERAL PRINCIPLES OF. TREATMENT It is evident that the first steps in the treatment are rest, the removal of irritants, and the giving of most easily assimilable nourishment. Th^se principles apply to all forms of dysentery. The patient should be put to bed and the use of the bed pan insisted on. If the condition of the patient will permit the rectum should be inspected with a speculum or with a procto- scope and a piece of mucus or a scraping from an ulcer if any. are visible obtained for examination. This should be examined immediately on a warm slide for amebae which are recognized by the ameboid movements. If no amebae are found the mucus and feces should be examined bacteriologically for other causes of dysentery. Following this examination the rectum and colon should be irrigated with physiologic saline solution. After the fecal matter and mucus have been washed away and the water is returned clear, the colon may be treated with a weak permanganate of potassium solution, 1 : 10,000, or peroxid of hydro- gen solution 1 :8 may be used. In making these irrigations the tube should not be pushed too far, which might increase the injury to the rectum. A few inches is sufficient. Such irrigations may be repeated once a day in the early stages. The Diet. — The diet should consist of milk and water, rice water bouillon, beef juice or. other suitable liquid food. If the tongue is coated, the other foods mentioned agree better than milk, but if the tongue is clean give milk either alone or diluted with some of the other foods. The food must not be hot or cold. Milk predigested with pancreatin may obviate the tendency to the formation of an undue amount of intestinal gas. MEDICINAL TREATMENT OF DYSENTERY 307 If milk is desirable but is distasteful, it may be diluted with Vichy; or the milk may be given hot and salted. The milk given must be known to be pure and uncontaminated. Preferably it should be pasteur- ized. Tea and coffee may be allowed at such times of the day as not to disturb the sleep. While large amounts of water are inadvisable and iced water should not be given, still, if much water is lost by the stools, the amount must be equaled by that which is ingested; otherwise the patient's tissues lose water, the blood vessels lose water, the urine becomes con- centrated, the skin dry, and the patient suffers from this deprivation of water. Such a condition alone may be the cause of death; Preferably, liquids or foods should be given hot, as anything cold entering the stomach is likely to start peristalsis. It may be advisable to give some thin cereal gruel once a day, at least if the disease lasts more than a week. As soon as convalescence is established, broiled lamb chops, roast beef, and the white meat of chicken may be added to the diet. All solid food should be thoroughly masticated and the digestion may be hastened by giving a few drops of hydrochloric acid directly after meals. As convalescence progresses favorably, toast, stale bread, and boiled rice may be added to the diet and, later, baked potatoes. The first fruit that is allowable is either lemon or orange juice. MEDICINAL TREATMENT It is generally advised to give at once a dose of castor oil or small doses of calomel with additional laxative treatment in the form of saline laxatives if necessary. The following prescription is sometimes efficient in arresting milder forms of dysentery of unknown causation. Gm. or C.c. ^ Magnesii sulphatis 25 Acidi sulphuric! aromatici. . 10 Syrupi zingiberis SO Aquae ad 100 Si lis iiss flSii ad flS iv M. Sig. : One teaspoonful in water every four hours. This will have a laxative effect with a secondary astringent effect, due to the sulphuric acid. 308 TREATMENT OF BACILLARY DYSENTERY Bismuth subcarbonate may be administered in large doses, but the value of this is often problematical. However, if the inflammation is in the cecum or has migrated into the ileum, the bismuth is probably of value. Bismuth, however, must not be too long con- tinued, as it tends to form scybalous masses and cause more irritation and more inflammation. Pain and too frequent movements should be stopped by small doses of morphin. Tenesmus is relieved by small ice water enemas or by suppositories of morphin and atropin. Kaolin or bolus alba has been recently revived as a remedy for dysentery. This treatment was in vogue more than a century ago but fell into disuse. It is claimed that the powder encloses the bacteria and prevents their pathogenic action. Probably this drug has an action in every way similar to that of bismuth in forming a protective coating to the mucous mem- brane. TREATMENT OF BACILLARY DYSENTERY The microscopic examination may show any one of a number of already classified dysentery organ- isms; for example, the Flexner, Shiga, and other types. Such examination should include fermentation tests and other biologic reactions as well as a studv or morphology. The classification, while a matter of great scientific interest, is not, however, an impor- tant guide for the prognosis or treatment. The general treatment already outlined is applicable to bacillary dysentery. Certain special measures also may be followed. Antidysenteric serum may be administered. A reduction in the mortality rate of bacillary dysentery from 30 to 50 per cent, through the use of some serums has been reported by some observers but not confirmed by all. It would seem the best results may be ascribed to an antitoxic action in infection with the Shiga-Kruse type of dysentery bacillus. The most favorable results are observed in the early stage of the disease. Mathieu (Abst. Jour. A. M. A., Nov. 28, 1914, p. 1986) advises the administration of the serum even before the diagnosis has been made, in order to secure its early action. Shiga favors a poly- TREATMENT OF AMEBIC DYSENTERY 309 valent serum as meeting the requirements whatever the variety of organism present. If the disease progresses and immediate healing of the inflammation does not occur, and actual ulceration seems to have developed, as shown by the amount of bleeding, an occasional irrigation of nitrate of silVer, 1 part to 1,000, not more than 1 pint at any one time, viz., 0.50 gram {7^2, grains) to a pint of water, is of benefit. Such an injection should be given but once in four or five days, and if the liquid does not immediately flow out of the colon, a solution of salt should be immediately injected. The salt for-tning an insoluble sodium chlorid, will prevent any poisonous absorption of nitrate of silver. TREATMENT OF AMEBIC DYSENTERY The diagnosis of amebic dysentery should always be confirmed by a competent study of the morphology of the organism isolated, as well as the injection of the organisms into the rectum of kittens. The general treatment of amebic dysentery is the same as that of'bacillary dysentery. The specific treatment of amebic dysentery, which is comparatively recent, is with the aid of ipecac and emetin. Whether the amebae are on the surface of the mucous membrane, deeply embedded in the ulcers, or localized elsewhere in the body, they" may be reached by properly administering ipecac and emetin. The amebae on the surface of the mucous membrane are not likely to be affected by emetin administered hypodermically. On the other hand, emetin given hypodermically becomes more quickly active on the deep seated organisms and the localized lesions. Jones reports the following method of administration is used at the Army hospital in Manila : Emetin hydrochlorid 0.008 gm. by hypodermic for ten days (twice a day for four days and once a day for six days). Ipecac started about the eighth day with from 1.5 to 2 gm. doses given at bedtime, con- tinued for three consecutive nights ■ and thereafter decreased by 0.3 gm. each consecutive night. The disagreeable effects of the ipecacuanha were never 310 TREATMENT OF AMEBIC DYSENTERY manifested. It is quite necessary to precede the administratiofl of ipecacuanha by tinctura opii in from 0.6 to 1 c.c. doses or by a hypodermic of % gr. of morphin. Happy though the results of this combination may be in treating amebiasis, the fact should not be over- looked that emetin is an amebacide and has little to do with the healing of ulcerations. Every case of ame- biasis should, after this treatment, be considered- one of ulcerative colitis and so treated from a dietetic point of view. At the same time every effort should be made to enhance resistance by change of climate, tonics, etc., to obviate the distressing sequelae charac- teristic of the disease. It should be remembered that even after the amebae have been removed, there still remain unhealed ulcers. These should be treated by rest in bed, proper diet and local irrigations. The latter serve not only to promote healing but also act to prevent relapses. Sulphate of quinin is believed by many to be specific in its destructive action on the amebae, and is much used for irrigating the rectum and colon. It should be used in a 1 to 5,000 to 1 to 1,000 solution. Cures are believed to have been effected by such irrigations in many cases. Bates, who has treated a great many of these patients successfully in the tropics, has outlined the treatment as follows: Complete rest in bed. Give a saline purge or a cathartic; give y2 grain (.032 gm.) injections of emetin daily until two grains (.13 gm.) are given; then increase the dose to 1 grain (.065 gm.) daily until stool is clear of amebae. Usually a total of 5 (.32 gm.) to 6 grains are required. Discon- tinue emetin and give large doses of bismuth sub- nitrate; one dram ( 4.0 gm.) every four hours during waking hours until stools are well formed or some constipation supervenes; then decrease dosage grad- ually. As soon as effects of saline purge wear off begin enemas of saline solution, two or three quarts at a time every four hours during waking hours. Discontinue when beginning with bismuth, using only once or twice a day to counteract constipation. As food give sweet milk every two hours during the day in quantities of from four to eig^t ounces. As GASTRIC ULCER 311 improvement continues gradually add soft diet, as poached eggs, slice of dry toast, etc. If, in spite of the remedies which have been enum^ erated, the case still continues rebellious, resort to surgical interference may be deemed advisable, and appendicostomy may be performed, and. irrigation of the colon by means of the insertion of an irrigation tube through the appendix may be practiced. This, however, is a measure almost of last resort. Great care and patience are required in the treat- ment of this disease, and the treatment should be long continued, and after the patient is apparently cured, he should be kept under observation for months ^in order that, if a relapse occurs, treatment may be promptly instituted. Abscess of the liyer is a not infrequent complication. Such cases usually recover with emetin treatment if it is instituted early. It may be necessary, however, to open and drain, especially in the event of secondary infection. Physicians should not temporize with inefficient medical treatment in severe cases of dysentery. There is a possibility of obtaining curative results by prompt surgical measures such as appendicostomy, etc., which may be lifesaving. GASTRIC AND DUODENAL ULCER Ulcers occurring in the neighborhood of the pylorus, either on the lesser curvature in the pyloric antrum or in the first part of the duodenum, are probably due to similar etiology and have the same general character. They may, therefore, very properly be considered under the same head. Their causation is to be found probably to some extent in abnormal conditions affect- ing the nerves, the motor activity of the stomach and duodenum, the character of the food and the acidity of the gastric juice. Rosenow has found streptococci which he believes are specific in causing gastric ulcer, having a special affinity for the gastric mucosa. An acute loss of the mucosa in a healthy stomach is rapidly repaired; an acute ulcer of the stomach com- monly gets well rapidly. A chronic ulcer behaves dif- 312 GASTRIC ULCER ferently, indicating that there is some complicating factor to keep it from healing. Considerable experi- mental work has been done to show that the nervous supply of the stomach is necessary to maintain a healthy condition of the mucous membrane. Further, the experimental v/ork seems to show that a throm- bosis of the blood vessels or an "infection" of an area of the mucosa is sufficient to cause the destruction of a portion of the mucosa and institute an ulcer. Ulceration thus produced is favored arid the necrotic tissue digested and carried away by a gastric juice of a high degree of acidity. A very marked influence pr^ilonging the existence of such a lesion is the occur- rence of pyloric spasm and the retention of the rem- nants of food and gastric contents containing a large proportion of hydrochloric acid. In such cases the layer of protecting mucus is digested away and the ulcerated mucous membrane is exposed to long con- tinued action of highly acid and irritating gastric contents. The process of ulceration in the stomach, in the light of our present knowledge, may involve the fol- lowing steps : initial weakness or predisposition of the tissue; initial injury in the form of abrasion, throm- bosis, or necrosis from infection; removal of necrotic tissue by active gastric juice; recovery in a normal stomach, but in the presence of pyloric spasm or of gastric stasis and the continued action of irritating food or secretions a continuance of chronic ulceration. In addition anemia must be put down as a complicating condition, although not always present. SYMPTOMS The symptoms of gastric ulcer are various, but a certain number, have been considered classic and should be kept in mind by the physician as the basis of a diagnosis. At the same time the practitioner should bear in mind the fact that any of these signs may be absent or may fail to present their usual characters. The principal symptoms and signs are pain, vomiting, hematemesis, melena, tenderness at epigastrium, ten- der points near the spine. GASTRIC ULCER 313 Pain in gastric ulcer occurs in attacks with intervals, sometimes of days or longer, and is excited by the digestive process; it does not occur immediately after taking food, but corresponds to the period «f high acidity. It is aggravated by coarse foods, but often relieved by the taking of bland foods or of alkalies. The pain is referred to the epigastrium but this does ■ not necessarily indicate tlic exact location of the ulcer. Vomiting is likely to occur after the taking of food and has little that is characteristic about it when it does not contain blood. • Hematemesis, or the vomiting of blood, is an impor- tant symptom and when the other symptoms are pres- ent it may suffice to confirm the diagnosis of gastric ulcer. It must be remembered, however, that blood may be vomited after it i's swallowed from pulmonary hemorrhage, or it may be shed into the stomach from the bursting of a branch of one or the radicles of the portal vein or from an esophageal varix. The latter forms of hemorrhage are sometimes the result of high blood presure in the portal circulation in hepatic cir- rhosis, etc. The presence of large quantities of blood in the stpols may be discovered macroscopically by their dark, tarry character. Such a condition of melena is cor- robative of the diagnosis of gastric ulcer, but other symptoms should be present to indicate that the stomach is the source of the bleeding before we should give the mere presence of blood in the stools much weight in the diagnosis of gastric ulcer. A tender point in the epigastrium is found in most cases of gastric ulcer. It corresponds io the location of the solar plexus and is elicited by slight pressure with the finger, differing in this respect from the tenderness due to neurasthenia, which requires con- siderable pressure to bring it out. The tenderness of ulcer is referred to a point about midway between the ensiform cartilage and the umbilicus, the point being constant in one locality and strictly circumscribed. Nearly as constant and quite as characteristic are tender points felt sometimes on both sides, sometimes only on the left, in the dorsal region near the spinous processes of the tenth to twelfth vertebra. The dis- 314 DUODENAL ULCER appearance of these tender points during treatment for ulcer is a valuable indication that the patient is improving. The diagnosis of gastric or duodenal ulcer may be confirmed by the roentgen ray when observed by repeated pictures or by fluoroscopic observation. Test meals afford only corroborative evidence of the existence of an ulcer. Excess of free hydrochloric acid is usually present. There is frequently evidence of delay in evacuation of the stomach contents, and Mood, either macroscopic or occult, is present in the majority of cases. The presence of occult blood in the stomach contents is not pathognomonic. Macro- scopic bleeding may be due to injury of the mucosa by the stomach tube. Occult blood in the feces is' of more importance. If not constantly found, it is a strong indication of ulcer, presumably in the neighborhood of the pylorus. ULCER OF THE DUODENUM The principal symptom is pain, more or less local- ized in the region of the pylorus, intermittent, occur- ring generally about two hours after a meal. In other words, this pain occurs when the stomach is more or less empty. This pain is more frequently relieved by eating some bland food or drinking milk than is the pain of ulcer of the stomach. The appetite is generally good, and vomiting and other symptoms of gastric indigestion are infrequent. Attacks of diarrhea may occur, and occult blood is often present in the stools. There may be marked hyperchlorhydria. TREATMENT One of the chief factors in the continuance of ulcer seems to be the irritating gastric contents which owe their irritating properties larg'ely to their acidity. Hence the acid secretion should be reduced as a first step by regimen, diet and remedies. Not only should the degree of acidity be determined and a search made for any oth^r condition of the stomach which might cause chronic irritation, but the condition of other organs should be interrogated for other possible cause of hyperacidity and proper treat- TREATMENT OF ULCER 315 ment^should Be applied. Medicinally the best reme- dies are alkalies combined with bismuth; thus one may give Gm. or C.c. IJ Magnesii oxidi I Bismuthi subcarbonatis aa 1S| or 5ss M. Sig. : Take a small teaspoonful once in three hours. If such a powder tends to make the bowels too loose, sodium bicarbonate may be substitutea for the mag- nesium oxid. Atropin or atropin sulphate may be given in doses of from 0.00025 gm. (gr. Vas'o)' but the use of atropin should not be continued too long. As hyperacidity seems to increase the ulceration, certainly increases the pain, and is likely to increase the vomiting, anything that diminishes the acidity is good treatment, and a diet free from the substances that cause the greatest outpouring of hydrochloric acid is the diet of choice. In other words, a diet without meat and without meat broths, without toast, and with- out any hard particles of food that can scrape or irri- tate the inflamed part, should be selected. The Len- hartz diet with raw eggs is considered quite sensible as giving nutrition and at the same time inhibiting the production of hydrochloric acid and tending to heal the ulcer. ** The raw eggs are beaten up whole and placed in a cup or glass surrounded by ice. The small amount of milk given is also served iced in the same manner, and the egg and milk feedings alternate with each other every two hours, at first two teaspoonfuls of the egg and four teaspoonfuls of the milk. The first day two eggs are used and six ounces of milk. The eggs and milk are gradually increased from this minimum until by the sixth day seven eggs and twenty-two ounces of milk are given. From the third day on a little granulated sugar is added. At the end of a week the number of eggs is reduced and some scraped beef is allowed, with soon a small amount of boiled rice. During the following week, the second week, the eggs may be soft boiled, and four may be administered a day, with the milk increased to nearly a quart, sugar as before, and scraped beef or chopped chicken and rice or bread with a little butter may be gradually added and the diet thus varied. lEven when the eggs 316 SIPPY TREATMENT OF ULCER are used soft boiled, four should be taken a, day. Whatever is taken, if solid, it should be very com- pletely and slovifly masticated and, as above stated, at first the amounts ingested at one time must be very small and taken at intervals of two hours during the day. The