1 .'.' : '- ■•'•'..'■ '. v< : .s'-'-' ■/'■: ' : ■.:■ : ' : "■■ . HaOOQO< B50000o«5COCOOOOCCcCflCCQOC*jqCCqO .134 Broncho-pneumonia 137 CONTENTS ix PAGE Bronchitis, chronic 140 Bronchial asthma 143 The Lungs 144 Emphysema 144 Edema 144 Pneumonia 145 Phlebotomy . . . 151 Pleurisy 154 Thoracocentesis 156 Phthisis 164 Climatic treatment 169 Antiseptic treatment 176 Symptomatic treatment 181 Chapter IV. — Diseases of the Digestive Tract .... 188 The Mouth 188 Stomatitis 188 Acute stomatitis 189 Chronic stomatitis 189 Traumatic stomatitis 190 Thrush 190 Aphthous stomatitis 191 Ulcerative stomatitis . . . '. . . . 191 Mercurial stomatitis 191 Scorbutic stomatitis 192 Pyorrhea 192 Noma 192 Geographical tongue . 192 Leukoplakia oris 193 The Esophagus 193 Inflammation 193 Stricture 194 Spasm 197 The Stomach .200 Gastralgia 200 Anacidity 201 Hyperacidity 202 Gastric ulcer 203 Cancer 204 Pyloric stenosis 205 Portal congestion 206 Neuroses 207 Dilatation 208 Gastric lavage 210 The Liver 216 Icterus 217 x CONTENTS PAGE Hepatitis 220 Cholangitis and cholecystitis 221 Chronic cholecystitis . . 224 Gallstones 225 Gummata 226 Cirrhosis . * 226 Abscesses 228 Hydatid cysts 228 The Intestines 229 Enteralgia . . t # . .229 Enteritis 231 Flatulence 233 Typhoid fever 234 Colitis .237 Parasites 241 Ameba 242 Pinworm 243 Round worm . . 244 Enteroptosis 244 Pancreatitis 245 Peritonitis 246 Hemorrhoids 250 Fistulse and fissures 251 Pruritus ani . . 253 Chapter V. — Diseases of the Circulatory System .... 255 The Heart 255 Neuroses 255 Pericarditis 257 Myocarditis 260 Endocarditis 262 Constitutional diseases 266 Schott movements 267 The Blood Vessels 269 Arteriosclerosis 269 Apoplexy 270 Varicose veins . 271 Varicose ulcers 272 Relaxed vessels 272 Capillary hemorrhage 274 Purpura 275 Hemophilia 276 Scurvy 276 The Blood 277 Primary anemia . . 277 Pernicious anemia . . ,• 279 CONTEXTS xi PAGE Secondary anemia 280 Leukemia 280 Trypanosomes 281 Chapter VI. — Disorders of the Genito-urinary Tract . . . 282 Uremia 282 Oxaluria . 284 Phosphaturia 285 Acute nephritis 285 Chronic nephritis 286 Suppurative nephritis 291 Degenerative nephritis . 292 Renal calculus 292 Cystitis 293 Catheterization 294 Enuresis 299 Acute urethritis 300 Chronic ulceritis 301 Prostatitis 304 Epididymitis 306 Sexual neurasthenia . . . . . . . . 306 Endometritis 307 Salpingitis 308 Oophoritis 308 Bartholinitis ...'.' 309 Chapter VII. — Disorders of the Nervous System .... 310 Intracranial disorders 310 Tabes 311 Embolism 311 Neoplasm 312 Meningitis 312 Sunstroke 312 Hydrocephalus 312 Infantile palsy 312 Lumbar puncture 313 Spinal disorders 317 Chronic pachymeningitis 317 Myelitis 317 Anterior poliomj-elitis .317 Tabes 318 Tetanus 319 Neuroses 320 Mania 321 Chorea 323 Epilepsy 324 xii CONTENTS PAGE Hysteria 325 Neurasthenia 333 Neuralgia 336 Neuritis 337 Beri-beri 338 Chapter VIII. — Disorders of the Glands 339 Lymphatic glands 339 Acute lymphadenitis -. . 339 Lymphatic anemia 339 Venereal buboes 339 Tuberculous glands 340 The spleen 341 Splenomegaly 341 The adrenal bodies 342 The pituitary body 342 The thyroid gland 343 Chapter IX. — Disorders of Metabolism 345 Gout 345 Arthritis 346 Diabetes mellitus 349 Rickets 361 Chapter X. — Infectious Diseases 363 Actinomycosis 365 Anthrax 365 Bacillary dysentery 365 Chicken pox 366 Cholera 366 Yellow fever 369 Erysipelas 370 Glanders . . . . 371 Hydrophobia 371 Influenza 373 Malaria 375 . Measles 375 German measles 376 Plague 376 Scarlet fever 377 Septicemia 378 Smallpox 380 Syphilis 384 CONTENTS xiii PART III NOTES ON REMEDIES PAGE Chapter XL — Miscellaneous Notes 391 Baths in common use 391 Doses proportionate to age 392 Substances excreted in milk . 392 Alcohol table 393 Percentage solution table 394 Metric and apothecaries' equivalents 395 Chapter XII. — Materia Medica 396 Acetic acid 396 Acetone 396 Aconite 396 Aloe .397 Alum 397 Ammonium salts 397 Anise 397 Antip3 r rine • . . . 398 Apomorphin 398 Argyrol 398 Arnica 398 Arsenic 399 Asafetida 401 Atropin 401 Benzoin . 402 Berberis 403 Bismuth 403 Boric acid 404 Bromide 405 Bromural 406 Cade, oil of . . 407 Caffein 407 Calcium 408 Carbo animalis 410 Carbo ligni 410 Cardamom 410 Cascara sagrada 411 Castor oil 411 Chloral hydrate 412 Chloroform 413 Chloretone 413 Citric acid 413 Coal-tar derivatives 413 Colchicum 415 xiv CONTENTS PAGE Materia Medica. — Collodion 415 Colocynth 416 Co'ndurango . ' . 416 Creosote 416 Cresol, compound liquor 417 Cupri sulphas . . . . ■ 417 Digitalis 417 Dormiol 419 Dover's powder 420 Elixirs .420 Epicarin 421 Epinephrin 421 Ergot 422 Ether 422 Ethyl chlorid 423 Eucain 423 Eucalyptus 424 Fibrolysin 424 Formaldehyd 425 Gelsemium . . . 425 Gentian 426 Guaiacol 426 Hexamethylenamin 426 Hydrastis 426 Hydrogen dioxid 427 Hyoscin 428 Hyoscyamus 429 Ichthyol 429 Iodids 429 Ipecacuanha 430 Iron 431 Kaolin 432 Lactic acid 432 Lysol 433 Mercury 433 Methylene blue 434 Naphthol 434 Nitrites . . . ' 435 Nitrous oxid 438 Opium 439 Orthoform 442 Oxgall 442 Pancreatin 443 Papain 444 Peppermint 444 Pepsin 445 CONTENTS xv PAGE Materia Medica. — Permanganate of potash .,«... 445 Petrolatum . 445 Phenol 446 Phenolphthalein . . 446 Phosphorus 447 Piperazin 447 Pollantin 448 Potassium compounds 448 Quinin 450 Resorcin 451 Rhubarb 451 Rochelle salts 451 Sabromin 452 Salicylates 452 Saline solution 453 Salol 455 Sandalwood oil 455 Santonin 456 Senna 456 Silver 457 Sodium 458 Starch 460 Stramonium 460 Strychnin 461 Stypticin 462 Sulphonal . 462 Sulphur 463 Syrup of orange 463 Tannin 463 Tars 466 Theobromine 466 Thiosinamin 467 Thymol 468 Thyroid extract 468 Tolu 468 Trichloracetic acid 468 Turpentine 469 Urea . 469 Valerian 470 Veratrum viride 470 Veronal 470 Mineral waters 470 Wool fat 485 Yohimbin .......... 485 Zinc compounds 486 LIST OF ILLUSTRATIONS FIG. PAGE 1. — The Forth thermophore 8 2. — Portable bath tub for the sick room 29 3. — Ice bag for spine 30 4.— Flat ice bag 30 5. — Leiter coil for flat surfaces, such as chest 30 6. — Leiter coil for the head 30 7. — Massage of the colon for constipation 48 8. — A portable tub 62 9. — Hot-air cabinet, arranged for gas heat 71 10. — Applying heat by means of a 500-candle-power electric light . . 80 11. — The permanent bath 91 12. — The application of heat by means of the high-candle-power lamp . 94 13. — Application of zinc oxid adhesive bandage for muscular strain and myalgia 106 14. — Position of hand and wrapped scalpel for incising peritonsillar ab- scesses 119 15. — Intubation set 127 16. — Intubation of the larynx 128 17. — Technique of intubation 129 18. — Tracheotomy tube 132 19. — Trocar-pointed obturator for tracheotomy tube 132 20.— Respirator 140 21. — Turpentine pipe 141 22. — Applying a clay poultice 145 23. — Covering the clay poultice with the cotton jacket 146 24. — Fomentation to the back of the chest 149 25. — Median vein 151 26. — Conditions in which the aspirating needle fails to withdraw fluid . 158 27. — The Potain type of aspirator 159 28.— The Truax aspirator . . . . . . . . . . . .160 9 6 XV11 xviii LIST OF ILLUSTRATIONS FI »- PAGE 29. — Points recommended for the insertion of the aspirating needles . 162 30. — The Mosny-Stern apparatus for aspirating a "blocked" pleurisy . 163 31. — Cohnheim's apparatus for dilating the cardia 198 32. — Trousseau's bougies 198 33. — Pouche sous-pylori que of Chapotat 209 34. — Original method of gastric lavage without the help of a physician . 210 35. — Ordinary type of stomach tube with funnel and bulb . . . .211 36. — Pulling the larynx forward before inserting the tube . . . . 212 37. — Stomach washing in adults 214 38.— The Ewald tube . .215 39. — Esophageal stricture 216 40. — Electric bath cabinet room 219 41. — Manner of holding trocar ' 228 42. — Apparatus for continuous proctoclysis 248 43. — The various limits of the left pleura . 259 44. — The sinus prostaticus 294 45. — Obstruction at the mouth of the urethra 295 46. — Obstruction offered by the sphincter 295 47. — Catheter obstructed by the sinus pocularis 295 48. — Method of pushing catheter out of the sinus pocularis .... 296 49. — Metal catheter for normal cases 296 50. — Metal catheter for enlarged prostate 297 51. — Position for passing catheter under pubic arch 297 52. — Position of catheter after it has entered the bladder .... 298 53. — Treatment of the prostate through the urethra 304 54. — Treatment of the prostate through the rectum 305 55. — The spaces for lumbar punctures 314 56. — The permanent bath for quieting mania 322 57. — The permanent bath in use in a hospital for the insane . . . 322 58. — The two methods of vaccination 383 PAET I GENERAL THERAPEUTICS CHAPTER I SYMPTOMATIC THERAPEUTICS INTRODUCTORY To treat a patient successfully the. physician should learn, if possible, the pathological process present (the pathological physi- ology, as some use the term), and then either (a) remove the cause, or, if that be impossible, (6) check or change the processes so as to bring relief to the patient. Thus, in the palpitation and gas- tritis of the tobacco user, one can easily correct the condition by stopping the use of tobacco. But in the palpitation and gastritis incident to enteroptosis one cannot remove the cause, and it then becomes necessary to change the habits of life and the diet, and to give drugs to get rid of the irritation proceeding from the nerve plexuses of the abdomen, either by depressing these reflex arcs or by stimulating the heart action and the digestion so that these reflexes no longer upset the rhythmic action of these organs. Hav- ing then determined the point of attack (whether, for example, the reflex arcs or the organs themselves), we can select intelligently the therapeutic agents needed. The work of the pharmacologists of the last quarter century has thrown great light on the action of the drugs composing our materia medica. We have learned, among other things, that many plants and drugs have as essential elements but variations of one single active principle, and that physicians have been championing practically identical active principles even when they have been disputing about the merits of their favorite prescriptions. Thus, atropin has been the basic principle for those who have sworn by the virtues of the Jimson weed as well as for those who repudiated the Jimson weed and chose for themselves the deadly nightshade or henbane. Again, the homeopath who used spongia in croup was really giving the same drug as the man who used iodized calcium. 3 4 SYMPTOMATIC THERAPEUTICS Hence, there is great need of revising our drug lists and select- ing from them for our use those active principles that have proved their worth and whose action is known, and then of using those active principles in the dosage appropriate to the result we desire to obtain, as our fathers did when they used the crude drugs which contained these same active principles, although in varying proportions. Thus, atropin may be used in dosage appropriate for flushing the skin, or for checking the sweat, or loosing a spasm of the peristaltic mechanism. The physician of the older school could have used belladonna, agaric, and hyoscyamus for the re- spective purposes. Proceeding on this principle, it has been found that only a com- paratively few drugs are needed in the ordinary practice of medi- cine — provided that the physician knows all about the action of these few. Thus, it is not sufficient to know that atropin causes a rapid heart beat or dries the throat ; it must be known how it does this. To be sure, our laboratories have not finished their work of studying our drugs for us, but enough has been done to justify our learning therapeutics from the new standpoint. Hence, in this text we emphasize everywhere the physiologic action of our drugs and endeavor to point out the work to be accomplished by each. Furthermore, the physician must not deceive himself and be- lieve that he is proceeding causally when he is merely checking the mechanism bringing about the symptoms — as in giving morphin in appendicitis — because, as in the disease instanced, such self- deception may make him indeed a blind leader of the blind, with the proverbial result. Very often we must proceed symptom- atically — for we must quiet pain and relieve distress long before we can learn, in a new case, all the train of events that led up to the present outbreak. Hence, it would be a mistake for our young laboratory-trained physicians to scoff — as many of them do — at symptomatic relief and leave their patients to suffer while they go away to make blood counts and urine analyses. The careful and accurate noting down of the symptoms presented — relieving the patient of his suffering as much as we can, while we proceed with a deeper study of the ease, will enable us to maintain our self-re- spect as scientific physicians and at the same time please our patrons, who generally judge us by the quickness with which we afford them relief. PAIN 5 Hence, in our study of symptomatic therapeutics, we endeavor to trace out the functions or processes that are defective and lo- cate, whenever possible, the point of irritation — or at least the point to which treatment should be applied — and then select the remedy best adapted to do the work. The fine art of therapeutics consists in securing as specific an action as possible — not to affect the whole body when we wish simply to relieve pain in the finger, for instance — and thus interfere as little as possible with the nor- mal bodily processes. I. PAIN Pain may be caused by an irritation in the course of a sensory nerve, or it may be referred to such a nerve even though the irri- tant does not actually touch the nerve. Therefore, since the treat- ment in the different cases would vary greatly, it is important for the therapeutist to determine the location of such an irritation; that is, whether it lies near the nerve center, along the trunk, or at the end organ. This cannot be ascertained from the apparent location of the sensation, for in any case the pain is referred to the place where the end organ lies. To illustrate these statements : the pain of trigeminal neuralgia may seem to be in the face or teeth, but we usually find the irritation either in the nerve trunk or the ganglion. Again, an inflammation or disturbance in the cavum tympani may cause a toothache. Similarly, a cholecystitis may give rise to a pain in the back or the shoulder. A hernia ob- turatoria presents a pain radiating down the inner aspect of the thigh toward the knee. Renal calculus causes a pain running the whole length of the ureter, and even extending to the end of the urethra. Headache may be due to a tumor at the base of the brain, but is nevertheless felt as if in the periphery or even in the scalp. Because of this reference of pain, causal treatment can be effective only when the location of the irritation is known, and then only when the irritant can be removed. In the present state of our knowledge, this removal cannot al- ways be accomplished. Therefore, very frequently we must have recourse to symptomatic treatment in our effort to relieve pain. This type of treatment aims at relief rather than at cure. It is accomplished in one of three ways: (1) We inhibit the end organ of the sensory nerve, so that the sensation is not started out. Thus, 6 SYMPTOMATIC THERAPEUTICS in a raucous ulcer, it is the exposure of denuded nerve endings that causes the pain. If these are deadened by the application of a local anesthetic, the pain ceases. (2) The nerve trunk may be blocked so that the sensation cannot be transmitted. Thus, for small surgical operations, injecting cocain along the nerve trunk prevents the sensation of pain from reaching the sensorium. Spinal analgesia, wherein a local anesthetic is injected into the spinal canal to stop the pain in operations below the diaphragm, is also an instance of this form of relieving pain. And (3) the sensorium may be so depressed that it does not perceive the sensa- tion of pain. Thus, morphin or the coal-tar derivatives inhibit the cortical centers, and the unpleasant sensations are not perceived — although the irritation in the periphery continues as before. Local Treatment There are several kinds of local treatment for the relief of pain, and these sometimes are causal, sometimes symptomatic, but always empirical. Thus, heat is applied to the spot where the pain seems to originate. This treatment is most effective in those cases where a local hyperemia will remove the irritation. But there is some relief in nearly every case. Therefore the local ap- plication of heat is usually the first attempt at treatment made both by doctor and layman. The simplest method of applying heat is the use of the hot-water bottle or other heated object. One can secure a longer continuance of such heat by using an incandescent electric light over the painful area, the details of the use of which are given below, or, if that be not at hand, by using a rubber water bottle full of sodium acetate which has been immersed in boiling water for ten minutes. Bags of sodium acetate thus treated will remain at a temperature of 150° to 170° F. all night, while they gradually discharge their heat of liquefaction. Still another variation is the application of a combination of waxes and rosins, which shrink as they cool, thus furnishing both heat and com- pression. This combination has been given the trade name of Tambrine or hyperthermaline. Somewhat more effective for circumscribed areas of inflamma- tion is the application of the moist and hot bandages or hot poultices. The first consists in applying bandages wrung out in hot PAIN 7 water and covering them with some impermeable covering, such as gutta-percha tissue, oiled silk, or even waxed (paraffin) paper. For example, in a case of tonsillitis, a moist bandage should be wrapped around the neck — covering the whole area from the ear to the shoulder — and this covered with a dry bandage, or, better, oiled silk or muslin. In the original form, as devised by Priess- nitz, the bandage was cold (that is, the inner part was moistened in cold water) when applied. It then became heated by the body heat. But nowadays the bandage is more often applied hot. This bandage must be removed and renewed as soon as it becomes cold or loose. The second application is best illustrated in the clay poultice (the Cataplasma Kaolini of our Pharmacopeia), which holds the heat well, and, since it contains both glycerin and methyl salicylate, has added power for the relief of pain. The habit of the laity of using poultices has brought with it many sad results, because there is considerable danger from the use of dirty poul- tices. Thus, eyes have been infected by the application of raw meat, and skin infection has been added to the original disorder when bread-and-milk or linseed poultices have been used to re- lieve pain. Hence our belief that it is usually best to employ the clay poultices (known best in the form of antiphlogistine), because this is both sterile and clean. Such poultices must be applied hot and must be removed as soon as dry. They must be thick enough to retain the heat if they are to be effective. When intense backache is to be attacked a modification may be employed as follows : The patient may be stripped and made to lie in a warm room on a warm flannel blanket, then cloths wrung out in water as hot as can be borne are laid on the patient's back along the spine. After about three minutes these are removed and ice is rubbed over the same area. Then another hot cloth is ap- plied, and so on in alternation for one half to three quarters of an hour. Such treatment must, of course, be promptly discon- tinued should the patient fail to react, that is, if he should become chilled. When considering the various methods of applying heat we should not forget the sand bag, because that material is cheap and the bags can be thoroughly sterilized. They should be made into sizes and shapes adapted to the part of the body to be treated. Moreover, it is well to have many bags, so that a limb can be com- 8 SYMPTOMATIC THERAPEUTICS pletely surrounded with them. They are specially useful in neu- ritis and rheumatism. In using the ordinary incandescent electric light we attach to a sixteen-candle-power lamp a metal reflector (preferably in the form of a cone), and rest the edge of this reflector on a moistened towel which surrounds the painful area. In most cases it is well to have no cloth between the light and the skin. The whole should then be covered by a blanket or towels to re- tain the heat. There are on the mar- ket pieces of apparatus called photo- phores or thermophores, which have stands and adjustable arms, so that they can be applied to any part of the body and at any distance. The ad- vantage of the electric light is that it produces considerable heat without in- juring the skin, and can be applied or removed instantly and with little or no trouble. Hyperemia. — The introduction of local hyperemia for relief of pain and cure of local infection has been brought to scientific excellence by Pro- fessor Bier, now of Berlin. Thus it has become rational, and, since the laws governing its efficiency are becoming known, it is also losing its empirical character. This hyperemia is produced either by vacuum or by stasis. The first is accom- plished by using glass suction cups, like the cups for bleeding of former generations, shaped to fit the surface to be treated. In the smaller cups the vacuum is maintained by rubber bulbs, in the larger by pumps. These cups are applied to the painful area for from three to five minutes, then removed and the area allowed to rest for an equal period. The length of a treatment is usually forty-five minutes. Treatments may be repeated several times a day if need be. In the other method of producing hyperemia — applicable only to the extremities — an elastic ligature is thrown around the limb Fig. 1. — The Foutch Thermo phore. PAIN 9 just tight enough to retard the superficial venous flow. This, when applied aright, can be kept on continuously for from twenty-four to forty-eight hours. Of course, the extremity should be at rest as nearly as possible during the treatment. This form of treatment seems to be especially well adapted to tuberculous joints. Massage. — Great relief from the more chronic sorts of pain can often be obtained by massage. Of massage, there are four primary movements — stroking, friction, kneading, and percussion. The movement should be toward the heart, beginning at the extremity and working toward the trunk, in order to assist in quicken- ing the circulation of the body fluids. Of course, massage can- not be used where there is tenderness, or where the movement is liable to cause a breaking down of tissue or hemorrhage. Hence considerable knowledge of the pathological condition is needed by one who would prescribe this form of treatment. It is best adapted to functional troubles, such as strains, nervous exhaustion, fatigue, and lethargy. Shoemaker gives the following description of these various movements: Stroking is done with the whole palm, with the radial border of the hand, or with the thumb or ends of the fingers. The pressure may be as light as possible, and vary gradually from this to as much weight as can be borne, the operating hand being reenforced by pressure made upon it with the other, or the weight of the other parts of the body may be called into play to give sufficient force to the stroke. The direction is nearly always venous (centripetal, or toward the heart), but in rare cases it may be arterial (centrifugal, away from the heart). Friction consists in more or less forcible circular rubbing of a sur- face, with the palm of the hand usually, or with the fingers or final phalanx of the thumb. During the manipulation the remaining fingers of the hand, or it may be of both hands, clasp the limb which is under treatment, making it a point of support. It is advisable to begin at the border of the pathologically altered tissues, and work out the exu- date into the surrounding healthy tissue in all directions, always con- cluding, however, with centripetal strokings. Kneading. — This is what is meant by " massage," which, however, as an English word is now used in a comprehensive sense to include all the manipulations in manual mechano-therapy and is applied to such treatment, even though kneading proper be not included in the pre- scription. The restricted application of this term is to the method of picking up or grasping a certain portion of muscle or other tissue with 10 SYMPTOMATIC THERAPEUTICS the fingers of one hand and subjecting it to pressure between them, or upon a hard substance such as a surface of a bone. Dr. Douglas Graham, of Boston, who is especially skilled in massage, recommends that in kneading " a group of muscles should be systematically worked upon, and for this purpose one hand should be placed opposite the other; or when the circumference of the limb is not great, one hand may be placed in advance of the other, the fingers of one hand partly reaching on to the territory of the other, so that two groups of muscles may be manipulated at the same time, with grasping, circulatory, spiral manipu- lations, one hand contracting as the other relaxes, the greatest extension of the tissues being upward and laterally, and on the trunk, forearms, and legs, away from the median line. ... It is well first to go over a surface gently and superficially before doing the manipulation more thoroughly and in detail." For instance, to take up a limb of consid- erable size, such as a leg, he finds three divisions of surface necessary: the posterior and lateral aspects will form one; the stretching of the peroneal muscles from those of the anterior tibial region will make another; and for the third a rolling of the tissues will be made away from the crest of the tibia. " In large muscular masses we seize them in successive portions with both hands and squeeze in all directions, as one would squeeze water out of a sponge," says Reibmayr. At the moment of making pressure a certain amount of longitudinal traction may be practiced, which adds to the value of the manipulation. An- other, but much less effective form of kneading consists in rolling the limb between the palms of the hands. The movements here are very rapid and the pressure less important, the principal effect being pro- duced by the frequently recurring stretching and forcible separation of the individual muscles, fasciae, and nerves. Vibration is a form of massage, the alternate pressure and relaxa- tion being made with great rapidity. It is generally performed by means of a mechanical contrivance by which any portion of the body or limbs may be thrown into vibration at the rate of several hundred per minute. Electrically driven instruments are now generally used. There are two general types and many variations of each type. Thus the whole body may be shaken by shaking rhythmically the chair or bed. On the other hand the tissues of a circumscribed area may be alter- nately compressed and released by small vibratodes which have either an oscillatory or a percussion stroke. This latter type is described more in detail below. Vapor Massage. — By the use of compressed air, fluids may be nebu- lized and driven with considerable force against the surface of the body. Ordinarily, the objects sought after are the removal of adherent mucus PAIN 11 from the upper air passages and the application of medicated solutions; but excessive force is injurious. An apparatus has been devised by which the pressure can be regulated and made intermittent and the spray given at any desired pressure, or to have a vibratory effect, pro- ducing results similar to manual massage. Vapor massage has proved to be especially useful in the affections of the nose, throat, middle ear, and bronchial tubes. Percussion may be performed either with the border of the hand, the tips or knuckles of the fingers, the closed fist, or with some instrument constructed for the purpose. The shocks should be rapidly, but not for- cibly, delivered— usually from the wrist only. For this purpose various instruments have been invented, such as those above referred to. They are now so perfect that the. force and length of stroke can be accurately gauged and thereby deep or superficial tissues affected. Usually one should not work over any one area longer than five minutes. This is sufficient to deaden the hyperesthesia and produce hyperemia. After massage has been performed active and passive movements of the neigh- boring joints are usually resorted to, especially in case of diseased joints and in chronic cases with stiffened articulations. In the north of Europe massage has been systematically combined with Swedish reme- dial gymnastics (so-called movement cure) with great advantage. In this method various kinds of gymnastic exercises are resorted to, and peculiar forms of apparatus (such as the so-called Zander apparatus) are provided to meet various requirements of treatment. Electro-massage. — A massage electrode, in the form of a small roller, affords an excellent means of combining the effects of electricity and massage. It is usually connected with the faradic apparatus, but in cases of paralysis or exudation it might be very advantageously used with galvanism. As can be inferred from the above description of the move- ments, massage stimulates the lymphatic and venous circulation — and, secondarily, the arterial — thus being most useful where active hyperemia is needed. We use it, therefore, somewhat causally and somewhat symptomatically for paralyses, for parts immobilized in splints, and for obesity — in short, wherever we wish to stimulate the active nutrition as well as to relieve the pain. Hot Air. — This is another measure for relief of pain. The cabinet is akin to the thermophore, but enables us to utilize higher temperatures and secure something more than merely symptomatic relief. The body, or that part of it to be exposed, is wrapped 12 SYMPTOMATIC THERAPEUTICS loosely in three or four folds of coarse (the so-called Turkish) tow- eling and inserted into the cabinet. The temperature of the in- terior of the cabinet is brought to 250° to 350° F. and kept there for one half to one hour, or at least until the forehead of the pa- tient has been bathed in perspiration for ten minutes. Then the cabinet is removed and a rub with tepid water given. This treat- ment relieves muscular and neuritic pains in a very satisfactory manner. So much for the various nonpharmacal procedures that are used for the relief of pain. As may be inferred from the descrip- tion, these measures are usually palliative and secondary to other and more forceful remedies. Their special value lies in cases of weakness, nervousness, and neurasthenia, where the weakened nerv- ous system prevents the patient's withstanding slight irritations and disorder which in health he would not feel as pain, but simply as discomfort. Since they can be applied and removed quickly, and since their effects practically cease with their removal, mechano-therapeutics are usually to be preferred to the more sys- temic and permanent pharmacal agencies whenever they are equally effective. Drug Treatment When we come to study the relief of pain by deadening the end organs of the sensory nerves, we find that, although heat and vibratory massage often accomplish this result, in many cases we must depend upon the use of drugs. Thus, the application on a pointed probe, covered with absorbent cotton, to a mucous ulcer of ethyl (or grain) alcohol in ninety-five-per-cent strength may cause a momentary increase in the pain, but is followed very shortly by a numbness that may persist for hours, and that is experienced as grateful relief. Similarly a probe dipped in a ten-per-cent aque- ous solution of nitrate of silver will sear over the denuded area, destroy the bacteria, and relieve the pain. This latter drug is more escharotic than the alcohol, and forms a hard scab and hence does not penetrate deeply. Where deeper action is desired, liquefied (ninety-five per cent) carbolic acid, which forms a soft scab and therefore affects the underlying tissues, is touched to the spot in the same way, and after the exposed tissue is whitened, the excess is wiped off with cotton moistened in alcohol. The value of the hard PAIN 13 scab is in its protection of the underlying nerves and blood vessels. The nitrate of silver is therefore to be preferred in all cases of mucous ulcer where we have no reason to believe that the underly- ing tissues are infected or necrotic. This would be generally in cases of abrasion. On the other hand, where the ulcer is due to a vegetable microorganism (such as oi'dium albicans), the carbolic acid, which penetrates deeply, is to be preferred. The student should use the strong carbolic acid for this work, and never the five-per-cent solution. Both of these drugs destroy the tissue with which they come into contact. Hence, it is not a matter of merely inhibiting the end organ when using them. For this reason, also, we should not use the carbolic acid when we are not willing to destroy the nerves in the tissue underlying the ulcer. Sometimes one would prefer to use a powder to overcome the pain of an exposed nerve, as in ulcus cruris or in crushing in- juries. In such a case the pulvis antisepticus of the National For- mulary proves quite successful. Its formula follows: Phenol Eucalyptol Menthol Thymol aa 0.1 grams. Salicylic acid 0.5 " Zinc sulphate 12.5 " Boric acid 86.6 " In this combination the zinc sulphate acts as an astringent, while the boric acid is chiefly a vehicle. The salicylic acid is somewhat analgesic and antiseptic, but it also softens epidermal tissues. Bismuth subnitrate is another drug that is used for local anti- sepsis and analgesia. This may be used with zinc oxide and chalk in any convenient proportion. If we are dealing with a painful area of the intact skin, we must find a sedative analgesic drug that will be absorbed through the skin without injuring it; and for this we find atropin, menthol (or the other camphors), aconite, etc., available. But we must be careful to choose a drug and dosage that will not give a systemic toxic effect when used in this way. Hence, five-per-cent oil or alco- holic solutions of menthol are very popular, because their applica- 14 SYMPTOMATIC THERAPEUTICS tion does not run the risks connected with the more toxic atropin or aconite. So, also, is methyl salicylate (oil of wintergreen), when diluted with an equal quantity of olive oil. All of these remedies give the greatest relief when, instead of being simply smeared on the surface, they are rubbed in thoroughly and the part covered with an impermeable bandage (e. g., paraffin paper) to prevent evaporation. For local use atropin is generally prescribed in the form of the unguentum belladonna? (ten per cent) because it is difficult to make an ointment with the alkaloid itself that would not be danger- ous when handed over to a layman to use on himself. This oint- ment is indicated more especially in cases of pruritus and pares- thesia. This mention of the unguentum belladonna? brings up the ques- tion of the relative value of ointments, aqueous solutions, and al- coholic solutions. As may be inferred from the preceding para- graph, a strong alcoholic solution is bound to destroy tissue, and one who uses it freely on his hands will find the skin becoming hard, cracking, and finally peeling off. Hence, we should avoid alcoholic solutions where we do not desire this result. The advan- tage of alcohol as a solvent or vehicle lies in its universality and the quickness with which it penetrates the skin. For this reason a five-per-cent solution of menthol in alcohol affords almost instan- taneous relief from itching, even when but slightly rubbed into the intact skin. On the other hand, it would be painful to sensitive parts, and when applied freely would lead to peeling (desquama- tion). Aqueous solutions are less prompt in their action, but have no effect on the skin beyond that of the contained drug. Glycerin has the advantage of being of itself easily absorbed by the skin, but it sometimes is slightly irritant. The ointments, on the other hand, are sedative because they protect the skin from the air, and, if made of the right materials, are not only not injurious, but preserve the skin and promote the absorption of the contained drugs. But they are greasy, and for that reason often objected to. The fact that the phenols and camphors are but slightly soluble in water restricts of itself the use of aqueous solutions for the application of analgesics. Hence, we find that most of the local remedies for pain contain enough alcohol to make a good solution and enough water to prevent the injurious effects of the alcohol; PAIN 15 or they are ointments with a wool- fat base (because wool-fat is the one ointment base that is easily absorbed). Thus, the popular ap- plications for bruises, tincture of arnica or witch hazel, contain enough alcohol to be sedative, even if they did not contain any other active ingredients. Again, the analgesic balm of Dr. Bengue is a wool-fat ointment containing menthol, methyl salicylate, etc., in appropriate percentage. We can make as an illustration of these principles the two fol- lowing prescriptions for the relief of pain where the skin is intact : 31. Menthol 2.5 grams. Methyl salicylate 10.0 " Alcohol 15.0 " Glycerin 15.0 " Sig. Rub into the painful area with gentle pressure. 