foods for the first week should be taken cold and the next week only warm, never hot. Small sips of iced water may be taken as often as desired or advisable. In view of the hyperacidity, it is well to add to the diet as much fat as can well be borne, in the form of butter or cream. SIPPY TREATMENT The Sippy method of treatment is scientific and is based on a consideration of the pathology of ulcer. It consists primarily in protecting the ulcer from the acid corrosion from the gastric juice. This is accom- plished by frequent feedings and the use of alkalis given frequently. The patient remains in bed for at least the first three or four weeks of the treatment. Three ounces of a mixture of equal parts of milk and creiam are given every hour from 7 a. m. to 7 p. m. After a few days soft eggs and well cooked cereals are gradually added to the diet. After about ten days the patient is receiving three ounces of milk and cream mixture every hour, three soft boiled eggs and nine ounces of cereal each day. Cream soups of vari- ous kinds and vegetable purees, egg nog, etc. may be substituted now and then as desired. Between the feedings the patients are given powders of magnesia and soda and of bismuth and soda, to neutralize the acid secretion. HEMORRHAGE If there is hemorrhage, an ice-bag should be placed over the stomach and a large dose of bismuth subni- trate should be administered, perhaps 3 or 4^rams (45 or 60 grains) at once. It generally seems advisable to give bismuth in large doses, at least 2 grams (30 grains) once a day. This can be taken stirred up in water or in milk and quickly drank. HEMORRHAGE IN GASTRIC ULCER 317 The treatment above suggested generally stops the pain. If pain is still severe morphin should be resorted to, but with this treatment it rarely will be necessary, and the dose required, hypodermatically, is small. It must be remembered that the pain is generally caused by the free hydrochloric acid and the fact that pain disappears gives no evidence that the ulcer is healed, but the lesion may still continue in a latent state and make its presence felt by symptoms when the increased acidity of a new attack sets up renewed irritation. Sippy's practice is to give alkali enough not only to relieve the pain, but also to neutralize all the free acid and keep it neutral during the greater part of the twenty-four hours. This is accomplished by repeated examinations of the stomach contents. The alkali is repeated whenever the examination shows that free acid is present. The patient should not get up to urinate or for the bowels; a bed-pan should be used. If the patient is constipated the bowels may be moved by the rectal injection of a half ounce to an ounce of glycerin wfth an equal amount of water, and soap suds could be used if needed. As these patients are already short on iron and for a number of days are to receive no meat, it ii advis- able to give the saccharated oxid of iron (eisen- zucker) 3 grains in tablet form twice a day. The patient should thoroughly crush the tablets with the teeth before swallowing. If after a month of this treatment the patient cannot normally convalesce and be apparently cured, in other words, if the symptoms quickly return, an operation should probably be recommended as the future of such a recurrent case is uncertain. Recurrent severe hem- orrhage should cause operation and of course when there is perforation operation is immediately neces- sary. Treatment of Hemorrhage. — In case of hemorrhage from the stomach perfect quiet, both mental and physical, must be insisted on. A hypodermic injection of morphin and atropin in full dose should be admin- istered. If the symptoms show that hemorrhage is persistent 1 c.c. (15 minims) of a 1 : 1,000 adrenalin chlorid solution in 30 c.c. (1 ounce) of distilled water 318 OPERATIVE INDICATIONS IN ULCER should be given and followed in half an hour by from 50 to 100 c.c. (about 2 to 3 ounces) of a 10 per cent, solution of sterile gelatin. Ordinarily food should be withheld from 48 to 72 hours, no food being given even by the rectum. As nutrient enemata have been shown to increase the flow of gastric juice, the first enemata should be normal salt solution and later pep- tonized milk and egg may be used. During the treatment of gastric ulcer the feces should be frequently examined for occult blood. When blood ceases to be present in the feces we have an indication that the healing of the ulcer is progressing and it is justifiable to use larger quantities of food and that of a more solid character. In case bleeding reap- pears after it has been absent for some days this should be taken as indicating the propriety of lessening the amount and simplifying the character of the food. Some physicians believe that morphin should never be given to relieve the pain with hemorrhage, because it tends too increase the stasis and hyperchlorhydria , tftat is present in ulcer. Gelatin may be given or any of the other colloidal solutions such as acacia may be utilized. It may be advisable to consider seriously the question of blood transfusion or the use of some of the hehiostatic preparations described under the sub- jects of hemophilia and purpura. FOCAL INFECTION In the treatment of gastric and duodenal ulcer the experiments of Rosenow indicated the wisdom of thorough search for foci of infection and their removal if possible. This is especially important in the preven- tion of a possible recurrence. OPERATIVE INDICATIONS When there is marked tenderness at a location aside from the region of tenderness common to the ordinary ulcer or if there should be a slight rise of temperature and an increased leukocytosis one may entertain the suspicion of an approaching perforation. In such case no delay should be permitted before open- ing the abdomen and ascertaining the true condition. According to Billings, surgical treatment is indicated when the unhealed ulcer or the scar produces deforrti- HYPERACIDITY 319 "ties which persistently interfere with gastric and intes- tinal function and also when accidents, like perforation and medically unmanageable hemorrhage, occur. To this might be added failure of the case to improve under persistent medical treatment, and with frequent recurrences. HYPERACIDITY The changes of opinion that have occurred and the changes in method of treatment in the so-called hyper- acidity of the stomach were reviewed by Adolf Schmidt of Halle, Germany, in 1915. Practically the term is taken to mean cases of increasing gastric dis- turbance, appearing at various intervals after meals, or the ingestion of special kinds of food; heartburn is a common accompaniment. Tests with the stomach-tube reveal either hyperacidity or hypersecretion, and the latter may be separated into a digestive and a continu- ous type. The latter, when appearing periodically, is known as Reichmann's disease or gastrosuccorrhea. Pawlow's opinion that pure gastric juice has the same percentage of hydrochloric acid, must in the light of recent research be abandoned unless we assume that the superficial epithelium produces concentrated alka- line fluid, together with pure gastric juice, which is paradoxical according to Gregerson. Schmidt con- cludes that the stomach secretion must vary under pathologic conditions. Nervous influences come into play and the question arises whether or not there is an etiologic relationship between the hyperacidity of the stomach and the subjective symptoms. The anamnesis must not be depended on without the use of the stomach-tube. Still more important is the ques- tion whether this hyperacidity occurs as a disease dependent only on nervous causes, or whether it always has some organic lesion as a cause. The old notion that it was a pure gastric neurosis has changed on account of the rediscovery of duodenal ulcers. The purely nervous cases are less to the fore, but we would be premature in entirely denying hyperacidity in some cases as a unit per se. C. H. Neilson, St. Louis {Jour. A. M. A., Feb. 7, 1915), considers hyperacidity a symptom of disease rather than a disease itself. It frequently occurs in the sedentary and overworked and in connection with 320 TREATMENT OF HYPERACIDITY other abdominal disorders, such as appendicitis, galh' stones, enteroptosis, uterine displacements, etc. It is also an early sign of the beginning of hyperthyroidism and of tuberculosis, and it may be due to ear troubles or eye-strain. It is a complex affair to deal with, and hence calls for a correct diagnosis of the casual con- ditions, with the removal of which the hyperacidity often disappears. In addition to these general or exciting causes, the local conditions in the stomach must be considered. Any one who has had hyper- acidity for any length of time will have certain path- ologic changes in the gastric mucosa, hypersecretion and hyperesthesia, and we often find pylorospasm, hypermotility or gastroptosis. He divides hyperacidi- ties as follows : "1. Chemical hyperacidity with a nor- mal quantity of gastric content after a Boas-Ewald test breakfast. 2. Chemical acidity combined with hypersecretion or with a continued secretion. Here the quantity of gastric content is abnormally and con- stantly large. 3. Chemical hyperacidity combined with hypersecretion and hyperesthesia. 4. Clinical or symptom hyperacidity with hyperesthesia. In this class of cases we have all the subjective symptoms of a chemical hyperacidity. In these cases we find a normal total acidity or even a subacidity. The symp- toms are due to the hyperesthetic condition of the gastric mucosa, which is painful in a normal or even subnormal acid content. 5. In this class we may find any one or a combination of the foregoing, together with pylorospasm, hypermotility or peristaltic unrest." TRKATMENT OF HYPERACIDITY The principal point is, not to confine the active treatment entirely to the stomach, but also to calm and strengthen the nervous system. Some patients are best treated by being sent at once to a hospital or sanatorium, and Schmidt demands this in every severe case. Naturally, we try first to reduce the secretion. Atropin acts in this way> but its continuous use is not advisable, nor is that of the alkalies, which may irri- tate the stomach glands. Schmidt favors the use of the magnesium oxid, combined with a small amount of belladonna and a purgative, such as sodium sulphate. TREATMENT OF HYPERACIDITY 321 Diet is very important, and foods that act as secre- tory stimulants, like spices, coffee, strong alcoholics, etc., should be avoided. As to special diets, it is dif- ficult to keep them up for any length of time. Schmidt has returned to a mixed diet and strict observance of the following rules : All food must be thoroughly cooked and thoroughly minced. The stom- ach must come to rest at least once during the twenty- four hours and the times of the meals changed to secure this. Drinking should be generally diminished and restricted to times when the stomach is not filled with food, especially in cases of ptosis. If the condi- tion is severe or combined with ptosis, he makes the patient stay in bed for two weeks, and this he con- siders important. " Sometimes hot compresses are used to bring relief — twice daily for. two hours. At night they are replaced by cold hydropathic compresses. Washing the stomach is indicated only when the hyperacidity is based on catarrh. Temporary relief, however, will always be afforded by the administration of an antacid, and the burning, distress, pyrosis, and flatulence that may be present will all be made imme- diately better by the administration of 1 gram (15 grains) of bicarbonate of soda. Such treatment is, of course, purely symptomatic. If it is advisable to give bicarbonate of soda, which is perhaps the best of all the antacids, three times a day, before meals, the dose should be smaller, perhaps generally O.SO gram (7% grains). It will act, as above stated, as a gastric sedative and will soothe the irritated mucous mem- ■ brane, will cause a quicker outpouring of the hydro- chloric acid, and will thus hasten the completion of the stomach protein digestion; all of which will tend to make the disturbance and the dyspepsia better ; but, unless there is actual inflammation of the stomach, is not treating the cause. If gastritis is present, no one treatment is perhaps more successful than the combination of bismuth and soda, as : Gm. 5 Bismuthi subnitratis 201 or Sy Sodii bicarbonatis 1Q| 3 i Jss M. et fac chartulas, 20. ^ . , , Sig. : A powder three times a day, before meals. 322 TREATMENT OF HYPERACIDITY A glass of hot water taken a half-hour before the meal to wash ofif the mucus from, and to deplete, the inflamed gastric mucosa is, of course, excellent treat- ment. If the antacid is given after a meal the digestion of the starchy foods will go on longer than usual, on account of the alkali keeping the contents of the stom- ach longer alkaline, viz., free hydrochloric acid or a large amount of acid peptones will not so soon be present to inhibit further salivary digestion. If with the dyspepsia, or gastritis, constipation is present, some magnesium oxid should be added to the above prescription or substituted for the sodium bicar- bonate. Also in hyperacidity the precipitated carbon- ate of lime is used, and is often a- most successful treatment. " If an antacid is indicated and diarrhea is present, it is advisable to use lime water. If an acute hyperacidity is present and there is paU pitation or cardiac disturbance, hysterical or other, the aromatic spirits of ammonia is perhaps the best ant- acid to use or milk of magnesia in warn) water may be given. Jacobson (Jour. A. M. A., Nov. 24, 1917) argues that the hydrochloric acid of the stomach comes from the sodium chlorid of the blood and that the body gets its chlorids from food and from common salt. Foods without inorganic salts will not maintain life. In treat- ing hyperacidity we do not need to ^exclude all inor- ganic salts, but rather to exclude the chlorid. If unto- ward symptoms should arise, however, and show that the deprivation has gone too far, it is conceivable that a limit might be found at which favorable clinical results are gained, but beyond which we should not go. But even after a prolonged salt-free diet, the tissues still supply chlorin to the gastric glands. In man the gastric juice is resorbed in the intestine, and the same dose of salt can be used again indef- initely for the secretion of gastric juice. Says- the writer: "We must seek to promote elimination of chlorids by giving plenty of potassium salts (Burige), by avoiding the use of sodium bicarbonate, which decreases elimination (Goldberg and Hertz), by fre- quent aspiration, and by giving plenty of water (Rulon INTESTINAL STASIS 323 and Hawk). But if excess of water increases the gastric secretions, as is supposed, it may prove better to restrict the use of the fluids." The method of attack, then, is to use a well-balanced diet. save for the lack of chlorin. Food stuffs should be either naturally poor in chlorin or freed from it by boiling. To season their food, these patients should be given a special inorganic salt mixture, about as the proportion is found in milk, except that calcium lactate is substituted for calcium chlorid. The following formula, also used for patients with nephritis who are on a salt-free diet, is given by the writer: gm. Dicalcium phosphate 5 8 Monomagnesium phosphate 3 4 Dipota'ssium phosphate 11 Potassium citrate. 17. Sodium citrate 74 Calcium lactate '. 4 Mix and pulverize. "Important articles," he continues, "are fresh meat, . potatoes, oatmeal, carrots and cauliflower, cut fine and then boiled for hours, with several changes of water; stewed apples, prunes and apricots-; very weak tea and^ coffee ; butter freed from salt by washing fine particles thoroughly in running water ; one egg and about 50 c.c. of milk or cream per day, but no more. Dis- tilled water is used for drinking, but, if need be, tap water may be used for cooking if the chlorin content is low. Of course, these articles of diet will var> with the nature of the disorder, the complications and the stage of treatinent. In same cases it might be well to begin with a period of starvation, followed by the special diet. In case of gastric ulcer, additional treat- ment may be needed, but potassium bicarbonate will take the place of the sodium salt if an increase in the excretion of sodium chlorid is sought. The acid- ities are determined by titration and the chlorids esti- mated by Van Slyke and McLean method. IN.TESTINAL STASIS— CONSTIPATION The term intestinal stasis has of late years been used to include what was formerly classed as consti- pation, but with an extension to more serious cases which -require surgical treatment. Intestinal stasis 324 DIET IN CONSTIPATION includes all cases in which the contents of the bowel fail to move in a normal manner, whether the cause be a mechanical obstruction or a functional failure due to the character of the intestinal contents or to the functional inactivity of intestinal musculature. The stasis may occur at various locations in the gastro- intestinal canal, but the usual location in the cases under consideration are stasis in the lower part of the ileum, stasis in various sections of the large intestine and stasis in the rectum. Hindrance to the evacuation of the feces may be due to a paresis of the rectum or sigmoid, brought on either by repeated distention with feces or by the use of daily large rectal enemas. In these cases help may be obtained by daily diminution of the bulk of water used. A very fre- quent cause of constipation is insufficiency of feces resulting from the general insufficiency of the food taken or from the fact that it contains too little of the indigestible vegetable matter which favors the evac- uation of the bowels. In such cases the feces are hard and dry, from the fact that during their stay in the large intestine the water has been absorbed to an undue extent. This form of constipation must be treated by proper diet. DIET The constipated individual shbuld aim to add to his diet a larger quantity than normal of fluids, either in the form of water or perhaps of buttermilk. Tea should be avoided because it contains tannin which may, by its astringent action, counteract the good effect of the larger quantity of liquid. Liquids should be given not only at meal times but in the inter- vals, in which case they serve better to replace the water absorbed irom the large intestine. The diet for constipation should also contain as' large an amount of fat as the patient can tolerate. The amount of vegetables which- contain considerable quantities of cellulose should also be increased. This means plenty of vegetables. Fruits should be given freely, except the astringent fruits. The amount of water taken depends on the patient's habits and the condition of the circulation. A patient who is muscu- larly active should drink more water than the one MASSAGE IN CONSTIPATION 325 whose life is sedentary. A glass of cold water drunk in the morning while dressing is a great help to a physiologic movement of the bowels directly after breakfast. LAXATIVE FOODS The vegetables that are especially useful in chronic constipation are spinach, peas, cauliflower,, cabbage, asparagus', salads, onions, celery and tomatoes. The cereals of importance are oatmeal and cornmeal, as well as graham, rye, whole wheat and bran breads. The following are also classed as laxative foods: Honey, cider, molasses, apples, pears, peaches, oranges, prunes, dates and figs. Buttermilk is preferable to sweet milk. HABIT The patient should go to stool every morning at the . same hour whether the desire is present or not, and should attend to the matter at hand, and, especially should not read for diversion. It is especially valu- able to use a seat that is not too comfortable and to be able to flex the knees well up toward the abdomen ; if the seat is too high a footstool may be used. Abdominal massage, calisthenics, regulated exercise, walking, rowing, riding, golf playing, or any other muscular exercise that seems advisable should be ordered for the patient of sedentary habits, and it must be urged on him that if the habit of constipation is not now cured the future promises intestinal indi- gestion, dyspepsia, imperfect action of the liver, imper- fect bile, nervous irritations, kidney irritations, and early cardio-vascular-renal disease ; i. e., arterioscle- rosis, weakening of the heart, and chronic interstitial nephritis. MASSAGE Before any severe exercise or any abdominal mas- sage is ordered, or advised, a careful abdominal exam- ination should be made and the physician assured that there are no inflammatory conditions present, as chronic appendicitis, gallbladder, pelvic