1*2. Menthol 5.0 grams. Methyl salicylate 5.0 Camphor 5.0 Wool fat 30.0 White wax 10.0 Paraffin 10.0 M. f. ung. D. S. Apply to painful area. The use of such applications will be found indicated in rheu- matism, myalgia, neuritis, neuralgia, and even in forming boils. If the application of these drugs is followed by the use of the ther- mophore or hot-air bath, the sedative effect of the drugs is in- tensified. For merely temporary relief, eocain (in two- to ten-per-cent solution) may be applied to the mucous membranes. The drug, however, is too toxic to be handed over to a patient for continued use, and should be kept in the physician's hands for use in dead- ening the pain of small operations. For deadening the nerve trunk, eocain, or one of its substitutes, is practically the only drug used. Cocain deadens any part of 16 SYMPTOMATIC THERAPEUTICS the nerve with which it is brought into contact. Hence, we may use it to deaden the end organs in mucous membranes, to deaden the nerve fibers, and, could we get at them, the nerve centers them- selves. For application to mucous membranes, cocain is applied with a spray or swab dipped in one- to ten-per-cent solution, be- cause the absorption of cocain solution from mucous membranes is so rapid that simply painting the surface with it is sufficient to produce an anesthesia sufficient for slight operations. For opera- tions on the eye, nose, or throat, adrenalin chlorid is frequently added to the cocain or eucain (a substitute for cocain) solution in order to secure constriction of the blood vessels and freedom from hemorrhage during the progress of the operation. For this purpose a 1 : 10,000 solution of the adrenalin is sufficient. When using cocain for injection into or under the skin, one should always remember that one grain of the drug is the limit of safety. Hence, of a one-per-cent solution only four syringefuls of 25 minims each can be used if it is liable to be all absorbed. This fact explains why less toxic substitutes are being sought for. Of such substitutes beta-eucain is still the one most generally used. With it a very good formula for infiltration anesthesia is the fol- lowing : Beta-eucain 0.1 gram ; Adrenalin chlorid (1 : 1,000) 8 drops; Normal saline solution 100.0 e.c. With such a solution, quite severe operations may be performed. The operation takes somewhat longer than with general anesthesia, because each layer of tissue must be anesthetized before it is cut into. But for patients with whom it is inadvisable to use general anesthesia, this method has proven both safe and, relatively speak- ing, pleasant. When the location of the painful area is such that it is im- practicable to reach all the nerves supplying it with one or two syringefuls of cocain, the other method, that of infiltrating the skin, is employed. Thus, when we wish to resect a rib in empy- ema, we prefer infiltration to simple nerve blocking. This method has been brought into logical and usable form by Schleich, whose formulae are: II III 0.1 0.01 0.025 0.005 0.2 0.2 PAIN 17 Solution I Cocain 0.2 Morphin 0.025 Sodium chlorid 0.2 Five-per-cent phenol . . 5 drops 5 drops 5 drops Water (sterile) 100.0 100.0 100.0 The solution selected is injected into (not under) the skin of the area to be incised. If the skin on the proximal side be thoroughly infiltrated first and the nerve trunks blocked, the injection of the rest of the area is not nearly so painful. The anesthesia appears in from three to ten minutes and remains usually some thirty minutes. Hence, one has time to perform any ordinary operation. Nerve trunks are also blocked in neuritis (e. g., sciatica) by injecting into or about the sheath of the nerve alcohol or other solution, some using the simple normal salt solution. The latter seems just as successful as the former. One selects for the place of puncture the point where the nerve is most easily reached prox- imal to the painful area. The skin is disinfected with hot water and soap, then alcohol and ether. The sterilized needle is then plunged into the sheath; should no blood escape from the butt of the needle, or no other disturbance result, the syringe is attached and the solution slowly injected. The needle is then withdrawn and the place covered with hot cloths for a few minutes, and sealed with collodion. Should blood escape, or the puncture prove too painful, the needle is withdrawn and inserted elsewhere. Of the normal salt solution one uses 80 to 120 c.c. at body temperature, or 10 to 20 c.c. at zero centigrade. Of the beta-cocain salt solution recommended by Schleich (cocain hydrochlor., 0.1; morphin hy- drochlor., — 0.02; sodium chlorid, 0.2; aqua. dest. ad 1,000) one uses 60 to 100 c.c. at body temperature. The alcohol is used at •seventy to eighty per cent strength, and 1 or 2 c.c. in quantity. Disastrous results have followed its use in sciatica, and it is there- fore to be used only when the other and less toxic solutions have proven unsuccessful. (Hecht, Journal A. M. A., Feb. 6, 1909.) To locate the sciatic nerve we can ' ' draw a line from the sacro- coccygeal joint to the postero-external border of the great trochan- ter; at the junction of the inner one third and the outer two thirds of this line is found the spine of the ischium. Placing the 18 SYMPTOMATIC THERAPEUTICS needle a thumb's breadth to the outer side of this spine, and pene- trating in a directly perpendicular line to a depth varying from 4 to 10 cm., we reach the sciatic nerve " (Hecht). When the nerve is touched the patient feels a sharp pain in the heel or low down in the back of the leg, and usually gives an involuntary jerk to the leg. In inserting the needle it is usually better to keep the stylet within the needle, withdrawing it from the point while penetrating the skin, but pushing it in advance of the point again as soon as the skin is passed, in order to prevent the sharp needle- point from injuring the underlying tissues. The needle should, of course, be 8 to 12 cm. long and the syringe contain at least 30 c.c. of the solution. The injections may be repeated in twenty-four to seventy-two hours, if needed. For these injections the patient must lie flat on his abdomen in as comfortable a position as possible, with his legs fully extended. A similar technic is, of course, used for neuralgia in other loca- tions, with the variations made necessary by the anatomy of the part. Magnesium sulphate and many other drugs have been used, but all without such general success as to render the procedure standard. We should mention in this connection the anesthesia produced by infiltrating the tissues of the anus and rectum by sterile water (Gant). This is a blocking of the nerve trunk by tension rather than by the chemical action of the solution upon the cells. Its success explains why extensive operations (such as herniotomy) are successfully performed after infiltrating the tissues to be in- cised with solutions too weak in their content of eucain to be ef- fective through their direct chemical action. In this category comes the use of 0.5-per-cent solution of quinin and urea, now so popular for infiltration anesthesia. Hence, it is possible for us to relieve pain by blocking the trans- mitting fibers, (a) by injecting simple sterile solutions in sufficient quantity to distend the tissues; (6) by rapid vibratory massage with an electrically driven apparatus; (c) by applying consid- erable heat or cold, and finally, (d) by injecting a drug of the tropin series for its chemical effect. For deadening the sensorium, morphin is the typical drug. Morphin is better than crude opium, because the local effects of the latter on the stomach and intestines are avoided, as well as the PAIN 19 secondary effects due to the presence of the other opium alkaloids. Morphin affects primarily the higher centers of the central nervous system by a slight primary stimulation followed by a depression, especially of the powers of perception. The effect on the medulla is more stimulant and less depressant, especially for the heart beat. The respiratory reflexes are, however, decidedly weakened, so that coughing is checked and the rate of respiration reduced. This removal of the influence of the hemispheres is sometimes desirable, and in nervous patients frequently the heart beats more steadily and the respiration is more normal after a dose of morphin than before. Its effect on the perception of pain alone is frequently demonstrated when patients accustomed to the drugs describe their sensations. They say, for instance, that the pain does not cease — they can feel it — but they can bear it. Morphin does not damage the heart muscle, and therefore can be used for quieting pain even in heart disorders. It is given hypodermically in £ to \ grain, ordinarily in the form of the sulphate. The effect appears in from ten to thirty minutes, and with patients unaccustomed to the drug leads to sleep. When given by the mouth, morphin is liable to cause nausea, and is slower of effect. To overcome this nausea (due to the secretion of morphin into the stomach), atropin is added in doses of jfe to -g-fo grain. This is done, also, even when the drug is given subcutaneously, because atropin acts as a check on the medullary effect of morphin, and thus prevents too great a stimulation of the inhibitory mechanism controlling the circu- latory and respiratory apparatus. Doses of morphin may be re- peated in from four to eight hours, but usually smaller doses than the initial dose are sufficient to keep up the effect. Technic op Hypodermic Medication The mention of the subcutaneous administration of morphin leads us to discuss at this point the technic of Hypodermic Medi- cation. There are three types of hypodermic syringes on the market: (1), all glass; (2), all metal; (3), glass and metal. The all-glass syringes are best because they can be the most thoroughly steril- ized. The difficulty in using them consists simply in their liability to break. The best all-glass syringe is probably that made by the 20 SYMPTOMATIC THERAPEUTICS Hahnhart Company, Zurich, Switzerland. A similar one, but made in pieces, is put out by Burroughs, Wellcome & Company, London. Only those all-metal syringes are valuable which have no rubber packing around the piston, and in which the piston is carefully ground to fit the barrel. The danger in the use of these is that they rust when they are not used every day. There are various types on the market, but in purchasing a syringe one should very carefully test the joints oneself. In the mixed type of syringe there is the constant trouble from the drying up of the packings, and one must expect his syringe to be useless if he is not using it frequently. No matter which type of syringe is pur- chased, it should be cleansed immediately after use, and the most satisfactory cleansing is probably that in which first water and then alcohol is run through the syringe several times. This not only cleanses the syringe, but also renders it less liable to rust. (Of course, alcohol shrinks the packings, consequently this is not very well adapted to the mixed type of syringe.) The needles may be had in either steel, platinum, or gold plate. The difficulty with the steel needle is that the lumen rusts shut. When one must inject corrosive material, such as mercury, it is best to have either the platinum or the gold needle. A needle should be cleansed in alcohol immediately after using, and when put back into its case a piece of wire should be left in the bore. This will prevent, as nearly as possible, its rusting shut. Just before using, the syringe, with the needles attached, should be thoroughly rinsed in hot water. One should draw up hot water into the syringe and expel it, repeating this several times before putting in the medicated solution. If this precaution be ob- served, practically no abscesses will be found from hypodermic medication. In this connection, it should be remembered that most hypodermic tablets are insoluble in alcohol, and therefore the pres- ence of a slight trace of alcohol in the syringe or in the needle will greatly hinder the solution. The injection may be subcutaneous, or intramuscular, or intra- venous. In the first case, the skin on some part of the body where there is considerable subcutaneous fat is pinched up between the thumb and forefinger of the left hand and the needle inserted into this fold parallel to the surface of the body. The contents of the syringe are slowly expelled underneath the skin and the needle PAIN 21 quickly withdrawn. The clean finger tip is placed over the point of injection until the tissues have taken up the fluid. Intramus- cular injection is usually made over the larger and coarser muscles. Thus the gluteal muscles are the favorites. In this case the needle should be plunged straight inward through the subcutaneous fat. Therefore the physician should carefully estimate the thickness of this fat in choosing his needles and making the injections. Intra- venous injections may be made in the manner of venesections by putting the ligature around the arm and pushing the loaded needle into one of the distended veins and allowing the fluid to flow in drop by drop after the ligature has been removed. Of course, in this latter case, the syringe should be pointed in the direction of the blood current. In all these injections the skin overlying the point of injection should be cleansed with hot water and soap, followed by alcohol, before the needle is brought into use. The effect of intravenous injection is seen almost immediately. That of intramuscular varies according to the absorbability of the drug used. Thus adrenalin chlorid will give a very prompt effect, while the gray oil of mercury or atoxyl, would not be seen for some hours. The subcutaneous injection, unless a vein happen to be pierced, is the slowest of the three. Should there be some pain accompanying the injection, a cloth wrung out in hot water should be applied for several minutes. It is important in using the syringe and needle to avoid forc- ing air into the tissues with the drug. In subcutaneous injections, where the needle is to be inserted already attached to the syringe, the air is removed by holding the syringe vertically, with the needle pointing upward, and pressing on the piston until drops of the solu- tion come out of the needle point. In intramuscular injections it is necessary to attach the syringe to the needle (which, of course, is already in the tissues) firmly, and then, by withdrawing the piston slightly, cause the air to bubble up through the solution to the piston end of the syringe, and finally, when pressing the piston home, to avoid driving the air back into the needle. In intra- venous injections the air should be removed as for subcutaneous ones, and the additional precaution taken of inserting the needle with the solution practically flowing from its point. 22 SYMPTOMATIC THERAPEUTICS Other Drugs The coal-tar derivatives are also very generally used to quiet pain. They are best adapted for the relief of neuralgias and head- aches — that is, pain of nervous origin. These drugs all depress the heart, and in heavy doses produce methemoglobin. Hence, they should be used with even greater caution than morphin, for, be- sides the habit-forming danger common to both, they are apt to lower very materially the resistance of the patient to the toxins of the underlying disease. Of the coal-tar products, phenacetin (acetphenetidin), antipyrin, and acetanilid are the ones generally chosen to quiet pain; the others of the series display more promi- nently the antiseptic and toxic effects. Of these, antipyrin is the most soluble, acetphenetidin the least so. The latter is also the least toxic. The dosage varies from 25 to 50 centigrams (0.025 — 0.5 = 3 to 10 grs.). In order to neutralize the depressant action of these drugs, when giving them for nerve pains, sodium bicarbonate is usually combined with them. The following, for instance, is a conventional combination for nerve sedation, especially headache: Acetanilid 0.25 (gr. iij) ; Camphor monobromated 0.15 (gr. ij) ; Sodium bicarbonate 0.10 (gr. jss.). Mix and make one tablet. One of these tablets might be given with safety every two hours for the ordinary patient, yet I have seen the coal-tar cyanosis ap- pear with two doses of a similar combination. This, of course, was due to the personal susceptibility ; but this is always to be watched for. Acetphenetidin, because of its lesser toxicity, is more often given alone than acetanilid for the purpose of stopping a headache. It is usually given in five-grain powders or tablets, to be repeated, if needed, in two hours. In this connection it should be noticed that the salicylates, the phenolates, the creosotes, and other coal-tar derivatives all have analgesic properties — a fact that makes them all the more useful in septic and rheumatic disorders accompanied by severe pain. To illustrate these principles, let us enumerate some of the con- ditions in which pain is a prominent symptom, and discuss its PAIN 23 treatment. Thus, in arteriosclerosis we often meet the retrosternal pain when the patient is active. The first part of the treatment is causal; the patient is put to bed and the strain on the arteries removed. Then, since the pains are due to spasm of the blood vessels, we can adopt the plan of releasing the spasm by the appli- cation of heat, and we order hot cloths (moist) applied — to be changed every three to five minutes. This usually is sufficient. If, at the beginning of our treatment, we should give T ^g- grain of nitroglycerin by the mouth or subcutaneously, we secure a quicker effect to the relaxing treatment, and the effect of the nitrite would be disappearing just about the time when that of the heat was beginning. Again, in severe pains of acute nephritis, we find local treat- ment extremely helpful. Ortner mentions as the first treatment re- vulsives applied to the lumbar region, that is, cups, leeches, or actual cautery to Petit 's triangle. The cupping is done once or twice a day, leeches are applied every other day, and the actual cautery usually only once. The ice bag is also recommended. The purpose of all this is to relieve the congestion in and about the kid- neys. This same result may be secured by venesection of the dorsal vein of the foot to the extent of ten ounces. Probably the majority of us would differ with Ortner and prefer to use drugs and relieve the pain by giving atropin d-j^-) and morphin (£) subcutane- ously. The lactate of calcium is a somewhat more causal treatment for the relief of this pain : ten grains four times a day. The atropin, however, relieves the pain by its local effect on the kid- ney and is, therefore, well worth trying. The pain of pleuro-pneumonia should be relieved by limiting the excursion of the ribs — that is, by bandaging the thorax tightly with adhesive plaster. If the pain still continues, morphin should be given. The pain of cancer of the stomach receives local treatment when we give bismuth subnitrate or tincture of belladonna. Usually, however, in this condition morphin is needed sooner or later to give relief. The pain of congestion of the liver is best relieved by produc- ing a local hyperemia. For this hot and cold fomentations, the thermophore, and similar measures may be employed. The pain of tuberculosis of the larynx can be relieved by the 24 SYMPTOMATIC THERAPEUTICS inhalation of ethereal oils. We use chiefly the oil of eucalyptus vaporized in water, because the steam of itself seems to have a sedative effect. If guaiacol and olive oil, in equal parts, be rubbed on the outside of the neck, their effect will also be analgesic. The pain of a bruise would be subjected first to the application of heat, and, if that did not succeed, to the subcutaneous injection of morphin. The pain of dysmenorrhea also demands a word, for our teach- ing has been that this is a symptom rather than a disease. But we should probably admit that Herman's contention (British Medical Journal for April 17, 1909) is correct when he maintains that there is a genuine dysmenorrhea which should be distin- guished from the pains at the menstrual season in cases of sys- temic weakness or of local pelvic disease. Real dysmenorrhea consists of morbidly painful uterine contractions accompanying menstruation. Such pains begin with the menstrual flow. From these, therefore, we must carefully distinguish the discomfort due to the pelvic congestion of the menstrual season — the sense of heaviness and weight in the pelvis. We must differentiate them also from the cramplike pain preceding the flow and usually at- tributed to ovarian disorders. Furthermore, we must remember that any nervous disorder is liable to be made worse by the strain of the menstrual season. When now we remember that only about one third of our women menstruate without pain, we realize that the family phy- sician must find a large share of his practice in the symptomatic or causal treatment of menstrual disorders. But, on the other hand, we should not be led thereby to magnify the condition. On the contrary, the psychical treatment that leads our patients to bear pain with equanimity and to focus their attention on the good points of their physiques rather than their weak ones, will do much toward eliminating their dysmenorrheas. Hence, although we should endeavor to learn the cause of the painful menstruation, this should be done in such a way that the woman's attention is not concentrated on the disorder. The emphasis should be on hygienic living rather than on local treatments or operative in- terference. If we can do this, we shall find that our patients will be the better and stronger for it. The positive indications call for either raising the nervous re- PAIN 25 sistance to pain and discomfort or decreasing the amount of nerv- ous strain endured by the patient. Thus, in some cases we need to prescribe tonics, out-of-door life, and hydrotherapy; in others, longer hours of sleep, more rational diet, less arduous employ- ment. Each patient's life must be studied in order to remove the factors for overstrain, and to add those making for health and vigor. For relief at the menstrual season the coal-tar analgesics are usually employed. It is best to employ them sparingly, both on account of the liability to habit formation and their tendency to free the patient from a feeling of necessity for improving her inter- menstrual regimen. Acetphenetidin may be given in five-grain tablets, or acetanilid (three grains) and sodium bicarbonate (two grains), combined to make a tablet or powder. With many pa- tients atropin in y^-grain doses will prove almost specific in giving relief. Whenever it does so, it should be chosen in prefer- ence to the coal-tar products. Morphin should be used only as a last resort, and then only in sufficient quantity to benumb the pain, not to put the patient to sleep. Membranous dysmenorrhea is proving to be a misnomer be- cause investigation is showing that many women who menstruate painlessly discharge the membrane in chunks. Hence, we should not immediately curette the uterus of such a patient unless we find other evidence of an endometritis that demands curettement. Probably the best treatment for genuine dysmenorrhea is dila- tion of the cervix. This frequently brings about a cure after the first trial. Sometimes it is necessary to repeat it once or twice. Better than dilation is pregnancy; but inasmuch as this is inap- plicable in a large percentage of our cases we must content our- selves with the palliative treatment. Thus, in general, we seek to use in each case the analgesic which has the least systemic effect, and only when that fails do we resort to morphin or other systemic narcotics. Finally, general anesthesia may be thought of as the symp- tomatic treatment of pain ; but since it is a distinct branch of the medical curriculum we treat it but cursorily here. In general, we may say that the members of the series of the hydrocarbons are all narcotic and are effective in proportion to their volatility. Practically, we use ether and chloroform for the more severe opera- 26 SYMPTOMATIC THERAPEUTICS tions and nitrous oxid or ethyl chlorid for the minor ones. When we wish to secure full relaxation of the patient, even if it be for a minor operation, such as hemorrhoidectomy or setting a broken bone, ether or chloroform is necessary. Ether is the less danger- ous to the heart, but the more irritant to the air passages. Hence, we prefer ether, even if it be slower and more irritant, for we can overcome the bad effects of these qualities by giving morphin (J) and atropin (y-J-y) one quarter hour before the administration of the anesthetic. It is best given by the drop method — just as chloro- form is given. We prefer the chloroform for relieving the pains of childbirth and those of accidents and emergencies where haste is essential. The administration of anesthetics is an art by itself, and should not be attempted without special instruction and an appren- ticeship. II. FEVER Probably the shortest definition of fever is that it is the reac- tion of the body to insult. By this we mean that the elevation in temperature may of itself be Nature's defense against injury; or, again, it may be only a by-product, so to speak, of that defense. This insult may be the absorption of foreign bodies or toxins — the bruising of flesh, the attack of microbes, or anything that inter- feres with the smooth running of the body's machinery. Thus, the fever due to the absorption of bruised tissue is simply a chemical result of the breaking up and washing out of the body of these waste products. Such a fever is harmless. But the fever due to the action of toxins on nerve centers is bad in that it is the index of the struggle between the toxins and our body cells. This theory may be contrasted with that of Avicenna (980- 1037), who said: " Febris est calor extraneus accensus in corde et procedens ab eo mediantibus spiritu et sanguine per arterias et venas in totem corpus, ' ' in that we look upon the fever as the effort of the body to free itself from the poison or condition, rather than (as he did) as the poison or condition itself. The physician's atti- tude is very different in the two cases : Avicenna would make direct effort to lower the temperature; we would try rather to free the body of the poison or material that caused the temperature to rise, and thus secure a return to normal by the removal of the cause of FEVER 27 the fever. (See McCallum in the Archives for Internal Medicine for January, 1909, and Sollmann's " Therapeutics," p. 350.) The increased temperature may be due either (1) to an increase in the combustion of the tissues — as in the case of intense muscular effort — or it may be due to (2) a blocking up of the channels through which the heat is normally dissipated. Thus, to cover the body with a coat of varnish would raise its temperature. To surround the body with a moist medium, warmer than the body, would also cause the temperature to rise. The reason is this: that since the glands of the skin dissipate much heat through perspira- tion we have a retention of heat leading to fever whenever the secreting glands cease to act. The two terms — fever and increased temperature — are not, however, exactly synonomous. But, like most words, they are not always used in their strict sense, and are therefore often used in- terchangeably. In general, fever always presents' an increase in temperature, but all increases in temperature are not fever. Fever is a pathological increase in temperature. But this word is often used still more technically — that is, because most of the infective and septic diseases have fever as the most prominent symptom, therefore the whole disease is often spoken of as the " fever." Strictly speaking, however, the fever is but one of the symptoms of the inflammation. Its treatment, therefore, is the treatment of a symptom and not of a disease itself. Fever of itself may or may not be dangerous, according to the condition and age of the patient. Thus the infant and child bear the increased temperature easily, while the white-haired grand- father would be in danger of death, simply because his body can no longer accommodate itself to such great changes. A robust man may bear with impunity a temperature which would exhaust all the strength of a feeble woman. Again, an alcoholic would be much sicker than his temperate neighbor with the same tempera- ture. Finally, we find personal idiosyncrasies which make our patient more or less resistant to the hyperpyrexia. In