or other dis- turbances. Manual massage may be applied to the abdomen from fifteen to twenty minutes, beginning with light, 326 MEDICINAL TREATMENT OF CONSTIPATION circular stroking of the abdomen about the umbilicus, first having lubricated well the parts with olive oil. The course of the colon is gradually massaged deeply, all fecal masses broken up and moved down toward the rectum. When massage is deemed inadvisable or inconvenient, faradic electricity may be used. A large electrode may be over the lumbar or sacral spine and the other is moved over the abdomen, stroking from right to left. The duration of the treatment and strength of current should vary with the result on the patient. A vibrator may also be used gently over the abdomen. MEDICINAL TREATMENT The best medicinal treatment of constipation con- sists in the administration of the fluid extract of rham- nus purshiana (cascara sagrada) or some form of aloes or aloin (generally best combined with bellar- donna and strychnin). Sometimes podophyllin may be used separately or combined with other laxatives. There are no other laxatives or cathartics so likely to benefit constipation as these drugs. Whichever one of these is used, it should be given, week by week, in gradually diminishing doses. Whether they should be given in small doses three times a day, or larger doses once a day depends on the conditions. Generally, the patient, not being sick and not willing to be bothered, and with the intent of haying a stool after breakfast, and the medicine requiring a certain length of time to act, directly after supper or at bedtime, in one dose, is the best treatment. However, even with the best possible care, when these drugs are given, some patients require a dose daily for months and even years, and can not obtain a stool without it. This is generally not due to the- action of the pill on the mind, as the substitution of an inactive tablet will prove. Perhaps the next best laxative is phenolphthalein. This drug generally acts well and, if given in tablet, should be crushed with the teeth before swallowing, as it apparently acts better when well granulated. It should not be used too long as it may cause colon and rectal irritation. SPASTIC CONSTIPATION 327 In the simple constipation that is now being dis- cussed it is inadvisable to resort- regularly to enemas of any kind or to more brisk cathartics than those above mentioned or to saline cathartics. Of late liquid petrolatum has achieved great vogue, as it acts merely as a lubricant, is inert, easy to take and supposedly does not form a habit. In large doses it may cause unpleasant rectal oozing. SPASTIC CONSTIPATION This form, which is usually reckoned as a distinct variety, is characterized by the distress experienced during the act of defecation and by the appearance of the stools, which are narrow, sometimes of the caliber of a lead pencil, and often covered with mucus. Sometimes separate masses of mucus in the form of strings or membranes are passed with the stool or at times when no stool is passed. This spastic form usually occurs in neurotic patients and the whole clin- ical picture is dominated by the nervous element. These cases should receive treatment appropriate to their nervous condition and they are also benefited locally by oil enemata, given as a rule on alternate evenings. The technic of administering the -oil is very simple. About 250 cubic centimeters of cottonseed oil, as warm as can well be borne, are injected through a funnel attached to a colon tube and allowed to remain in the rectum until the next morning. Patients unac- customed to these injections should put on a large diaper after the enema to obviate the danger of the oil leaking through the anus. It is necessary to recog- nize a constipation of psychic origin and one due to habit, which must be treated by suggestion and educa- tion with appropriate hygienic aids. What has been said above refers to the treatment of a symptom and only in the mildest cases is it curative in the sense of being addressed to the underlying lesion. Even in cases of spastic constipation which have been interpreted as pure neuroses it is probable that an anatomic basis is present in the form of a colonic catarrh which is greatly aggravated by the nervous condition. Following Lane, a large number of surgeons have explained the symptoms in a large cate- gory of abdominal and constitutional disorders as due 328 SPASTIC CONSTIPATION to a mechanical hindrance to the passage of the intes- tinal contents and the consequent putrefaction occur- ring in the 'bowel. Ptosis of the various parts of the intestine are believed to form the basis of the obstruction from which the abnormal symptoms arise. In other cases it is supposed that adhesions, inflammatory membranes, etc., cause bends and kinks in the intestine which pre- vent the free movement of the intestinal contents. Unanimity in the interpretation of these facts has not been reached by clinicians. A number, including Ein- hbrn, Bastedo, Wilcox and others, consider that the bands and ptoses do not account for the stasis inas- much as the symptom of stasis is frequently intermit- tent and persons with equal mechanical hindrances may be free from syrriptoms indicating the occurrence of putrefaction. Eirihorn refers the doctrine of ptosis to Glenard. The theory of putrefaction and its resultant autoin- toxication is due to the teaching of Bouchard, Combe and others. This theory is made by Lane and his disci- ples the foundation for their plan of treatment. The digestive canal is called "a drainage tube" and com- pared to a sewer system in which any clogging must cause disaster. It has been asked if our body is resourceful in adequately fighting enemies that it has never, before encountered — ^pneumonia, typhoid fever, etc. — how much more must we expect from it in the way of every-day defenses. It is surely well fitted to debar the entrance of harmful digestive products through the intestinal wall, for this is a continuous happening. ■Unless there is a real mechanical obstruction or a definite organic lesion interfering with the intestinal current, a temporary delay of the contents may not be significant. It may even serve to make absorption more complete. The usual simple habitual constipation does not cause autointoxication. As is well kno.wn, a patient may have no bowel movement for several days and still present no abnormal symptoms. The symptoms frequently associated with chronic constipation may DIAGNOSIS OF SPASTIC CONSTIPATION 329 be ascribed to nervous disturbances, and not to auto- intoxication.. Reassurance arid nerve sedatives in such cases will often do more good than drastic measures. In mild cases Lane, following Glenard, recommends an appropriate abdominal supporting bandage. In the severer type Lane recomfnends operative measures — ileocolostoiny or colectomy. With this radical plan of treatment most clinicians and some eminent ^surgeons do not agree. SYMPTOMATOLOGY The symptoms of the milder forms of intestinal stasis are the same as those commonly attributed to constipation. Much of such -symptomatology may result from the effect of ptosis on a neurotic constitu- tion and it is probably erroneous to attribute all symp- toms observed in such patients to intoxication from the intestines. A proper estimate of the effects of the various factors influencing the clinical course of such cases is important, as indicating the relative importance to be assigned to different measures employed. Other symptoms are mechanical from the pressure of the delayed fecal, masses, still others may result from dragging on the adhesions or bands con- necting different organs ; still others are due to nervous reflexes from irritation or inflammation of the mucous membrane of the colon. Lastly there are symptoms of actual organic lesions which may result from putre- factive changes in the contents of the colon. Such symptoms in severe cases may form a serious clinical picture. DIAGNOSIS It is fortunate that we possess means of making an accurate diagnosis of intestinal stasis by means of roentgen-ray examinations, either radiographs or flu- oroscopic examinations. In this way the length of time that is required for food to pass through the different sections of the intestine can be determined, and it may be learned at what point the delay, if any, occurs. Abnormalities in the contour and position of the different parts of the intestine can also be deter- mined in the same way. The existence of intestinal putrefaction is shown with certainty by the appearance 330 TAPEWORM of indican in the urine. The extent of the putrefactive changes are, not, however, easily estimated in this way. If, on shaking out the urine with chloroform after treating it with Obefmeyer's reagent (a solution of ferric chlorid in strong hydrochloric acid, two parts to one thousand) the chloroform has a deep blue color, a considerable amount of indican is present, and it is justifiable to assume that there is a considerable degree of intestinal putrefaction. TREATMENT The treatment of mild degr.ees of intestinal stasis is the treatment of constipation as previously outlined. To this should be added such mechanical supports as are necessary to obviate the effects of ptosis of the intestine. As a laxative agent Lane has strongly rec- ommended liquid petrolatuin. Bastedo and more recent literature generally object to the use of the ordinary drug laxatives and recommend the use of agar-agar or of liquid petrolatum. Surgical Treatment. — The question of what surgical measures should be resorted to and the proper time to apply them is very important. Medical treatment should be given a thorough trial. If medical measures fail, operation may be resorted to. Moynihan beheves that nothing short of colectomy offers a substantial chance of cure. The part of the gut that needs removal is, he thinks, the last part of the ileum, the cecum and the ascending colon. TAPEWORM Treatment to eradicate a tapeworm is based on several factors which, though simple, are fundamental. The treatment should be grounded on a knowledge of the worm, its pathology and method of existence. The diagnosis of the presence of any of the tape- worms in the bowel must be finally settled by the find- ing of the organism in the stools. However, other phenomena such as indefinite, pains, a sense of disten- tion, ravenous hunger, etc., are not unusual. Before administering the anthelmintic several days should be devoted to the preparation of the bowel. TREATMENT OF TAPEWORM 331 The patient should take only a light liquid diet and should gradually cleanse the bowel by the use of the following prescription : ' Gm. or C.c. R Magtiesii sulphatis. 65 S ii Spirittis chloroformi IS or . flS iii Aquae q. s. ad 200 flSvi M. Sig. : A tablespoonful, in water, three times a day, an liour before meals. An enema of soap and water may be given at night. This treatment removes solid fecal matter from the bowel as well as any adherent mucus coating which may be present. The night before the final treatment is to be administered the patient is given a final cleansing dose^ perhaps two tablespoonfuls of the above mixture, and then takes no food and but little liquids. The next morning after the bowels have moved male fern may be given as follows : Gm. B Oleoresinae aspidii 4| or 3i Fac capsulas, 8. Sig. : Four capsules, with half a glass of hot water at 9 a. m., and four capsules, with hot water, at 10 a. m. [Impor- tant : Before taking the above capsules each one should be uncapped.] -At 12 o'clock three tablespoonfuls of the magnesium sulphate mixture should be taken, to insure the rapid passage of the male fern through the intestine lest too much absorption take place. During the morning no nutrition should be taken other than black coffee, clear tea, or bouillon. Except when momentarily otherwise engaged, the patient should be in bed, and should stay in bed the remainder of the day. For unavoidable faintness brandy may be administered at any time, or a hypo- dermatic injection of strychnin may be given. After 1 o'clock any food may be given the patient that he desires. Diiring the three or four hours of this active treat- ment, viz., from 10 a.m. to 1 or 2 p.m., the physician should remain with the patient, or a thoroughly trained nurse should be in attendance. The stools should all be passed into receptacles where they can be thoroughly strained afterward, in 332 ROUNDWORM order that the parasite's head may be sought, and if the above treatment is carried out it will generally be found. Pomegranate has been highly lauded by various physicians as an efficient anthelmintic in these cases. It is best given, after thoroughly cleansing the patient's bowel as has been described , in the form of a fresh infusion. Three ounces of the fresh bark are macer- ated in twelve ounces of water for a half day and the infusion then boiled down one half. This quantity is taken" within an hour, in several doses, and followed within an hour or two by castor oil. Pomegranate may cause dizziness and extreme nausea where given in this form. As alternative an alkaloid derived from the bark— pelletefin tannate — is sometimes used. The dose is from 3 to 6 grains, and should be given fasting, mixed with a little water. A glass of water should be taken a little after its administration and an hour afterward a cathartic. Other vermifuges include turpentine, kousso, pump- kin seed and thymol. ASCARIS LUMBRICOIDES: ROUND WORM The round worm is a common parasite, often very difficult to diagnose. The symptoms are indefinite and include vague colicky pains, foul breath, itching at the nose, etc. The common source of infection is water or food. The finding of the worm in the feces is the final proof of its existence. It is of reddish brown color, about %-inch in diameter. The male varies in length from 4 to 8 inches, the female from 6 to 12 inches. Though the intestinal tract is the nor- mal habitat the worms wander, and they have been found in the larynx, nose, Eustachian tube, tonsil and other contiguous structures. TREATMENT The diagnosis having been confirmed, treatment should be begun by administering laxatives at night to cleanse the bowel. Santonin is a favorite vermifuge in these cases, but many cases of poisoning have fol- lowed its use and it shoiild be given with caution. The PIN WORMS 333 dose is 2 to 5 grains. The drug may be administered in the following form: Gm. or C.c. IJ Santonini ~ Hydrargyri chloridi mitis.... Saccliari lactis 3 30 gr.v 20 or gr. iii gr. xlv Sig. : A powder, in water, every hour for three doses. Thymol has been used with good results in these cases and wormseed oil {oleum chenopodii), an Amer- ican product, has given good results. The dosage of the latter may be five dfops on a lump of sugar and this may be repeated and followed by a cathartic. OXYURIS VERMICULARIS: PIN WORMS This worm varies in length from 1/S-inch for the male to 2/5-inch for the female. The former has a blunt tail, curved upward, the female a pointed drawn-out tail. The most common symptom is itching about the anus, caused by boring movements of the female in depositing eggs in the rectum. The worm's chief habitat is the bowel from the jejunum to the anus. It is believed that the source of infection is the swallowing of ripe eggs in drinking water or food. The treatment consists in removing the worms by frequent washing of the region infected. Internally salts, such as magnes.ium or sodium -sulphate; may be given, or large doses of calomel. To dislodge, the worms from the rectum enemata should be given. Among various enemata which have been recommended are decoctions of quassia — an ounce of quassia chips in a pint and a half of water boiled down to a pint and strained; lime water; salt water; glycerin and water; turpentine — 1 dram to a pint of soap and water, etc. For local itching and abrasion such ointments as the official unguentum phenolis (3 per cent.) or some mild sulphur ointment may be employed. SIMPLE CATARRHAL JAUNDICE This condition is due to a blocking, from more or less inflammation and swelling, of the_ common bile duct. While this duct alone may be involved, it is genefally secondary to inflammation of the duodenum. 334 SIMPLE CATARRHAL JAUNDICE This irritation and inflammation of the duodenum may itself be secondary to a simple gastritis, and the whole condition, may be a sequence of serious mal- digestion or infection and irritation from some deterio- rated or toxin-bearing food. The ingestion of too much alcohol or of too much simple irritant, as mus- tard or rich sauces, or of some irritant drug or an irritant poison may cause secondarily the condition of simple catarrhal jaundice. In a person who' has had this condition once, or is predisposed to abdominal congestions, chilling of the abdomen, either from a sudden change in temperature, or from exposure of an insufficiently clothed abdomen to cold air, may -cause duodenal congestion and catarrhal jaundice. This kind of jaundice is most likely to occur in the season of the year in which there are sudden changes to lower temperature, especially in the fall and in the early spring following warm periods. Whatever may be the exciting cause, cold frequently plays a con- tributing part in the development of the disease. A true epidemic form of this disease has been termed Weil's disease, and has been accredited to a spirochete known as Spirochaeta icterohemorrhagiae. This is ushered in with a high fever, lasting one or two weeks, with a gradual decline in the second week, and is attended with considerable prostration. Albumin has been found in the urine, and the spleen has been enlarged. Whether the simple catarrhal jaundice so frequently seen is a sporadic form of such an infection has not been determined. Until they have been proved to be related, it would seem well not to consider simple catarrhal jaundice as the disease described by Weil. Simple catarrhal jaundice generally develops insid- iously; rarely shows any increase of temperature, and if there is a fever it is vefy low, and often the tempera- ture is subnormal; there is considerable prostration; slow pulse ; entire loss of appetite ; some nausea ; often vomiting; and there is likely to be constipation, although there may be diarrhea. The head feels dull, or there is real headache. The tongiie is heavily coated, either brown or yellow. The breath is very bad, and there is a bad taste in the mouth. There is soon bile in the urine, and there may be traces of TREATMENT OF CATARRHAL JAUNDICE 335 albumin. Jaundice may be present when the patieht is first seen, if the digestive symptoms are sufficient to cause the patient to seek a physician early. Soon the stools are clay colored, and the skin is dry and irrita.ted sufficiently to cause itching. The perspiration gen- erally stains the clothing. There is much mental depression, and inability to do mental work, but gen- erally not much abdominal pain. The jaundice usually lasts two, three of even four weeks; if it lasts much longer than four weeks, some other cause for the jaundice than a simple inflammation must be sought. The more at rest the patient is, the quicker will the jaundice generally subside. In the beginning a dose of calomel, in amount considered .sufficient, should be given, followed by a saline. A gram of bismuth sub- carbonate and a gram of sodium bicarbonate may be given every three hours during the day for two or three days, and then three times a day, before meals, for a few more days." The bowels must be moved daily by some simple saline or laxative water. If there is much epigastric tenderness and soreness, or if there is nausea, milk of magnesia in teaspoonful doses every ■ three or four hours, in hot water, is advisable. The patient should be given plenty of wa:ter to drink. Hot water is also advisable. For the first twenty-four hours, nothing but water may be given, unless food is especially desired. On the following day the nourishment should be bouillon or hot broths, tea, toast, thin oatmeal gruel, or some other simple thin cereal. Malted milk may be given, and in another day or two a poached egg or two, if they are well tolerated. All fats and milk, except possibly skimmed milk, should be avoided in catarrhal jaundice. It is a mistake to consider milk a good food in this condition. No liquid should be given cold, and no cold food should be given ; anything cold taken into the stomach in this condition is probably disadvan- tageous. As soon as the sodium bicarbonate in com- bination with the bismuth subcarbonate is given less frequently, an alkali should be given, as potassium citrate, 2 gm., in wintergreen water, lO-'c.c, three times a day, after the main nourishments. 