fever, the increased temperature is generally due to the in- creased formation of heat, the first of the causes mentioned above, and indicates an increase in the rate of tissue consumption or waste. Hence, in the treatment of fever we must decide whether we shall get rid of this high temperature by depressing the vital 28 SYMPTOMATIC THERAPEUTICS centers concerned in regulating heat production, or whether we shall simply increase the heat dissipation, and thus get rid of it before it injures the body. The weight of opinion now seems to be that it is unwise to check this heat production (i. e., depress the heat centers) except where we feel positive that it is injuring the patient, or where the cause is evidently so transient that the de- pression used to combat the temperature will not be sufficient to overcome the patient's resistance to the underlying disease. In making such a statement we must remember that it goes without saying that the doctor should always seek to rid the body of the cause of the increased temperature. For instance, if it be the in- vasion of germs, the physician strives to inhibit their growth; if it be the absorption of toxins from the bowels, he seeks to cleanse the bowels of their putrefying contents; if it be the absorption of iodoform from the dressings of a wound, to remove the dressing and apply a different sort; or if the cause be of the second type, such as an impermeable skin, to soak it and cleanse it in hot water until the glands become active, and so on. But in many cases we either cannot find the irritant or cannot remove it. In such cases, symptomatic treatment is indicated. But such an indication holds good only as a temporary meas- ure — until the cause is found and removed. In self-limited dis- eases too many physicians content themselves with stimulating the body of the patient to perform its normal functions — that is, with the correction of the symptoms due to the underlying disease, and do not make any active attack upon the cause of the trouble. This naturally is a hazardous procedure and should never be followed when the physician can do anything to discover and remove the cause. On the other hand, it is not wise to give one's whole attention to causal therapy and none to making the patient comfortable ; but rather the wise physician is the one who keeps both methods in mind. The easiest way of increasing the dissipation of heat is, for in- stance, by the application of cold water to the body. The most radical method of giving the cold bath is to dip the patient in a tub of cold water at about 60° P. This is a great shock to the system and can be endured only by robust people. On the capil- laries and glands of the skin it causes first a contraction, followed FEVER 29 shortly by an expansion, with an increased excretion of water vapor. This latter process, of course, rids the body of much heat energy. In case of typhoid fever, such a bath (called there the Brand bath) reduces the temperature from one to three degrees. In giving the bath, one should be careful to keep the patient in the Fig. 2. — Portable Bath Tub for the Sickroom. water only a minute or two, and should take pains to give a thor- ough rub immediately afterwards. The bath may be given accord- ing to the following method: The patient is lifted out of bed on a strong sheet held by two or more nurses, and let down into the water; the nurse strokes the patient gently with the palms of the hands while he is in the water. Then the patient is lifted out again and laid on a rubber blanket, dried off under flannel, and returned to bed. For those patients who cannot withstand the shock of these plunges into cold water, cold sponging may be used. In prepara- tion for this, flannel blankets are placed both above and below the patient. The water is made ready at 60° to 70° F. and kept stead- ily at that temperature by the addition of ice. Only one part of the body is wet at a time, and this is dried off with towels before proceeding to the next part. To be effective, the sponging must be slow and steady — the whole operation demanding an hour for completion. Besides reducing the temperature, this sponging seems to stimulate the mind and give the patient a refreshing feeling of well-being. In cases of inflammation of the brain and spinal cord, it is bet- ter to apply the cold locally. Thus, ice packs are placed about the head and along the spine. The packs are best made by filling 30 SYMPTOMATIC THERAPEUTICS large-mouthed rubber bags with cracked ice. These bags are made in special shapes to fit the various parts of the body. The rubber should not come in contact with the skin, but should be covered with a towel or napkin. The water from the melted ice should be removed as soon as it is Fig. 3. — Ice Bag for Spine. Fig. 4. — Flat Ice Bag. formed, in order to keep the temperature of the ice bag uniform. When the rubber bags are not available, ice packs or poultices may be made by mixing sawdust and cracked ice and wrapping the mixture in oilcloth and towels. This local application of cold is also used in heart disease and peritonitis, and, in general, wherever it is desired to inhibit the processes of localized inflam- mation. Another local application of cold for dissipating heat and causing local vascular contraction _, Fig. 5. — Leiter Coil for Flat Sur may be made with the cold-water faces, such as the Chest. Fig. 6. — Leiter Coil for the Head. (Leiter) coil. This is made by winding four or five yards of J-inch tubing into shape to fit the part of the body affected. One end FEVER 31 is placed in a vessel of ice water above the level of the patient's body, and the other end in a vessel on the floor and the water passed through the tube by siphon action. When the upper vessel is empty, it is replaced by the lower one ; and the process continued without needing additional water. The only necessity is the ad- dition of fresh ice. Sometimes a high temperature may be reduced by setting up vigorous diaphoresis — either by the use of -J grain (0.02 gm.) of pilocarpin hypodermically or by a hot pack. The latter is made by placing a rubber blanket both above and below the patient and then tucking in about the patient a sheet wrung out of hot water. This sheet needs to be renewed every three to five minutes, and should be renewed without exposing the patient to the cold air of the room. This is accomplished by slipping the fresh sheet in under the cooled one and the overlying flannel blanket. Such an application of heat must be kept up for an hour to set up sufficient diaphoresis to accomplish results worth while. Needless to say, the indications for using the sweating pack for reducing the tempera- ture in fever are rare. It is indicated rather in acute intoxications, collapse conditions, etc. The second method of reducing temperature is by preventing the formation of heat — that is, by depressing the " heat centers." This depression is accomplished chiefly by drugs, and of these the coal-tar antipyretics hold the first rank. They act largely by the lessening of heat production, although with some there is a flushing of the skin leading to an increased dissipation. Most of these drugs are plasmodial poisons, and therefore decrease the rapidity of metabolic processes (i.e., the production of heat), but their first and most noticeable effects are the depression of the cen- tral nervous system. The heart is also depressed and the blood it- self attacked. Hence, these drugs are to be used with caution, and rarely in cases where there is heart weakness or danger of collapse. Thus, to give them in pneumonia, typhoid fever, and diphtheria, where a fatal issue is liable to occur because of toxemia (i. e., of the depression of the nerve centers by the toxins of the disease themselves), would be unwise. They are best adapted for use in short and ephemeral fevers, where there is little danger of a long and prostrating confinement. Of the coal-tar antipyretics, the best and least toxic seems to be 32 SYMPTOMATIC THERAPEUTICS phenaeetin (acetphenetidin) . This may be used in doses from 0.3 to 1 gm. (5 to 15 grains), as a powder or in capsules. It is so in- soluble that it does not work up well in liquid preparations. Next comes acetanilid, more toxic but more soluble. With this a dose of 0.5 gm. (7-J gr.) should rarely be exceeded. In fact, it is better to give acetanilid with some antagonistic drug to overcome its depressant action. Thus, a dose made up of: Acetanilid 0.2 gm. (3 gr.) ; Sodium bicarbonate 0.2 gm. (3 gr.) ; Camphor monobromated 0.1 gm. (1J gr.), makes a relatively efficient and safe combination for quieting the nervousness and reducing the temperature of a fever patient. Antipyrin is the third important antipyretic, recommended by its solubility, but possessed of greater toxicity than the other two. Because of its solubility, its action is more rapid. The dose varies from 0.25 to 1 gm. (3 to 15 gr.). Quinin has an analogous action, but its toxic effect on muscle tissue makes it unsafe as an antipyretic. In peritonitis and phthisis, good effects may be obtained from an inunction with liquid guaiacol. Fifteen drops of this with an equal amount of olive oil rubbed into the abdomen reduce the tem- perature quite markedly. Its effect is also analgesic. Hence, it is very useful where we wish to save the stomach from distressing drugs. Since the guaiacol is so readily absorbed, and since it is so antiseptic, it should always be thought of in septicemic condi- tions, when a reduction of the temperature is desirable. The vegetable remedies, aconite and gelseminum, are so slow and unreliable that they have given place to the above prepara- tions in fever. They are apparently just as dangerous, if not more so, than the coal-tar derivatives. In other words, they offer no advantage over these, and may therefore be omitted from the armamentarium. With some physicians one drop of the tincture of aconite given hourly at the beginning of acute fevers seems to have proven of value — probably more because of its relaxing effect on the nervous mechanism than because of any temperature reduction obtained. FEVER 33 Calcium sulphid (Calx sulphurata) has been put forward by some American missionaries in Turkey (Van) as a cure for typhus, smallpox, scarlatina, and similar fevers. The profession has used this drug spasmodically for years, but it seems never to have been able to obtain a permanent place in our armamentarium. Its dose is 1 grain (0.065 gram) three to six times a day, until the system is saturated — as is shown by the odor of hydrogen sulphid exuding from skin and breath. One should be careful to watch for en- teritis when using the drug, because of its tendency to irritate the bowel mucosa. Probably some of its good effects are due to the calcium rather than the sulphid — since lime is proving to have a decided influence on the condition of the body fluids, as is shown by the work of Bell and Hick in Liverpool (British Medical Journal, February 23, 1909). The question of diet in fever is also an important one. The history of medicine shows periods when starvation was urged in all cases, and, again, other periods of time when high feeding was in vogue. The ideal is, of course, to give the patient the greatest amount of nourishment consistent with obtaining a good influence on the course of the disease. For if feeding the patient with a strong diet raises his temperature or prolongs the course of his fever, it would be better to feed more lightly. Therefore, in fevers having their seat in the intestinal tract it is generally wise to use nonfermenting, nonirritating food, and that in only such a quan- tity as shall be easily cared for by the digestive glands. / Tissue consumption in fever is greater than in health. Hence, if we endeavor to prevent the loss of weight and maintain our patients in equilibrium, we must give much more than the 33 cal- ories of heat energy per kilogram of body weight that is required for the healthy adult at rest. In fact, the amount needs to be be- tween 50 and 60 calories per kilo. For typhoid fever Shaffer and Coleman have shown, that by giving 60 to 90 calories of food energy daily, consisting chiefly of carbohydrates, the patient's equilibrium can be maintained (Archives for Internal Medicine, December 15, 1909). Whether the course of the disease is not lengthened thereby and the net gain therefore very small remains to be seen. A good rule to follow is to give all the food the patient can com- fortably take and to make it consist chiefly of the fuel-giving foods 34 SYMPTOMATIC THERAPEUTICS in an easily digested form. Thus we prefer to give milk, cream, eggs, oven-dried toast (or triscuit) rather than beef extracts and broths. We give the food at three-hour intervals, and thus avoid weighing down the stomach with either quantity or variety. III. ITCHING Itching may be due to some constitutional disorder, such as diabetes mellitus or jaundice, or it may be due to local irritation, such as the presence of living parasites or chemical irritants. Hence, one should always try to ascertain its cause, even if its tem- porary relief be easy. In order to epitomize the possible causes of itching, I give here the following table from Bulkley. The causes are : 1. External 2. Idiopathic Parasitic i TMicrobic -j Vegetable [Animal f Mechanical Miscellaneous J Toxic [Climatic f Senile 1 Neurotic [ Autotoxic 3. Constitutional J fReflex ^Functional f Acute 1 Chronic I Dermato-pathologic Even symptomatic treatment would necessitate a differential diagnosis between the external and constitutional causes, because there are two possible lines of treatment, namely: (a) local and (b) internal. Local treatment means the soothing of irritated nerves, and should therefore be employed only when the sensory nerves in the skin are really irritated. On the other hand, internal treatment, which means a depression of the nerve centers to pre- vent reflexes and the transmission of the uncomfortable sensation, should be employed only when these reflexes are exaggerated or the psyche is abnormally excited. We would repeat, then, that symptomatic treatment cannot be successfully followed out until some conclusion as to the cause of the trouble has been reached. ITCHING 35 The most frequent form of itching is that due to the presence of parasites, and here causal treatment can be successfully com- bined with the symptomatic. Thus, an ointment that will soften the epidermis and kill the parasites can also soothe the irritated nerves. In fact, the three requirements of any local application for itching due to the presence of parasites would be : (a) Ability to penetrate (or soften), the epidermis; (6) Ability to kill the parasite and its ova or larvae; and (c) Ability to quiet the nerve irritation. Such local treatment means practically the application of an ointment or of an alcoholic or glycerin solution. When the skin is dry and scaly, the ointment, excluding as it does the air, is the usual choice; when the skin is moist or greasy, the alcohol or glycerin does better. The base of an ointment, to penetrate the skin, should be wool fat (adeps lanae), and where this is too fluid, paraffin and wax may be added. Of course, the drug chosen for the different parasites varies. Thus, for scabies, one usually prefers either mercury or sulphur; for pediculi, mercury or naphthol (epicarine) ; for vegetable organisms (e.g., barber's itch), thymol or guaiacol. The best drug for softening the epi- dermis is salicylic acid. The most sedative drugs are menthol, camphor, atropin, phenol, etc. One then might write for ring- worm or other eruption due to a vegetable organism the following prescription : Acidi salicylici 5.0 grams. Mentholis 2.0 " Adipis lanse q. s. ad 30.0 ' ' M. f. ung. Sig. Rub into eruption and bandage overnight. The pharmacopeial sulphur ointment that we might use for scabies consists of fifteen per cent sulphur in eighty-five per cent of benzoinated lard. The sulphur softens the epidermis as well as kills the louse, while the benzoin keeps the lard from becoming rancid. The mercurial ointment that we might use for the same pur- pose contains about fifty per cent of mercury and is prepared as follows : 36 SYMPTOMATIC THERAPEUTICS Mercury 500.0 grams. Oleate of mercury 20.0 ' ' Prepared suet 230.0 " Benzoinated lard 250.0 ' ' 1,000.0 " When this is weakened by the addition of a third part of pe- trolatum, we have the blue ointment (ung. hydrargyri dilutum), which is therefore about thirty per cent of mercury. It is more often used than the stronger ointment given above. A rather more modern mercurial ointment for parasitic dis- orders is the ung. hydrargyri ammoniati, made up as follows : Ammoniated mercury 10.0 grams. White petrolatum 50.0 " Hydrous wool fat 40.0 " 100.0 " In this we have a better base and a more active form of the mer- cury. Hence, the fact that it contains less mercury does not make it any less useful than the other mercurial ointments. Of the coal-tar series it is naphthol that seems most successful as a parasiticide and sedative. Of the naphthol derivatives epicarine is now enjoying the greatest popularity. One could pre- scribe it in the formula last given by substituting it for ammoni- ated mercury. This has the advantage of being somewhat more cleanly than the mercurials. Besides the above we find among the standard ointments the following, called variously the Itch Ointment of Hebra, Wilkin- son's salve, and the ung. sulphuris compositum, N. F. : * Calcium carbonate 10.0 grams. Sublimed sulphur 15.0 ' ' Oil of cade 15.0 " Soft soap 30.0 " Lard 30.0 " This is more irritant than the others and would not do for delicate skins or sensitive people. 1 The abbreviations N. F. and U. S. P. refer to the National Formulary and United States Pharmacopeia respectively. ITCHING 37 Still one other formula deserves our attention. This is the ung. resorcini co., N. F. : Resorcinol 6.0 grams. Zinc oxid 6.0 " Bismuth subnitrate 6.0 " Oil of cade 12.0 " Paraffin 10.0 " Petrolatum 25.0 " Lanolin (wool fat) 35.0 " Here we have the sedative effects of zinc oxid and bismuth sub- nitrate, the antiseptic effects of resorcinol, and the stimulant effects of the oil of cade. It is, therefore, a general ointment of weaker parasitical power, but more sedative than the sulphur or mercury. Its power of penetrating the stratum corneum is also less. It is, however, an ointment which, with slight variations, is being sold under different copyrighted names directly to the public, and for all sorts of skin diseases. When we wish to avoid the grease and dirt of ointments, we make use of alcoholic preparations because they are quickly ab- sorbed and leave no telltale evidences on the skin. We use them, therefore, in the disorders due to less resistant parasites and where the patients are in position to apply them frequently. A sample prescription is the following : Thymolis 5.0 grams. Methylis salicylatis 10.0 ' ' Phenolis 5.0 " Alcoholis Glycerini aa 40.0 ' ' Sig. Apply every hour until relieved. In the types of itching due to mechanical, chemical, or thermal irritants there is often a watery exudate. This makes desirable another form of treatment; that is, something that will keep the surface dry and at the same time soothe irritated nerve ends. For this a powder is desirable. The base of such powders is usually absorbent enough to take up the excess moisture and firm enough 38 SYMPTOMATIC THERAPEUTICS to form a protecting crust when combined with such moisture. For sedative purposes zinc oxid is the favorite addition, because it is both astringent and sedative. For antiseptic purposes a great variety of drugs are in use, as iodoform, bismuth subgallate, ace- tanilid, boric acid (very weak), the camphors, etc. For instance, a powder made up as follows would be both seda- tive and antiseptic: Acidi salicylici 10.0 grams. Camphorag 5.0 " Amyli 40.0 " Talci purificati 45.0 i i Most of the so-called talcum powders on the general market de- pend upon boric acid for their antiseptic qualities. Hence, they are too weak for our use, and, besides, are usually not sterile when compounded. For special purposes we should make prescriptions for suitable powders rather than try to have a stock powder for all purposes. Thus, for the condylomata lata of syphilis we should need the pres- ence of calomel, and we might write for the following powder: Hydrargyri chloridi mitis 20.0 grams. Acetanilidi 20.0 " Amyli 30.0 " Talci purificati 30.0 " Sig. Dusting powder for condylomata. For the distress attendant upon ivy poisoning, we might pre- scribe : Zinci oxidi 20.0 grams. Acidi tannici 10.0 ' ' Mentholis 5.0 " Talci purificati 65.0 " Sig. Dusting powder for weeping eczema. And, in general, we should endeavor to use the drug that will give the special sort of relief called for. We might even find occa- ITCHING 39 sion to employ the soluble antiseptic powder of the National For- mulary, which is made up as follows : Salicylic acid Phenol (U. S. P.) ... Eucalyptol (U. S. P.) Menthol (U. S. P.) . Thymol (U. S. P.) Zinc sulf Boric acid, in impalpable powder 5.0 grams. 1.0 1.0 1.0 1.0 125.0 866.0 This, as can be seen, would be astringent, antiseptic, and seda- tive to the surface applied, and if mixed with equal parts of talc or starch would do for dusting over wounds and abrasions. Where the skin is not broken it could be used in full strength. The relief of the idiopathic itching, due as it is to senile and other tissue changes, is more difficult because the causes are not so easily removed. Hence, while we can quite easily afford tem- porary relief, the treatment must be kept up so long and so con- tinuously that many patients grow tired and go from doctor to doctor and from drug store to healer, always with the same un- satisfactory result. These alterations in the skin can perhaps best be influenced by the internal or hypodermic use of arsenic com- bined with massage. The diet and exercise of the patients need also to be carefully regulated, to the end that all these factors work toward a more active nutrition of the skin through an in- creased flow of blood as well as increased activity of the cutaneous glands. The local relief is obtained usually by means of weak ointments — ointments just strong enough to soothe the tissues, but not as strong as would be needed for parasiticidal action as was needed in the ointments we have been describing. The base is best made of wool fat and the active ingredients of thymol and menthol. Some- times it is necessary to add carbolic acid and similar more powerful drugs, but they are liable to do quite as much injury as good. In such cases the unguentum resorcini compositum, N. F., given above, affords a good general formula. For the ordinary cases the local application of the following should be sufficient for temporary relief : 40 SYMPTOMATIC THERAPEUTICS Bismuth subnitrate 5.0 grams. Thymol .'. 3.0 Menthol 5.0 Zinc oxid 10.0 Wool fat 40.0 White petrolatum sufficient to make . . . 100.0 Perhaps the most troublesome form of senile itching is the pruritus vulvae vel ani. For this one needs to use more stimulant applications than elsewhere, although in many cases the formula just given would prove sufficient. Here the addition of tincture of belladonna or atropin will, often afford the element of relief, lacking in the more locally acting ingredients. One might even use an oil compounded somewhat as follows : Ung. belladonnas (U. S. P.) 15.0 grams. Olei gaultherias 5.0 ' ' Glycerini 10.0 " Olei olivas 10.0 " Sig. Apply with finger or cotton only as needed for relief. In the neurotic type of itching it is the systemic treatment upon which we must depend for effect. Here the bromids, to reduce the reflex irritability, will be most often called for. In addition, of course, the causes of nervous excitement to be found in life and environment must be removed (causal treatment). For temporary relief hot baths, massage, oil inunctions, etc., will render much better service than the topical application of ointments. To par- ticularize: The bromids would be given in doses of fifteen grains, three times a day, in dilute solution, thus: ^ Sodii bromidi 20.0 grams. Tct. belladonnas 10.0 " Glycerini 40.0 " Aquas destill q. s. ad 100.0 " Sig. One teaspoonful in a half glass of water, three times a day. We would prescribe the hot baths at a temperature of 100° to 110° for fifteen minutes every day for three or four days, then INSOMNIA 41 gradually decrease their frequency. Each should be followed by a friction rub and rest in bed for an hour or two. Sometimes the hot-air cabinet, or the electric-light cabinet, on alternate days, continued until the forehead has perspired for at least eight minutes, and followed by gentle friction, would prove even more effective than the tub bath. It should be followed by sponging in cool water and rest in bed, as with the tub bath. When we discuss the constitutional causes, we should not for- get to mention the diseases of which itching is a direct symptom. Thus it may be the only symptom vigorous enough to call the patient's attention to his condition in diabetes mellitus. Itching also usually accompanies jaundice. Lead poisoning, alcoholism, and gout are accompanied by itching. Various nervous diseases, particularly lesions of the cord, are accompanied by itching, and formication is a symptom of cocain poisoning and pelvic disturb- ances, as well as of the other diseases just enumerated. Hence, in these troubles all that we need to do is offer temporary relief and depend for the cure upon the removal of the underlying lesion. For this purpose the application of camphor water, witch hazel, and similar mild sedative astringents may prove entirely sufficient. These aqueous solutions require frequent application, and where that is impracticable it is wise to prescribe a mild ointment like the following : ^ Thymolis Mentholis Phenolis aa 2.0 grams. Paraffini 10.0 " Adipis lange q. s. ad 30.0 ' ' In autotoxemia itching is frequently a vigorous symptom. Here active catharsis, sweat baths, and diet constitute the causal treatment. The symptomatic is practically that just outlined for the other forms of constitutional disease. IV. INSOMNIA Sleeplessness may find its cause in the (1) pain the patient is suffering from in some intracranial disease or lesion, (2) in the 42 SYMPTOMATIC THERAPEUTICS lack of need of sleep, (3) in some psychic disturbance, or (4) in a general nervous exaltation. Thus, after an accident or injury the patient does not sleep because the pain of the wound prevents his mind from reaching the stage of quiet necessary for sleep. Again, if one overslept the preceding night, or has a nap in the afternoon, one is hardly apt to fall easily into slumber at night. Similarly, a patient on the sick bed who dozes much during the day is apt to have wakeful nights irrespective of his being com- fortable and contented in every other respect. Again, mania or other psychic disturbance has what is perhaps its most charac- teristic and distressing symptom in the inability of the patient to sleep. Not until the sleeplessness is conquered can the physician in charge hope to treat the underlying causes. And even when there is no specific mental disturbance, there may be such an exuberance of spirits, such a joy of living present, that the patient cannot sleep. Physiologically, the condition of sleep is one of relative cerebral anemia. Whether or not the individual neurones are out of con- tact with each other during sleep may still remain an unsettled theory, as far as our methods of treatment are concerned, because the anemia is sufficient to explain the phenomena of sleep and is also sufficient as a goal toward which to aim. Considered physiologically, as distinguished from the clinical study mentioned above, the causes of insomnia may be mentioned as follows: 1. Disturbance of the nerve reflexes. (a) From within, as from intense thought or excitement. (b) From without, as from noises, bright lights, disturb- ing odors, etc. 2. Congestion of the brain from some disturbance of the cir- culation. 3. Intracranial pressure, as from a tumor, or hydrocephalus, or a disturbance of the equilibrium of the cerebrospinal fluid. * Granting the above analysis to be approximately correct, the aim of our therapy would then be : 1. To put the mind out of contact with the outside world. 2. To reduce the amount of blood circulating in the brain. 3. To cause the body's vegetative machinery to run smoothly. INSOMNIA 43 The first of these could be obtained by making the sick-room quiet and dark, preventing unnecessary disturbance from passers- by, and the entrance of the odors from the kitchen, etc. The sec- ond is sometimes brought about by such a simple procedure as giving the patient a light lunch ; the consequent gastric hyperemia is naturally accompanied by a corresponding, anemia of the brain. A similar effect is sometimes obtained by giving a hot foot bath. The third requirement calls for a regulation of the respiration, circulation, digestion, and excretion of the patient. For it goes without saying that sound sleep is impossible if the body's machin- ery goes by fits and jerks. The treatment above outlined would in a general way be spoken of as etiologic, but it is nevertheless so schematic as to be con- sidered somewhat symptomatic. The real symptomatic treatment of insomnia, however, simply goes to work to depress the whole upper part of the central nervous system. An ideal drug would depress the higher centers without affecting the lower. Hence, the ideal hypnotic is a drug that shows its effect on the nervous sys- tem, beginning with the higher and working downward toward the lower functions. In other words, thought, will, and judgment are rendered difficult and slow, while the spinal reflexes and the breath- ing and the cardiac action are hardly touched by such hypnotics. The standard hypnotic, because it affects the nervous system from above downward, still remains chloral hydrate, although con- stant effort is being made to improve it so as to secure the hypnosis without endangering the heart or the vital nerve centers. Chloral should be given in doses of 1 to 3 gm. (15 to 45 gr.) in dilute solu- tion. It is best given an hour or two before bedtime, and the vehicle should be chosen for its ability to overcome the nauseating effects of the drug. Hot milk, the digestive mixtures, and even water, are useful for the solution. A prescription might be made up as follows: ^ Chlorali hydrati 5.0 grams. Ext. fl. cascaras sag 1.0 " Tct. gentian co 5.0 " Glycerini 25.0 " Aquae 15.0 " Sig. One dessertspoonful in water two hours before bedtime. 