336 TREATMENT OF CATARRHAL JAUNDICE As stated above, the more at rest the patient is (in other words, the more he Hes down) the better. There is less abdominal congestion, and the circulation in the congested regioii is improved. As an aid to resorption • of the exudate in these swollen parts, abdominal warmth is advisable, and an electric heating pad or hot water bottle kept on the abdomen for hours at a time is good treatment. When the patient is up and about, the abdomen should be kept extra warm by flannel or absorbent cotton. To relieve internal congestion and to increase the secretion of the skin and stop itching, it is advisable to have a daily hot bath. It is of advantage especially in removing the irritating crystals that occur on cer- tain parts of the body from the perspiration in this condition. As the patient improves, the diet can be enlarged with oranges, baked potatoes, rice and more meat, still withholding the fats, except that foods with cooked milk, as custards, may be well digested. If the jaundice lasts more than ten days or two weeks, ammonium chlorid in half-gram doses, three times a day, after meals, may. be given. Ammonium chlorid apparently increases the secretion of the mucous membranes. Probably it increases the secre- tion of the bile ducts as it does that of the bronchial tubes. It may be a valuable treatment in this condi- tion, when the improvement is slow. The following prescription may be utilized : Gm. or C.c. B Ammonium chlorid 10 Syrup of citric acid 2S Water up to 100 Mix and label : A teaspoonful, in water, three times a day; after meals. DISEASES OF THE KIDNEY PYELITIS The causes of infection in the kidney, as elsewhere jn the body, may be stated as a lowered resistance of the tissue and an organism capable of infecting the kidney tissue, coming usually from a focus else- where in the body. Barber and Draper have shown that ascending infection by the ureters seldom if ever occurs as long as the peristalsis of the ureters is unim- paired and the uterovesical valves maintain their integ- rity. Most infections are therefore probably hema- togenous. The large number of such infections occurring in girls is evidence, however, that the condition is quite frequently a- direct, ascending infec- tion. Among the factors lowering the resistance of the kidney tissue, nephrolithiasis or kidney stone, is per- haps the most common cause, others being traumatism, urinary obstruction, displacement, etc. The pyelitis of pregnancy arises from pressure of the gravid uterus which may mechanically obstruct the ureters. Not infrequently the pyelitis is a complication of. such acute infectious fevers as typhoid and pneumonia. Among the various focal infections which may bear an etiologic relationship to pyelitis are tonsillitis, alveolar abscesses, and infections of the accessory nasal sinuses. According to MacGowan, Smith, Quimby and others, the organisms producing pyelitis are, in the order of their frequency, colon and tubercle bacilli, staphylococci, streptococci, gonococci, typhoid bacilli, paratyphoid bacilli and pneumococci. These infec- tions occur rapidly, are usually acute and persistent, may cause multiple abscesses and also may destroy the kidney and often the life of the patient. In their early diagnosis the chief means is exclusion, as. the symptoms are essentially abdominal and may simulate other troubles like appendicitis, liver disorder, etc. The most prominent symptom in kidney suppuration besides fever is marked tenderness at the costovertebral angle, which is always present. The urine does not 338 TREATMENT OF PYELITIS indicate the microorganism and in advanced or serious) cases it will contain leukocytes . and there will be _a leukocytosis, usually not over 25,000. A severe chill usually means a high grade of infection. Staphylo- coccus and streptococcus nephritic attacks are most frequent and have been observed following boils, tonsillitus, acute osteomyelitis, felon, ulcerations about the rectum and contagious impetigo. TREATMENT Primarily in the treatment of pyelitis the cause must be' sought, that is, the focus, the nephrolithiasis, or cystitis, and this ' condition treated primarily. • The patient should be kept absolutely at rest in bed on a soft, meat-free diet. The liquid intake should be sufficient to cause the patient to pass from two to three quarts of urine daily and thus flush the kidneys out thoroughly.. The bowels should be kept moving freely and regu- larly. The medicinal treatment of pyelitis depends on whether the urine is. acid or alkaline. If the patient is troubled by frequency of and distress on urination it is best to render the urine alkaline as it is then less irritating. The alkalinization of the urine is further- more an excellent method of treating the pyelitis, for the bacteria causing the pyelitis do not thrive in an alkaline medium. The alkalinization of the; urine may be accomplished by the use of alkaline drinking waters, or fruit juices, of acetates, citrates or carbonates. The carbonates are the most effective, but are not always well tolerated by the stomach, in which case some of the other salts may be tried. It is best to use this method of treatment until the bladder irritabiUty has disappeared and then allow the urine to become acid and to prescribe hexamethylenamin for a few days until the bladder becomes irritable again, when the alkaline treatment is resumed. Other drugs, such as salol, methylene blue and the oils of tiirpentine, sandaL wood, juniper and copaiba, have also been used in the treatment of this condition. Relief is frequently afforded to patients with pyelitis by ureteral catheterization and pelvic lavage with weak solutions of silver nitrate (1 per cent.), mercuric oxycyanid from 1 : 10,000 to 1 : 5,000, or formaldehyd RENAL TUBERCULOSIS 339 ( 1 : 20,000) . Argyrol, coUargol and other silver prep- arations have also been mentioned for this purpose. It should be remembered, however, that ureteral cath- eterization requires expert technic. In children, in whom the disorder is common, the majority of cases will yield to alkaline treatment and sweat baths. Vaccines are rarely useful in pyelitis.- Autogenous vaccines may be tried, but they must be used with great caution, as violent reactions may be produced.. If a purulent kidney does not improve rapidly, if the patient is becoming debilitated, or if the kidney • is found enlarged and examination of the urine from this kidney shows that the kidney structure is diseased, temporizing should cease, and the kidney should be removed, unless the other kidney is so diseased as to render the operative danger very great. RENAL TUBERCULOSIS Renal tuberculosis is a progressive infection, slow in its development, often remittent and probably incur- able by medical means. It may appear in the miliary form as a part of a general tuberculosis. .There also exists a chronic parenchymatous nephritis occurring in the later stages of lung tuberculosis. According to some writers, there is an interstitial tuberculous nephritis. Most important, perhaps, is the type of minute focal infections tending to coalesce almost invariably unilateral at first and occurring in persons not affected with active tuberculosis. This is. the form usually meant by the term renal tuberculosis. There are no diagnostic symptoms for the early stages. The first is vesical irritability, followed later by albuminuria and perhaps hematuria. It is apt to be confused by the practitioner with renal stone, though that is a much rarer condition. Pus in the urine is not long delayed and with it the tubercle bacillus appears. The blood stream is the mode of invasion except in very rare cases. One kidney is first affected in most cases, but the other kidney later becomes involved. After the bacillus is discovered the diagnosis is clear but the cystoscopic appearances will confirm it. There 340 ALBUMINURIA are two ways of treating the patient, either the general treatment for tuberculosis or nephrectomy, which gives immediate relief in 75 per cent, of cases, and permanent cures in perhaps 50 per cent. ALBUMINURIA The appearance of albumin in the urine may be due to any one or more of many different causes. These ■ may be classed as follows : 1. A symptom of nephritis. 2. Accidental albuminuria : (o) Dietary (alimentary). (6) Qiilling of the body. (c) Unexplained (frequently focal infection). 3. Incidental albuminuria: (o) Cold baths. (&) Menstruation. (c) Athletics or other physical strain. (d) Cardiac weakness. • (e) Irritation in some "part of the urinary tract. (/) Hypertension. (g) Ether or other anesthesia. 4. Orthostatic (lordotic, cyclic, adolescent). Albumin in the urine comes either from the kidneys or from the urinary tract. If it is the result of a localized irritation, inflammation or hemorrhage, there are more leukocytes present in the urinary sediment than in ordinary albuminuria. In case of hemorrhage erythrocytes will be found. Albuminuria caused by nephritis will be discussed under that head. When albuminuria is caused by any of the conditions listed as accidental or incidental the prevention and treat- ment is self-evident. Orthostatic albuminuria is shown to be related to lordosis which produces a passive hyperemia of the kidneys with leakage of albumin. It should be limited to that albuminuria without casts which occurs after standing or moving about, and which disappears with a reclining position. It may also be due to an insuffi- ciency of the kidney circulation, possibly congenital, with or without lordosis. It may also be due to -cer- tain occupations which throw an especially large amount of work on the kidneys, resulting in passive congestion. Before an albuminuria is considered a ACUTE NEPHRITIS 341 simple alhumia leak, all suspicion of more serious con- ditions of the kidneys must be eliminated by examina- tions of the urine under varying conditions. Casts must be absent, and there must be no cardiac hyper- trophy or other symptoms which would show that the kidneys are suffering from localized or general inflam- mation. The results of urine examination on first rising in the morning and again in the latter part of the after- noon will show whether the condition is-an orthostatic albuminuria. Dietary tests and exercise tests will also show the limitations of the kidneys and their ability to sustain increased work. TREATMENT Strenuous exercise should be forbidden, and the body functions should be regulated in an effort to secure as near an approach. to normal as possible. A great deal of rest should be enforced. Anemia should be lookied for and treated. The condition of the heart should be studied and regulated. The bowels should be regulated and the intestinal condition kept normal by the use of a carefully diosen diet. Sea bathing and cold bathing should be prohibited. A warm bath may be allowed regularly to aid elimination through the skin. The muscles of the back should be strengthened by proper exercise and professional massage may be helpful. ACUTE NEPHRITIS Acute nephritis arises as a result of injury to renal parenchyma due to bacterial infection or chemical toxins. To the first of these belong the acute nephritis of scarlet fever and the other acute infections, though there may be a toxic element in addition. The classical example of the infectious type of acute nephritis is that which follows an acute tonsilHtis or sinusitis. As examples of the toxic type, we have the cases follow- ing extensive burns and poisoning with such sub- stances as turpentine, cantharides, phenol, the sali- cylates, potassium chlorate, iodoform, mineral acids, arsenic, phosphorus, mercury and lead. The acute nephritis of pregnancy is also probably in part of 342 FISCHER TREATMENT OF NEPHRITIS toxic origin. Alcoholism is of itself probably not. a cause of nephritis, but the exposure that so often accompanies excessive use of alcohol may give rise to an acute infection which is the cause of the nephritis. Dick has shown that bacteria are present and responsible in nearly all types. As to prognosis, the acute nephritis may clear up entirely, it may become chronic, or it may end fatally due to uremia, anasarca, or to a pneumonia .or other terminal infection. A condition which sometimes fol- lows an acute nephritis should be mentioned; in some cases there results a permanent albuminuria which is not, however, accompanied by symptoms of renal dis- ease. In fact, in these cases there is no impairment of renal function as shown by such functional tests as the phenolsulphonephthalein test. The cause of this albuminuria is probably a permanent cicatrization in a portion of one or both kidneys which is, however, not sufficient to impair the renal function. There are two rather diametrically opposed methods of treating acute nephritis, one based wholly on clinical experience and the other principally on the experi- mental work of Martin H. Fischer. FISCHER TREATMENT Fischer in his experimental work has shown that acidosis will cause edema and albuminuria and that this edema and albuminuria can be overcome by over- coming the acidosis with alkalies. He argues that in nephritis we have conditions similar to those that he has experimentally produced by acidosis and over- come by the use of alkalies. Further, he has shown that by using sodium chlorid, a smaller amount of alkali is needed to overcome the acidosis and the resulting edema. He has outlined a treatment for nephritis based on this experimental work which in many cases seems to produce better results than any other treatment. He recommends that this hypertonic solution (sodium chlorid 14 grams, sodiiim carbonate 10 grams and water 1,000 c.c.) be given per rectum; this is best given by the drop method and, unless the patient is becoming uremic, 500 c.c. at a time twice a day. If the patient is showing symptoms of impend- GENERAL TREATMENT OF NEPHRITIS 343 ing uremia 1,000 c.c. may be given per rectum or even intravenously. In giving the solution intravenously care must be taken that none of the solution enters the tissues as the hypertonic solution may cause a slough. The best method oi giving it intravenously is through a needle into one of the veins of the forearm, such as the median basilic vein; the solution should enter slowly, so that it may be well mixed with blood. Fischer's directions should be followed in preparing the solution for intravenous use. In addition to the above intravenous or rectal medication, he recom- mends giving alkalies and sodium chlorid by mouth. The alkalies may be given in water or in fruit juices. The liquid intake is not limited, but all liquids should be isotonic or hypertonic so as not to overcome the effect of the solution given per rectum. The diet is composed of soft foods which are heavily salted. The 'patient should be kept at rest in bed until well on the road to recovery and then allowed up a little more each day. The bowels should be kept moving freely by the use of salines. The total liquid intake and output must be accurately measured to make sure the edema is lessened. GENERAL TREATMENT The following method of treatment is based on clin- ical experience and is in many ways opposed to Fischer's method. The patient should be put to bed in a warm, well ventilated room. All irritant drugs should be avoided; cold applications should be avoided and also all chilling of the body. Baths should be taken in warm or hot water. Meat and meat proteins should be avoided as soon as traces of albumin are found in the urine and the diet should be quite rigid including milk, thin gruels, barley water, etc. If possible the diet should be very free of salt. It is generally considered advis- able because of the edema to restrict the water intake, but if the diet is salt free a moderate amount of water may be allowed. A refreshing drink may be prepared from a teaspoonful of cream of tartar in a pint of boiling water to which is added the juice of a lemon and a little sugar. 344 GENERAL TREATMENT OF NEPHRITIS If the patient's stomach is disturbed, a short starva- tion period is advisable. Liberal quantities of hot water may be given to relieve the vomiting, and if this is not sufficient, several 1 gm. doses of bismuth sub- carbonate and sodium bicarbonate should be given every three hours until relief ensues. To promote elimination the body should be kept quite warm and hot sponge baths, given. Warm appli- cations may be applied to the kidney region. A few grains of calomel, or a saline purgative should be given to free the intestinal canal of toxic substances. In children rhubarb or cascara sagrada may be used. Enemas may be substituted for the cathartics. Diu- retics should not be given with the exception of water, to which sodium citrate or orange or lemon juice may be added. As has been stated the patient should be kept physi- cally and mentally at rest. If he is restless and can- not sleep a dose or two of chloral or of a bromid may be given. It is well to avoid the synthetic, drugs because of their irritant effect on the kidney. Warm applications to the ki.dney region will aid in allaying the inflammation and to hasten the stage of resolution. These applications may be applied as hot alcohol and water fomentations bound close to the back by a bandage around the abdomen, kept warm by a hot water bag and changed as soon as cool; by the old fashioned flaxseed poultice ; by an electric heat pad, or by any othei: simple method. Under good treatment the albumin and casts usually disappear in from five to six weeks. During conval- escence the diet is gradually increasedj a little salt being given from time to time. The patient may be given bread, rice, more cereals, potatoes, less milk and no meat. Small doses of iron (tincture of ferric chlorid, 5 drops three times a day) may be given in orangeade or lemonade. Eggs, vegetables and fruit are gradually added to the diet and then after several months o-f a normal output of urine meats in sma;ll quantities may be tried. The forerunners of approathing uremia are eye- blurs, possibly retinal changes, severe headache, momentary loss'es of consciousness, twitching of the muscles, cramps and eventually convulsions and coma. / CHRONIC NEPHRITIS 345 The treatment of uremia will be discussed in a sep- arate article. Treatment of acute nephritis by nephrotomy or by renal decapsulation has been practiced by some, espe- cially in those cases in which there is an abundance of lumbar pain and not very severe urinary symptoms. These operations have in some cases caused relief of symptoms, but should- be tried as a last resort. The resulting scar tissue as it contracts may of itself aggravate conditions, especially if a chronic interstitial nephritis should ensue. As many cases of acute nephritis are due to bacterial infections the question of the use of vaccines arises Vaccines as yet have not proved to be of anj assistance in the treatment of nephritis in the acute, subacute or chronic stages'. CHRONIC NEPHRITIS Chronic nephritis, B right's disease, or as it is some- times called, cardio-vascular-renal disease, is appar- ently increasing in frequency in this country. Its treatment, both active and prophylactic, is naturally important. Patients suffering from this disease usually first consult a physician complaining of the symptoms that are usually associated with high blood pressure. The physician should then analyze the case to find out the fundamental cause of the trouble. In some of the cases there is a history of a previous acute nephritis, of acute inflammatory rheumatism, there may be an old heart lesion or some other point in the history that makes the solving of the problem relatively simple. In the majority of the cases, how- ever, this is not the case and a. physical examination reveals nothing but a slightly enlarged heart with perhaps a little dilatation of the arch of the aorta and a slight edema of the feet. Urinalysis may reveal nothing, but on repeated examination^ the urine will be 'found to be of low specific gravity and occasionally to contain casts and a trace of albumin. The blood pressure will be found to range from 170 to 200. In these cases a careful search for a chronic focus of infection sometimes reveals infection in the tonsils, teeth, sinuses, or gallbladder. This focus of infection should be removed. J46 TREATMENT OF CHRONIC NEPHRITIS SYMPTOMS The general symptoms of chronic nephritis may include in addition to the characteristic changes in the urine, headache, indigestion, diarrhea or constipation, mental apathy or irritabihty, insomnia, dyspnea, edema, intermittent eye and ear disturbances, enlargement of the heart, high blood pressure, neuralgias, anemia, retinal changes, various inflanimations or beginning uremia. TREATMENT The diet selected for chronic nephritics should be based on the excretory ability of the kidneys, the non- protein nitrogen content of the blood, the condition of the heart, the blood pressure, the state of the digestion, the weight of the patient and the physical and mental work required of him. The diet should be varied quite frequently. It is well for the patient to have nothing but skimmed milk, one day in the week: This will rest his alimentary tract. It has not been shown that fresh fish, poultry and meat except kidneys, sweetbreads, liver and shad roe (rich in purins) are any more harmful to the nephritic patient than are the vegetable proteins such as nuts, peas, beans and oatmeal, though some patients may tolerate these better. In the cases in which there is an old organic heart trouble this must be treated primarily, and as the heart condition improves so does the kidney trouble. The best treatment for these cases is rest in bed on restricted liquids and a soft, meat-free salt-free diet. In the more severe cases the Karell management is efficacious. The Karell treatment consists of rest in bed and a light diet of milk and eggs. The fluid. is . limited to iy2 pints per day. At first this is given, for two or three days, as milk only, 6 to 7 ounces at 8 a. m., and 4 to 8 p. m. This is the most trying part of the method. Then 1 egg is given at 10 a. m., and a biscuit at 6 p. m. for a couple of days. Then 2 eggs with bread, and a little minced meat are allowed. In twelve days the patient returns to a careful ordinary diet,, the fluid being still kept down to l^/^ pints, but not necessarily milk only. . This method is said to be indicated for weak hearts for which digitalis is less TREATMENT OF CHRONIC NEPHRITIS 347 appropriate. About the third day diuresis sets in for a short time, the dyspnea is relieved, the pulse im- proves and the edema subsides. Elimination through the gastro-intestinal tract should be promoted by the use of calomel (3:5 gr.) at night and salines in the morning. If the patient is showing signs of intoxica- tion, and is strong enough, hot air sweats may be bene- ficial. Venesection may also be indicated in such cases and, by relieving the heart and removing toxins, often causes marked improvement. The same management is applicable to the cases in which the kidney is the most affected organ. A most important item in the treatment of chronic nephritis is the preservation of cardiac compensation. The high blood pressure and cardiac hypertrophy of chronic nephritis constitute a compensatory mechan- ism enabling the kidneys to .maintain adequate func- tion. They consequently are essential to the preserva- tion of life and should be protected by every hygienic and dietetic safeguard. High blood pressure should not be made the object of direct therapeutic attack. Nitrites should be reserved for emergency use to com- bat such developments as angina, cardiac asthma, etc. The appearance of dropsy in primary chronic nephritis almost invariably signifies the advent of cardiac fail- ure. At this stage digitalis becomes the mainstay of treatment and should not be withheld because the blood pressure is high, as they act just as well, or even better,»with a high blood pressure as with a falling pressure. In the cases that are primarily cardiac the use of caffein, digitalis, strophanthus and the other cardiac tonics is of great value. The use of theobromin and other drugs, the action of which is essentially diuretic, should be guarded, as in many cases of chronic renal disease they do not increase the output of urine and act rather as a poison to the system. In certain cases of chronic nephritis in which there is considerable edema without dilatation of the heart the Fischer treatment, as described under acute nephri- tis, ^produces excellent results, but on the whole it does not seem to be as efficacious in the chronic as in the acute nephritides. 348 CARDIOVASCULAR-RENAL DISEASE ARTERIOSCLEROTIC TYPE Another form of chronic nephritis that must be considered is that caused by general arteriosclerosis. In this form there are two causes for the trouble, namely, the injury to the kidney parenchyma from the altered blood supply to the kidneys and the toxemia arising from the altered metabolism throughout the body which is due to impairment of the circulation from the arteriosclerosis. In this form the treatment niust necessarily be purely palliative, as the cause can not be removed. These cases are usually weak, anemic and poorly nourished and consequently the sweats and venesection cannot be used. The Karell management is the best to use in severe cases of this type, but ordinarily restriction of liquids to oile quart or so, a flieat-f ree diet and free catharsis suffices to keep these patients comfortable. In- these cases diuretics and car- diac stimulants must be used with great care and in many of them are contraindicated. In those cases of nephritis in which there is amyloid- osis the treatment should aim primarily at the causa- tive condition, as the kidney condition is secondary to it. CARDIOVASCULAR RENAL DISEASE WITH HIGH BLOOD PRESSURE As to the treatment of the cases of long standing cardio-vascular-renal disease that are to all appear- ances in excellent health, but have a constant high blood-pressur-e and much of the time have albumin or casts in the urine : Most of these cases may be kept very comfortable and the blood-pressure kept reasonably low if they will diet carefully and exercise only moderately. Such individuals should eat but little meat of any kind. Coffee, tea, alcohol, rich spiced foods and tobacco should not ■ be used at all. The diet then should consist of fruits, cereals, veget- . ables, eggs, milk, cream, butter, and in most cases a little meat once a day. Shell fish may be used in moderation. These patients may exercise moderately, and indeed it is best. for them to get a definite amount of out-of- door exercise. Walking is the best form and for some UREMIA 349 golf in moderation. Whatever form of exercise is taken, it should be begun gradually and increased slowly. While this is being done the patient should be frequently examined by the physician to make sure that he 'is not overdoing. MASSAGE AND BATHS The massage and bath treatment of nephritis, when rugiilated by a physician who is in close touch with the patient's general condition, given at many places abroad and in this country, is excellent. However, unless controlled by a physician, such treatment may do a great deal of harm. Massage is only a form of exercise and if overdone may do as much harm as too much exercise of any other sort. Baths are quite enervating and fatiguing even to a healthy individual who is not accustomed to them, and so to the nephritic with his lowered vitality they may be a source of great danger. i CLIMATE When it is possible, patients suffering from chronic nephritis should spend as much time as possible in warm climates, as warm weather promotes elimination through the skin. Furthermore, by causing a super- ficial vasoconstriction, cold tends to increase the ten- sion in the deeper vessels and so increase the possi- bility of cerebral hemorrhage or hemorrhage from other vessels. Angina pectoris, which may be a com- plicating factor in many of these cases of hyperarterial tension, is often subsequent in appearance to sudden exposure to cold. UREMIA When uremia is imminent premonitory symptoms occur, such as headache, fulness of the head, vertigo and blurring of vision, muscle twitching, muscle cramps; restlessness, insomnia or drowsiness and fre- quently nausea and vomiting and diarrhea. The blood pressure increases and the urine shows a decrease in amount of solids excreted. Chilling, a high protein meal, extra muscular exercise, nervous or mental excitation, or anything which may suddenly increase metabolism and nitrogen waste may precipitate an attack. 350 TREATMENT OF UREMIA TREATMENT The diet in impending uremia should be the mini- mum diet, perhaps only as much as a pint of milk a day. The water intake should depend on the amount of water elimination, edema and dropsy. As the diet is' increased considerable alkali and cereals may be given, to combat acidosis. In uremic patients there is a severe toxemia due to renal insufficiency. When the patient is quiet, the . relief of the toxemia is the chief requirement except such great supportive measures as may prove neces- sary. This toxemia has usually been treated by the promotion of elimination through the skin by sweats, through the intestines by free catharsis and rarely by venesection. .The diuretics are generally of little use in treating these conditions. Fischer's solution admin- istered intravenously or per rectum has proved to be one of the best methods of promoting elimination through the kidneys in these cases ; the general symp- toms are also greatly relieved; eyen when sweating and venesection are not used. Some of the most striking results obtained by the use of Fischer's solution have been in cases in which there was insufficient excretion of urine and a consequent uremic condition with no clinically demonstrable anasarca. RESTLESSNESS' In those cases of uremia in which the patient is extremely restless, and also in those in which there are con-voilsions, the eliminative treatment must be used, and in addition the patient must be quieted. In the first place the usual methods of restraining a patient in bed must be practiced; windows should be protected to prevent accidents ; all instruments with which injury might be done to attendants or to the patient should be kept out of reach. Bromids may be given in enemas in doses of twenty to thirty grains in place of the salt of the Fischer's solution. If the patient will take them, they may be given by mouth. Chloral may also be administered either by mouth or per rectum. In the more severe cases it is necessary to use opiates and sometimes even chloroform to qiiiet the convulsions. CYSTINURIA 351 VENESECTION If the blood pressure is very high, and apoplexy or sudden dilatation of the heart threatens, venesection should be done, as also in threatening convulsions or coma. CYSTINURIA Cystinuria may be classed among the rarities of medical practice. However, the perversion of metab- olism whereby cystin, one of the amino-avid frag- ments of the protein molecule, is not destroyed in the body as it is in a normal person, is not so uncommon as statistics might lead one to believe. As the metabolic disorder may exist for very long periods without revealing itself by any easily detected symptom other than the presence of the unutilized cystin in the urine, the discovery of the cases becomes more or less fortuitous. Only when urinary concretions arise to direct attention to their cause, or when the presence of crystin is detected by chance in a routine examina- tion of the urine, does the anomaly come to the knowl- edge of those who are interested in its cause and treatment. From the point of view of the patient the chief prob- lem in connection with cystinuria is either to decrease the output of cystin or to increase its solubility in the urine — or both — with the aim of avoiding the impend- ing danger of calculi. The pronounced insolubility of cystin in urine of the usual reaction makes the pos- sibility of attacks of "kidney colic" and related conse- quences an ever-present one. It has long been known that the output of cystin can be decreased by a diminu- tion of the metabolism of its mother-substance; pro- tein. In the entire absence of any intake of albu- minous foods the urinary excretion of cystin is reduced, to an endogenous level, represented in an illustrative case in literature by 78 mg. a day. Klemperer and Jacoby (Therap. der. Gegenw., 1914, Iv., p. 101) studied the results of alkali administra- tion in such a case. They found that the deposited cystin pediment promptly decreased in amount 'and soon completely disappeared from the urine following the daily ingestion of from 6 to . 10 gm. of sodium bicarbonate. From the point of view of preventing 3S2 INDICANURIA the precipitation of cystin and consequent formation of calculi, this treatment was evidently "successful. Incidentally, it further developed that even dissolved cystin entirely disappeared from the urine as the result of the. alkali therapy. INDICANURIA Indicanuria is of comparatively frequent occurrence and is generally understood to mean that some protein putrefactive process is taking place in the ileum and colon with the production and absorption, of indol and the excretion of indoxyl potassium sulphate (indi- can). Indican in the blood is not poisonous, but other products of decomposition and toxins absorbed from the intestines at the same time as the indol may produce symptoms of intaxication. Indol, skatol and cresol with toxalbumin will frequently produce symp- toms of poisoning such as headache, restlessness, insomnia, gastro-intestinal indigestion, dryness of the skin or sometimes a profuse perspiration, eruptions, and even a rather severe kidney irritation. TREATMENT If it is found that the amount of indican excreted is increased the diet should be modified. Animal pro- teins should be removed for a time and there should be thorough purging. The caUse of the condition should be sought. The. bowels should be caused to move daily and regularly; colon washings may be given until the urine is practically indican free. Yeast or lactic acid bacilli may be administered, but it is doubtful that they exercise any very prolonged effect. Liquid petrolatum is now much used .but it is a ques- tion whether it may not interfere with the secretions if given over long periods. Phenyl salicylate (salol) in a dose of 0.25 or 0.30 gm. in capsules, three times a day after meals, for a short period is often of benefit in preventing intestinal fermentation. Anemia is not rare accompanying chronic intestinal putrefaction. The weight of the patient should be noted carefully and the skin watched for the appearance of eruptions, dryness or profuse perspiration in order to regulate properly the food, drink and possible drug administra- tion which may be required. DISEASES OF MEJABOLISM DIABETES MELLITUS DEFINITION Diabetes has been defined as a "specific deficiency of the power of assimilating food." The generally accepted view, based on experimental evidence, refers the deficiency to a diminished functional capacity of the pancreatic islets. A persoii with a normally func- tionating pancreas may ingest a quantity of food con- siderably in excess of his energy requirement and completely assimilate all that is digested and absorbed, even though the greater part of the food may be carbo- hydrate. An average adult, performing light work, will ingest and metabolize from 300 to 500 gm. of car- bohydrate a day. With impaired pancreatic function, the organism becomes incapable of assimilating even such quantities of carbohydrate as are contained in a general mixed diet, that is to say, a diet sufficient to cover the energy requirement in which from one half to two thirds of the total caloric intake is in the form of carbohydrate. Where there is a deficiency of the power to assimi- late carbohydrates, glucose accumulates in the blood; and when the concentration reaches a certain limit, the excess of glucose overflows through the kidneys. Thus, fflycosura constantly occurring m an individiuU whose food intake is within the limits mentioned above, is evidence of diminished pancreative function of the specific type here considered — it is evidence of diabetes. Strictly speaking, this statement requires some modi- fication, for there are certain persons who pass sugar in the urine when the blood sugar concentration' is normal or even below normal. The glycosuria in such cases seems to be due to an increased permea- bility of the kidney for glucose. This condition of "renal diabetes" is of infrequent occurrence; it is unaccompanied by the characteristic symptoms of dia- betes, such as polyuria, polydipsia, and polyphagia: 354 ETIOLOGY OF DIABETES the amounts of sugar excreted in the urine are seldom large, and bear but little relation to the carbohydrate intake. A positive diagnosis of the condition can be made only by demonstrating a normal or low blood sugar content coincident with glycosuria. If the food intake of a diabetic is diminished so as to come within his assimilative capacity, sugar excre- tion ceases. Absence of glycosuria is, therefore, not to be taken as evidence that diabetes is not present, unless the individual is on a full, mixed diet. For the detection of glucose in the urine a very satisfactory reagent is- Benedict's {Jour Biol. Chem., 1909, V. 485), modification of Fehling's solution, since it is very sensitive to glucose, but, unlike the original Fehling's solution, does not react with a number of normal and accidental urinary constituents. The reduc- tion test, if slight, should be confirmed by the fermen- tation test. In diabetes, there is a lowered functional capacity, not only for the assimilation of carbohydrate, but also . for protein, since the latter food may yield a consider- able amount of carbohydrate in the course of its metabolism. When fat is added to the diet of a diebetic, glyco- suria may occasionally occur, although it is very doubtful if fat itself is actually converted into carbo- hydrate; the glycosuria is to be considered rather as a result of stimulation of the metabolism. In diabetes the metabolism of fats is affected since, as Naunyn has expressed it, "fats burn in the fire of carbohydrates." With failure to assimilate carbohydrates the "fire" may be but a smoldering one, so that fats are incom- pletely burned with the formation of acetone, aceto- acetic acid, and beta-oxybutyric acid. The latter two substances, being acids, may, if produced in sufficient amounts, lead to a serious disturbance of the acid base equilibrium of the body, known as acidosis. It is acidosis that is presumably the cause of diabetic coma. OBJECT OF TREATMENT The object of the treatment of diabetes is to supply a diet that can be metabolized and that will not over- tax the weakened pancreatic function. Allen has aptly ALLEN TREATMENT OF DIABETES 355 compared the functionally weak pancreas to a "weak" stomach. If the latter, with frequent rests, is supplied with food of such quality and such quantity as can be readily digested, it may functionate satisfactorily, and may even be able to digest larger and larger amounts of food, although it will never become a "strong" stomach. Continued dietary insults, on the other hand, would further weaken the organ. The same holds true for the functionally weakened pancreas; it may be able to provide for the assimilation of a certain amount of food, but if overwhelmed with an amount in excess of its capacity, a progressive diminution in capacity results. A weak stomach if overtaxed usually gives warning in discomfort; an overtaxed pancreas gives no such warning. THE ALLEN TREATMENT The diabetic who constantly indulges in food in excess of his assimilative capacity invariably becomes progressively worse; hence the conception has arisen that diabetes is characterized by an inherent downward tendency. As a matter of fact, practically every dia- betic has some tolerance for food, and the tolerance is usually sufficient to allow for a great enough food intake to cover the basal energy requirements. With proper treatment, it is possible to maintain or even to increase this tolerance. This is the underlying prin- ciple of the modem treatment of diabetes as formu- lated by Dr. Frederick M. Allen. On the basis of animal experiments and carefully controlled clinical observations, he has recently proposed a system for the treatment of diabetes that incorporates those fea- tures of the older methods that are of proved value, but introduces, in addition, a number of features, some of which are in direct opposition to the older teachings. This treatment may be briefly outlined as follows: 1. A preliminary fast is taken until the urine is free from sugar. 2. Following the fast, carbohydrate food is grad- ually added, at first in the form of green vegetables. 3. Coincident with the addition of carbohydrate, or in place of it if the carbohydrate tolerance is very * 3S6 FAST IN DIABETES low, protein is added to the diet in small but gradually increasing amounts until glycosuria occurs, or a suffi- cient amount of protein is taken to cover the basal requirement. 4. Fats are added in small amounts during the time of addition of carbohydrates and protein. Subse- quently, a sufificient amount of fat is added to make up the fuel requirements of the body, provided this amount can be tolerated without the appearance of glycosuria or acidosis. 