44 SYMPTOMATIC THERAPEUTICS It may be given by the rectum, but is irritant to the mucosa (hence, it must be in very dilute solution), and should be in slightly greater dosage than when given per os. The dose should not be repeated within two hours at least. When the lower centers are the seat of some excitement — when general nervousness is the cause of the insomnia — sodium or potas- sium bromid is a better drug than chloral. This should be given in similar dosage and in similar form to the chloral. This, for in- stance, is the drug to choose in the insomnia of heart disease. Hot milk also offers a good vehicle for the bromids. The sodium salt should be used unless one wishes to secure the katabolic effect of the potassium ion. It should always be remembered that long-con- tinued use of bromids may produce bromism, a condition charac- terized by skin eruptions and a foul breath. The synthetic hypnotics, planned to take the place of chloral, follow apparently one of three lines : the line of effect produced by the use of urea, that of the ethyl derivatives, or, finally, that of chloral. Of the first group veronal is the best example. This is given in capsules or hot milk. The dose varies from 0.3 to 1 gm. (5 to 15 gr.). The drug seems to be fairly effective. Of the second group trional offers the best results. This is usually given as a powder in a dosage of 1 gm. (15 gr.). Toxic effects have been met with, but they are rare. Of the third group dormiol may be used as an example. This is a combination of chloral and amylene hydrate. It is not pleasant to take and is therefore given in syrup. Fifteen cubic centimeters (J oz.) of a ten-per-cent solution should be used. Another useful hypnotic is tromural. This represents an effort to combine the effects of valerian, bromides, and urea. The drug is therefore best adapted to hysterical types of insomnia. It is put out in five-grain tablets, which should be swallowed whole. If the patient cannot take a tablet, the drug should be given in a hot solution. Ten grains (0.6 gm.) seems to be the minimum effective dose for hypnosis. Chloretone is an acetone chloroform and seems effective in cases of simple nervousness. One gram (15 gr.) is necessary for effect. Hyoscin may be used hypodermically Cr^ to -gV gr. — 0.001 to 0.002 gm. — of the hydrobromid) for cases of mania and similar CONSTIPATION 45 troubles. It is somewhat uncertain in its effects, but when com- bined with morphin is quite uniform in quieting the patient. This combination should be used cautiously when there is any lesion of the nervous apparatus controlling respiration, because even in the normal individual the rate of respiration is sometimes reduced by it even to five or six in the minute. Its special indication, there- fore, appears in cases of general nervousness, such as those follow- ing emotional shock and worry. The effect of one dose of \ grain of morphin and yjhj- grain of hyoscin may last from four to eight hours. In every case of insomnia much help is to be obtained from mental suggestion and the quieting influence of the physician's re- assuring words and acts. If the physician show that he is sure of himself and his methods, that he is in command of the situation, the amount of depressing drugs needed will be greatly reduced. "With these patients, therefore, the physician should never be brusque or sharp. He must take the time to sit down by his pa- tient and by his very quietness and placidity influence the patient toward self-control. Sometimes such influence is helped by light massage ; probably as much by the touch of a sympathetic hand as by the mechanical effect of the stroking movement. V. CONSTIPATION Constipation is such a general complaint among our patients that it is worth while to spend a moment in investigating its char- acter and causation. Since we find it more prevalent among the leisured classes than among those who lead an active out-of-door life, we must conclude that the cause of the trouble lies in the habits of life rather than in inherent weaknesses. For the poor, those who eat coarse foods and who work long hours, are most subject to disorders due to extraneous influences, and yet suffer less from constipation than their wealthier neighbors. Indeed, we reach a similar conclusion when we look at the matter from the a priori standpoint, for we know that our bodies are what they are because they have proven to be the most fit to meet the conditions of life imposed upon them by our environment; that is, our bodies have been slowly following the changes in environment. Now, our en- vironment has greatly changed in the last millennium, for whereas 46 SYMPTOMATIC THERAPEUTICS our ancestors in the forests of Europe lived in rude huts, with little or no protection against the changes of weather, and with the roughest of food — lived a life that compelled them to be very active and rugged — we live in overheated houses, are protected from every extra exertion, and eat foods that are not only well masticated for us, but are also partly predigested. Hence, where our ancestors needed long intestines to work over and store up quantities of tough and weakly nutritious food, we need hardly any more than is sufficient to absorb the highly concentrated nour- ishment that is put within them. Moreover, our ancestors ate at long intervals and great quantities; we, however, eat frequently, though, alas ! often also in too great quantity. The extra room for storage is not needed in our mode of life. But this extra room renders the excretion of the unused portion of our food material slower and more difficult, both because of the lack of stimulus which was found in the old days in the rough nature of the food ingested, and also because of the unnecessary distance through which the waste portion must pass. The excitation of the digestive fluids by the reflexes from the act of mastication is also lacking, because we do not masticate our food as our ancestors had to do, and the exhortation to such mastication of food that almost melts in the mouth presents such an illogical proposition that it is rarely heeded. The conditions found in cases of constipation may be summar- ized, for the sake of convenience, in three classes, viz.: (1) spasm, (2) paralysis, and (3) atony. Sometimes we find that normal defecation is prevented by a nervous contraction of the intestinal walls so great as to prevent the natural propulsion onward of the food masses. This may be due to reflexes from some ulcer or abraded or inflamed surface either in the mucosa of the intestine or in the serosa of .the peri- toneum, or it may be due to a general nervous exaltation. At any rate, the condition is one wherein the nerve plexuses of the intes- tinal wall are in a state of tonic spasm — a spasm that must be broken up if normal peristalsis is to result. We find such a spasm in case of pericolitis, hernia incarcerata, prolapse of the bowel, intussusception, etc. Hence, the search for the cause must consider many and varied possibilities. The second type is quite the opposite, for here there is a lack CONSTIPATION 47 of " nerve tone." There is not the normal response of peristalsis to the stimuli given by the presence of food and bowel secretions. This may be due to a general nervous flaccidity or to a relaxation of blood vessels and musculature in the splanchnic area. This is the type found among sedentary people and those who eat much and exercise little. The third type is found among invalids and weaklings. It is a condition of weakness on the part of the muscle rather than of the nerves. It may result from the paralysis of the in- testinal tract, or from the use of predigested foods, or in any way that leads to idleness or nonuse of the intestinal muscles and glands. From the above, it is easily seen that the causal treatment of chronic constipation calls for a building up of the musculature of the whole abdominal area, both of the muscles of the abdominal walls and those of the intestines and the walls of the blood vessels also. This means, of course, the increased use of these muscles either by means of special exercises or by massage. The exercises best adapted to this are the bending exercises detailed in books on medical gynecology and similar works. The most important move- ments are: (1) Lying on the back and raising the legs to the ver- tical, both singly and together; (2) standing and bending forward and touching the floor with the finger tips while both knees are kept stiff, and then bending backward with the arms over the head; (3) standing with the hands on the hips and twisting the shoulders to an angle with the hips; (4) standing between two chairs and ' ' dipping ' ' with the hands on the backs and then rais- ing oneself until the arms are straight again; (5) chinning oneself by pulling oneself up to a door lintel or other crossbar. Besides working on the musculature in the above way, one should seek to develop normal peristalsis by the use of appropriate foods, selected drugs, and externally by massage. The foods best adapted to stimulating peristalsis are the bulky vegetable foods. For instance, a colleague of mine is very partial to popcorn and sweet potatoes for this purpose. Cauliflower, lettuce, corn on the cob, peas, beans, cabbage, etc., may all be used for the same pur- pose. For similar reasons cooked fruits and sauces are helpful in that they afford some chemical stimulus to the peristalsis. Of these, apples and prunes seem to have the best reputation. 5 48 SYMPTOMATIC THERAPEUTICS Externally, also, one can accomplish much by massaging the abdomen. One generally uses heavy pressure with the flat hand — the one supporting the other — and moves his hands in the direc- tion of the hands of a clock, considering the abdomen as the clock face, beginning at the caecum and following the course of the colon. Fig. 7. — Massage of the Colon for Constipation. This should be done in the morning in order that it may conform to the normal time of defecation. The patient, of course, lies on his back on a rather firm couch or table. Sometimes this massage may be done by oneself by employing a heavy ball or other round object. Thus, one can get a six-pound cannon ball and cover it with a flannel cover in order not to chill or irritate the skin, and roll it about the abdomen in the same way that the massage is given. Among the drugs that promote the evacuation of the bowels we observe two general types : those that serve for temporary use and those adapted to chronic cases. Thus, in the first class we find calomel, mineral salts, and castor oil. In the second class we find cascara, ox gall, colocynth, phenolphthalein, etc. Prom the first class we select calomel when there is fermentation or putrefaction present, or when we seek to put the emphasis of our work on the CONSTIPATION 49 upper part of the bowel. We can use castor oil when we desire a sweeping out, as it were, of the upper bowel, without any stimu- lation of secretion or other glandular action, because castor oil excites peristalsis in the small intestine by means of its chemical irritation. Ox gall sets up an active peristalsis when injected into the colon. It seems to have no peristaltic effect on the small bowel. The mineral salts are best used when it is desired to flush the bowel and secure a watery stool. They effect the result both by means of chemical irritation and by the withdrawal of fluid from the tissues by endosmosis. The most effective of the cathartic salts is sodium sulphate (Glauber's salts). It has also the most dis- agreeable taste. Magnesium sulphate (Epsom salts) is changed into sodium sulphate by the action of the contents of the bowel. Consequently, its action is probably that of the sodium sulphate. But since its taste is pleasanter it is usually preferred to the lat- ter. Rochelle salts (potassii et sodii tartras) is slightly pleasanter to take, but rather weak in its action. All salts are most effective when given in concentrated (i. e., hypertonic) solution, though, of course, such concentration makes them more bitter to the taste. This bad taste is sometimes alleviated by giving the salt dissolved in a very small quantity of hot water and following it up immedi- ately with a bit of syrup, glycerin, or similar pleasant-tasting sub- stance. For immediate catharsis these salts are most effective when given on an empty stomach. The dosage of all of them ranges upward from one half ounce for the adult. These salts form the basis of most of the cathartic mineral waters. Hence, mineral waters are frequently nothing more than cathartic salts prepared in a pleasanter form than that of the ordi- nary artificial salt. For instance, the Carlsbad Sprudel spring water shows the following composition (in grains in the liter) : Sodium chlorid 15.45 Sodium carbonate 20.415 Sodium sulphate 35.58 Calcium carbonate 4.455 with traces of other salts of strontium, iron, manganese, silica, etc. Another, an American water, the Veronica, shows the following composition (in parts per million) : 50 SYMPTOMATIC THERAPEUTICS Ammonium chlorid 0.24 Potassium chlorid 169.50 Sodium chlorid 3,170.00 Sodium sulphate 802.70 Magnesium sulphate 15,151.40 Sodium nitrate (NaN0 3 ) 744.30 Calcium bicarbonate 1,397.80 Iron and aluminum oxid 3.70 Silica 18.10 The nauseating taste of castor oil is overcome when one floats the dose (-J to 1 oz.) on coffee, or adds a few drops of lemon juice to it. Its cathartic effect should be obtained in one or two hours. The saline cathartics require about the same time, while cascara requires from eight to twelve hours. Phenolphthalein requires at least four hours for effect. For these reasons castor oil and the saline cathartics are generally chosen when one seeks the prompt evacuation of the bowel, and phenolphthalein and cascara when an overnight cathartic is desired. For chronic conditions, on the other hand, the mineral salts are rarely given, but cascara sagrada and similar vegetable cathar- tics are chosen instead. As a general principle, one should not con- fine oneself to one drug, but should change from one to another in order to prevent the development of an immunity. Thus, the giving of fifteen drops of fluid extract of cascara for a fortnight should be succeeded by a like period of phenolphthalein in one- to two-grain doses. And so on. Whatever the drug used, catharsis is promoted by drinking much water on an empty stomach, as at bedtime (one to two glasses), on rising, and between meals (e. g., ten glasses pro die). Of course, periods of mineral-water drinking may be interspersed between periods devoted to other drugs. The symptomatic treatment, when considered for itself, with- out thought of the subsequent developments of constipation, calls simply for the immediate and thorough evacuation of the intestine. This, therefore, may be accomplished in its simplest form by using enemata to soften the masses or scybala lying in the colon, and to wash them out; and by giving castor oil or saline cathartics to carry down the masses from the upper intestine. CONSTIPATION 51 Enemata. — This leads us to a consideration of various solutions used for enemata. The first principle is to use a solution that will not harm the bowel. For unless the enema agree in chemical re- action with the contained fluids it is liable to injure the mucosa. The gentlest of enemata is that with the normal saline solution. This does not irritate the bowel and rarely excites even the peri- stalsis. It simply dissolves and washes out the material lying within reach of the solution. Naturally, therefore, it must be used in greater quantity than more stimulating solutions, two or three quarts being a minimum quantity. The next more vigorous solution is glycerin. This may be given in the strength of one part of glycerin to eight parts of water. Fol- lowing glycerin in strength come solutions of ox gall and the cathartic salts. These may be used in varying dilution, according to the amount of water it is desirable to use. This in turn depends on whether a solution of the fecal masses is desired or whether the stimulation of the peristalsis is the chief object sought. This in turn depends on whether one uses a long or short rectal tube. The ordinary " rectal " tube is 19 inches long, while the " colon " tube measures 30 inches. The former is used when it will suffice to put the solution into the ampulla recti, or at most into the sigmoid flexure. The latter must be used if one desires to put the solution above the sigmoid flexure. To accomplish the lat- ter feat, the patient must lie on the left side with the knees drawn up, with the abdomen as relaxed as possible. The tube is thor- oughly oiled with vaselin or olive oil and inserted with a turning motion. As soon as it meets an obstruction, the solution is turned on with the irrigator or bag two feet above the level of the anus, and the pushing forward of the tube, with the turning motion (to prevent the tube from bending on itself), continued. The force of the flowing solution usually forces the intestinal walls, as well as the fecal masses, out of the way so that the flexure is finally passed. From the above, it will be seen that large quantities of water must be at hand for high colonic flushing; that is, when washing out rather than stimulation is sought. In such cases the solution is much more dilute, say one ounce each of ox gall and sodium sulphate to the quart, than when the short tube is used. In the latter case the solution should contain at least two ounces 52 SYMPTOMATIC THERAPEUTICS of each ingredient to the quart. This same principle applies also when we use the other ingredients — glycerin, soapsuds, etc. In summarizing the above discussion we may note : (1) To empty the bowels we give castor oil, calomel, or saline cathartics, preferably with an enema to soften the hard masses lying in the colon. (2) To overcome tonic spasm of the bowel we use atropin. (3) To overcome flaccidity we use strychnin or similar vaso- motor stimulant. (4) To combat habitual constipation we use the slower-acting cathartics, such as phenolphthalein, cascara, podophyllin, etc., but lay the emphasis on correcting the mode of life that has brought on the condition, and finally (5) When everything else fails we can resort to a surgical op- eration (Lane) to " short-circuit " the bowel and rid the patient of some of the long passage leading up to the stasis. 1 VI. VOMITING Quite frequently we find it necessary to produce vomiting in order to empty the stomach hurriedly, and again we find occasion to check vomiting. Hence, a brief study of the conditions govern- ing this symptom will be profitable. Put briefly, vomiting is due to a spasmodic contraction of the abdominal muscles (including the diaphragm) with or without a coincident contraction of the stomach itself. These contractions may be brought about by irri- tation within the intestinal tract itself, by psychic influences, and by reflexes from other parts of the body. Hence, manifold influ- ences may excite vomiting, and we can rarely exclude the psychic influences. To excite vomiting the layman sticks his finger down his throat. The old Romans and our predecessors of the Middle Ages followed up the principle somewhat further and used feathers and elongated glove fingers to produce the same result. Other laymen use mus- tard water or some other nauseous compound. We may follow their example ; or may use drugs definitely affecting the vomiting center of the medulla. Thus, a subcutaneous injection of T V grain 1 For the details of this operation, see Binnie, " Operative Surgery," vol. i. VOMITING 53 of apomorphin will within a very few minutes produce a complete evacuation of the stomach. Or syrup of ipecac (one teaspoonful for children) effects the same result, in somewhat longer time, when taken internally. The apomorphin acts centrally, ipecac acts locally, or practically as the crude mustard water or sulphate preparations do. Hence, in the great majority of cases, apomor- phin is the preferable drug. It should therefore always be present in the physician's emergency equipment. It should, of course, always be used with the hypodermic needle. To quiet vomiting is usually not easy. If the cause be peri- toneal irritation, the frequent washing out of the stomach with the stomach tube is probably the best procedure. For this pure water is as good as any solution, and little or none should be left inside the viscus. If the cause be a reflex from a loaded colon and other results of constipation, castor oil in coffee, 1 fol- lowed by ox-gall enemata, will be found quite efficient. If the cause is pregnancy, nerve sedatives should be used, and when these fail and there is danger of death from a continuance of the vomit- ing the uterus must be emptied. Of such sedatives the bromids and atropin are the types. The bromids are to be chosen when there is no local irritation and the atropin where there is such irri- tation. When the vomiting is due to ulcers and erosions in the stomach and duodenum, atropin and bismuth are the drug types. The atropin inhibits the sensory nerves and the bismuth forms a coating over the lesion. The vomiting from gall-bladder disease and appendicitis is partly due to peritoneal disturbance and partly to the more local reflexes, hence gastric lavage accompanied by nerve sedation is called for when there is no opportunity to pro- ceed directly against the underlying lesion. It is usually unwise to use morphin in such cases, because it obscures the picture. Vomit- ing, due to reflexes from the olfactory center or psychic influences, is best treated by causal treatment accompanied by psychothera- peutic procedures, such as a change of the environment and a sooth- ing of the mind. The vomiting of seasickness is best relieved by the recumbent posture, closing the eyes, and keeping the stomach 1 Castor oil excites the peristalsis in the small intestine only, ox gall excites a similar movement in the colon. Thus, the two are necessary for complete evac- uation of the tract. 54 SYMPTOMATIC THERAPEUTICS empty. The vomiting after anesthesia is often relieved by laying ice-cold cloths over the throat, moistening the lips with vinegar, and the use of the ice bag over the epigastrium. The swallowing of cracked ice assists in keeping the patient comfortable in all those conditions where the local conditions do not forbid its use. In using bismuth subnitrate for vomiting, better results will be obtained if large doses suspended in water be employed. Thus, a teaspoonful of bismuth subnitrate floated in one half glass of water will be more effective than a five-grain tablet followed by a little water. The bromids should, of course, be used in solution. The vehicle should be carminative, such as the so-called essence of pepsin, com- pound tincture of gentian, etc., both taken well diluted. The dose of the bromids is 15 grains. It may be necessary to give the bromids by the rectum in order to secure the bromid effect without the ac- companying danger of gastric irritation ; in this case they should be used in doses varying from 20 to 30 grains in 2 to 4 ounces of water. Atropin fortunately can be used hypodermically, and one could use doses of -gV grain in that way. But in order to secure the local effect on the gastric mucosa, it would be better to use the tincture of belladonna — ten drops in a dessertspoonful or more of water. The tincture may be given again in two hours if needed. VII. HICCOUGH Another distressing and obstinate symptom is hiccough. This may be due to peritoneal irritation, and as such is a very unfavor- able sign as to the condition of the patient. On the other hand, hic- cough may be a reflex from the sympathetic nerve centers, or may indicate nothing more than hysteria. For its quieting we would best proceed to diminish the activity of the reflex arcs; that is, use general rather than local treatment. For this purpose the bromids and atropin are the typical drugs. In fact, the two may be combined as in the following prescription: Tct. belladonnas 2.5 grams. Sodii bromidi 5.0 " Tct. gentiame co 10.0 " Aquas q. s. ad 20.0 " Sig. One teaspoonful every two hours if needed. COUGH 55 For the local treatment of the stomach, when we believe that the cause lies therein, we might use cocain, tincture of belladonna, or bismuth subnitrate. It is best, of course, to use the belladonna and bismuth and reserve the cocain to the last emergency. Both these drugs should be used as directed in our discussion of vomit- ing. That is, the tincture of belladonna should be used in ten-drop doses every hour or two until relieved. The subnitrate of bismuth, to be effective, would have to be used in at least ten-grain doses. The cocain could be used in doses varying from one twelfth to one quarter grain; the action of this drug is so evanescent as to be al- most useless except for introducing some other drug. It is usually best to have the bismuth in ten-grain powders at hand and sus- pend it in water (and add, if necessary, the belladonna) extem- poraneously rather than try to secure a permanent mixture of such incompatible drugs. VIII. COUGH Cough is Nature's response to some irritation in and about the respiratory passages; the irritation may be in the mucous mem- brane itself, or conveyed to the same center from the irritation of neighboring nerves. For instance, cases have been known wherein irritation in the external auditory canal, or the cavum tympani was found to be the cause of a persistent ringing, hollow cough. Similarly, irritation in the mucous membrane of the upper gastro- intestinal tract has been sufficient to excite the cough center and produce an uncomfortable hacking cough instead of vomiting, as one would naturally expect. Usually, however, the irritation is in the mucosa somewhere between the naso-pharynx and the alveoli; most frequently, perhaps, in the larynx, because that membrane seems the most sensitive. Before treatment of cough may be begun it is important to as- certain whether or not that cough is something necessary to relieve the tissues of some irritating or toxic debris, or whether the reflex is caused by something not to be removed by coughing. For in- stance, if there be an irritating substance on the mucous membrane, it would be unwise to stop the cough. On the other hand, if the cough be due to an abrasion or ulcer, then the cough is unproduc- tive and unprofitable. For this reason, a careful investigation 56 SYMPTOMATIC THERAPEUTICS into the causation of the cough is necessary before we begin even symptomatic treatment. The symptomatic treatment consists in depressing either the nerve endings of the mucous membrane in which the irritation starts, or the medullary center that gives rise to the cough stimulus. The first is accomplished by subjecting the mucous membrane to a stream of soothing vapor. Of the substances used for this purpose the most effective and the most easily used is steam, either alone or medicated. For instance, by pouring a film of turpentine or an essential oil over the boiling water one can secure a vapor carrying that oil in finely divided form and influence the air pas- sages as far down as the bronchioles. To make the inhalation most effective it is wise to have some sort of closed cabinet in which the steam is generated and inhaled. The cabinet may be of cloth, as in the case of the bronchitis tent (q. v.), or an umbrella may be raised over the patient's head and the steam allowed to rise under it. Or again, a towel or sheet may be thrown over the patient and the steaming dish, and the patient in that way secure the benefit of the inhalation. Next to steam, the most important sedative for cough is the oil spray. Of the oil sprays a good type is the chloretone inhalant of Parke Davis & Company, which is made up as follows: Chloretone 0.1 grams. Camphor 2.5 " Menthol 2.5 " Oil of cinnamon 0.5 ' ' Refined liquid petrolatum 93.5 i i This, as every oil for inhalation, must be vaporized by strongly compressed air. The hand vaporizers are usually ineffective, as at least twenty pounds' pressure is needed for thorough work. Each treatment should be continued for ten or fifteen minutes if it would be effective. For depressing the medullary centers, the best drug is heroin. This should be used in doses of ¥ V to J-grain every three hours, according to the patient's age, size, and idiosyncrasies. It should be remembered that heroin gives a tendency to dizziness, and for SHOCK 57 that reason patients should not move around while taking it. If heroin be not at hand, morphin is the next best choice. The addition of syrups to make a so-called " cough syrup " is a useless punishment of the stomach. IX. ASTHMA Asthma is essentially the spasmodic contraction of the bronchi- oles, thus preventing the normal inspiration and expiration of air. In some cases it is due to inflammation of the bronchial membranes. In others it is a reflex from various other organ systems, for we find descriptions of renal asthma, cardiac asthma, nasal asthma, and even hysterical asthma. Hence, asthma is also a symptom that demands a search for its source and the institution of vigorous causal treatment. Asthma is characterized by its paroxysmal occurrence, an ex- piratory dyspnea, and acute transient emphysema (Edwards). Hence, it must be differentiated from edema or spasm of the glot- tis, laryngeal paralysis, or similar causes leading to inspiratory dyspnea. The relief of the symptom is obtained by the use of atropin to overcome the nervous spasm or of the nitrites to stimulate the vaso- dilators. The former is given among the laity in the form of the fumes from burning dried stramonium or other herb of the atropin group. It is better, however, for the physician to give atropin it- self subcutaneously. Both nitroglycerin and atropin may be given in the first dose, because the former acts sooner than the latter, and thus more prompt relief is obtained. In some cases it is necessary to depress the medulla by giving morphin (gr. ^). The intramus- cular injection of adrenalin also sometimes gives relief. The treatment between the attacks consists in building up the body as well as removing the special cause of the disorder. For this the out-of-door life, the regulation of the diet, hydrotherapy, as well as such drugs as arsenic and potassium iodid are employed, as we shall learn when we discuss the underlying lesions. X. SHOCK We shall have occasion to mention shock in various connections, so here we need speak only of its symptomatic relief. 58 SYMPTOMATIC THERAPEUTICS The raising of the body temperature and the contraction of the blood vessels are the two most effective measures. The first is ac- complished by placing bottles filled with hot water about the pa- tient's body, taking care that neither glass nor rubber touch the skin. At the same time hot drinks should be given the patient. The second is accomplished by injecting intravenously ergotoxin or some form of nonirritating aseptic ergot subcutaneously, or adre- nalin intravenously. The first is used in a dosage of T V grain (0.0013 gm.) (Cronyn & Henderson), the second from 1 to 2 c.c, and the third in doses of 10 to 25 drops. Of course, friction and other means of stimulating the circula- tion should not be neglected. Constricting clothing should be re- moved. It may even be necessary to start up artificial respiration. XI. EMACIATION The symptomatic treatment of emaciation is sometimes neces- sary. Of course, if one can discover the causes at work and check their action one does this as the first duty. But even then some direct attack on the condition of the body weight should be made. The conditions in which emaciation is a marked feature are con- sumption, diabetes, hyperthyroidism, malignant disease, and some sorts of gastritis. In consumption the raising of the weight con- stitutes practically causal treatment. So, also, in some mental and nervous disorders the raising of the body weight is at least coin- cident with improvement in the other symptoms. In the other con- ditions named, one feels that the whole force of our therapy should be directed against the primary causes, and that the patient will regain his weight as soon as these causes cease to operate. Bed- sides the above well-known and definite conditions there are many conditions of general malaise in which we can discover nothing more definite than unhappiness and worry. Here the body weight is an index of the metabolic processes, and its move- ment upward or downward is an index of our success as thera- peutists. The first condition essential to the putting on of weight is free- dom from worry and overwork. In some cases the physician will be able by suggestion and education to put his nervous patients into greater harmony with their environment. In many, however, EMACIATION 59 he will find it necessary to change the environment. This means, in some cases, a visit to health resorts or friends. In others it means the Weir-Mitchell treatment in a well-appointed sanitarium or hospital. In all cases it demands that the patient become quiet and passive and subject to the directions of the physician. Those patients who have well-developed religious natures are more easily dealt with than the light-minded and frivolous, because they are more willing to consider themselves subject to divine will, to fate, or to the laws of nature, or whatever term each may have for the Infinite. This submission to natural laws rids the body of irritat- ing nervous impulses and permits all the bodily machinery to run smoothly and efficiently. Such patients sleep better, rest better when awake, digest their food better, and eliminate waste products better than do their neighbors, who insist on managing for them- selves all their affairs, and violating every law, both external and temporal, hygienic and moral. This passivity is so important that the physician does well to make a definite attempt to bring it about, both by example and precept; even hypnosis should be utilized when necessary. The next element of cure is a good digestion. This demands a free movement of the bowels, as well as the digestion and absorp- tion of the food taken. Some of this effect is to be obtained by drugs, but more by means of careful dieting. The principle gov- erning the arrangement of the diet is that a few articles of food in frequent meals are more easily cared for than heavy meals and greater variety at longer intervals. Thus, a patient will put on flesh if given steak, toast, and baked potato three times a day, with eggnog twice a day between times. He does so because he utilizes a greater percentage of the foodstuff ingested. Of course the dietary must not become monotonous, nor should the food be served in an unappetizing form or manner. The following is Binswanger's modification of Weir-Mitchell's dietary for build- ing up the emaciated : First Meal, 7 a.m. 250 gm. (1 tumblerful) boiled milk, or cocoa made with half milk and half water. 2 to 3 triscuits or zwieback. 60 SYMPTOMATIC THERAPEUTICS Second Meal, 9 a.m. A cup of bouillon. 20 g-m. (f oz.) meat. 30 gm. (1 oz.) of Graham bread or toast. 10 gm. (J oz.) of butter. Third Meal, 11 a.m. 125 to 175 gm. (4J to 6 oz.) milk, with a tablespoonful of con- densed malt or the yolk of an egg. Fourth Meal, 1 p.m. 80 to 100 gm. (2J to 3 J oz.) soup, with oatmeal, barley, or rice. 50 gm. (If oz.) roast beef. 10 gm. (^ oz.) potatoes. 7 to 10 gm. (J to J oz.) vegetables. 20 gm. (f oz.) sweet rice pudding. 50 gm. (If oz.) compote. Fifth Meal, 4 p.m. 125 gm. (4J oz.) weak tea, cocoa, or malted milk. 2 triscuits. Sixth Meal, 6 p.m. 20 gm. (f oz.) meat (hot or cold roast, scraped raw meat, tongue, ham, etc.). 10 gm. (-J oz.) Graham bread or toast. 5 gm. (■£■ oz.) butter. Seventh Meal, 8 p.m. 125 gm. (4-J oz.) soup, cooked with 10 gm. (J oz.) of butter and the yolk of an egg, oatmeal, barley, etc. Eighth Meal, 9.30 p.m. 125 gm. (4J oz.) malted milk. EMACIATION 61 The drugs used are the bitter tonics and laxatives. Thus the following prescription secures the stimulant effect of strychnin and the cathartic action of cascara and glycerin: Tct. nucis vomicae 10.0 c.c. Flext. cascaras sag 5.0 ' ' Glycerini 40.0 " Aquae destill 40.0 " Sig. One teaspoonful, diluted in water, three times a day. In many cases it is necessary to use the more constitutional ef- fects of arsenic and mercury. Thus, the old-fashioned x Donovan's solution will be found useful as a general tonic in cases of senile debility. Again, corrosive sublimate in doses of ¥ V grain will be found useful ; of course, particularly so in syphilitic subjects. Prob- ably the intramuscular injection of mercury in consumption finds its chief value in the stimulus it gives to the entire metabolism. The use of hydrotherapy and massage aids greatly in building up wasted bodies. Thus, the cold morning bath in the tub or with the shower, followed by a vigorous rub, sets the whole circulatory system in a healthy glow. Then again a soothing oil rub at bed- time puts the patient in condition to enjoy a good night's sleep. For the individual disease, special modifications must, of course, be made. Thus, the hysterical and neurasthenics will need spinal fomentations, salt glows, drip sheets, alternating sprays, etc., to stimulate the bodily processes and produce a regular and healthy alternation of fatigue and rest. The consumptive and diabetic, on the other hand, must be treated very gently. But we shall discuss those points under the different diseases. The morning cold bath must begin with the patient as the phy- sician finds her. If she is used to a daily tub bath, this should be continued, but the water should be made one or two degrees cooler each day until she can plunge with pleasure into a tub of water at 70° F. If she is not used to the tub, sponge baths must be used at first with the water at 80° F. and gradually cooling it to 60° F. When 60° F. is reached, the patient is usually able to begin the tub baths at 80° or 85° F. These then should be cooled from day 1 Donovan's solution is composed of 1 per cent each of the iodides of mer- cury and arsenic. It should be given in five-drop doses well diluted in water. Fig. 8. — A Portable Tub. 62 SYMPTOMATIC THERAPEUTICS to day until 65° or 70° F. is reached. The tub bath should not last more than five minutes and never long enough for the patient to become blue or chilly. On emerging from the tub the patient should be vigorously rubbed and kneaded until her body glows. She should then lie down, and after a rest of thirty to forty-five minutes take breakfast. The evening rub should, on the other hand, be gentle and sooth- ing. Friction, with inunction of olive oil in long, slow strokes in a warm room, kept up for nearly an hour, should be employed. Its success is to be judged by the patient 's sleepiness. The person- ality of the nurse has much to do with the success of such treat- ments. Hence, the physician must often modify his prescription according to the type of nurse available. The spinal fomentations and similar invigorating treatments should be given during midday, not less than an hour after the full (or second) breakfast, nor later than four in the afternoon. They should be followed by at least an hour's rest in bed. The technic of the spinal fomentations has already been given. That of the salt glow is as follows : The initial bath is made up of about 40 gallons of water, with 6 pounds of sodium chlorid and 8 ounces calcium chlorid (or, if in a larger tub, in similar proportions). If the course consists of twenty-eight baths, the final bath should be of 10 pounds and 8 ounces to the 40 gallons. The strength of the min- eral content is increased from time to time by the addition of 1 pound of the sodium chlorid and 1 ounce of the calcium chlorid until the above maximum has been reached. The patient is put in the tub and the water poured over him and slapped about him until the skin is all in a glow. He is then dried off and allowed to rest. The drip sheet is described best by saying that the patient is shrouded in a sheet and then cold water is thrown over him and his sheet-enshrouded body gently slapped. The pouring and slap- ping continue until the desired state of stimulation is obtained. The temperature of the water and the length of the treatment must be suited to the patient's resistance, varying in temperature from 70° to 50° F. and in length from two to five minutes. OBESITY 63 The alternating douche or spray demands the use of a com- plete apparatus by which the temperature of the spray can be in- stantly changed from 70° to 110° F., or similar changes as needed. Such sprays are given in the form of a fan, needle sprays, or solid currents, as the resistance of the patient may demand. In general, in neither exercise nor treatment should the patient be quite fatigued. On the contrary, we should try to have these things make him just pleasantly tired. Hence, as his body weight and strength increase, the vigor of exercise and treatment need to be proportionately increased, until the patient is able once more to meet his daily duties and still maintain his equilibrium. XII. OBESITY There is a condition that may be properly called pathological obesity (adiposa dolorosa), accompanied by backache, shortness of breath, and scattered pain. There are also many cases of obes- ity where there is no pathological process, but simply the results following the ingestion of too much food with too little physical ex- ercise. The former type requires, of course, definite and causal treat- ment. For the latter simple symptomatic treatment is sufficient. The causal treatment of obesity is based on the observation that lack of sufficient thyroid secretion tends to the laying on of fat. Hence, in pathological obesity we give dried thyroid gland in tab- let or powder three times a day in five-grain doses. This should be given on an empty stomach and at least one half hour before meals. The symptomatic treatment demands first of all an attempt to balance the amount of food or energy ingested with the amount of energy needed for the work that the patient must do. This means, of course, the prescription of less food in one case and more exercise in another. In general, it seems more practicable to have the patient increase his exercise than to decrease the quantity of food. Voit and Pettenkofer, of Munich, many years ago determined by actual experiment the average amount of energy, measured in calories of heat, consumed by male adults in twenty-four hours. This proved to be about 3,000 to 3,400 calories. Later researches have put the amount somewhat lower, viz., 2,500. To supply this energy physiologists advise the consumption of 3 to 4 ounces of 6 64 SYMPTOMATIC THERAPEUTICS proteid, 17 ounces of carbohydrates, and 2 ounces of fat for an average man doing average work. Or, reduced to kilograms (2.2 lbs.) of body weight, for average work our patients need for each kilogram of normal weight 1.7 grams of proteid, 0.8 gram of fat, and 7.1 grams of carbohydrate each day. By multiplying the weight of our patient expressed in kilograms by these figures we secure the amount of each class of food needed by that patient, expressed in grams. (To reduce this to ounces we have simply to divide by 31.5.) These amounts include the food that is undi- gested and passed out through the alimentary canal. This loss is estimated at^ in the ordinary mixed diet. The relation between calories and grams may be expressed as follows (Ortner), where ' ' gross ' ' means the total amount ingested and ' ' net ' ' the amount absolutely absorbed: 1 gm. proteid = 4.1 gross calories or 3.2 net calories. 1 " fat =9.3 " " " 8.4 " 1 " carbohydrate = 4.1 " " "3.8" Of course this relation between net and gross must vary consid- erably according to the variety of food used. Thus in meat, flour, bread, etc., ten per cent is lost, while in rye bread, vegetables, etc., thirteen to seventeen per cent is lost. Of late years the matter of energy needed to run the body has been studied over again, and it has been found that with some attention to the selection of the food and increased care in masti- cation, the amount of food needed may be greatly decreased. This is the movement calling upon us all to reduce the amount of food which was introduced by Horace Fletcher and known as Fletcher- ism, and followed up by Professor Chittenden, of Yale. The ques- tion, however, narrows down to that of the necessity of what Voit called the luxus consumption, the extra amount of food taken by most individuals that is not needed by a strict analysis of the balance of ingestion and excretion, but which seems necessary to protect the organism against accident and disease, or is at least so considered by many conservative thinkers. For therapeutic purposes it is sufficient to know that most of our patients suffering from obesity would do better on 1,500 calories than 2,500 pro die. For governmental studies of dietaries the following factors are used in calculating meals: OBESITY 65 Man at hard muscular work requires 1.2 times the food of a man at moderately active muscular work. Man with light muscular work and boy fifteen to sixteen years old require 0.9 the food of a man at moderately active muscular work. Man at sedentary occupation, woman at moderately active work, boy thirteen to fourteen, and girl fifteen to sixteen years old require 0.8 the food of a man at moderately active muscular work. Woman at light work, boy twelve, and girl thirteen to fourteen years old require 0.7 the food of a man at moderately active mus- cular work. Boy ten to eleven and girl ten to twelve years require 0.6 the food of a man at moderately active muscular work. Child six to nine years old requires 0.5 the food of a man at moderately active muscular work. Child two to five years old requires 0.4. Child under two years old requires 0.3. One other standard of values needs now to be studied, and that is the relation of weight to height. The following is the European standard (Quetelet) : Males. Females. Age in Years- Height in — Weight in kilos. Weight in lbs. Age in Years. Height in — Weight in kilos. Weight in lbs. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 25 30 40 ft. in. 71 3 6 10 1 3 5 2 4* 6* 8* 10§ 1 2* 4 5 5§ 6 6 6 3.20 9.45 11.34 12.47 14.23 15.77 17.24 19.10 20.76 22.65 24.52 27.10 29.80 34.40 38.80 43.60 49.70 52.90 57.90 60.10 62.90 63.70 63.70 7.0 20.7 24.8 27.2 31.2 34.5 37.8 42.0 48.5 49.7 52.8 59.6 65.5 75.6 85.3 95.9 109.3 116.3 127.3 132.3 138.3 140.1 140.1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 25 30 40 in. 7 24 6* 91 1 2* 7 9 10 10* 1 3 5 7 9 10* 1 H 2 21 21 21 2.91 8.79 10.67 11.79 13.00 14.36 16.01 17.54 19.08 21.36 23.52 25.70 29.80 32.90 36.70 40.40 43.60 47.30 51.00 52.30 53.30 54.30 55.20 6.4 19.2 22.3 25.8 28.6 31.5 35.2 38.5 41.8 46.9 51.7 56.5 65.5 72.3 80.7 88.9 95.9 104.0 112.2 115.0 117.2 119.4 121.4 66 SYMPTOMATIC THERAPEUTICS Males. Females. Age in Years. Height in — Weight in kilos. Weight in lbs. Age in Years. Height in — Weight in kilos. Weight in lbs. 50 ft. in. 5 51 5 4" 5 3i 63.50 62.90 59.50 139.7 138.3 139.9 50 60 ft. in. 5 * 5 5 56.20 54.30 51.30 123.6 60 119.4 70 70 112.8 The American standards are the following: WEIGHT TABLE (Male) 1 (Showing average weight for each height and age.) Based on "Nylic Graphic Table." Correct to one pound. Age. 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. 20.... 104 108 Ill 114 117 121 125 128 132 136 140 144 149 153 158 163 167 21.... 105 108 111 115 118 122 125 129 133 137 141 145 150 154 159 164 168 22.... 106 109 112 116 119 123 126 130 134 138 142 146 151 155 160 165 169 23.... 106 109 113 116 119 123 127 130 135 138 143 147 152 156 161 166 170 24.... 107 110 114 117 120 124 128 131 136 139 144 148 153 157 162 167 171 25.... 108 111 114 118 121 125 128 132 136 140 144 149 154 158 163 168 172 26.... 108 111 115 118 122 126 129 133 137 141 145 150 154 159 164 169 173 27.... 109 112 116 119 122 127 130 134 138 142 146 150 155 160 165 170 174 28.... 109 112 116 120 123 127 130 134 138 142 147 151 156 161 166 170 175 29.... 110 113 117 120 124 127 131 135 139 143 148 152 157 162 167 171 176 30.... 110 114 117 121 124 128 132 136 140 144 148 152 157 162 167 172 177 31.... 111 114 118 121 125 129 132 136 140 145 149 153 158 163 168 173 178 32 ... . 111 115 118 122 125 129 133 137 141 145 150 154 159 164 169 173 179 33.... 112 115 119 122 126 130 133 138 142 146 150 155 159 164 170 174 179 34.... 112 116 119 123 126 130 134 138 142 147 151 155 160 165 170 175 180 35.... 112 116 120 123 127 131 134 139 143 147 152 156 161 166 171 175 181 36.... 113 117 120 124 127 131 135 139 143 148 152 156 161 166 172 176 181 37.... 113 117 120 124 128 131 135 140 144 148 153 157 162 167 172 177 182 38.... 113 117 121 124 128 132 136 140 144 149 153 158 162 167 173 177 183 39.... 114 118 121 125 129 132 136 141 145 149 154 158 163 168 173 178 183 40.... 114 118 122 125 129 133 136 141 145 149 154 158 163 168 173 178 184 41.... 114 118 122 125 129 133 137 141 146 150 154 159 164 168 174 179 184 42.... 115 118 122 126 130 133 137 142 146 150 155 159 164 169 174 179 185 43 ... . 115 119 123 126 130 134 138 142 146 151 155 161 165 170 175 180 185 44.... 115 119 123 126 130 134 138 143 147 151 155 161 165 170 175 180 186 45.... 116 119 123 126 131 134 138 143 147 151 156 161 165 170 176 181 186 46.... 116 119 123 127 131 135 139 143 147 152 156 161 166 170 176 181 186 47 ... . 116 120 124 127 131 135 139 144 148 152 157 161 166 171 176 181 187 48.... 116 120 124 127 131 135 139 144 148 152 157 161 166 171 177 182 187 49.... 117 120 124 127 131 135 139 144 148 153 157 162 167 171 177 182 187 50.... 117 120 124 127 132 136 140 144 148 153 157 162 167 172 177 182 188 51 ... . 117 120 124 128:132 136 140 145 149 153 158 162 167 172 178 182 188 52.... 117 121 125 128|132 136 140 145 149 153 158 162 167 172 178 183 188 53.... 117 121 125 128 132 136 140 145 149 154 158 163 168 172 178 183 188 54.... 118 121 125 128 132 136 140 145 149 154 158 163 168 173 178 183 188 55.... 118 121 125 128 132 136 140 145 149 154 158 163 168 173 178 183 188 This table is quoted from Ortner's " Treatment of Internal Diseases. OBESITY 67 WEIGHT TABLE (Female) 1 (Showing average weight for each height and age. Based on "Nylic Graphic Table. ") Age. 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. Ins. 20.... 100 103 106 109 113 116 120 123 127 130 134 138 142 147 152 156 161 21.... 101 104 107 110 114 117 120 124 127 131 135 139 143 148 152 157 162 22.... 101 105 107 110 114 118 121 124 128 132 136 140 144 149 153 158 162 23.... 102 105 108 111 115 118 122 125 128 132 137 140 145 149 154 158 163 24.... 102 106 108 111 115 119 122 126 129 133 137 141 145 150 155 159 164 25.... 103 106 109 112 116 119 123 126 130 134 138 142 146 151 155 160 165 26 ... . 103 107 110 113 117 120 124 127 131 134 139 143 147 151 156 161 166 27.... 104 107 110 113 117 121 124 128 131 135 139 144 148 152 157 162 166 28.... 104 108 111 114 118 121 125 128 132 136 140 144 149 153 158 162 167 29.... 105 108 111 114 118 122 126 129 133 136 141 145 149 154 158 163 168 30.... 105 109 112 115 119 123 126 129 133 137 141 146 150 154 159 164 169 31.... 106 109 112 116 119 123 127 130 134 138 142 146 151 155 160 165 170 32.... 106 110 113 116 120 124 127 131 135 138 143 147 151 156 161 166 170 33.... 107 110 113 117 120 124 128 131 135 139 143 148 152 156 162 166 171 34. . . . 107 110 114 117 121 125 128 132 136 140 144 149 153 157 162 167 172 35.... 108 111 115 118 122 125 129 133 137 140 145 150 154 158 163 168 173 36.... 108 112 115 119 122 126 130 133 137 141 146 150 154 159 164 169 174 37 ... . 109 112 116 119 123 126 130 134 138 142 146 151 155 160 165 170 175 38.... 109 113 116 120 123 127 131 135 139 142 147 152 156 161 166 170 175 39.... 110 113 117 120 124 128 131 135 139 143 148 153 157 161 166 171 176 40.... 110 114 117 121 124 128 132 135 140 144 148 153 157 162 167 172 177 41.... 111 114 118 121 125 129 132 136 140 145 149 154 158 163 168 173 178 42.... 111 115 118 122 125 129 133 137 141 145 150 155 159 163 169 173 179 43.... 112 115 119 122 126 130 134 138 142 146 150 156 159 164 169 174 179 44.... 112 116 119 123 127 130 134 138 142 147 151 156 160 165 170 175 180 45.... 113 116 120 123 127 131 135 139 143 147 152 157 161 166 171 175 181 46.... 113 117 120 124 128 131 136 139 143 148 152 157 162 166 171 1176 182 47.... 114 117 121 124 128 132 136 140 144 149 153 158 162 167 172 177 182 48.... 114 118 121 125 129 133 137 141 144 149 154 159 163 168 173 178 183 49.... 115 118 122 125 129 133 138 141 145 150 154 159 164 168 174 179 184 50.... 115 119 122 126 130 134 138 142 146 150 155 160 164 169 174 179 185 51.... 116 119 123 126 130 134 139 143 147 151 156 161 165 170 175 180 186 52.... 116 120 123 127 131 135 139 143 147 152 156 161 166 170 176 181 186 53.... 117 120 124 127 131 135 140 144 148 153 157 162 166 171 177 182 187 54.... 117 120 124 128 132 136 140 144 148 153 158 162 167 172 177 182 188 55.... 118 121 125 128 132 136 140 145 149 154 158 163 168 173 178 183 188 1 This table is quoted from Ortner's "Treatment of Internal Diseases.' The above studies furnish us with standards of weight and food. When, therefore, an obese patient comes to us we should from these tables ascertain what should be his weight and food in- gestion. We then proceed to arrange a dietary. To do this we need the fuel value of the different foods. This is found in the following table, from page 28 of Farmers' Bulletin No. 142 of the U. S. Department of Agriculture: 68 SYMPTOMATIC THERAPEUTICS NUTRIENTS AND ENERGY OF DIGESTIBLE PORTION OF SOME COMMON FOODS, WITH NUTRITIVE RATIOS 1 Kind of Food Materials. Animal Food. Beef, fresh: Chuck, ribs Loin, medium Ribs Round, medium Shoulder and clod Beef, dried and smoked Veal: Cutlets, round. Leg Mutton: Leg.. Loin. Pork, fresh: Loin, chops. Ham Pork, salted and smoked: Bacon Ham Salt, fat Poultry: Fowl. . . Turkey. Fish, fresh: Cod, dressed Mackerel Shellfish: Oysters, solids Fish, preserved and canned: Cod, salt Salmon, canned Eggs, uncooked Per cent 4.7 3.4 14.2 18.4 16.0 7.7 13.6 25.9 22.7 29.9 44.7 24.9 11.2 Per cent 52.6 52.5 43 60.7 56.8 53.7 68.3 60.1 51.2 42.0 41 48.0 17 34 7.9 47.1 42.4 58.5 40.4 88.3 40.2 63.5 65.5 Ire Per cent 1 1 1.8 1.4 1 4 Digestible Nutrients, Per cent. 15.0 15.6 13.5 18.4 2 15.9 5 25.6 19.5 15.0 1.414.6 2.013.1 1.8 1.9 4.4 3.1 5.4 1.2 1.6 5.1 1.9 1.1 Per cent 14.3 16.6 20.0 12.2 9.3 6.6 7.1 7.5 14.0 26.9 13.023.0 13.124.6 8.859.1 13.831.7 1.881.9 13.3 15.6 10.8 9.9 5.8 15.5 21.1 12.7 11.7 17.5 .2 4.0 1.2 .4 11.5 !2 B Per cent 3.3 Per cent. 0.6 .7 .5 .8 .7 5.5 3.1 3.2 2.9 13.9 2.0 .7 ft m ft Calo- ries. 910 1,025 1,135 890 715 790 695 625 890 1,415 1,245 1,320 2,720 1,635 3,555 765 1,060 220 370 225 325 915 635 Calo- ries. 2.1 2.4 3.3 1.5 1.3 .6 .8 1.1 2.2 4.6 4.0 4.2 15.1 5.2 2.0 2.5 1.0 .1 1.2 1.7 1 " Nutritive ratio " is the ratio of the digestible proteins to the digestible fats and carbohydrates. The normal ratio is 1 to 3 J or 4 (Williams). For a detailed discussion of this matter, see Williams's " Food and Diet," pp. 188, et seq. OBESITY 69 NUTRIENTS AND ENERGY OF DIGESTIBLE FOODS.— Continued. Kind of Food Materials. Animal Food. — Continued. Dairy products: Whole milk Skim milk Cream Butter Vegetable Food. Cereals, etc.: Corn meal Oat breakfast food Rye flour Rice Wheat flour, patent process . Wheat breakfast food Bread, etc.: Bread, white wheat. Crackers, cream .... Vegetables: Beans, white, dried. . Beets, fresh Cabbage Potatoes Squash Sweet potatoes, fresh. Tomatoes Fruits: Apples Bananas Grapes Oranges Strawberries . Per cent. 20.0 15.0 20.0 50.0 20.0 25.0 35.0 25.0 27.0 5.0 Per cent. 87.0 90.5 74.0 11.0 12.5 7.8 12.9 12.3 12.0 9.6 35.3 6.8 12.6 70.0 77.7 62.6 44.2 55.2 94.3 63.3 48.9 58.0 63.4 85.9 "3 a Per cent. .5 .3 1.1 4.9 3.3 5.1 2.9 2.9 3.4 3.8 2.9 4.5 1.2 1.6 1.7 1.0 1.0 Digestible Nutrients. Per cent, 3.2 3.3 2.4 Per cent. 3.8 .3 17.6 1.080.8 7.8 14.2 5.8 6.8 9.7 10.3 7.8 8.2 17.5 1.1 1.2 1.5 .6 1.2 .7 1.2 10.9 1.6 .1 .2 .1 .2 .5 .4 .3 .4 1.1 .1 .5 «T5 o >> Per cent, 5.0 5.1 4.5 73.9 64.9 77.1 77.4 73.6 73.7 52.0 68.3 57.8 7.3 4.6 14.0 4.3 20.8 3.7 9.7 12.9 13.0 7.7 6.3 Per cent .5 .5 .4 2.3 .8 1.4 .5 .3 .4 1.0 1.3 2.6 .7 .7 > O — , a Calo- ries. 310 165 865 3,410 1,640 1,800 1,620 Calo- 4.3 1.8 18.4 10.0 5.6 13.6 1,625 11.5 1,635 1,680 7.8 7.5 1,200 7.0 1,925 11.3 1,520 160 115 295 100 440 95 190 260 295 150 150 3.5 6.8 4.2 9.5 7.8 18.3 6.6 34.7 19.7 17.2 15.8 9.3 Sometimes, instead of putting the patient on the dietary normal for his age and size, we reduce the dietary to the lowest limits and give him a " hunger cure," according to the suggestions of Bant- ing, Oertel, or Ebstein. In these starvation dietaries care must 70 SYMPTOMATIC THERAPEUTICS be taken to keep the protein about normal and to put the chief reduction on the fats and carbohydrates. By reducing these grad- ually we can compel the body to use up its own superfluous fats and yet not cause the patient great discomfort. Of course the pa- tient's heart and urine must be watched to prevent weakening him with too little food. A dietary for this purpose suggested by De Bove and recommended by Oertel is the following: Breakfast — Cup of tea with milk. Dinner — 1 to 2 slices lean meat, small amount of green vege- tables or salad, 3 to 5 oz. (100 to 150 gm.) of bread, cheese, fruit (freely), cup of black coffee (without sugar). Supper — 1 pint hot sugared milk, 1 to 1J oz. (30 to 50 gm.) bread (without butter), fruit (freely). Ten drops of the tincture of aloes are given before each meal. After the required reduction in weight has been obtained, a normal dietary is given and the patient asked to adhere to it for months. The next means of reducing the patient's weight is that of graduating his exercise. If he can go to the mountains and live a vigorous out-of-door life, the desired result is obtained with very little detailed prescription, because the altitude of itself assists in the reduction and the food in the mountains is usually coarse and wholesome. Men who are otherwise healthy may be subjected to fatigue cures, such as that at White Plains, N. Y., where the patient is made to run across the country five or six miles even at the start, to ride horseback, to box, etc., until he is utterly exhausted. This is kept up until the muscles grow strong and the fat disappears. Of course such a cure demands constant supervision and regu- lation. Patients who are not otherwise strong are subjected to hot-air baths and massage. The hot-air cabinet is given daily for about one hour with the temperature at 200° to 250° F. At its close the patient is rubbed off thoroughly with water at 60° to 70° F. If necessary, patients may be required to take walks after their meals instead of taking naps, and to restrict their sleep to seven or eight hours nightly. For medication one simply uses mineral waters or saline laxa- CONVULSIONS 71 tives to keep the bowels loose. The value of the treatment at the various " springs " lies in the regulation of the life rather than in the virtue of the waters. For the pain of adiposa dolorosa we find that inunction with fifty-per-cent oil solution of guaiacol and the continued use of the Fig. 9. — Hot-air Cabinet, Arranged for Gas Heat. thermophore are very effective. The former may be used in one- half -dram doses t. i. d., and the latter three or more times for about fifteen minutes. XIII. CONVULSIONS The term convulsions is used very freely and seems to include both spastic and flaccid types of seizures, and of the former both tonic and clonic spasms. We have, therefore, the term applied to attacks of eclampsia, of uremia, of hysteria, of ptomain and strychnin poisoning, of epilepsy, of meningitis, of simple hyper- pyrexia in childhood. The symptomatic relief must depend upon the type of the seiz- ure, for such relief must release the spasm in the spastic type and stimulate the nerve centers in the flaccid type. Then, again, we must distinguish organic and functional attacks; that is, if the 72 SYMPTOMATIC THERAPEUTICS attack be due to emotional disturbance we should proceed very differently from the way in which we would approach a case of strychnin or other " convulsant " poisoning. If now we find our patient rigid and made worse by touch- ing or moving, we judge that we have the tonic spastic type of convulsion before us. Then, if we have reason to believe that we can exclude hysteria or emotional shock, we administer the bromids and chloral. Thus, we might give 15 grains (1 gram) each of po- tassium bromid and chloral hydrate in an ounce of hot water. If the patient cannot swallow, we should give it by the rectum. The administration of chloroform by inhalation may be begun at the same time. On the other hand, if we think that the attack is hysterical, or if we think that it is due to poisons or fermenting food in the stomach, we should inject at once subcutaneously one tenth or one fifth of a grain of apomorphin. This drug, besides emptying the stomach, has considerable sedative effect on the higher centers. The effect should appear within fifteen minutes. In tetanus (lockjaw), the opisthotonos will be relieved by the lumbar injection of magnesium sulphate (see Tetanus). Morphin (one fourth to one half grain) may also be of use in the lighter types of convulsions. Now should the seizure be of the flaccid type, we choose strong stimulants. Thus, we may slap the patient with towels wet in ice- cold water, or may apply first hot, then cold, fomentations. We may at the same time hold a bottle of ammonia under the patient's nose, or we may give a teaspoonful of the aromatic spirits of am- monia. Both of these measures (the cold cloths and the ammonia) afford quickly acting but evanescent stimulation to the medullary centers through the medium of the skin (or gastric) reflexes. Therefore, when such reflexes are depressed, inhibited, or ex- tinguished, such measures fail. When they do fail we must have recourse to the subcutaneous or intravenous injection of such drugs as strychnin, nitroglycerin, ergotoxin (or aseptic ergot), adrenalin, pituitary substance, etc. Even in the flaccid type of convulsion we often find occasion to resort to the subcutaneous injection of apomorphin. During either sort of attack the patient should be freed from all tight clothing, especially that of the neck and chest, and laid CONVULSIONS 73 flat in the open air or in a well-ventilated room. Idle bystanders should be kept out and every obstacle to the free access of pure air removed. When we learn the cause of the attack our therapy may be much more rational and effective. Thus, in eclampsia we must reduce the blood pressure. This is accomplished by the use of the nitrites (sodium nitrite, 2 grains, or, better, nitroglycerin, T ^ grain), or veratrum viride (two to five drops of the fluid extract). Venesection also accomplishes a similar result. The causal treat- ment is, of course, the emptying of the uterus, and this should be attended to at once. In uremia a preliminary dose of morphin, followed by thorough diaphoresis and catharsis, is necessary. Pilocarpin (J grain) sub- cutaneously may be of value when the heart is not weak. Gener- ally, however, hydrotherapy is needed (see Uremia). Hysterical convulsions are usually best relieved by apomorphin subcutaneously. After the relief of the seizure, interval treatment should be undertaken according to the principles discussed else- where. Poisoning by strychnin requires the apomorphin, followed by thorough gastric lavage. Here the sedative effects of the bromids and chloral are demanded (30 to 40 grains of each). The nitrites also may be of use. Ptomain poisoning usually demands active catharsis (castor oil and salts) and diaphoresis (pilocarpin), followed by the tonic action of caffein or strychnin, as the symptoms may demand. Epileptic seizures require only good care, removal of tight clothing, access to pure air, rest, and the prevention of the pa- tient's biting himself. This last is cared for by slipping a cork between the teeth. The seizures due to meningeal irritation are helped by apply- ing heat to the feet and ice to the head, to influence the flow of blood away from the inflamed area. Atropin may frequently be needed to overcome some of the rigidity. This should be given with the needle in y^-g-- to -^--grain doses. In the simple convulsions of infancy the best procedure is to empty the bowels thoroughly with soapsuds enemata and apply hot packs to set up diaphoresis. Thus, in each case we seek to remove the irritant or counteract 74 SYMPTOMATIC THERAPEUTICS it. We apply our counteraction to the medulla (chloral), spinal cord (bromids), or end plates (atropin), according to our belief as to the location of the irritation. Hence, the closer our diagnosis the more specific and satisfactory our treatment. "We should never be satisfied with the diagnosis " convulsions/' CHAPTER II THE TREATMENT OF LOCALIZED INFLAMMATIONS I. ACUTE INFLAMMATIONS The three elements which from our standpoint must receive most thought in any localized inflammation are: (1) the individual cells, (2) the local circulation, and (3) the reflexes. The individ- ual cells react to inflammation first by increased cellular activity, including proliferation, and secondly, if the inflammation be too severe or prolonged, by becoming depressed and finally by dying. Hence, the degree of the inflammation is an important factor in de- termining the therapeutic indication. The second element, the circulation, is affected first by the dila- tion of the capillaries and the exudation of the hemic elements. When continued, this dilation causes the walls of the capillaries to become fixed in dilation, and the flooding of the surrounding tissues leads to the production of fibrous tissue with a coincident death of the parenchymatous tissue. The third element, the reflexes, differs, of course, with the in- dividual. The swelling of the tissues puts the contained nerve fibers and end plates on a stretch, and produces pain, or at least discomfort. The psychic element then enters and stimulates or depresses, as the individual feels, the supply of nutrition to the affected part. We may present the above in another form and say that there are three degrees of localized inflammations: (1) A stage of active congestion and cellular stimulation — that is, a stage of increased function; (2) a stage of passive congestion and cellular depres- sion — that is, decreased function; and (3) the stage of death. Now from the time of Greek medicine the cardinal symptoms of acute inflammation have been redness (rubor), heat (calor), swell- ing (tumor), pain (dolor), and finally disturbed function. The 75 76 TREATMENT OF LOCALIZED INFLAMMATIONS redness is due to the suffusion of the parts with blood, the heat to the increased activity of the tissues, the swelling to the congestion, the pain to the distention of the tissues, and the disturbed function partly to the cellular changes and partly to the reflexes. Some of the symptoms are useful, some detrimental, according to the cause of the inflammation and their effect on the local condition. Thus, the suffusion of the tissues with fresh blood brings to the inflamed cells the assistance of the opsonins and other protective agencies of the blood serum; but the suffusion of the tissues with stagnant blood, or serum with little or no active bactericidal power, would only weaken, not strengthen, them. Then, again, we may consider that intrinsically those symptoms are valuable which are the re- sult of the body's reaction to the cause of the inflammation, and those liable to be detrimental which are the direct result of the causa morhi. Thus, the redness and heat, in so far as they are due to the body's reaction, are instrumental in discouraging the in- flammatory processes, but where they are the result of active com- bustion of tissue by microbic processes they indicate an injurious process and should be checked. Hence, here as with the other symptoms, we must convince ourselves that they are injurious be- fore we institute procedures to do away with them. The treatment must consider all three elements (cells, circula- tion, and reflexes), but practically must be directed chiefly toward controlling, or at least influencing, the circulation. For it is by increasing or decreasing the flow of blood that we may hope to supply fresh and active blood serum, or to free the tissues from the excessive and stagnant fluids and stimulate the growth and pro- liferation of healthy