5. Frequent urine examinations are made, either by the medical attendant or by the patient himself, and the appearance of glucose is taken as an indication for a fast of sufficient length to cause a cessation of the glycosuria. Feeding is subsequently begun with not more than one half of the carbohydrate contained in the diet at the time of the appearance of glycosuria. Subsequent carbohydrate increase is made very grad- ually. 6. At intervals, the patient is fasted for a day or else takes a greatly restricted diet. 7. Body fat is reduced to a minimum and the adult diabetic is not allowed to gain weight; children may gain, but the gain must not be adipose tissue. 8. Active daily exercise carried to the point of healthy fatigue is advocated. THE PRELIMINARY FAST The object of the preliminary fast is to remove from the body the excess of unassimilated carbo- hydrates, and to allow for a rest of the overtaxed pancreatic function. As a result of the fast and, indeed, during the fasting period, a proportionately larger amount of carbohydrate may be metabolized. Paradoxical as this may appear at first sight, it has been definitely proved by calorimetric observations on severe diabetics. With the removal of the unassimi- lated excess, the organism is better able to assimilate an amount of carbohydrate which it was previously unable to utilize. During the fast, in the majority of instances, there is a decreased production of the potentially harmful FAST IN DIABETES 357 aceto-acetic and beta-oxybutyric acids. This, presum- ably, is the result of the relative increase in carbohy- drate assimilation. The length of fast required before the urine becomes sugar free is usually less than five days ; exceptionally, it may be as long as eight or ten days. Water is allowed ad libitum, and tea or coffee in moderate amount if desired. No sugar or cream is allowed, though saccharin may be used for sweetening. A reasonable amount of clear meat broth may be taken after the second day of fasting. Alcohol, in the form of whisky, has been recom- mended, since it does not increase glycosuria, and in certain cases seems to inhibit the production of the acetone bodies. The amount of whisky given may be _ 1 ounce three times daily. It may be given in black "coffee. Alcohol is not cm essential in the treatment, and should not be administered to patients in whom it produces such smyptoms as burning in the throat, headache and nausea. During the fasting period weak patients should be in bed. More vigorous ones should exercise as far as practicable, since by exercise the duration of the fast may be shortened. DURATION OF FAST The great majority of diabetics may be fasted until the urine is sugar free, without the development of any untoward symptoms or complications. Exceptionally marked prostration, nausea, increasing drowsiness and deep breathing (acyanotic hyperpnea) may occur. These are symptoms referable to acidosis, and occur coincidently with alterations in the composition of the blood, alveolar air and urine. With the appearance of a severe and progressive acidosis, the fast must be terminated for the time being, and treatment directed against the acidosis. (This phase of the subject will be discussed under the head of Acidosis.) After a period of restricted diet a subsequent fast usually results in a sugar-free urine without the development of acidosis. 358 DIET IN DIABETES THE DIET Addition of Carbohydrates to the Diet. — When, as a result of the fast, the urine has been free from sugar for twenty-four hours, feeding may be cautiously begun. All the food given must be weighed and its composition must be known approximately, at least. Unless this is done, no accurate idea of the food tol- erance or of its caloric value can be obtained, and subsequent treatment becomes of necessity a "hit-or- miss" afifair, with the probabilities all in favor of its being a "miss." Information as to the composition of the common foods may be obtained from various trea- tises on dietetics and food chemistry. The accompanying table, compiled by Joslin, con- tains in a compact form all the essential information. The figures, although only approximate, are sufficiently • accura,te. JOSLIN'S DIET TABLE Strict Diet— Meats, Fish, Broths, Gtelatin, Eggs, Butter, Olive Oil, Ooffee, Tea and Oraclced Cocoa Foods Arranged Approximately According to Percentage of .^ Carbohydrates Vegetables 5 Per Cent. 10 Per Cent. 15 Per Cent. 20 Per Cent. Lettuce Onions Green peas Potatoes Spinach Mushrooms Artichokes Shell beans Cauliflower Squash Parsnips Baked beans Sauerkraut Turnip Canned lima Green com String beans Carrots beans Boiled rice Celery Okra- Boiled maca- Asparagus BeetB roni Cucumbers Brussels sprouts Sorrel Endive Dandi!hons Swiss chard Sea kale Tomatoes Bhubarb Egg plant Leeks Beet greens Watercress Cabbage Badishes Pumpkin Kohlrabi Broccoli Vegetable marrow DIET IN DIABETES Fruits 359 Bipe olives (20 per Lemons Apples Plums cent, fat) Oranges Pears Bananas Grapefruit Cranberries Apricots Strawberries Blaeberries Blackberries Oberries Gooseberries Currants Peaches Basnbeiries HucKleberries Pineapple Watermelon Nuts Butternuts Pignolias Brazil nuts ' Black walnuts Hickory Pecans y Pilberts Abnonds Walnuts (Eng.) Beeebnuts Pistachios Pinenuts Peanuts 40 Per Cent. Chestnuts B Per Miscellaneous. — U unspiced pickles, scallops, liver, fle Cent, isweetened and clams, oysters, h roe Beckon actually available carbo- hydrates in vegetables ot 5 per cent, group as 3 per cent., ol 10 per cent, group as 6 per cent. Thirty gm. or 1 ounce, of each ol the following contain approximately: Calo- ries Oatmeal, dry weight iUeat (uncooked) Meat (cooked) Broth Potato Bacon (cooked) Cream, 40 per cent Cream, 20 per cent Milk Bread.; Butter Egg (one) Brazil nuts Orange (one) (jrapefruit (one) Vegetables, 5 and 10 % groups Protein, Pat, Carbo- Gm. Gm. hydrates, Gm. 5 2 20 6 • 2 8 3 0.7 1 6 5 15 1 12 1 1 6 1 1 1 2 3 18 25 « 6 5 20 2 10 10 0.5 1 110 40 80 155 120 60 20 00 240 75, 210 40 40 6 1 gm. protein, 4 calories. x 1 gm. fat, 9 calories. 6.25 gm. protein contain 1 gm. nitrogen. 30 grams (gm.) or cubic centimeters (c.c), 1 ounce. A patient "at rest" requires from 25 to 30 calories per kilogram body weight. 1 gm. carbohydrate, 4 calories. 1 gm. alcohol, 7 calories. 1 kilogram, 2.2 pounds 360 DIET IN DIABETES A convenient scale for weighing food is a mov- able: dial spring balance. Feeding is begun with food containing but small amounts of carbohydrate and lesser amounts of pro- tein and fat. The most satisfactory diet to begin with is one composed exclijsively of green vegetables of the "5 per cent, group" (see table). These vegetables, although they contain but little available nutriment, have a large bulk and serve to fill the stomach, thus allaying in some measure the pangs of hunger. The indigestible residue is valuable in preventing constipa- tion. From 150 to 200 gm. of the vegetables of this group are given the first day. Approximately 5 gm. of available carbohydrates are contained ^n this amount. If no glycosuria occurs, the diet on the second day may contain vegetables equivalent to five more grains of carbohydrate, and this increase is made daily until 20 gm. of carbohydrate are given. Following this, S gm. are added every other day until glycosuria occurs or the patient is receiving as much as 3 gm. of carbohydrate per kilogram of body weight in twenty- four hours (Joslin). After the first day or two carbo- hydrate may be given in the form of vegetables of the 10 per cent, group, followed subsequently by those of the 15 and 20 per ceni. groups. Fruits are then added, and ultimately, if glycosuria has not supervened, bread and oatmeal. Vegetables are best cooked by steaming in a double broiler, as in this way nothing is lost. Ordinary bread is but seldom included in the dietary of the diabetic. There are on the market a large number of brands of "gluten" and "diabetic" flour which contain relatively little carbohydrate and much protein. Bread made from such flour, provided the composition is accurately known, may be eaten. These special brands of flour, however, are expensive and many are fraudulent. The patient's longing for bread may, in a measure, be satisfied by bran biscuits. These contain no carbohydrate and serve as a convenient vehicle for the administration of butter or other fats. The bulky residue fills the stomach and relieves constipation. * PROTEIN IN DIABETIC DIET 361 The recipe used at the Rockefeller Institute Hospital is: I"" 60 em. •5^" ■ % teaspoonful Agar agar, powdered 6 gm. Cold water 100 c.c. (% glass) Tie hran in cheese cloth and wash under cold water tap until water is clear. Mix agar agar in the water (cold) (100 c.c.) and hring to the point of boiling. Add to washed bran the salt and agar agar solu- tion (hot). Mold into three cakes. Place in pan and, when firm and cold, bake in moderate oveh from forty-five to fifty minutes. The appearance of glucose in the urine means that the patient's assimilative limits have been exceeded, and a fast must be instituted until the gylcosuria ceases. Following the fast, the carbohydrate ration should be diminished by one half and not increased beyond this amount for some days, and then very cautiously. The amount should be kept well within the limit of tolerance previously determined for a con- siderable period of time. Subsequently, if there is reason to suppose the patient can assimilate more carbohydrate, the limit of tolerance may again be determined by gradual addition of carbohydrate, even to a point in excess of the former tolerance. In severe cases some patients cannot assimilate even the small amount of carbohydrate contained in green vegetables, although they may still be able to assimilate minimal amounts of protein and fat. Such patients may be given at first green vegetables that have been cooked in three changes of water and the water discarded. Vegetables so prepared contain practically no carbohydrate. Addition of Protein to the Diet. — In severe cases of diabetes, it is advisable to determine the protein toler- ance in essentially the same way that carbohydrate tolerance is determined, eggs and meat alone being fed in increasing amounts until glycosuria occurs. In most cases of diabetes, however, protein may, to advantage, gradually be added to the diet during the period of testing the carbohydrate tolerance. During the first week of green vegetable feeding, provided no glyco- suria occurs, two or three eggs may be given during the day. Lean meat is then added from day to day in amounts corresponding to 10 or 15 gm. of protein (see table) until the patient is receiving daily about 1 gm. of protein per kilogram of body weight, or if the car- bohydrate tolerance is zero, only 0.75 gm. Later, if 362 FATS IN DIABETIC DIET desired, protein may be raised to 1.5 grams per kilo- gram of body weight (Joslin), provided, of course, this can be done without the development of gylco- suria. Children may to advantage be given as much as 2 gm. of protein per kilogram. Addition of Fats to the Diet. — When the amount of protein fed has reached 1 gm. per kilogram of body weight, fats may be added to the diet in gradually increasing amounts (25 gm. a day) until the caloric requirement of from 25 to 40 calories per kilogram of body weight is covered by the total food intake. Patients who are exercising require a higher caloric intake "than when resting, and growing children up to as much as 50 or 60 calories per kilogram, depending on the age. The caloric intake should eventually, be such that a progressive loss of weight does not occur. On the other hand, the patient must not gain in weight, _ or, more correctly, he must not gain in adipose tissue, though muscular development is allowable. Fat, besides that obtained in the eggs and meat fed, may be supplied in the form of bacon, cream, olive oil or butter. If marked acetonuria appears, it is advis- able to substitute olive oil for butter and cream. Weekly Fast Days.-^-For a long time it has been recognized that days of partial or complete fasting are of benefit to the diabetic. Allen has incorporated this idea into his system of treatment, and advises frequent fast days. Joslin's rule is to fast all patients once a week whose tolerance for carbohydrates is less than 20 gm. When the tolerance is between 20 and 50 gm., 5 per cent, green vegetables and one half the usual quantity of protein and fat are allowed on the fast days; when the tolerance is between 50 and 100 gm. of carbohydrates, the 10 and 15 per cent, vegetables are allowed as well. If the tolerance is more than 100 gm. of carbohydrate, the carbohydrate intake is halved on the weekly fast days. Exercise — This forms a valuable adjunct in the treatment of diabetes. It serves to raise the carbohy- drate tolerance and to build up active protoplasmic tissue at the expense of fat. In addition, the patients who exercise feel better and take more interest in life. The appetite is increased, but the increase is not ACIDS IN DIABETES 363 greater than the increased assimilative power. Allen advises active exercises for practically all diabetics. Strong patients may begin exercise during the prelimi- nary fasting period ; weaker ones, during the period of dieting. Exercise is especially advantageous immedi- ately following a meal containing carbohydrate. Short -periods of vigorous exercise are preferable to long continued monotonous walks. The patient should stop just short of uncomfortable - fatigue. In children, exercise is of especial benefit, as it aids in the building up of muscular tissue and favorably influences growth. Acidosis. — In the course of diabetes, large amounts of the "acetone bodies," namely, acetone, aceto-acetic acid and beta-oxybutyric acid may be produced. These substances, for the most part, are products of the incomplete combustion of fats, and appear when there is a disproportionately great metabolism of fat as compared with carbohydrate. For the complete combustion of fat, it seems essential that a certain amount of .carbohydrate be simultaneously burned. Under the older methods of treatment the production of large amounts of the acetone bodies at some stage of the disease was usual, and, as a result, a large proportion of all diabetics, and especially younger patients, ultimately developed coma — presumably as a direct result of overproduction of the acetone bodies. By strict adherence to the rules of treatment already formulated, it is usually possible to reduce the produc- tion of acetone bodies to a minimum. For the detection of acetone bodies in the urine, two tests are in general use, the nitroprussid reaction (Legal, Arnold, Rothera) and the ferric chlorid reac- tion (Gerhardt). The nitroprussid test is a yery deli- cate one for either acetone of aceto-acetic acid. The ferric chlorid test is a less delicate one and serves to detect aceto-acetic acid. Since amounts' of aceto- acetic acid smaller than are required to give the ferric chlorid reaction are of no especial significance, there is, in general, no reason for using the more delicate nitroprussid test. If one of the acetone substances is present in the urine, all are present, and there is no indication for testing for more than one of them. The ferric chlorid test is carried out by adding to the urine 364 ALVEOLAR AIR IN DIABETES a strong solution of ferric chlorid until no further precipitation of phosphates occurs; a purple color indicates the presence of aceto-acetic acid. Salicylates give a similar reaction, but the color may be obtained after the urine has been boiled for a few minutes, whereas aceto-acetic acid is destroyed by boiling.^ Of the acetone substances, acetone itself is an adventitious decomposition product of aceto-acetic acid, and is probably never formed in sufHcient quantity to do harm. Aceto-acetic acid and beta-oxybutyric acid, however, are fairly strong acids, and for that reason are capable of doing much harm to the organism by the neutralization and removal of the available bases. Acids of one kind or another are always being pro- duced in the course of metabolism, and the body possesses an efficient mechanism whereby these acids may be neutralized or excreted. A slight excess in acid production, such as a few grams of beta-oxybu- tyric acid, can be completely compensated for. With a larger production of acids, especially if continued over a considerable time, the compensatory mechanism of the body may become overtaxed, with the result that an actual depletion of the alkali reserve of the body fluids and tissues occurs. Such a condition is known as acidosis. In diabetes, the appearance of acetone bodies in the urine signifies that the ideal result of treatment has not been attained, but it does not nec- essarily mean that acidosis is present. Qualitative tests alone on the urine are not sufficient either to confirm or to exclude acidosis, as a strong test may be obtained when no acidosis is present, and only a faint reaction at the height of the coma of acidosis. A high excretion of ammonia y? a twenty-four hour specimen of urine is an indication of abnormal activity on the part of the defensive mechanism of the body, and is a warning signal. Certain symptoms, as increas- ing drowsiness and deep breathing of the "air hunger" type (acyanotic hyperpnea), may indicate to the skilled observer the onset of acidosis ; bi^it for an accurate quantitative idea of the degree of acidosis determina- tions on the alveolar air or blood must be made. Alveolar Air. — In acidosis, there is a diminished carbon dioxid tension in the alveolar air. The deter- mination of this tension is a simple bedside proce- ALKALI THERAPY IN DIABETES 365 dure. Marrott has recently described a rapid clinical method for the purpose, for the details of which the reader is referred to the original paper {Jour. A. M. A., May 20, 1916, p. 1594). It is important that the degree of acidosis be known, especially during the fasting period, since failure to recognize a progressive acidosis may result in serious or even fatal conse- quences. According to Stillman, diabetics may react in a number of ways to their preliminary fast, as regards the development of acidosis. Some show no significant acidosis either before, during, or after the fasting period. Others, with a severe grade of acidosis exist- ing before the fast, improve during the first fast, or during the subsequent fasts. A third group shows a fairly constant, low grade acidosis, not especially influenced one way or the other by the fast, but often relieved by subsequent, frequently repeated fasts, alternating with periods of low diet. A fourth group develops increasing acidosis during the fast, which may even become of a sufficient degreeto prove fatal. With proper dietetic regulation, the development of acidosis of a serious grade is unusual. The treatment of acidosis is mainly dietetic and preventive. Patients who show a tendency to acidosis while on a diet otherwise suitable should be frequently fasted. As has been , mentioned, however, a few patients develop acidosis of ah alarming grade during the fasting period, as shown by the characteristic symptoms and by a progressive fall of the carbon dioxid tension of the alve'olar air. The normal tension is in the neigh- borhood of 40 mm. ; a tension as low as 35 mm. may be considered as insignificant; tensions below 35 mm. indicate acidosis, and 20 mm. is to be considered the danger point. When such a degree of acidosis is approached during a fasting period, the indication is to break the fast by allowing a restricted diet, chiefly of green vegetables. In such cases, subsequent fasting frequently causes the acidosis to disappear. Alkali Therapy. — Dietetic treatment prevents the formation of acetone bodies and is the rational treat- ment for acidosis. Occasionally, however, the acidosis may become of such a grade that the administration of 366 ALKALI THERAPY IN DIABETES alkali is required. Alkalies neutralize acids already produced and replenish the depleted alkali reserve of the body, but have no effect in inhibiting the produc- tion of acids. Alkali administration is merely a temporary means of checking acidosis, but a valuable procedure when acidosis is of a severe enough grade to threaten life. Alkali therapy should not in any measure replace dietetic regulation and should be used only to tide the patient over a critical period. Alkali is indicated when, as a result oT the patient's failure to observe dietetic regulation, the alveolar carbon dioxid tension has fallen to 20 mm. or lower, or if coma is present, or obviously impending, and also when, as a result of fasting, progressive acidosis occurs which is not promptly checked by feeding green vegetables. Alkali in the form of sodium bicarbonate may be administered by mouth, intravenously or subcutane- ously. The amount necessary is determined by the degree of acidosis, the size of the patient, and the therapeutic result obtained as gaged by rise in carbon dioxid tension and symptomatic improvement. Sodium bicarbonate in solution may be given by mouth. In adults, it is usually futile to give less than 4 gm. at a dose, which may be repeated every four or five hours. Doses larger than 15 gm. are generally not well tolerated. Alkali should be continued until the alveolar carbon dioxid tension has risen above 30 mm. Many diabetics, especially those approaching coma, are unable to retain alkali when given by mouth, on account of nausea and vomiting. In such cases and, in fact, in the majority of cases in which alkali is required at all, intravenous injection is the method of choice. A 4 per cent, solution of sodium bicarbonate may be used and as much as 500 c.c. injected slowly at a time. The injection may be repeated as often as indicated by the alveolar air findings or the symptoms. When, for any reason, intravenous injections are not feasible, alkali may be administered subcutane- ously. Sodium bicarbonate, on boiling, is converted into the carbonate, which is so caustic that it cannot be injected subcutaneously with safety. If, however, th6 carbonate is reconverted into bicarbonate, it is available for subcutaneous injection. The conversion may be accomplished by passing a stream of carbon COMPLICATIONS OF DIABETES 367 dioxid from a cylinder through the cold sterile solu- tion until saturated, as shown by a change in color of a small amount of added phenolphthalein from pink to colorless. Solutions stronger than 3 per cent, bicar- bonate should not be used for subcutaneous adminis- tration. As in other methods of giving alkali, the quantity will depend on the degree of acidosis and the response obtained. From what has been written it is quite apparent that _ the treatment of diabetes requires special knowledge " and more constant and intelligent care than does any other chronic disease. Drugs, with the exception of the alkalies, are worthless, "organotherapy" is a fail- ure, many of the so-called "diabetic foods" are fraudulent, a laissez faire policy is fatal. The dis- ease is combated only by management of the diet, which requires as nice discrimination in its use both as to quantity and quality as does any drug. Coopera- tion on the part of the patient is another requisite. When proper care and satisfactory cooperation can be obtained, the results are usually satisfactory. COMPLICATIONS AND SEQUELAE It should be remembered that a generalized and per- sistent furunculosis may be an unpleasant accompani- ment of diabetes. Diabetic gangrene is another con- dition which may appear in the course of this disease and necessitate operation. Operations on diabetics are notoriously dangerous and usually undertaken only when deemed a life-saving measure. Addis (Jour. A. M. A., April 3, 1915, p. 1130) con- siders the necessary preparation of diabetics for opera- tion. One method of preparing diabetic patients for operation is to give them a sugar and starch-free diet. This is a useless procedure, according to Addis, because, although it may reduce the degree of hyper- glycemia and the amount of sugar in the urine, it will not lessen any of the risks of operation; it is danger- ous, since it increases the chances of the onset of dia- betic coma. When operation is not immediately neces- sary, and especially in those cases in which the decision as to whether or not an operation shall be performed rests largely on the question as to how much danger would be run by the patient after the operation because 368 DIABETES INSIPIDUS of his diabetic condition, it would be a great advantage to have some objective data to supplement the facts relative to this point, which can be gained by clinical observation. The quantity of sugar in the urine is no aid in this respect, for the special danger to life is the failure, not of the sugar, bUy of the fatty acid metabo- lism. The coma in which diabetic patients die after operation is, often at least, accompanied by the excre- tion in the urine of large amounts of unoxidized fatty acids, and there is good reason for believing that the condition is due to poisoning by these acids. The ina- bility of the kidneys to excrete large amounts of fatty acids is a factor in the production of diabetic coma. The giving of alkali helps the kidneys in this work. Before operation, therefore, it is important to give alkali until the urine becomes alkaline, and to maintain if possible this alkaline reaction after operation. Neither success in inducing a storage of glycogen in the body before operation, nor in keeping the urine alkaline is an absolute barrier against diabetic coma. They are only pallative measures. All those circum- stances which unite together to produce shock are fac- tors which act as exciting causes of the condition known as diabetic coma. It is possible to mitigate the action of these agencies by the application of the prin- ciples of "anoci association." DIABETES INSIPIDUS This condition is recognized by the excretion of large quantities of npn-sugar-containing urine, not directly due to an excessive intake of fluids (polydip- sia). Connected etiologically with this condition the following have been mentioned : cerebral irritation, dis- eases and injuries of the cerebrum, diseases of the pituitary body and, finally, a primary cause in the kidney. The diagnosis of the cause of diabetes insipidus hav- ing been made, the treatment may be aimed more or less successfully to cure the condition, or to prevent the operation of the cause. A simple polyuria from over- drinking can, of course, be easily prevented. Nervous causes may be modified if there is not actually some pathologic condition in the brain. If the blood-pressure PELLAGRA 369 fs high, the lowering of it by proper baths, massage, physical exercise, change to a warm climate, diet, or by vasodilators will prevent it. Polyuria may, however, occur with low blood pressure, causing perhaps some disturbance of the brain, as theoretically low blood pressure should not cause diabetes insipidus. Such instances may be helped by the vasoconstrictor drugs, and especially by ergot. It is possible that this effect of ergot is due to its action in preventing cerebral irritation, cerebral congestion, and possibly the slight cerebral exudate that may occur. PELLAGRA The zeistic theory of the origin of pellagra is not yet entirely abandoned, and some students of the subject are still endeavoring to connect the inddence of pella- gra with some factor related to maize, or Indian com, in the diet. A greater, interest centers in the broader hypothesis that pellagra is due to some communicable factor and should be placed in the category related to that of infectious disease or that it is essentially a deficiency disease. The Thompson-McFadden, Pella- gra Commission has stated that its efforts to discover the essential pellagra-producing food or the essential pellagra-preventing food have not been crowned with success. Their evidence suggests that neither sub- stance exists in the population studied by them. Hence they have been inclined to postulate a communicable agency in the etiology of pellagra. Goldberger of the U. S. Public Health Service and his associates announced the experimental causation of pellagra in a group of human beings, as well as the cure and pre- vention of the disease among three groups of persons widely separated from each other geographically. As a result of epidemiologic studies, Goldberger concluded that pellagra is not a communicable disease, that it is dependent on some as yet undetermined fault, in a diet in which the animal or leguminous vegetable com- ponent is disproportionately large, and that no pellagra develops in those who consume a mixed well-balanced and varied diet. Positive experiments in feeding have led to the more definite belief that pellagra is a nutri- tional disturbance and should be treated on that basis. 370 TREATMENT OF PELLAGRA Goldberger was unable to induce pellagra by the injec- tion of blood or secretions from pellagrous persons. On the other hand, a hygienic survey and the cleaning up of several pellagrous communities has resulted in a- disappearance of pellagra from the community. Alessandrini and Scala have advanced the view that drinking water, because of \he presence of silica in col- loidal solution, may be of consequence in the causa- tion of pellagra. Meyers and Voegtlin (Pub. Health Rep., June 19,- 1914) attribute it to the presence in vegetable foods of excessive amounts of a substance such as soluble aluminum "salts. TREATMENT OF PELLAGRA According to Voegtlin (Jour. A. M. A., Sept. 26, 1914), all physicians who have had much experience in the treatment of pellagra agree on one point; namely, that in the milder cases the symptoms will almost always disappear in a relatively short time if the patients are kept in a hospital, at rest, on a lib- eral mixed diet, with plenty of fresh meat. He has found drugs of little value but calls attention to the use of arsenic, which has been highly recommended by Lombroso. He warns especially against placing the slightest faith in proprietary pellagra "cures." In the hygiene of the disease two measures are of greatest importance, the forbidding of alcoholic bev- erages and the avoidance of direct sunlight except in spring and summer. There seems to be no doubt that the skin of the pellagrin is hypersensitive to sunlight. Diet. — Corn bread and corn products are prohibited until the zeistic theory is disproved, as a precau- tionary measure. The diarrhea does not indicate a limitation in the dietary regimen. Tender steak, roast beef or mutton may be allowed once or twice daily; if the mouth is too sore to allow chewing, beef or white meats, either scraped or ground, may be substituted. Eggs are generally permissible, though it is well to use only the whites if flatulence exists. Sweet milk is valuable when it agrees with the patient. Fresh or artificially soured buttermilk is nearly always suitable. Niles believes that during the whole course of pellagra the individual should be nourished to the limit of DIET IN PELLAGRA 371 assimilation. Goldberger advises that beans and peas may be eaten if fresh meat cannot be secured. In the winter the dried, not the canned, variety of the veg- etables should be as large a part of the diet as they form in summer. Vedder has formulated the follow- ing simple rules for the prevention of deficiency diseases : I. In any institution where bread is the staple article of diet, it should be made from whole wheat flour. 2. When rice is used in any quantity, the brown under- milled, or so-called hygienic, rice should be furnished. 3. Beans, peas or other legumes known to prevent beriberi, should be served at least once a week. Canned beans or peas should not be used. 4. Some fresh vegetable or fruit should be issued at least once a week and preferably twice a week. 5. Barley, a known preventive of beriberi, should be used in all soups. 6. If cornmeal is the staple of diet, it should be yellow meal or water-ground meal, that is, made from the whole grain. 7. White potatoes and fresh meat, known preventives of beriberi and scurvy, should be served at least once a week, and preferably once daily. 8. The too exclusive use of canned goods must be carefully avoided. As an illustration of the practical application of the above' recommendations for a health-preserving, pel- lagra-preventing diet, Goldberger presents the follow- ing bill of fare : Breakfast — Sweet milk, daily ; boiled oatmeal with butter or with milk every other day; boiled hominy grits or mush with a meat gravy or with milk every other day; light bread or biscuit (one- fourth soy-bean meal), with butter, daily. Dinner — A meat dish (beefstew, hash, or pot roast, ham or shoulder of pork, boiled or roast fowl, broiled or fried fish, or creamed salmon or codfish cakes, etc.), at least every other day; macaroni with cheese, once a week; dried beans (boiled cowpeas with or without a little meat, baked or boiled, soya beans with or without a little meat), two or three times a week; potatoes (Irish or sweet), four or five times a week; rice, two or three times a week, on days with the meat stew or the beans; green vegetables (cabbage, collards, turnip greens, spinach, snap b^ans or okra), three or four 372 MEDICAL TREATMENT OF PELLAGRA times a week; com bread (one-fifth soy-bean meal), daily; buttermilk, daily. Supper — Light bread or bis- cuit (one-fourth soy-bean meal), daily; butter, daily; milk (sweet or buttermilk), daily; stewed fruit (apples, peaches, prunes, apricots), three or four times a week, on days when there is no green vegetable for dinner ; peanut butter, once or twice a week ; syrup, once or twice a week. This bill of fare is primarily for older children and adults. The intelligent housewife will make such modifications as the age of her children, tastes and particular circumstances make necessary. The quan- tities of some of the foods may be reduced and replaced, in part or in whole, by other similar foods, but so far as possible no reduction should be made in the quantities of milk and lean meats. In the case of young children eggs make a very desirable addition and. the relative quantity of milk allowed them may advantageously be increased. Medical Treatment. — Niles gives hypodermically 16 minims of iron arsenite solutjon and % grain of sodium cacodylate in solution. These may be obtained in sterile ampules. The two drugs are given on alter- nate days, one being given every other day for about two weeks. After that the dose is given every two~ days, still alternating the ampules. After acute symp- toms have subsided the time between alternate injec- tions is increased to three days and this is continued over several months. By mouth saturated solution of potassium iodid and Fowler's solution, in the proportion of five of the first to three of the second, may be given. Beginning with 5 drops in water, three times daily after meals, the dose should be increased one drop each day, until symptoms of arsenical saturation are manifested. This generally appears when 20 or 30 drops are being taken. When there is puffiness about the eyes on arising, stop the drops for two days, beginning again at the min- imum dose of 5 drops, and increasing as before. This procedure is continued until the eruption and sore mouth are abated, and then continue in 8 or 10-drop doses for several months. Should there arise a gastric or intestinal intolerance, which is an occasional compli- cation, it may be necessary to reduce the proportion MJEDICAL TREATMENT OF PELLAGRA 373 of Fowler's solution to one or two in eight parts, instead of three. For the frequent diarrhea satisfaction is obtained from bismuth betanaphthol and resorcin, with milk of bismuth as a vehicle. This failing, 15 grains of tanni- gen after each loose action, or, as a last resource, pow- dered opium may be given. For the infrequent constipation, either castor oil, liquid petrolatum, phenolphthalein or enemas will serve, drastic cathartics being admissible. For the sore mouth, a solution thymol, 1 grain to the ounce of water, a little alcohol being used as a solvent, will generally prove sufficient ; or a solution of sodium borate and glycerin. For the stomatitis and glossitis, a daily application of a silver nitrate solu- tion (20 grains to the ounce of water) is in most instances efficacious. Stomach' lavage is unnecessary, except ih rare instances, when a great excess of sticky mucus con- stantly arises. The simple erythematous rashes or even the slough- ing conditions in the hands and feet may be benefited or cured by the bland ointments, such as zinc oxid, or a 5 per cent, boric aicid. Raw or weeping surfaces are soothed by a lotion of calamine and zinc oxid in lime-water, to which may be added a little rose- water, or other pleasant adjuvant. For the intense burning in the hands and feet, so often and bitterly complained of, either ice-cold com- presses of a mild solution of mercuric chlorid, phenol (carbolic acid), 60 grains to the pint, applied at fre^ quent intervals to the unbroken skin, or baths of hot mustard water are indicated. Two or 3-grain doses of acetanilid, or 5-grain doses of acetylsalicylic acid, when the heart action is fairly good, will greatly relieve the neuralgic pains. After the erythema has subsided, leaving a rough and harsh surface, alcohol rubs at frequent intervals will facilitate the disappearance of this horny layer. Should mental symptoms predominate, deepening into melancholia, or lapsing into dementia, 'the patients should be placed in an institution for the mentally sick, as it is unwise, because of their varying or suicidal moods, to attempt their care at home. 374 GOUT Hydrothterapy has in many instances proved so ben- eficial in pellagra that some form of it, such as hot or cold baths, simple or medicated douching, packs, moist or dry rubs, accompanied by special massage, may be employed in nearly every case. Increased oxi- dation of the tissues, more rapid elimination, greater metabolic activity,' sharpened appetite, improved diges- tion and assimilation, and a noticeable tonic effect on the v^hole living organism follow their use. GOUT The etiology of gout is unknown. It is generally believed to be connected in some way with an imper- fect or deranged metabolism of purins. Among various predisposing causes are heredity, alcohol, habits, over- eating, etc. Among the prominent symptoms are chalky deposits, tophi in the ears, gouty joints, with accompanying shooting pains, increased arterial tension and gastro- intestinal upsets. TREATMENT The treatment is directed toward lessening the formation of uric acid and to facilitating its elimina- tion. Alcohol, tea and coffee cause a retention of uric acid in the blood. A purin-f ree diet is given contain- ing all foods except meat, meat extracts, peas, beans, spinach, tea, coffee and alcohol. The patient should take a moderate amount of plain nutritious foods. Eggs, fresh vegetables, except such as have been excluded, various cereals, and fresh fruits and milk may be freely eaten. By determining the eliminative capacity of the body for exogenous uric acid, it is possible to. keep the intake of purins well within the limit. The continuous use of alkaline drinking waters causes a deposit of sodium biurate in the joints and cartilages and is capable of precipitating an acute attack of gout. The value of the periodic administration of atophan (30 grains or 2 grams during the day), or, in non- nephritic cases, of salicylates, in depleting the blood temporarily of uric acid, is a means of giving symp- tomatic relief and preventing the deposition of uric acid in the joints. Exercise, massage and hydrother- OBESITY ~ 375 apy may be of service in assisting in the elimination of uric acid. In acute attacks the giving of wine of colchicum, eight to fifteen minims (0.5 to 1.0 gm.) and a half dose during succeeding days; hydrochloric acid, the salicylates and large quantities of water is beneficial. The individual joints may be treated, as has been mentioned under arthritis, by rest, moist sedative fomentations, morphin to stop pain. OBESITY Obesity is a condition accoppanied by the accumu- lation of extraordinary, therefore pathologic quanti- ties of fat. Unless causing definite functional dis- turbance, no treatment is necessary. A reference to the table of height and weight at varying ages in the front section of the book will indicate what is normal. The treatment of obesity must include primarily a regulation of the diet to prevent the feeding of excess food over what the body can utilize and a regulation of body work to produce a demand for energy-giving constituents. DIET The number of diets which have been offered for obese persons is almost legion. Certain general prin- ciples must be observed. An average of several of the best known diets'is as follows : Protein, 140 gms., fat, 40 gms., carbohydrates, 90 gms., calories, 1,320. It can be taken as a matter of fact that most people eat too much. The appetite may be better controlled and hunger appeased by small quantities of food taken frequently. Depressing of the appetite is com- monly advised and may be accornplish'ed in several ways, notably by long chewing of the food and limita- tion of the variety. Steinberg believes that drugs should be used to prevent hunger and reduce the appetite. He has found preparations of iodin particu- larly useful for this purpose. The anesthetization of the mucous membrane of the stomach also, aids in warding away hunger. Peppermint lozenges and menthol tablets reduce the sensibility of the mucosa 376 ' HYDROTHERAPY IN