cells. Then, too, by checking excessive dila- tion of the blood capillaries and by securing more complete drain- age, we lessen the tension and decrease the pain. We can influence the circulation by raising or lowering the part with reference to the rest of the body ; thus, we sometimes suspend a leg vertically or at right angles to the body lying in the bed, or lower the head when we wish to increase the blood flow thereto. We can apply a tight bandage and compress the blood vessels, thus overcoming some of the dilation. We can apply heat to in- crease the flow of blood or cold to check it. We can tap a vein and remove considerable blood and secure a reactive contraction of the blood vessels, or we can apply a vacuum cup and increase the ACUTE INFLAMMATIONS 77 amount of blood in the area covered by the cup. We may secure a hyperemia by applying a counterirritant to the overlying sur- face, or by using the counterirritation in another part of the cir- culatory system decrease the flow of blood to the affected area. Finally, we may use drugs to increase or decrease the lumen of the blood vessels, some by their local action, such as adrenalin or eucain ; some by their systemic effects, such as atropin or digitalin. As may be seen by the above discussion, one of the dangers in- cident to inflammation is the breaking down of the capillary walls because of the prolonged distention and flooding. This is to be prevented by the methods outlined above (position, compression, cold, etc.), and should be looked after even if our attention is not directly called to it. The use of Bier's hyperemia, now so much the vogue, depends for its usefulness upon increasing the blood supply to the affected area, and thus furnishing the tissues with better and more active blood serum. When it is done by vacuum it is dependent upon the same principles as the cupping mentioned above ; when it is accom- plished by ligatures, it secures its results by checking the return flow of blood and thus increasing the amount of serum in the tissues. Similarly, hot and cold baths and other forms of hydrotherapy depend for their usefulness upon their influence on the circula- tion. Thus, holding an inflamed hand in hot water increases the blood supply, in cold water decreases it — which should be done depends upon the momentary and local condition. Thus, hot tub baths bring the blood to the surface, and decrease the amount in the viscera in visceral inflammations. In this connection, it may be well to recall the fact that the first flushing of the skin in a hot bath is followed by an attempt of the vasomotor system to equalize the circulation and contract the skin capillaries, and that a cold bath produces a reaction wherein an increased blood supply is sent to the skin in an attempt to overcome the chill. But if either sort of bath is maintained long the vasomotor control becomes para- lyzed, and we have only the direct physical effects of the heat or cold. Therefore, with short baths, the chief effect is a stimulation of the vasomotor centers and the better and quicker interchange of blood throughout the whole body. Poultices are a means of using heat to produce hyperemia, and are useful only in so far as they do this better than the other means 78 TREATMENT OF LOCALIZED INFLAMMATIONS just mentioned. In general, we should select that form of poultice, when we find it necessary to use a poultice at all, that is most cleanly and pleasant. Nearly everything that will hold moist heat has been used at one time or another for poultice material. At present in good usage the materials are linseed, bread, starch, clay, and mustard (sinapism). Linseed poultices are made by pouring one cup of linseed (flax- seed) meal into two and one half cupfuls of boiling water and stir- ring until a thick mush is formed. This should be spread while still warm (as warm as can be borne comfortably) on a piece of flannel and covered with the same material and then applied to the area affected. A new poultice should be applied as soon as the old one is cold, and the skin should not be allowed to cool during the change. This poultice is irritant to delicate skin. A pinch of bak- ing soda added to the boiling mixture may help to overcome this defect. Bread poultices are made by cutting the bread into thick slices, covering with boiling water, and letting the mixture stand say for five minutes. The water should then be poured off. Fresh boiling water should be added and the mixture allowed to simmer. The bread should then be drained and beaten smooth with a fork, then spread on a cloth and applied like the linseed poultice. Starch paste is made by stirring the starch in cold water until it forms a smooth mixture. Boiling water should then be added until the right consistency is obtained. The clay poultices are made two thirds of clay, one third of glycerin, with four and one half per cent of boric acid and a few drops of essential oils (especially wintergreen). This mixture is heating by setting the vessel containing it in water until the de- sired temperature is obtained. It is usually applied with a case knife direct to the skin, although it may be used like the other poul- tices named. It is less irritating than the others and more anti- septic. But even then it is less usable than a thermophore or other similar means of applying heat. The danger of infection should be ever in mind in applying a poultice, for the maceration incident to the poultice favors infec- tion, even if under ordinary circumstances one might consider the area germ proof. In the mustard poultice we have another element (besides the ACUTE INFLAMMATIONS 79 moist heat) to deal with, and that is the irritant (vesicant) influ- ence of the oil which is developed on the addition of water. Black mustard is used (one pound of ground mustard to from five to ten pounds of flour) and is made into a paste with lukewarm water and then spread on a cloth (thinner than linseed) and applied for fifteen to thirty minutes, or until the skin tingles and looks red. The influence of mustard may also be obtained by using mustard papers, by sprinkling mustard (powdered) on a linseed poultice, or by using flannels wrung out in one tenth to one fifth solution of mustard oil in fifty per cent alcohol. Mustard foot baths are made by adding one to two ounces of mustard to the gallon of water. A mustard bath for a child is made by adding a large tablespoonful of mustard to the child 's tub of water. The child should be im- mersed only until the arms of the nurse begin to tingle. In using mustard in a poultice one should always guard against vesication, and when the mustard is removed one should always wash off the skin with warm water, and if there be blisters cover them with cot- ton. It need hardly be added that the use of mustard in modern practice is very much restricted and rare. Usually other and pleas- anter remedies may be found to do its work. So much for influencing the circulation directly. We must now consider the treatment of the two last cardinal symptoms in order to correlate this discussion with those in which the subject is viewed at another angle. The symptom to which our attention is most forcibly called is, of course, the pain. We assist in relieving this when we overcome the local redness and swelling, but usually — that is, in most pa- tients — we have to use some means of direct sedation on the pain itself. For, as we have indicated, the quality of pain depends upon the individual reaction, and with nervous persons pain is much more important than with phlegmatic. In choosing our means of relief we keep this in mind, and for the phlegmatic person may confine our analgesics to the locally acting ones, and for the nerv- ous persons choose the systemic drugs. Among the local measures we must classify rest, heat and cold, emollients and demulcents, local anesthetics, and counterirritants. Among the systemic anal- gesics we have morphin (opiates), coal-tar derivatives, and some- times the hypnotics. Physiological rest is good not only for the relief of pain, but 7 80 TREATMENT OF LOCALIZED INFLAMMATIONS also for the promotion of repair. Thus, it is causal as well as symp- tomatic in its influence. By rest we mean the cessation of use of the organ or part. Thus, for inflammation of the stomach we avoid the use of food by the mouth. For a broken bone, the application of splints and the rest of the muscles attached thereto affords the rest necessary to repair. For inflammation of the nerves, the ab- solute quiet of the parts to which these nerves are attached must be insisted upon. Fig. 10. — Applying Heat by Means of a 500-Candle-Power Electric Light. What we have already said about heat and cold should be re- membered when we speak of them for the relief of pain. Some- times we find that it is the heat that affords the greater relief, sometimes the cold. In general, we prefer to apply the cold in a beginning inflammation and the heat in an old one, because the cold may help check the inflammation, and in old inflammations the heat may stimulate repair. We apply the heat in the form of hot air, hot water, incandescent electric-light bulbs, hot-water bot- tles, poultices, and the cold by means of cold, moist cloths, ice bags, Leiter's coils, etc. ACUTE INFLAMMATIONS 81 The emollients relieve pain chiefly by excluding air from abraded and inflamed surfaces; sometimes, indeed, they protect against the rubbing of clothing or the contact with rough objects. Most in use are lard, olive oil, wax, glycerin, starch, and cocoa butter. The demulcents are soft and jellylike, more or less nutritive materials, used for protecting inflamed surfaces in the intestinal tract. We use acacia, flaxseed, Iceland moss, starch, gelatin, etc. They therefore relieve pain to some extent, at least, when spread over the sensitive area. Counterirritation for the relief of pain is purely empiric. Thus, we may raise a blister on the back for the relief of spinal pain, or we may apply the actual cautery to the leg for the relief of sciatica, etc. Of course one element of relief is due to the distraction of attention. But aside from this there appears to be some influence due to the fact that the two sensations are simultaneous, and the relief seems almost physiologic in character. However, nowadays it is far better to secure this distraction and this ignoring of pain- ful impressions by direct psychotherapy. Of the systemic influences to relieve pain the opiates, and in particular morphin, deserve the first rank. Morphin acts by caus- ing the brain not to receive the impressions sent in from the in- flamed area. As we have noted elsewhere, this has no effect on the local condition and should be thought of purely as symptomatic treatment. So, too, the coal-tar derivatives. But it may be said of some of these that they are also antiseptic. Hence, in the microbic in- flammations the coal-tar analgesics may meet a causal as well as a symptomatic indication. Sometimes a systemic analgesic is not necessary, and a simple h'ypnotic, such as chloral, or a general sedative, such as a bromid, may be sufficient to induce sleep and rest. Accurately to gauge the degree of suffering so as to select exactly the drug most suited to the case will require much experience. In general, we prefer to err on the side of too weak rather than too strong a drug to quiet the patient. Finally, for the relief of disturbed function incident to acute inflammation there is nothing quite so efficacious as physiological rest. That is, the stimulation of cellular activity incident to mild 82 TREATMENT OF LOCALIZED INFLAMMATIONS inflammations, such as an increase in the mucus discharged, is useful in so far as it promotes nutrition. But its continuance would bring harm both because it would interfere with the rest necessary for repair and because it changes the character or quality of the cellular products. Therefore, we give opium or tannin to check peristalsis in diarrhea, we stimulate the skin and bowels in ne- phritis to rest the kidneys, etc. In addition we may use crutches, both actual and metaphorical, to assist the organs or muscles in carrying out their work. Thus, we give predigested foods in cases of inflamed stomachs or intestines where it is impossible to use rectal feeding exclusively. We wash off mucous membranes with fluids analogous to the normal secretions. We take the load off bones and muscles by mechanical supports when they are inflamed and need rest. Of course, in the depression of cellular activity due to the higher grade of localized inflammation we must lend assistance and afford rest directly; for here it is the natural thing to do; only in the cases of hyperactivity did it seem abnormal. Vicarious activity of other cells or groups of cells must be secured to assist us in bringing about the conditions under which the injured tis- sues may regain their strength. Practically all inflammations produce some toxins, so that the term " intoxication " has become the generally accepted term for the systemic effects of more or less localized inflammations and even for systemic perversion of function for which we find no demon- strable cause. Thus gout and rheumatism are looked upon as in- toxications, although the causative toxin has not been satisfactorily demonstrated. On the other hand, the toxins of typhoid fever and diphtheria are thoroughly demonstrable. Hence, it becomes the duty of the physician not only to treat the local inflammation ac- cording to the principles above stated, but also to remove from the body the toxins resulting from the inflammation. In general, we make use of three channels of elimination: in- testine, kidney, skin, and the stimulation of one or all of these requires special thought in every case of systemic intoxication. We use calomel and salines to stimulate the intestine, theobromin com- pounds for the kidneys, and pilocarpin and hot baths for the skin. CHRONIC INFLAMMATIONS 83 II. CHRONIC INFLAMMATIONS For an acute inflammation to become chronic, two factors are necessary: (1) persistence of the cause and (2) feeble reaction, or lack of reaction, from the body. Thus, gonorrhea tends to be- come chronic, because it can with extreme difficulty be eradicated from the local mucosa, and yet it does not excite a systemic reac- tion sufficient to influence its vitality. The pathological condition usually found in a chronic inflam- mation is characterized by an overgrowth of connective tissue with a decrease in parenchymatous tissue and an alteration in cell products, both in quantity and character. Thus, we find the blood vessels thickened, the septa thickened, secreting cells overstimu- lated, and the other parenchymatous cells apparently carrying on a losing battle against the encroachment of the fibrous tissue. The " cardinal " symptoms of an acute inflammation are no longer all present. There is apt to be some swelling and pain, but little or no redness and heat. The cellular function remains more or less disturbed, as might be inferred from our summary of the pathological findings. The treatment of chronic inflammation involves not only an at- tack upon the cause of the trouble, but also the stimulation of the body fluids to increased germicidal power, and the removal of as much as possible of the fibrous tissue. The first is accomplished by antiseptics, the second by vaccination, and the third by such agents as the X ray and fibrolysin — agents for destroying the less resist- ant cells, such as the pathological tissues always contain. The last function is also performed by caustics, such as carbolic acid and silver nitrate. 1. Antiseptics Antiseptics are used for a direct attack upon microorganisms, and the ideal antiseptic would be one that would destroy the germs but not attack the body cells. Practically, none such has been found, and we therefore try to regulate the strength of the anti- septic solution so that the microorganisms are at least inhibited, while the body tissues hardly suffer at all. It is necessary to use antiseptics either locally or systemically (or both) in practically every inflammation, because, even if caused originally by a non- 84 TREATMENT OF LOCALIZED INFLAMMATIONS living chemical agent, the derangement of function incident to the inflammation invites the growth of any bacteria present or near by, so that, sooner or later, every inflammation is a bacterial one. Of antiseptics there are many varieties and types, and we may classify them by cost, manner of action, chemical composition, or use. Thus, Wood gives the following table showing the relation of efficiency to cost: Mercury bichlorid = $0.01 Silver nitrate = 0.22 Phenol = 0.34 Phenol sodique = 51.00 Piatt 'schlorid = 66.00 Listerine = 495.00 Our comment is simply that the extensively advertised mixtures are expensive luxuries, and should be used only when the simpler antiseptics are not available. According to method of action, we find the following types: (1) mercury bichlorid forms a chemical union with protein to form an albuminate. It is therefore not selective in its action, but, accord- ing to the strength of the solution used, attacks everything with which it comes into contact. (2) Phenol, on the other hand, acts by destroying the nutrition of the cell; that is, it destroys the cells by altering their fluids. It acts more slowly and more selectively than the bichlorid, having little effect on dormant cells and spores. The coal-tar derivatives act, in general, like phenol. (3) Formalde- hyd acts by removing the fluids of cells and leaving them tanned or hardened and lifeless. It does not corrode metals, and is more selective, but also more irritant than mercury. (4) Potassium per- manganate and hydrogen peroxid oxidize the tissues with which they come into contact. Often, therefore, they have no effect at all on tissue cells, but simply destroy organisms that can live only in the absence of oxygen because they render the pabulum of the pathogenic bacteria unusable. Naturally, attempts are being made to combine the various types of antiseptics so as to secure all the advantages and none of the disadvantages of each. Needless to say, the attempts have been failures, except financially, and when we desire efficient service we CHRONIC INFLAMMATIONS 85 still have recourse to the single antiseptic of the type desired in the special case. Thus, for sterilizing sputum, we use carbolic acid or formalin, because neither attacks the metal of the cup and neither loses its strength by combining with the albumen present. For sterilizing instruments, we use formalin or phenol. For sterilizing skin for an operation, we use corrosive sublimate in 1 : 1,000 solution. For cleansing out an abscess after opening it freely, we use bichlorid or peroxid. For internal antisepsis, we find that hexamethylena- min has some effect, but that the members of the coal-tar group must be our main reliance. Thus, we use creosote (guaiacol), salol, salicylates, etc., for toxemias and septicemias. For local washes, such as irrigation fluids for mucous membranes, we frequently use agreeably flavored antiseptic mixtures. The following formula is an example of a popular composition for this purpose : Boric acid 2.0 grams. Benzoic acid 0.1 Thymol 0.1 Eucalyptol 0.025 " Oil of peppermint 0.05 Oil of wintergreen 0.025 ' ' Oil of thyme 0.01 Alcohol 25.0 Purified talc 2.0 Water to make 100.0 When we examine this formula, we realize that as far as intrinsic value is concerned the same results could be obtained with a much simpler mixture. Hence, we advocate in the following pages the making of extemporaneous prescriptions to fit the needs of each case. 2. Vaccination The second method of attacking inflammations, that of exhib- iting either the sera of animals immunized to the particular bac- terium or the weakened toxin of the bacterium, is only in its in- fancy. It is, of course, the specific medication of which our philosophers for ages have dreamed, and even our little experience 86 TREATMENT OF LOCALIZED INFLAMMATIONS has already demonstrated the fact that when the serum or vac- cine can be appropriately prepared and given the causa morbi must yield. In the case of the serums we neutralize the toxin or destroy the microbe by injecting into the blood stream of the patient its specific antibody. It does not require the patient to develop his own anti- body, and acts, therefore, more quickly and more independently of the patient than do the vaccines. Serums can be given, there- fore, to weaker patients and in more desperate cases than can vac- cines. The typical serum is that for diphtheria, which is given in 3,000 units and upward with only good results. This is made by immunizing horses to diphtheria, and then collecting and con- centrating their blood serum. Since this serum is a good type for study, we append the following notes from a recent pamphlet is- sued by a pharmaceutical house describing their preparation : Serum Therapy of Diphtheria. — The serum therapy of diphtheria is the use of antitoxic serum for curative or prophylactic purposes. The neutralization of the toxin by the antitoxin is due to a firm union be- tween the two substances. When the toxin and antitoxin are mixed outside the body at a given temperature and concentration, the rapidity and completeness with which the two unite is dependent upon the de- gree of affinity one has for the other. In the body the conditions are more complex. Two combinations are possible for the toxin generated by the growth of the diphtheria germs: one with the antitoxin which has been injected, and a second with the tissue cells. The union of the toxin with the cells finally becomes more than a chemical combination. Processes of a biological and biochemical nature occur and the toxin becomes an integral part of the protoplasm; when this occurs, no amount of antitoxin will effect a cure. It is important to recognize the fact that antitoxin cannot repair an injury already done by the toxin, the repair depending entirely on the recuperative power of the cells. The curative action of antitoxin consists not alone in neutralizing the circulating toxin, but in tearing away the toxin bound to the tissue cells and neutralizing it. A great excess of antitoxin is necessary to effect this, as is shown by the experiments of Donitz and of Madsen. These experiments show that while only a slight excess of antitoxin may be required to effect a cure if injected early in the infection, the quantity of antitoxin must be greatly increased as the case progresses. CHRONIC INFLAMMATIONS 87 If the dose is not enough to neutralize the toxin, death invariably follows. Diphtheria antitoxin should be administered hypodermically. We suggest the following method of procedure: Cleanse the site of injec- tion, using warm water and soap, after which apply five-per-cent solu- tion of carbolic acid. The latter is antiseptic and produces a degree of local anesthesia which tends to overcome the pain of puncture by the needle. Any part of the body where the skin is loose may be selected. The best place is between the scapulae, since the patient cannot witness the injection, and is, therefore, less likely to be frightened. It is well to take this precaution in every instance where hypodermics are given to children, especially in diphtheria, because the heart is always affected by the toxins of the disease, and care must be exercised to prevent excite- ment. Inject the serum slowly and do not massage the parts. If there is one fact absolutely proved in serum therapy, it is the im- munizing value of diphtheria antitoxin to prevent contagion. While the immunity lasts only for a short time — three to six weeks — this length of time is amply sufficient to prevent the disease from spreading. As an immunizing dose 1,000 units are generally used. A therapeutic dose of antitoxin should never contain less than 3,000 units. Children require larger doses than adults, as they have proportion- ately more surface for development of membrane; they are more sus- ceptible to the disease, and have less power of resistance. In treating a case of diphtheria, it is necessary to give enough anti- toxin to completely neutralize the toxin of diphtheria, since laboratory experiments prove conclusively that animals receiving an insufficient amount of antitoxin to neutralize the toxin of diphtheria die as surely as animals receiving no antitoxin. Hence, in a patient ill with diph- theria, since it is impossible to determine the virulence and the amount of toxin that has been secreted by the diphtheria germs, the only safe rule is to give sufficient antitoxin to produce the following characteristic reactions : When you have given enough antitoxin, the membrane shrivels, the odor becomes less fetid, the pulse becomes stronger, and the general con- dition of your patient is improved. Until all these conditions are ob- served, you have not given sufficient antitoxin, and repeated injections of double the initial dose should be made every six to eight hours until the above results are obtained. Finally, a serum does not confer a lasting immunity, its protec- tion enduring only until the antibodies introduced by the physician are exhausted. 88 TREATMENT OF LOCALIZED INFLAMMATIONS Vaccines are made either by extracting the toxins of the bac- teria or by using the more or less macerated bodies of the bacteria. The purpose of vaccination is to excite the body to develop antibodies more quickly than would be done if the inflammatory focus were the only source of stimulation. Vaccination is also used (as for smallpox and typhoid) to render the body immune to a disease by producing these antibodies without having to undergo the exhausting sickness incident to having the real disease. A typical use of vaccination for curative purposes is in chronic otitis media. For in this disease so little of the bacterial toxin escapes into the blood stream that practically no antibodies are developed. Now, if a culture of the active bacteria is made and a few million of these bacteria are killed by heat and their bodies either ground up or macerated and then injected (in a vehicle of normal salt solution) under the patient's skin, a febrile reaction usually occurs, resulting in the production of antibodies which render the tissues of the diseased ear uninhabitable for the bacteria, and the inflammation ceases. So, also, for chronic gonorrhea and other inflammations accompanied by little or no systemic reaction. If the dosage of bacteria or toxin be too weak, there is danger of rendering the patient more, rather than less, sensitive to the dis- ease. On the other hand, too great doses make the patient very sick. Hence, the size and frequency of doses of vaccine is a matter requiring great study and care, for each patient must be treated individually and carefully watched all the time. To do this ef- fectively it is wise to keep the patient under observation for a few days before beginning the vaccine treatment in order to note the temperature range (the temperature is recorded every two hours) , to examine the blood and urine, and, in general, to learn as nearly as possible the exact condition of the patient's metabolism. Only with such a preliminary study can we interpret correctly the phe- nomena following the injection of the vaccine. The ideal dosage causes little or no fever and very little malaise, and the ordinary interval between doses in chronic affections should be from three to five days. (For further details, see the discussion of Vaccination for Chronic Urethritis.) INFLAMMATIONS OF THE SKIN 89 3. Caustics, Etc. Finally, in treating inflammations, we must try to remove the sear tissue and other pathological formations. In simple and ac- cessible cases this is usually done with a caustic, such as phenol or silver nitrate. For the ' ' proud flesh ' ' and exuberant granulation tissue we usually apply pure liquid carbolic acid. For scars near vital organs, where we must avoid deep penetration, we use silver nitrate either in stick or as a ten-per-cent aqueous solution. In keloids and extensive scar tissues, where it is impracticable to use either the knife or a caustic, we find that the X-ray does good service in causing a dissolution of the tissues; but for the deep- seated adhesions and fibrous bands, such as, for instance, those resulting from cholecystitis, we have had no specific treatment. A few years ago thiosinamin, a product derived from the oil of mus- tard, was introduced to do this work. It was injected subcutane- ously with varying results, but the great pain accompanying the injection greatly limited its usefulness. Lately a salicylate of thiosinamin has been introduced under the name of fibrolysin, and this is now being tried out. Just enough success has ac- companied its trial to stimulate us to continue with it. It is therefore justifiable to try this drug in cases of painful or dis- figuring scar tissues. III. INFLAMMATIONS OF THE SKIN The exciting causes for skin inflammations may be grouped un- der (1) traumatic and (2) parasitic. Under the first we would include irritations, as from rough clothing or an ill-fitting shoe, as well as cuts, bruises, burns, and abrasions. Under the second we would include boils and similar bacterial inflammations, as well as the inflammations following the attacks of scabies and other para- sites. Skin inflammations are both acute and chronic. Some, however, are so mild in their symptoms that we must call them subacute. Then, on the other hand, we must note that we find many inflam- mations with all the earmarks of chronicity that have never been acute, thus differing from the general statement made above as to the onset of chronic inflammations. 