OBESITY and minute doses of camphor seem to produce a feel- ing of fullness. Coffee taken early in the meal has long been advocated by Sternberg as it reduces appetite and lessens the usual desire of the overcorpulent to sleep. Friedenwald and Ruhrah give the following general directions: Avoid sugars and starchy food and take little or no fatty food. Eat sparingly and take but little fluid — and that apart from meals. Obese persons may eat small quantities of chicken, beef, oyster, bouil- lon or clam soups ; meat once daily consisting of beef, lean, raw, scraped, boiled or broiled; steak, broiled; mutton, roasted; chops', broiled; chicken, boiled or broiled. Eggs should be only only soft boiled or poached. Of fish the following may be taken ; oysters, raw; mackerel, rock or trout, boiled. Vegetables are best taken mashed and strained. Of bread, but a small quantity should be allowed and then only in the form of stale wheat bread, zwieback, toast, graham or gluten bread. The following fruits, all of which are acid, may be recommended: lemons, oranges, raw apples, grapes, raw peaches, berries and cherries. Water should be taken sparingly at meal times. Tea and coffee may be taken but without sugar or milk. Mineral waters ordinarily may be allowed in quantity sufficient to assuage thirst without causing disagree- able symptoms. The following articles of diet should not be taken: rich soups, fried foods, pork, veal, stews, hashes, corned meat, potted meat, liver, kidney, duck, goose sausage, crabs, lobsters, preserved' fish, smoked or salted fish, salmon, bltiefish, salt mackerel, herring, hominy, oatmeal, rice, puddings, sardines, celery, pota- toes, turnips, carrots, parsnips, sweet potatoes, beets, hot bread or cakes, nuts, candies, pies, pastry, alcoholic stimulants. HYDROTHERAPY The use of cold baths in the treatment of obesity, as well as special forms of hydrotherapy, is generally well known. Besides improving the skin and aiding the circulation, it seems likely that such baths also accelerate the loss of fat. MEDICAL TREATMENT OF OBESITY 377 EXERCISE In the presence of circulatory disorders, the pre- scribing of exercise must be cautious ; otherwise it is a valuable aid in producing a loss of weight. Walking and horseback riding, swimming and graded calisthenics, may be of value. Golf and tennis may be likewise indicated if the physician thinks proper. Massage (if given vigorously and accompanied by passive motion) sometimes produces marked results, especially in those of established sedentary habits. The Zander aparatus produces passive mechanical exercise. Besides such machines others combining weight lifting, pushing, pulling and stretching move- ments may be employed in suitable cases. Bergonie has designated an apparatus which acts on the essential principle that the whole musculature of the body shall be stimulated by electric excitation to painless, rhythmic, passive contractions. Several observers have reported marked permanent losses in weight under such treatment. It has also been said that the method is a severe one and not to be continued too long at a single sitting because of the danger to the heart musculature. MEDICINAL TREATMENT Obesity cures of a fraudulent nature are legion. In most instances they are either dangerous of worth- less, or both. Thyroid extract has been and still is the basis of many so-called "fat reducers." Lemon juice has had its day and numerous iodid preparations, have been exploited. Bladderwrack, a form of seaweed, has likewise held a peculiar vogue. Von Noorden believes there is an endogenous con- stitutional type of obesity which he regards as trace- able to thyroid functioning. Congenital or acquired weakness or degeneration of the thyroid may induce the obesity directly or the thyroid may become a factor in the obesity only secondarily, as in case of pancreas disease (demonstrated only experimentally as yet) ; disease in the ovary or testicle (deficiency of the interstitial substance) ; disease in the pituitary body (adipose-genital dystrophy; disease in the pineal 378 MEDICAL TREATMENT OF OBESITY gland or thymus (both dubious). There may also be a combination of both the exogenous and endogenous type, especially in the young. Throughout the endogenous forms, abnormal thyroid functioning is common to all, and treatment of consti- tutional obesity must be based on thyroid treatment. It is unquestionable now that the reliance on thyroid treatment is increasing, the dread of it diminishing. The dangers frorn thyroid treatment are just as great as ever, but we know better how to watch out for them and guard against them. He adds that even in cases amenable to systematic dietetic measures alone, the prolonged restriction of the diet seems to him more of an evil than a course of thyroid treatment. With this the diet need not be so strictly regulated and the effect of the thyroid treatment is often permanent, so that the patients can eat like other people afterward without bringing back the obesity. During the thyroid course ample provision of albumin should be ensured. The urine should be examined often for sugar. The tendency to acceler- ation of the heart action and drop in blood pressure can be warded off by daily small doses of some digitalis preparation. The thyroid seems to lead to an increase of oxygen consumptioij and carbon dioxid excretion. If used it may be given in doses of one to two grains twice or three times daily and increased only very cautiously. DISTURBANCES OF THE HEART Of late years the disturbances of the heart are begin- ning to assume a more prominent place in the list of causes of death, so that perhaps only tuberculosis and kidney disturbances are more prominent. Although the majority of sudden deaths are due to a cardiac cause, there are few chronic diseases so amenable to treatment and so compatible with long life and com- fort, if judiciously handled, as cardiac cases. Of late years also there have come into prominence numerous delicate methods of examining the heart's functioning, testing its rate and it§ rhythm. These newer methods have pointed the way. toward effica'cious therapeutic measures. THE PREVENTION OF CARDIAC DISTURBANCES Although we shall consider under each heading the various elements in the etiology, it may be worth while here to take up some of the more general factors which produce cardiac disturbances. Recent studies of focal infections have shown that a tonsillitis, an abcessed toeth, or other focus of infec- tion may be the origin of germs that later may cause an endocarditis, or valvular infection. Patients are likely to manifest a desire to become active too soon after a serious illness or a surgical • operation. The physician or surgeon should not submit his patient to such strenuous cardiac tests. If th'e patient mani- fests a marked rapidity in the heart rate on first sitting up in bed, cautious consideration should be given to his symptomatology before allowing him to arise. All physicians are probably familiar with the serious car- dial disturbances in young men who have indulged too vigorously in modern athletic competition. -HYPERTENSION THE BLOOD PRESSURE It is presumed that the physician is familiar with the methods of determining th^ systolic and diastolic blood pressures and with the significance of variations in the readings from the normal. The average pres- 380 HYPERTENSION sure pulse is about 40 to 35 mm. (difference between systolic and diastolic pressures). Faught states his belief that the relation of the pressure pulse to the diastolic pressure and the systolic pressure is 1, 2, 3. In other words, a normal young adult with a systolic pressure of 120 should have a diastolic pressure of 80, and therefore pulse pressure of 40. If thfese relation- ships become markedly abnormal disease is developing and imperfect circulation is in evidence, with the dan- ger of broken compensation occurring some time in the future. It should be remembered that the diastolic pressure represents the pressure which the left ven- tricle must overcome before the blood will begin to circulate, that is, before the aortic valve opens, while the pulse pressure represents the power of the left ventricle in excess of the diastolic pressure. A high diastolic pressure is of serious import to the heart; a diastolic pressure over 100 is significant of trouble and over 110 is a menace. ETIOLOGY OF HYPERTENSION One of the most common causes of hypertension is excess in eating and drinking. The toxins from excess food are irritating, and therefore one of the first steps toward improving and lowering blood pressure in such cases is to diminish the amount of meat eaten or to remove it entirely from the diet. Alcohol, by affect- ing the appetite and increasing the amount of food taken, by interfering with the activity of the digestive tract, can indirectly disturb metabolism and thus affect the blood pressure. It should always be eliminated. Drugs or other substances that raise the blood pressure by stimulating the vasomotor center or the arterioles, when constantly repeated, may cause hypertension. This seems to be particularly true of caffein and nico- tin as taken in the form of coffee and tobacco. Thayer found a distinct relationship of hypertension to hard work. With such work is usually associated a hyper- secretion of the suprarenals. Neurotic conditions, and in some instances neurasthenic conditions, may show a. blood pressure higher than normal. Lead may be a cause of increased blood pressure', and diabetics occasionally have a high pressure, although more fre- quently there is a lowering of blood pressure in dia- PREVENTION OF HYPERTENSION 381 betes. Syphilis, as shown by Riesman, Levinson and others, is a very common cause of hypertension and arteriosclerosis without renal disease. When arterio- sclerosis and renal disease are combined, the highest systolic readings occur. PREVENTION OF HYPERTENSION The physician should continually caution the patients in whom the factors leading toward hypertension exist against the many things which will propagate and prolong that condition. They should be cautioned against severe athletic competition, recreation excesses, excessive use of tobacco, alcohol, and caffein, and over- eating. The pregnant woman should be carefully watched for changes in the urine and in the blood pressure. Patients with infectious diseases should have a slow convalescence during which they are care^ fully watched in order to prevent throwing too great a strain on weakened organs. StoU has outlined a short series of "Don't^' for patients with hypertensive cardiovascular disease, which are of distinct service in keeping the etiology and prevention of these conditions in mind : /. Don't tell the patient with moderate hypertension, few symtoms and whose kidneys are functioning well to stop eating meat or to go on a milk diet. 2. Don't tell him to immediately give up his business ; try to readjust his life so that unnecessary cardiovas- cular strain is reduced to a minimum. J. Don't tell him his kidneys are "all right," just because his urine exhibits neither albumin nor casts, ^. Don't miss the significance of nocturnal polyuria and a persistently low gravity. 5. Don't give nitroglycerin tablets to your patient the moment you discover that he has hypertension. Perhaps he requires a high pressure to get the blood through his small inelastic vessels. 6. Don't be satisfied with the systolic pressure — the diastolic is often of more significance. 7. Don't attribute the insomnia, nervousness and headaches in the middleaged woman to "the change" — take her blood pressure and examine her eye grounds. 382 HYPERTENSION 8. Don't make a diagnosis of neurasthenia till after a blood pressure estimation and a Wassermann test. It may save subsequent embarrassment and even be of advantage to the patient. p. Don't think you are doing your whole duty to your pregnant patient when you have examined her urine. She may have hypertension but no albumin today and eclampsia next week. 10. Don't consider hypertension solely a condition of middle life; it is occasionally present in childhood. 11. Don't forget the old man's enlarged prostate. It may be tl)e cause of the nephritic syndrome. 12. Don't hesitate to give digitalis when symptoms of cardiac failure are evident. It will not raise the blood pressure. 13. Don't wait until the patient is water logged and the heart dilated before suspecting a failing myocar- dium. 14. Don't deny your sleepless, gasping patient, whose course is nearly run, the relief that only morphin will give. 15. Don't make a prognosis solely on the blood pressure or the phenolsulphonephthalein test. Each tells but part of the story. 16. Don't overlook the fact that cardiovascular dis- ease is to a certain degree a familiar condition some- times present in several generations; nor neglect to explain the importance of a yearly blood pressure estimation of all members of the family. ly. Don't exclude syphilis, especially a parental infection, as the cause of the hypertension solely because the Wassermann is a negative. Study the family history; examine the brothers and sisters, and your patient's children for signs of hereditary syphilis. 18. Don't fancy that the management of hyperten- sion consists in watching a column of mercury or that success is measured in millimeters. TREATMENT OF HYPERTENSION Active treatment in hypertension should begin with a thorough cleansing of the gastrointestinal tract by purgation. Following this the most important mea- sure in the management of high blood pressure is the TREATMENT OF HYPERTENSION 383 proper regulation of the personal habits and diet. As' Elliott has said, "The gain over excess pressure accom- plished by this means is purely net gain, involving no interference with nature." Constipation should be kept under control by feeding fruits and vegetables, avoiding those that produce flatulency. The embargo on meat foods should be absolute at first and these things added to the diet according to the response of the patient to them. Alcohol, tea and coffee should be forbidden. The patient should be encouraged to drink milk. If the patient can be sure of good excre- tion, large quantities of fluid may be taken; but it is very important that the elimination be watched; if an appreciable portion of the fluid remains it adds quantity to the fluid in the blood vessels and thus does harm. As a purgative and also to aid in getting rid of the fluids, mercury probably holds first place. A patient with simple hypertension but otherwise well should have recreation periods one or more times a week and vacations not too infrequently. He should take a brisk purgative perhaps once in a fortnight or once in a week. Such physical methods as sWeat baths, electric light baths and similar measures may be utilized as occasion demands. If there is insomnia a dose of chloral may be given as needed but this should not be continued over long periods. If any other drug is needed nitroglycerin may be tried. If arteriosclerosis is present sodium iodid in small doses, 3 grains (0.2 gm.) two or three times a day may be serviceable. After a period which may be termed the normal period of hypertension in normal life, as age advances the systolic tension may lower, provided there is no kidney lesion. This is due to the slowly developing chronic myocarditis and a lessening of the tension and therefore lessening of the resistance to the heart. When the blood pressure is suddenly excessively high from any cause venesection may be life saving and should perhaps be more frequently utilized than it is. It may save a sudden heart attack or a cerebral hemorrhage. Patients with high tension may be bled frequently and as much as half a pint taken at a time. 384 ACUTE PERICARDITIS Such treatment will not long save life, as the blood pressure in most cases soon returns to its previous height. DRUGS IN HYPERTENSION The drugs that are most commonly used to lower blood pressure are the nitrites or drugs of that class including nitroglycerin, sodium nitrite, erythroltetra- nitrate and amyl nitrite. Other drugs more rarely used are iodids, thyroid, alkalies, chloral, bromids and very rarely nowadays, aconite. Amyl nitrite is required only when a sudden imme- diate effect is ■ desired in angina pectoris or in some other serious spasmodic condition. Sodium nitrite is more, likely to upset the stomach than is nitro- glycerin. Its action is more permanent, however. The dosage is from 0.03 gm. to 0.06 gm. (^^ to 1 grain) best given in tablet form with plenty of water. The tablets may be crushed before swallowing. Nitro- glycerin, in .doses of from 1/500 to 1/100 grain, three or four times a day, in the form of an easy sol- uble tablet is a very popular drug. It acts in two or three minutes and the blood pressure may drop from twenty to thirty millimeters. Thyroid extract seems to act beneficially in many cases and if no tachycardia is present it may be tried. As Leonard Williams has said: "In the way of drugs, then, there is nothing upon which we can, in the present state of our knowl- edge, depend for a definite and sustained action of a specific nature, without incurring risks which it does not seem to me we are justified in taking. And this is perhaps all to the good; for if we had such a drug we might be tempted to use it to the exclusion of those general principles of diet and hygiene on which the successful management of this diathesis is known to depend." ACUTE PERICARDITIS Pericarditis is almost invariably a secondary con- dition, the most frequent infectious cause being rheumatism, others being cerebrospinal meningitis, acute miliary tuberculosis, pneumonia and sepsis. Accidental causes are traumatism, and an adjacent inflammation of the pleura. Pericarditis may also be TREATMENT OF ACUTE PERICARDITIS 385 terminal in nephritis, adjacent abscesses, cancer and other new growths. The prevention of the disease must then be related to the removal of the cause. TREATMENT Of primary importance in the treatment of peri- carditis is rest. The patient should have absolute rest. He should not be allowed to sit up in bed, even to eat or attend to the calls of nature. He should have no visitors. Anything that increases the heart beat increases the. irritation of the inflamed surfaces of the pericardium. Just what can be done logically or generally to com- bat the inflammation actively must depend on the cause. When the inflammation occurs as a complica- tion of acute rheumatism, it has been suggested that salicylates, which do not inhibit rheumatism and may be depressant to the heart, should be stopped if they are being administered; but if the salicylates arc apparently improving the inflammation in the joints,^ pericarditis would not contraindicate their continued use. Except in large doses, salicylates probably do not depress the heart. In pericarditis it is perhaps well always to administer an alkali in some form unless otherwise contraindicated, whether the cause is rheu- matism or not. A diminished alkalinity of the blood would always increase the likelihood of an augmented amount of pericardial or endocardial inflammation. Alkalis may be freely given. It is possible that one of the reasons why pericarditis or endocarditis occurs so frequently in serious prolonged fevers is that the patient has not eaten enough cereals or other carbo- hydrates, and the system has become more or less endangered by acidosis. In other wojds, carbohydrate starvation is inexcusable with our present understand- ing of the danger from acidemia and even from a diminished amount of alkalis in the blood. The most valuable local treatment is cold, which may be applied either in the form of an ice-bag or by a small coil through which ice-water is caused to flow by siphonage. Cold may be applied more or less con- tinuously, depending on the sensations of the patient. The bag or ice-cap must not be overfilled and must 386 ACUTE PERICARDITIS not be heavy, as the patient often cannot stand pressure over the pericardium. Sometimes the relief from pain and the diminution of the number of the heart- beats is marked, and from this reason alone the cardiac inflammation may be inhibited. If cold applications are not tolera.ted by the patient (and they often are not in children) warm applications may be used, such as flaxseed poultices, or cloths wrung out of hot water and covered with oil-silk, and the pain will often be relieved thus. While hot applications would not tend to abort the inflammation, they probably do not tend to promote it. A diminished diet, of small amount at a time, and such purging asjhe patient's strength will allow are essential in attempting to curtail the seriousness or amount of this inflammation. Stopping the '