90 TREATMENT OF LOCALIZED INFLAMMATIONS 1. Traumatic Inflammations of the Skin Burns. — The indications here are for the relief of the pain, the prevention of intestinal ulcers and shock, and the stimulation or assistance of the injured tissues to regeneration. The pain is relieved chiefly by excluding the air from the de- nuded tissues. If this is not sufficient, morphin is given hypo- dermically in one-fourth-grain doses. Coal-tar products should not be given because they increase the tendency to methemoglobin for- mation, thus being synergistic with the injury, which also tends toward the destruction of the blood corpuscles. The exclusion of the air is best accomplished by the application of an astringent yet soothing ointment, but in default of better material simple sterilized vaselin will render good service. Or, when even this is not at hand, bandages saturated in neutral oils (as cotton-seed oil) will be useful. Of the astringent ointments, the simple zinc oxid (twenty per cent) is as useful as any. If one de- sires a more active ointment in order to secure antiseptic and stimulating power, the compound resorcin ointment of the National Formulary may be chosen. Its formula follows : Resorcinol 6 parts. Zinc oxid 6 Bismuth subnitrate 6 Oil of cade 12 Paraffin 10 Lanolin 35 Petrolatum 25 In extensive burns it is better to use the permanent bath (see illustration) than ointments for the exclusion of air, because this also keeps the surface clean and stimulates repair. The patient may be kept in this for forty-eight hours. The water is kept evenly at body temperature (100° F.) and constantly flowing, so that there is no danger of stagnation and sepsis. In burns covering a large part of the body surface jejunal ul- cers have been found at the post-mortem examination. Whether they are due to the changes in the blood or to more local conditions is not settled. A regard for prophylaxis, however, demands that INFLAMMATIONS OF THE SKIN 91 the bowels of the patient be kept open with saline cathartics (e. g., magnesium sulphate, \ oz. ; water, 4 oz. ; or calomel, \ grain every hour until the bowels act), and that the diet be simple and easily digested. Thus during the first few days eggnogs and rich soups Fig. 11. — The Permanent Bath. Note the heating chamber on the wall and the method of suspending the patient in the tub. (Courtesy of James B. Clow & Son, Chicago.) would be better than a general diet. The drinking of much water should be encouraged. Shock is essentially a temporary paralysis of the vasomotor system. It calls for vasomotor stimulants and vasoconstrictors. Heat is both prophylactic and remedial, and patients with severe burns need to be kept warm. The best vasoconstrictor in shock is ergot. But to be effective this must be given subcutaneously or in- 92 TREATMENT OF LOCALIZED INFLAMMATIONS tramuscularly in comparatively large doses. If available, ergo- toxin should be preferred to the crude drug and should be given in doses of ten milligrams. The ernutin of Burroughs, Wellcome & Co., or the aseptic ergot of Parke, Davis & Co., are types of com- mercial preparations of ergot for subcutaneous use that should be always at hand for such emergencies as this. The dose of these preparations when given for shock should be, in general, twice the ordinary dose. The vasomotor stimulant for shock is strychnin, and this should be given subcutaneously. Adrenalin may also be used in place of ergot when the latter is not at hand. The dose should be ten to twenty-five drops of the 1 : 1,000 solution injected into a vein or muscle. To introduce medicine into a vein one adopts, in general, the principles of phlebotomy (q. v.). Thus we prefer the median vein of the arm, but any exposed vein will do. We cleanse the surface with alcohol and ether, or soap and water and alcohol, place a com- press over the vein centrally from the selected site (the thumb of an assistant will do). As soon as the vein swells we introduce the needle into it, carefully avoiding the introduction of air, and pointing the needle parallel to the surface of the limb and in the direction of the blood current. The central pressure is now re- moved and the plunger of the syringe gently pressed home so that the fluid goes in slowly, drop by drop. As soon as the syringe is empty, the limb is raised above the level of the heart, the needle quickly pulled out, and slight pressure (best with a clean finger) is made over the puncture for a few minutes and then it is sealed with collodion. For intramuscular injections heavy muscles are desirable, therefore the glutei are preferred. When the injury does not pre- vent their use, the patient lies on his abdomen, the skin is cleansed with soap and alcohol, and the needle plunged for an inch or one and one half inches straight into the muscle of the buttocks. In obese patients the fat may be over an inch thick in this region, and we must always keep that figure in mind in inserting our needles. We must avoid plunging the needle into the tuber ischii or the ischiadic nerve. The best procedure is to take the needle from the syringe, sterilize it thoroughly, and insert it separately. We should watch for the escape of blood (indicating the puncture of a INFLAMMATIONS OF THE SKIN 93 vein) or pain (indicating the puncture of a nerve trunk). If either appears the needle is removed and reinserted elsewhere. If neither appears, the syringe is screwed on the needle, the air with- drawn from the needle (it bubbles up through the fluid to the top of the syringe), and the piston pushed slowly down. The needle is removed and the puncture treated as for the intravenous in- jection. The inflammation following the burn is treated by rest and pro- tection; in other words, the treatment is simply a sensible appli- cation of the principles already discussed. The dressings are changed only often enough to keep them clean and aseptic. If granulation tissue becomes excessive, it is touched with silver nitrate in the stick. If there prove to be insufficient skin material to cover the denuded area, islands of skin are grafted on (see a text- book on surgery for method). If there be a tendency to deforming contractures, splints are applied and passive movements used. Frost-bite. — Inflammations due to frost-bite require the treatment outlined in the discussion of chronic inflammation. Thus massage and cold baths are used to reestablish the vasomotor control, and if necessary soothing ointments are applied to overcome the itching and other symptoms of nerve irritation. (For details of remedies used, see the section on Itching.) Cuts and other open wounds are treated by cleansing the ex- posed tissue with sterile water, or in running water, until every- thing that can be washed out by the water and blood is removed. Then if dirt is still present, hydrogen peroxid should be poured in and allowed to foam out in the wound, or, if the dirt be grease, gasoline may be used (where the parts are not very delicate or sensitive). As soon as we feel certain that we have removed all of the for- eign material, we proceed to cover the exposed tissues with a sedative but antiseptic dressing to protect the exposed nerves from further irritation and the tissues from contamination. This relieves some of the pain, but it may be necessary to apply either heat or cold locally, and even morphin hypodermically before the patient is quieted. As in burns, so here, an oily substance is more soothing than a rougher one, hence comes the popularity of greases among the laity. For small wounds we can follow this in- clination and apply phenolated camphor on a bandage. This is 94 TREATMENT OF LOCALIZED INFLAMMATIONS made up of equal parts of phenol and camphor, and naturally is both antiseptic and sedative. It may be diluted with an equal amount of olive oil and still be sufficiently strong for most uses. Where the surface exposed is quite extensive, so that it is danger- ous to use an antiseptic on account of absorption, sterile bandages should be applied and the antisepsis obtained by means of the daily dressings, at which time the surfaces need to be irrigated with corrosive sublimate (1:1,000) or simple sterile water. In general, we may say that we apply moist dressings when we wish to produce a hyperemia to reduce the pain or overcome in- Fig. 12. -The Application of Heat to a Bruise or Strain bt Means op the High Candle Power Lamp. fection, and dry dressings in all other cases. For, as a general thing, bacteria cannot grow readily on a dry surface. It is for this reason that we sometimes shake a " dusting " powder over a INFLAMMATIONS OF THE SKIN 95 wound, because it keeps the surface dry, preventing thereby the development of the bacteria already within the wound and also the accession to the exposed tissue of germs from the outside. Only in case of absolutely sterile wounds do we close up the wound with impermeable dressings, such as collodion or adhesive plaster. Because of the unresisted desire to close up wounds im- mediately we have the development of tetanus in the Fourth-of- July injuries and the development of deep abscesses in abdominal wounds. Bruises. — Bruises require chiefly the alleviation of the pain and the removal of the hematoma and detritus. The first is secured through rest and the application of heat; the second through rest and the promotion of hyperemia; therefore the use of rest and heat generally bring about the cure of the bruise. The heat is produced by the hot-air cabinet where that is available; other- wise moist bandages covered with oiled muslin, silk, or paper are used. To the solution used for moistening such bandages, methyl salicylate may be added, or, better, a fifty-per-cent solution of methyl salicylate in olive oil is rubbed over the bruised surface before the warm, moist bandage is applied. Such bandages are treated as poultices and changed when they become cold or dry. Abrasions. — Abrasions are treated practically as open wounds. But the underlying tissues are usually bruised, hence they often require antiseptic, as well as moist, dressings. For this purpose, the bandages may be moistened in 1 : 2,000 bichlorid-of-mercury solution (or iodoform, five per cent) before applying. Then, if there be considerable swelling and pain, a covering of oiled silk or muslin should be wrapped about the moist bandage. 2. Bacterial Inflammations of the Skin The reaching and removing the cause of these inflammations is the point at which we usually fail, because the parasite, be it in- sect or coccus, usually lies underneath the stratum corneum of the skin. We must therefore either penetrate or macerate this layer before we can destroy the parasite. Furthermore, most of the skin parasites are propagated by eggs. We must, therefore, continue our treatment long enough to bridge over the interval until the eggs are hatched, or else use preparations strong enough to destroy 8 96 TREATMENT OF LOCALIZED INFLAMMATIONS the ova and spores, as well as the mature organisms. To meet this condition requires that the hair be pulled out whenever a hairy area becomes infected with a fungus or organism that can grow within the hair follicle and stalk. Finally, our treatment is very incomplete if it does not stop the irritation and pain caused by the organism. The standard drug for macerating the stratum corneum is sul- phur. This acts probably by being converted into the sulphids when applied to the skin, and these soften and thus make ready for removing with soap and water the horny layer. Of course the sulphur exerts some antiseptic influence on the parasites themselves, but the use of sulphur ointments without the vigorous use of soap and water is generally disappointing. Sulphur ointment is, according to the U. S. P., twenty per cent of washed sulphur and eighty per cent of benzoinated lard. Another drug that both penetrates the stratum corneum and attacks the parasite is naphthol. But naphthol is so toxic that only naphthol derivatives are used. Of these the best appears to be epicarine, and this is the drug we may use with our more fas- tidious patients who may have need of such vigorous treatment. It is applied in the form of a ten-per-cent ointment, using, if we desire to do so, even unguentum rosae as a base. Epicarine is also used in a five- to ten-per-cent alcoholic solution where the pro- longed application of the drug is not needed, as in case of the pediculi. The alcohol solution is very irritating to the inflamed skin, therefore it is wise to direct its dilution with water before ap- plying to any considerable area. Another useful drug is the ointment of ammoniated mercury (U. S. P.). This is more soothing than the others just mentioned and seems almost as effective. It is a ten-per-cent ointment in petrolatum and wool fat. The treatment of the inflammation itself follows closely the principles laid down in our general discussion of inflammations. The chief treatment is the production of hyperemia by means of the vacuum cup, constriction, heat, or poultices. Of the poultices the clay poultice is at present the most popular and the easiest to use. Its content of glycerin and methyl salicylate gives a sedative effect beyond that of the moist heat. Where it is undesirable to macerate the stratum corneum we INFLAMMATIONS OF THE SKIN 97 should choose those drugs that pass the skin quickest, such as guaiacol, camphorated phenol, methyl salicylate, etc. The writer prefers to use guaiacol in a fifty-per-cent oil solution followed by the application of heat (thermophore), because its effect is both antiseptic and sedative. Of the astringents used in dermal inflammation, the zinc-oxid ointment is the mildest and perhaps most generally used. More antiseptic and stimulating is the ung. resorcini compositum, N. F., referred to above in our discussion of burns. This quality makes it generally useful in chronic conditions and where the tissues need stimulation. Still more vigorous is the Wilkinson's ointment, also called Hebra's itch ointment, and known officially as ung. sul- phuris co., N. F. 1 All these ointments are usually reserved for chronic and obstinate cases, especially those where it is impossible to produce hyperemia or use hydrotherapeutic procedures that tend to stimulate and control the circulation of the blood through the affected areas. The use of ointments and bandages provide the physiolog- ical rest called for in our discussion of general principles. The reduction of the swelling, etc., and the restoration of function are all best provided for by the hyperemia, and when these measures do not care for the pain, the application of guaiacol is usually sufficient for that, thus obviating the use of a systemic analgesic. The inflammations shade off gradually into nutritional dis- turbances, and we^ often have to treat obscure conditions to which we can hardly apply the term inflammation because of the absence of most of the cardinal symptoms, but which, because of their sim- ilar pathogenesis, must be treated along similar lines. When con- fronted with such a condition we must ask ourselves: Is the irri- tation from without or within? Is the process atrophic or hypertrophic in character? Is it the reaction of the organism to some stimulus or is it the direct effect of some outside force ? formula: Calcium carbonate 10 grams Sublimed sulphur 15 " Oil of cade 15 " Soft soap 30 " Lard ,..,.,,,., 30 " 98 TREATMENT OF LOCALIZED INFLAMMATIONS If, now, it prove to be the action of an outside force, its treatment is the same as that of an inflammation, viz. : re- move the cause, protect the exposed tissues, and stimulate repair. But if it be a nutritional disturbance, such as the growth of a papilloma or wart, or the wasting of the skin, we must call to our aid other drugs to correct the deformity. Of such drugs arsenic holds the first place, because its dilation of the capillaries leads to a better nutrition of the tissues, and clinical experience has shown that epithelial tissues are preeminent among those bene- fited; hence, arsenic is always thought of for skin and nerve lesions. For its systemic effect, it is usually given as Fowler's solution in five- to ten-drop doses, otherwise it is given as the tri- oxid in doses of -gV to ^V grain. Frequently, in order to avoid an undesirable frequency of the dose, a slowly dissolving salt of arsenic is injected into a muscle. Of such salts we have the cacodylates, atoxyl, and arsacetin. Lately it is becoming cus- tomary to inject one of these salts every second or third day in the treatment of skin lesions that demand this quickening of the metabolic processes. Aside from its systemic effect, arsenic is useful in hypertrophies of the skin for its local caustic action. Thus, for epitheliomata it is the favorite caustic. For caustic purposes it is used in paste form, as, for instance, Marsden's paste: IJ Arseni trioxidi 1 part ; Pulv. acacias 2 parts. Another paste, less vigorous, is : Ty, Arsenous acid 1 part ; Charcoal 1 " Red mercuric sulphid 4 parts. Water sufficient to form a paste. The use of arsenic as a caustic causes pain, and therefore the 11 cancer doctors " who use pastes all try to combine analgesics with the arsenic, and for this purpose try everything from cocain to creosote. For the inflammations caused by tuberculosis of the skin INFLAMMATIONS OF THE SKIN 99 (lupus) nitric acid, or the acid nitrate of mercury, has proved to be the best caustic; apparently it forms a wall about the tissues through which the germs cannot penetrate. Atrophic nutritional disturbances in general call for stimulant applications, such as quinin, iodoform, etc. ; hypertrophic dis- turbances call for sedatives, such as oxid of zinc. In addition to such drug treatment we may use the high-fre- quency currents to influence skin nutrition. These act apparently by causing a stimulation of all the local vasomotor forces ; the skin feels warmer and moister and looks redder than before the treat- ment, hence we believe such treatments to be indicated in atrophic skin conditions, as, for instance, where the skin is dry and scaly, or where sluggish ulcers seemingly refuse to heal. This current is applied by means of vacuum glass electrodes for five to ten min- utes at a time. In all our discussion of skin inflammations, it must be under- stood that collections of pus, for example in case of boils, must be opened freely and drained. The cavity should be irrigated with an antiseptic, such as mercury bichlorid, or, if there be several pockets and recesses hard to reach, with hydrogen peroxid. The action of the latter is the more mechanical, of the former more chemical. We may here summarize the action of caustics by calling atten- tion first to the various degrees of caustic action : hyperemia, inflam- matory necrosis, and chemical solution. Second, the character of the scab (eschar) depends on the chemical action of the particular caus- tic. Thus the metallic caustics, as a general rule, give hard scabs, the alkalies give soft, and the acids hard. Thus silver nitrate forms a hard scab, carbolic acid a soft one, trichloracetic acid a hard one (carbonizing the tissue) ; so also nitric and sulphuric acids. The Vienna paste (equal parts of caustic potash and unslaked lime), London paste (equal parts of caustic soda and unslaked lime), and sodium ethylate all liquefy the tissue affected. Hence the latter are especially useful for removing horny growths (as warts), while the acids are better adapted to the softer ones. To illustrate a combination of synergists for caustic pur- poses, I give the following formula, recommended for soft warts : 100 TREATMENT OF LOCALIZED INFLAMMATIONS- Chloral hydrate 6.0 grams. Acetic acid 6.0 " Collodion 15.0 " Salicylic acid 4.0 " Ether 4.0 c.c. Mix and paint wart once a day. It is usually, however, better to use the individual drug indi- cated and thus secure a better control of its action. IV. INFLAMMATIONS OF MUCOUS MEMBRANES Since mucous membranes contain such an abundance of secret- ing glands, they need, when inflamed, more frequent cleansing than does the skin. This is the more necessary because their very moisture makes them more attractive to bacteria. Then again, their permeability permits the penetration of bacteria and their toxins to the blood stream and body fluids, thus making constitutional what was originally a local disorder. This permeability renders necessary, also, greater caution in employing drugs for the relief of mucous disorders.. For instance, we might employ many tinc- tures of powerful drugs on the skin with little or no effect on the general system; but every such tincture, when employed for the mucosa, would bring about symptoms of intoxication almost at once. Mucous inflammations are also more painful than dermal ones, and require a freer use of sedatives, which, on the other hand, need not be as strong as those required for the skin lesions. In general, it is best that the irrigating fluids which we must use so freely on mucous surfaces should have the same chemical reaction as the normal secretions of the membranes themselves. Thus alkaline fluids should be used in the nose, faintly acid ones in the vagina and bladder, etc. Secondly, these irrigating fluids do less harm if nearly isotonic with the body fluids, for they then avoid blanching or congesting the tissues irrigated unless we should seek this very osmotic effect. The term " catarrh " is often applied to chronic inflammations of the mucous membranes, but in so far as there is any definite meaning to the term, it refers simply to the disturbed function, the abnormal secretion from the membrane mentioned. Ordinarily, INFLAMMATIONS OF MUCOUS MEMBRANES 101 also, it means an inflammation in which the cell activity is too great rather than one in which it is too small. Another term often used in mucous inflammation is diphtheritis — referring to a false membrane of fibrin and leucocytes over the inflamed mucosa. This should not be confused with the disease entity known as diphtheria, in which such a membrane plays an important role. Here, as in skin lesions, atrophic conditions require stimu- lation and the hypertrophic sedation. Thus acute inflammations of the nose which incline toward turgescence and hypertrophy are generally irrigated with some soothing alkaline solution, while chronic atrophic inflammations are treated with vapors of tar, iodin, and other irritant antiseptics. Accessible Membranes In generalizing regarding the treatment of mucous inflamma- tions, we find it useful to separate them into two classes: the ac- cessible and the inaccessible. Now we can carry out the above principles when we treat accessible cavities, especially with refer- ence to irrigation — probably the most important part of the treat- ment. Thus for inflammations of the nose and throat we order the use of sprays several times a day to keep the mucosa free from detritus and to relieve the discomfort. This so completely meets the indications that in such inflammations we need to give little or no systemic treatment. The solutions for such alkaline irrigating fluids may be illustrated by the following formula: Sodii bicarb 3.0 grams. Sodii biborat 3.0 " Phenolis 1.0 " Glycerini 10.0 c.c. Aqua? q. s. ad 200.0 c.c. M. D. S. : Dobell's Solution. Add to a quart of water and use in an atomizer. The liquor antisepticus (N. F.) is another widely used formula for an indifferent fluid that may be used in many places and for many kinds of inflammation. 102 TREATMENT OF LOCALIZED INFLAMMATIONS For chronic conditions and for acute conditions where there is great discomfort and tenderness, especially of the nose and throat, we prefer to irrigate the membranes first with an aqueous solution like the above and then follow it up with an oil spray to coat over and protect the inflamed area. The following formula illustrates a type of the oil sprays used: Thymoli gr. x ; Mentholis gr. xx ; Eucalyptol gtt. xx ; 01. cubebae gtt. xl ; Benzoinol oz. vj ; 01. rosas gtt. x. M. S. : Douglass' formula. Another type of accessible mucous surface is represented by the vagina. Here there are fewer nerve-end plates or sense organs to be considered, and as a consequence the patients tolerate less care- fully selected medication. Thus in a recent text-book the following solutions are recommended for vaginal douches: Alum (1 dram to 1 pint), copper sulphate (-J dram to 1 pint), zinc sulphate (-£ dram to 1 pint), corrosive sublimate (1:3,000 to 8,000), phenol (1:30 to 60), formalin (1: 1,000 to 6,000), permanganate of potash, thy- mol, hydronaphthol, boric acid, etc. Inasmuch as the membrane is faintly acid in reaction, and the chief value of the irrigation lies in its mechanical influence, we would prefer in the above list the solutions that would do the least harm from their chemical action, e. g., potassium permanganate and boric acid. The former may be used in solutions varying from 1 : 1,000 to 1 : 4,000, the latter in two- to four-per-cent solutions. The stomach presents another slightly differing type, for it is partly accessible to irrigation by the stomach tube, yet for the most part inaccessible, largely because physicians do not recognize the value of gastric lavage. The best solution for gastric lavage is pure water, but slight modifications are made by using, for in- stance, one fourth to one half per cent salicylic acid, or, when much mucus is to be dissolved, rather strong solutions of sodium bicar- bonate or other harmless alkali. INFLAMMATIONS OF MUCOUS MEMBRANES 103 Inaccessible Membranes For the completely inaccessible membranes we must imitate the irrigation and give by the mouth solutions that will to some ex- tent at least cleanse the inflamed surface. Thus for enteritis we use mineral waters freely, choosing the less drastic and more seda- tive. For cystitis we use solutions of hexamethylenamin, but here we can also use in many of our cases direct irrigation; so it is customary to treat cystitis both by the mouth and through the urethra. In other respects than those which we have mentioned localized inflammations of mucous membranes are treated like those of other tissues and according to the general principles discussed above. Drugs Used in Mucous Inflammations Of the drugs most used in mucous inflammations, the following are the most important: Besorcin; this is practically a coal-tar derivative. It is both less irritant and less toxic than phenol, but more antiseptic; hence it is an excellent constituent for antiseptic washes. Resorcinol should not be confused with the proprietary article put out under that name. It is used for sprays in two- to four-per-cent solution and for ointments (skin) in five to thirty per cent. It is also given internally in doses of J to J grain. Bismuth subnitrate is used for gastric and intestinal inflamma- tions. It is sedative chiefly because it coats over and thus protects from irritation the denuded surface. It is slightly antiseptic. It is best given in suspension. Orthoform (methyl-ester of amido-oxybenzoic acid) is decid- edly antiseptic and anesthetic, but it is very insoluble and slowly absorbed, hence it may be added to powders (insufflation), oint- ments, or solutions to quiet the pain. Silver nitrate is given in gastric inflammation in J- to J-grain kaolin pills. It is used in one- to ten-per-cent solution for paint- ing mucous membranes to destroy the microbes and form a necrotic coat (eschar) over exposed tissue. Thymol is stimulant and slightly antiseptic. It is a phenol and shows the phenol action in paralyzing the end plates of the nerve. It is soluble in 900 to 1,000 parts of water, but freely in 104 TREATMENT OF LOCALIZED INFLAMMATIONS alcohol and oils. It is used in five-per-cent alcoholic solution for the skin, but only in 0.5 per cent for the mucosa. Eucalyptol is less stimulant than thymol. It is eliminated by the skin or bronchi. It is irritant enough to give a warm taste. Tar is such a mixture of creosote, turpentine, acetic acid, etc., that its action varies at different times. It may even have a caustic effect. V. INFLAMMATIONS OF SEROUS MEMBRANES Since the cavities lined with these membranes can be reached only through the blood stream or by positive trauma involving other structures as well, their inflammations are usually parts of constitutional disturbances and rarely confined to the one mem- brane. The treatment also in only a small percentage of the cases can be local, but must seek to affect the inflamed area through other tissues and chiefly through the circulation. True, we can puncture the pleural sac or pericardium and as- pirate an exudate, but the operation is such that we hesitate to employ it except in case of real need. Hence, in order to . avoid such an operation and at the same time follow our principles and secure rest and better blood supply, we need to employ more gen- eral measures than we needed to use for the skin or mucosa. To secure rest for the serosa? it is practically necessary to put the patient to bed and forbid any unnecessary activity, and reduce even the excursions of the thorax and the movements of the heart to the minimum. Thus in pleurisy the chest is tightly bandaged, and in pericarditis the heart is slowed by the application of ice bags, both in addition to the bed rest, which in general quiets all the bodily functions. The local circulation has to be stimulated from the outside of the body by the application of heat or cold, and since so many tis- sues besides the serosa must be affected with the serosa, we succeed less well than with inflammations in more exposed situations. We secure antisepsis only by saturating the body fluids with our drugs, hence our success is always problematic. We do find, however, that hexamethylenamin may be demonstrated in the serous fluids, and also, to a somewhat lesser degree, salol. Hence these two drugs are used generally for their antiseptic effects in serous inflammations. INFLAMMATIONS OF MUSCLES AND TENDONS 105 For the regeneration of the function of the inflamed cells and for the absorption of exudates we must depend upon stimulating the functions of the entire body. Hence we give nux vomica and cathartics, such as cascara or calomel, and potassium iodid in our cases of pleurisy ; for example, for their systemic rather than their local values. This point must be emphasized, because there is a tendency to laud drugs as specifics in serous disorders when the simplest reflection is sufficient to show the absurdity of the claims for limited local effects. On the other hand, the vigorous use of systemic treatment, either with drugs or hydrotherapy, or both, cannot fail to bring about an improvement in such inflammations. VI. INFLAMMATIONS OF THE MUSCLES AND TENDONS Inflammations of these tissues are usually either secondary or due to trauma, hence a bacterial inflammation limited to these tissues is rare, either at the inception or close, for the protected position as well as the character of the muscle tissue are inhibitory to bacterial growth. There are a number of disorders, however, that need a moment's discussion. Therefore, in spite of the obscurity that still sur- rounds the most of them, we shall mention them in this connection. In practically none do we find all the cardinal symptoms, and in most we find the characteristics of chronic rather than acute in- flammations. The treatment in general, then, is directed rather toward the relief of pain and the restoration of function than toward antisepsis or reduction of heat. Bruises. — So far as the muscles are concerned in contusions and bruises, the first indication is simply for rest. The carrying off of the detritus resulting from the injury is best obtained by the production of a hyperemia through the application of heat (ther- mophore) and gentle friction. Most of the pain in bruises is due to the injury to the skin, and the treatment of this has already been discussed. To prevent permanent contractures and to pro- mote the restoration of function, passive movements are added to gentle massage as rapidly as the tenderness and inflammations dis- appear. More damage is done possibly by too vigorous than too gentle treatment. It is well, then, to keep from making the tissues sore or red in carrying out such exercises. 106 TREATMENT OF LOCALIZED INFLAMMATIONS Strain. — When tendons and muscles have been stretched beyond their normal powers of extension, it is essential for their recovery that they be kept in a state of absolute rest for a considerable length of time. In fact, such injuries require longer periods of rest than fractures of the bones ordinarily do. Bandag- ing the muscle tightly affords such rest and also seems to have considerable good effect in the way of relief. The local application of heat to produce a hyperemia gives both relief and aids tissue regeneration in that the increased circulation helps to rebuild (or replace) rapidly. .the injured cells. As soon as the skin shows the signs of the atrophy that results from the tight bandaging, or the muscles' seem in danger of the atrophy from disuse, massage and passive movements must be begun. This insures the growth of more elastic fibers in the regenerated tissue than would occur if the tissues were kept in just one position. Rare- ly should a muscle be bound more than a week without having the dressings removed and the surfaces rubbed and brightened up ; but to set any time limit for all cases is, of course, illogical and dangerous. Myalgia. — The pathology of this condition is not well under- stood. It is probably due to an accumulation within the con- tractile tissue of irritant products, either from without the body or from a breaking down of the normal tissue. The first thera- peutic indication is for the relief of the pain. Ordinarily this will yield to the application of heat and the administration of the sali- cylates. If it is severe, morphin may be needed to tide the patient Fig. 13. — Application of Zinc Oxid Adhesive Bandage for Muscular Strain and Myalgia. INFLAMMATIONS OF MUSCLES AND TENDONS 107 over until the salicylates act. Sodium salicylate is given in fifteen- grain doses every two hours for eight doses, unless ringing in the ears appears before the whole eight are given. The local applica- tion of a fifty-per-cent oil solution of methyl salicylate (oil of win- tergreen) will prove very helpful and will have to be relied upon in case the stomach will not bear the sodium salicylate. An " im- proved " oil of wintergreen is " mesotan," which is diluted with an equal quantity of olive oil and rubbed in two or three times a day. This, like the oil of wintergreen, needs to be covered with an impermeable bandage, such as oiled muslin or paraffin paper, in order to secure thorough absorption. Most cases of myalgia are relieved by the application of the strong galvanic current, as well as by the use of considerable heat. If the incandescent lamp, or thermophore, be held over the surface, previously moistened with oil of wintergreen, it seems to have a very valuable effect in rid- ding the patient of pain and also in producing hyperemia, which in turn aids in removing the cause, in that it washes out the affected tissues. Of course, physiological rest is essential to the successful treatment of any myalgia. Since the deposit in the muscles of such irritant materials in- dicates a constitutional disorder, the treatment is not sufficient unless considerable attention be paid to the elimination of the irri- tants from the system and the stimulation of the nutrition of the body in general to insure a more perfect metabolism. Hence we give a prescription like the following, to be used for the several days succeeding the relief of the acute attack : ^ Magnesii sulf atis 90.0 grams ; Tct. gentian, co 10.0 c.c. ; Potassii iodidi 10.0 grams ; Glycerini 40.0 c.c. ; AquaB 40.0 c.c. Sig. Dilute one teaspoonful in four ounces of water and drink one half hour before meals. Dystrophia. — This is a nutritional disturbance, at present still unconquered by medical research. The best that can be done for it is the stimulation of the nutrition of the whole body by elec- tricity and massage. The electricity can best be given in the form 108 TREATMENT OF LOCALIZED INFLAMMATIONS of the sinusoidal current, using from 3 to 30 milliamperes for five minutes twice a day. The high-frequency current can also be used with the electrode to the affected muscles. This seems to have an especially strong stimulant action on the epithelial tissues, perhaps through the production of a hyperemia, perhaps through its stimulation of the nerves. It should be tried in every case of dystrophia. The application from three to five minutes daily would be advisable. Arsenic will also be found valuable for its systemic influence in these conditions. Whether it should be given in the form of Fowler's solution in from three- to ten-drop doses, or injected in- tramuscularly every other day in the form of arsacetin (twenty to twenty-five drops of a ten-per-cent solution) is a question that must be decided after the study of the individual patient. Its effect is, of course, simply general and nutritional, and in no wise specific. VII. INFLAMMATION OF THE BONES The bones suffer from bacterial attack, starting either in the marrow (osteomyelitis) or in the periosteum (periostitis). Their frequent fracture gives also an illustration of a traumatic inflam- mation. In the inflammation of bones, the cardinal symptoms of an acute inflammation are frequently all present, and with them comes the application of nearly all the general principles that we have mentioned. For instance, we find in nearly every case the need of relieving the pain, reducing the tumor, and restoring the function. The first therapeutic indication in case of a bacterial inflam- mation is, of course, rest ; usually complete rest in bed. If there is pus present, the abscess must be opened and drained. Then hyper- emia needs to be produced by the application of hot-air or vacuum cups until the diseased area is suffused w T ith good new blood. Drugs are usually of secondary importance. It may be neces- sary to give morphin at the beginning, pending the action of the local treatments. If the pus prove to be that of an organism for which we have a curative serum, this should be administered. If the general fever be high, the salicylates, salol or hexamethylena- min, are used for their systemic effect; but in general the stimu- lation of the systemic metabolism is attempted rather than the INFLAMMATION OF THE BONES 109 specific medication of the diseased area. Thus we might prescribe mix vomica for its stimulant action, hexamethylenamin for its bac- tericidal power, acetanilid for its analgesic effect, and magnesium sulfate for its cathartic action, as in the following formula : 1J Tct. nucis vomica? 10.0 c.c. ; Hexamethylenanrinaa 5.0 grams; Acetanilidi 3.0 " Magnesii sulfatis 20.0 " Elixir simplicis q. s. ad 180.0 c.c. Sig. One teaspoonful in water every four hours. Fractures (that is, traumatic inflammation) are hardly thought of as belonging to the department of therapeutics, because the set- ting of the bone and its consequent fixation in splints affords the condition necessary both for the relief of the symptoms and the restoration of function. Thus drug treatment is rarely needed, except to relieve the pain incident to the manipulation needed for restoring the bones to their proper relation. However, the restoration of function and the removal of debris resulting from the trauma are usually facilitated by gentle massage and passive movements, measures designed to stimulate the local circulation. Tuberculosis of the bones is notable because it produces no heat and very little pain. Hence tuberculous abscesses were long known as " cold abscesses " before the bacterial nature of the in- flammation was understood. The usual treatment is, therefore, simply to open wide and curette the cavities. But this treat- ment is so unsuccessful that tuberculous fistula? sometimes call for medical aid as well as surgical treatment, and the injection method suggested by Dr. Beck, of Chicago, is worth trying in every obstinate case. He injects these fistula? full of bismuth paste, and he finds that after a few injections the sinuses and fis- tula? close up and seem to heal out. In the older days a ten-per- cent solution of iodoform in glycerin was used, but this never seemed to heal the lesions as completely as the bismuth does. There are two formulae. The first, for the active cases, consists of 30 grams of bismuth subnitrate with 60 grams of white vaselin, The mixture should be made and thoroughly stirred while boiling. The second formula, for quiet cases, consists of bismuth subnitrate, 110 TREATMENT OF LOCALIZED INFLAMMATIONS 30 grams; white wax, 5; soft paraffin, 5; and vaselin, 60. Either mixture should be injected with sufficient pressure to fill up all the interstices and folds throughout the diseased area. It is not very painful, and may be repeated in two or three days. 1 In bone tuberculosis the use of the vaccine method of treatment is winning more adherents daily. The material used is one of the tuberculins, and the amount is selected according to the reaction of the patient. 1 See Baer, Bulletin of Johns Hopkins Hospital, October, 1909. PAKT II REGIONAL THERAPEUTICS CHAPTER III DISEASES OF THE RESPIRATORY TRACT THE NOSE Rhinitis Acute Rhinitis (Coryza). — The nasal membrane seems pecul- iarly susceptible to influences from other parts of the body, hence its disorders are traceable to manifold causes. Thus simple nerv- ous excitement may produce in susceptible persons an engorgement with symptoms simulating those of a beginning inflammation. Similar nasal symptoms are found introducing attacks of such systemic diseases as measles and influenza. Finally, chemical and mechanical irritation, due to the exposed position of this mem- brane and the pollution of our atmosphere with smoke, dust, and other irritants, tends to complicate the therapeutic problem. Apparently the first process in acute rhinitis is that of conges- tion. The next is infection, and with it we have all the elements of the typical inflammation. If, now, we start our treatment while the rhinitis is a simple congestion, we have a chance of stopping its progress, of " abort- ing the cold." We seek first to produce a relative ischemia of the nasal membrane by withdrawing the blood to other parts of the body. Thus a hot foot bath with mustard in the water, hot drinks, a hot pack (sweating) all tend to send the blood to the parts where the heat is applied and thus deplete the nasal supply. If now in addition we blanch the mucosa of the nose by applying active astringents, we add to the force of our efforts and sometimes suc- ceed in averting an inflammation. In the first rank among such astringents stands adrenalin chlorid (1:1,000 solution), which should be applied with a swab or spray every thirty minutes until either the feeling of congestion and oppression disappears, or we 113 114 DISEASES OF THE RESPIRATORY TRACT give up our attempt at abortion and change to the treatment of the inflammation. As in all inflammations, so here, we should accord the inflamed membrane physiological rest. This demands that the patient keep away from irritating and changeable air; that is, that he stay in his room and breathe pure, cold air. This alone is sufficient to care for most colds. In addition to the above, the mucosa should be irrigated with antiseptic and soothing vapors or fluids. Thus sprays of simple alkaline aqueous solutions, or steam from such solutions, cleanses, soothes, and stimulates the repair of the inflamed cells. Such a solution may be made of sodium bicarbonate and sodium benzoate, of each four grains to the ounce. This may be used several times a day. Somewhat further along in the disease an oil spray, driven by compressed air or by a hand nebulizer, containing menthol and similar drugs, would be very grateful. If the secretions need to be checked, atropin may be used either in minute doses (g^o grain) frequently repeated, or as one or two doses of -gV to y^o grain. For the constitutional malaise an active cathartic with a coal- tar sedative will be quite sufficient. Thus a half grain of calomel and three grains of acetphenetidin every hour until relieved would be ample. For those who wish to give more drugs, we suggest the following prescription : ^ Acetphenetidini 0.2 gram. Camphorae monobrom 0.1 Caffeinas citrataa 0.05 ' ' Hydrargyri chlor. mitis 0.03 M. f. chart, no. I. Da tales doses no. VI. Sig. One pow- der with hot water every hour until relieved. Or this: ^ Pulv. doveri gr. x ; Quin. bisulph gr. v. M. f. chart, no. I. Da tal. doses no. III. Sig. One every four hours. THE NOSE 115 To prevent the rhinitis from becoming chronic, the irrigation of the mucosa is the most important measure. While doing this, one should examine the passages to learn if there be hypertrophied turbinates, spurs, polypi, etc., which would keep up the inflam- matory irritation. Until such defects are removed, the mucosa cannot be thoroughly cleansed and kept in order. Chronic Rhinitis. — This may be due to repeated acute inflamma- tions, or to occlusions and hypertrophies, or even to the constant influence of irritants in the atmosphere. Prophylaxis plays a great role in dealing with this trouble, and therefore acute inflamma- tions, especially in children, should be thoroughly treated. Aden- oids, deformed palatal arches, and other causes of nasal catarrh should be carefully watched out for and treated. The treatment of chronic inflammation demands, first, the thor- ough and long-continued irrigation of the membranes, and sec- ond, the raising of the patient's constitutional resistance. The first is obtained by using in a good atomizer (such as the De Vilbiss) alkaline aqueous solutions twice or three times a day. The patient should be instructed to do this properly; i.'e., point the nozzle horizontally backward and move it about so as to cleanse out all the various cavities and recesses. Each treatment should be continued until the solution runs down into the mouth. Solu- tions such as the following are sufficient : ^ Sodii bicarbonatis 5.0 grams. Sodii biboratis 5.0 " Sodii benzoatis 5.0 " Resorcini 2.0 " Glycerini 25.0 c.c. Aqua? 75.0 " M. f . inhalatio. The second is obtained by strengthening the vasomotor control by means of cold sponge baths, sleeping with the windows open, and the use of appropriate tonics. The washing of the face, neck, and thorax in cold water (beginning at 70° F. and lowering the tem- perature gradually from day to day) and following this with a brisk rubbing with a rough towel does much toward strengthening the circulation of the upper part of the body. After a while the 116 DISEASES OF THE RESPIRATORY TRACT patient will be able to take cold tub baths (always of short dura- tion), and thus tone up the whole vasomotor system. The quality of air breathed has much to do with the condition of the mucosa of the air passages. Therefore every effort, es- pecially with children, should be made to keep this cold and pure. Warm and used-up air can only lead to mucous congestion and hypertrophy; that is, it weakens the circulation and dilates the capillaries. Hence sleeping with the windows shut and in warmed rooms is to be condemned. If the patient be anemic, have swollen glands, suffer from con- stipation, or have other constitutional disorders, these should be corrected as preliminary to the successful treatment of the catarrh itself. Epistaxis Nosebleed may be the symptom of constitutional disease, such as pernicious anemia or typhoid fever, or of irregular blood pres- sure following disorders of the ductless glands. Even vicarious menstruation would belong to this latter class. On the other hand, the hemorrhage may be due to the presence of nasal ulcers or varicosities. The first group requires, of course, constitutional treatment, but the temporary and local treatment is the same as for the local dis- orders. Ulcers should be touched with lactic acid (ten per cent to forty per cent) under the guidance of the eye. Varicosities and diffuse hemorrhage should be treated by the application of adrenalin chlorid applied on a tampon. Such a tampon should remain in place for thirty minutes to an hour. It should then be removed, and, if the bleeding be not stayed, a new one applied. To treat epistaxis without a speculum and the careful examina- tion of the mucosa is beneath the dignity of any well-trained physician, for every graduate nowadays has been trained in rhinol- ogy, and need not call in a specialist to clean out and examine the nares in case of hemorrhage. Syphilitic and leprous ulcers need, of course, medicines inter- nally as well as locally. THE THROAT 117 Hay Fever Hay fever is a constitutional peculiarity and not entirely due to the condition of the nasal mucosa. A disordered condition of the latter, however, intensifies the trouble. Hence patients with hay fever should have the nasal membranes and passages put thor- oughly in order. Then, if the hay fever still persists, the only real relief is to keep away from the irritating pollen. The use of serums to overcome the intoxication gives still only temporary re- lief. Similar relief seems to be given by adrenalin. Both pollan- tin (q. v.) and adrenalin should be at hand for use by such hay- fever sufferers as cannot leave home at the pollen season. THE THROAT Pharyngitis Acute pharyngitis usually accompanies an acute rhinitis and shares in its treatment. Chronic pharyngitis is generally due to the irritation arising from changeable climate, sulphurous-acid gas and other irritants, from the smoke of factories and industrial plants, or the excessive smoking of tobacco. Because of its ex- posed position and the utter impossibility of removing all the irritants, chronic inflammation of the pharynx is practically in- curable. Relief, however, may be afforded by painting the mem- brane frequently with a caustic if the membrane be hypertrophic, and with a stimulant if it be atrophic. In the former case, silver nitrate in ten-per-cent solution is usually selected. In the latter, Lugol's solution may be used. Following such topical applica- tions, the spraying the membrane with oily vapor from a nebulizer, to coat over and protect the mucosa, will be helpful. Like chronic bronchitis, chronic pharyngitis may require a change of residence and great attention to the conditions of life for even moderate alleviation. Suppurative pharyngitis and peritonsillitis require, of course, free incision and drainage. Such incisions are made where the pus seems to be bulging out the membranes, but frequently the patient cannot open his mouth wide enough to give us a clear view of the field. Then the incisions are made through the faucial pillars ver- Fig. 14. — Position of Hand and Weapped Scal- pel fob Incising Peritonsillar Abscesses. 118 DISEASES OF THE RESPIRATORY TRACT tically, about one fourth of an inch deep. To avoid too deep incision, the blade of the knife is wrapped with adhesive plaster up to the required distance from the point, and then inserted, pro- tected by the index finger. Free incision, even if the pus be not found, will prove beneficial. Ice is packed about the neck, or heat may be used if there is no danger from too free a development of pus. The throat is irrigated with cocain or menthol solutions to relieve the pain due to the tension. Sodium salicylate (fif- teen grains every two hours) or salol (five grains every hour) is given internally. Atropin is injected sub- cutaneously or given by the mouth until the throat feels its drying influence. Of course it may be necessary to give morphin by the needle to relieve the pain when it is intense. The bowels need to be kept free in both acute and chronic pharyngitis, and the use of cathartic sulphur waters for this pur- pose seems to be somewhat better than the ordinary alkaline cathartics. For available waters, the reader is referred to the sec- tion on mineral waters. The use of throat lozenges for relieving the discomfort of phar- yngitis is justified, although they do but little toward an absolute cure. The essential constituents seem to be benzoin, menthol, and some astringent (e. g., tannin). The following formula is an illus- tration of a harmless variety : Menthol gr. £%; Oil anise 1U -fa ; Benzoic acid gr. T V; Eucalyptol TTl tV- For one compressed tablet. Tonsillitis Because tonsillitis is a bacterial inflammation from the outset, it is accompanied frequently by constitutional depression out of THE THROAT 119 all proportion to the gravity of the disease. We have then to stop the progress of the local inflammation, to prevent septicemia, and to eliminate the toxins. The local treatment for tonsillitis follows the general outline given for irrigating the mucous membrane of the throat, This con- sists in the application of ten-per-cent aqueous or even alcoholic solutions of resorcinol or the swabbing of the tonsil with camphor- ated phenol — measures which are sufficiently discussed in the treatment of localized inflammations of mucous membranes (q. v.). For the constitutional treatment, the first indication is that of stopping the pain, and the following ointment may be applied to the side of the neck to relieve the feeling of tension and irritation : Menthol 2.0 grams. Methyl salicylate 5.0 c.c. Camphor 3.0 grams. Lanolin 15.0 " Soft paraffin 10.0 " Or morphin in the usual dosage may be used by the mouth or subcutaneously. It is more usual, however, to use the coal-tar products internally to relieve the general distress, both to avoid the bad effects of the morphin and to secure the antiseptic and eliminant effects of the latter. Thus a dose or two of acetpheneti- din (five grains every two hours) will relieve the pain and enable the patient to take with greater comfort the aggressive treatment outlined below. For the systemic antisepsis, it is usual to give salol in doses of two and one half grains every hour ; or sodium salicylate, ten grains every two hours. This not only renders the intestinal tract some- what antiseptic, but also seems to have some effect on the body fluids in rendering them less useful as nutrient media. The sal- icylates have also a grateful analgesic effect that makes unneces- sary other treatment for pain. Calomel or a saline laxative should be used in connection with the salol, according to the condition of the bowel. The giving of calomel in J to \ grain with each dose of salol will frequently prove a satisfactory method of administering a laxative. A prescription embodying the above features would be the fol- lowing : 120 DISEASES OF THE RESPIRATORY TRACT ^ Phenylis salicylates 0.1 gram. Hydrargyri chloridi mitis 0.01 ' ' Sacch. lactis 0.2 " M. f. chart, no. I. Da tales doses no. X. Sig. One every hour during day. The above line of treatment is usually sufficient, but our dis- cussion would not be complete if we did not mention other usages. Thus the use of tincture of aconite in one-drop (every hour) doses to relieve the fever and headache has many advocates. We do not advocate this usage because it is less certain and more depressant than salol, etc. Besides this, it lacks the stimulant influence so desirable in this disease. Where one wishes, however, to use aco- nite and belladonna instead of the coal-tar derivatives, the follow- ing prescription might be substituted for the one given above. Its value lies in its power to reduce the sensibility of the sensory nerves, to send greater amounts of blood to the surface, thus reduc- ing the temperature and the feeling of oppression, and lastly, it is cathartic. 5 Tct. aconiti 0.5 c.c. Tct. belladonna? 0.8 " Ext. colocynth. co 0.4 gram. Elixir simplicis 60.0 c.c. Sig. One teaspoonful every hour. Still another and more conventional prescription is the fol- lowing : ^ Tct. aconiti 4.0 c.c. Sodii salicylatis 4.0 gram. Spts. setheris nitrosi 15.0 c.c. Syrupi aurantii florum 30.0 ' ' Aquae dest q. s. ad 90.0 " Sig. One teaspoonful every one or two hours. This prescription combines many features, which fact, of course, has made it popular. The aconite depresses the nervous system, the salicylate is antiseptic and analgesic, and the sweet spirits of niter is diaphoretic. On the other hand, the dose of aconite THE THROAT 121 is too large and the sodium salicylate too small to meet our views. For those patients with whom we wish to use topical treatment rather than drugs much relief can be secured by utilizing the fol- lowing procedures. Thus considerable relief may be obtained by applying externally to the neck a Priessnitz bandage. This, as has already been explained, is a strip of cloth about six feet long and wide enough to reach from the angle of the jaw to the root of the neck. One third of the length of the bandage is wet in warm water, that end wrapped around the neck, and the dry por- tion wrapped over it. This tends to keep the moisture from evapo- rating and to produce a local hyperemia, with consequent relief. The cataplasma kaolini may be used for the same purpose as the Priessnitz bandage. This poultice is made up of the following ingredients : Kaolin 577.0 grams. Boric acid 45.0 ' ' Thymol 0.5 " Methyl salicylate 2.0 c.c. Oil of peppermint 0.5 " Glycerin 375.0 " This must be kept in an air-tight container and heated for use by setting the open container in hot water until it is warmed through. It is then spread on with a case knife to the depth of about one eighth of an inch thick all over the neck, from the angle of the jaw to the root of the neck and from the mastoid process on one side to that on the other. Absorbent cotton or clean gauze is then laid over the poultice and simply fastened in place with safety pins or similar appliances. It is, of course, very important to keep the stomach and bowels active during the course of tonsillitis, for the purpose of both eliminating the toxins and keeping up the patient's strength. Of cathartics calomel is the best, although magnesium sulphate is a good variant. Calomel should be used in the amount of one to two -grains daily in divided doses; magnesium sulphate should be given in solution; one dessertspoonful in three ounces of water morning and evening would be sufficient. The diet needs to be at least semiliquid and stimulating, thus 122 DISEASES OP THE RESPIRATORY TRACT hot soups, beef extracts, custards, eggnogs, illustrate what is de- sirable. The prophylaxis of tonsillitis requires the cleansing of the mouth daily with hydrogen peroxid or some equally good cleanser, and the removal of the tonsils if they show hardening, hyper- trophy, or the deposit in the crypts of white masses. The same care that keeps the teeth in order tends to keep the pharynx free from inflammation. Laryngitis The general principles of the treatment for laryngitis are the same as those for tonsillitis. There is less liability, however, of the disease having in adults so prostrating a constitutional effect. Hence more attention perhaps needs to be paid to the local treat- ment and less to the constitutional, except in children, where spasm of the glottis and other reminders of croup must be prevented. With children, therefore, it is wise to use internally some active form of iodin, such as iodized lime (one grain every hour until re- lieved), or the burnt sponge (spongia combust a) of the home- opathic pharmacopeia, as well as the local treatment mentioned below. The local applications must be in the form of sprays or vapor, or else the solutions must be applied with a camel's-hair brush under the guidance of the eye by means of the laryngoscope. The most available treatment is the inhalation of steam charged with eucalyptol or resorcinol. This is carried out by the usual method mentioned in detail elsewhere. It affords us the desired irrigation plus the sedation of the irritated nerve endings. Adrenalin can be successfully used in this condition if there be a tendency to local edema and congestion, such as usually accompany such inflamma- tions. This may be applied with a swab or sponge in the form of the 1 : 1,000 saline solution, or may be sprayed over the throat in the form of an oil solution with chloretone (Parke, Davis & Co.) vaporized in a nebulizer. The patient must, during the inflammation, avoid irritating the throat membranes by talking, or by breathing irritant gases (e. g., tobacco smoke), or by exposing himself to sudden changes of tem- perature. In other words, here as elsewhere, the most important factor«for recovery is physiological rest. We therefore ask our THE THROAT 123 patients to stay indoors and keep quiet for the forty-eight hours when the inflammation is progressive. If, on the other hand, the inflammation be chronic and there be a tendency to sclerosis, a spray of iodin and alcohol should be used to bring about an active hyperemia with a consequent regeneration of the tissue. A formula for such an application would be : Tct. iodin 120 HI ; Carbolic acid 120 1TL ; Fluid tolu soluble 1 f 5 ; Glycerin 1 f 5 ; Alcohol sufficient to make 3 f§. This should be vaporized in a nebulizer, preferably by compressed air, and taken as often as convenient; at least three times a day, for at least five minutes. The constitutional treatment, the " hardening " of the throat, and climatic changes should never be neglected in chronic laryn- gitis. Since these are thoroughly discussed elsewhere, we need only mention them here. Among such measures, we would put in the first rank the proper use of the voice, and it may be necessary to send patients to competent vocal instructors for exercises in breathing, speaking, and singing before we can cure their lar- yngitis. Spasmodic Laryngitis. — Spasmodic laryngitis is really only an exaggerated reflex to local or allied irritation, hence the treat- ment of croup and laryngismus stridulus resolves itself into a qui- eting of the reflexes. The first drug to be thought of is a bromid. Thus potassium bromid (ten to twenty grains given in solution) will, though some- what slowly, quiet these reflexes. While this drug is acting, we should apply hot compresses to the neck, supply steam medicated either with baking soda or vinegar, or use the fumes of burning stramonium leaves (or some similar herb containing one of the atropin bodies). The heat, of course, relaxes the spasm. The alkaline or acid vapor tends to fluidify the mucus. The atropin inhibits the sensory ganglia causing the disturbance. Potassium or sodium bromid should be kept in our emergency cases in five-grain tablets. For the emergency treatment of croup 124 DISEASES OF THE RESPIRATORY TRACT these tablets should be given in plenty of hot water. If we have the time and prefer to do so, we may write a prescription, of which the following may serve as an example : IJ Potassii bromidi 5.0 grams. Magnesii snlphatis 20.0 ' ' Glycerini 20.0 c.c. Essentia pepsini 20.0 ' ' M. f. mist. D. S. One dessertspoonful every half hour until relieved. In this prescription the purpose of the magnesium sulphate, it is needless, perhaps, to point out, is to open the bowels. The glyc- erin usually is pleasant to the palate in cases of sore throat, and this tends to quiet the reflexes. The essence of pepsin is here chosen as the vehicle because it is stimulant to the digestive ap- paratus. Edema Glottidis Edema glottidis is also a reflex condition, and if seen in time may be handled by quieting the reflexes, as in croup. But if not seen until all the membranes are so engorged that they practically fill the passage, we must use mechanical means for keeping the lumen free. Thus we may intubate (see Diphtheria) if the instru- ments are at hand. If not, we*may take a knife and incise the pil- lars of the fauces and other projecting masses of membranes until the exudation of blood and serum frees the passage. Then, too, we may surround the neck with cold compresses and give the pa- tient pieces of ice to hold in the mouth. We may swab the con- gested membranes with adrenalin chlorid and spray the same down into the larynx. Finally, we may do a low tracheotomy (q. v.), and should never abandon a case as hopeless until we have done it. Diphtheria Diphtheria is an inflammation of the mucosa of the pharynx and larynx of specific bacterial origin and characterized by the formation of false membrane and by great constitutional intoxi- cation. THE THROAT 125 Hence attention must be given to the local as well as the sys- temic treatment of the disease. Since the introduction of antidiphtheritic serum, we have a specific medication for diphtheria. This consists in the subcu- taneous injection of the blood serum of animals immunized to the diphtheria bacillus. Its action is that of neutralizing the toxins in the body fluids, hence it must be used before the toxins become fixedly united with the body cells of the patient, and it must be used in quantity suf- ficient to flood the patient's blood stream, and thus have an excess to neutralize additional toxins as they are discharged into the blood current. It has been found that small doses of the serum may sensitize the patient to the bacillary toxins; hence there is more danger of giving too little than too much of the serum. The initial dose is 3,000 units of concentrated serum. It should be injected in the back in the loose subcutaneous tissue near the angle of the scapula. The skin should be previously cleansed with hot water and soap and with alcohol. The site chosen should be pinched up between the thumb and forefinger and the serum slowly injected parallel to the body surface. The point of injection should be covered as soon as the needle is withdrawn with clean adhesive plaster or with collodion. Do not rub or massage the tumor formed. When a needle is not furnished with the serum, a 3 to 4 c.c. glass syringe should be used. This should be boiled and thus thoroughly sterilized before using. Additional doses of 3,000 to 5,000 units should be used every four hours until the false membrane begins to peel or other symp- toms of recovery are manifest. 1 In addition to the specific medication, stimulants and tonics 1 Investigations by Fritz Meyer (Berliner Klinische Wochenschrift, June 28, 1909; editorial comment, Medical Record, July 31, 1909) on the effect of diphtheria toxin and antitoxin upon the heart, demonstrate: 1 . " Antitoxin, if administered early in sufficient doses, absolutely prevents the fall of blood-pressure." 2. "If given later, but before the fall has occurred, it delays the onset"; but 3. "If given after the pressure has once fallen, it is quite without effect." 4. "Antitoxin given early in sufficient dose prevents myocarditis after the injection of toxin in any amount." Meyer states that large doses of antitoxin given early will eliminate cardiac complications and postdiphtheritic cachexia. He recommends 5,000 units as 126 DISEASES OF THE RESPIRATORY TRACT need to be used, as each case may demand to keep up the patient's strength. Thus strychnin and digitalis should be given to keep up the cardiac action and respiration. Atropin should be used to relieve laryngeal or tracheal spasm, and nitroglycerin should be administered in case of sudden dyspnea. The doses of each may be studied from the accompanying table (Rotch) : Age. 3 months. . 6 months. . 9 months. . 12 months. . 2 years 3 years 4-10 years 10-12 years Tinct. Digitalis. Minim. ^o to i -A to | i to 1 I to 1J * to 2 * to 3 l to 5 3 to 8 Strychnin. Grain. siooo to TooU T7T0U to 5 o 70~0 tO ^oo" 600 tO -syo irk to Too I 5 to- J to Totf TOO tO 6u Nitroglyc- erin (1 per cent solution). Minim. tV to £o A to-fV ■is to rV TV tO ^ rV to \ i to f \ to 1 Atropin. Grain. 70~OU tO 1500 TToo tO ToolS 750 to Tg-Q- TWOO to -500" TBTJ to YT5 6 00 tO ?QQ 75 o to -ris- Yoo" to ioo Locally, antiseptics and soothing vapors should be used from the beginning. Thus steam charged with lactic acid (two and one half per cent), acetic acid (vinegar), resorcinol or guaiacol, used either in a bronchitis tent or through a face mask, will be helpful in keeping the patient from choking up. This effect can be further assisted by injecting pilocarpin hydrochlorate (^ to ^ grain) hy- podermically to induce sweating and salivation. The throat should also be thoroughly swabbed out with Loef- fler's solution on a cotton wool swab. This solution is made up of Menthol 10.0 grams. Toluol 26.0 " Liq. ferri sesquichlorati 4.0 c.c. Alcoholis absoluti 60.0 " M. f. mist. Da in vitro nigro. Sig. Loeffler's solution. To apply such local treatment is difficult, and Osier recommends the following : ' ' The nurse should hold the child on her knees, well first injection, and when this is not promptly effective, 20,000 to 50,000 units at a dose. These doses conform with those of McCollum and other competent observers, who, recognizing the danger in giving too small doses to neutralize the toxins, advocate 5,000 to 40,000 units. THE THROAT 127 wrapped in a shawl, with its head resting on her shoulder. The nose is then held, and as soon as the child opens it mouth a cork should be placed between the molar teeth, ' ' and the treatment then carried out. This should be repeated every hour or two. When the nose is affected, it should be sprayed out with a strong atomizer (hold the tube horizontally) carrying Loeffler's solution diluted to twenty-five per cent. In fact, such thorough spraying (but re- peated at longer intervals) should be done in all cases in order to free the nasal passages of debris and prevent the upward spread of the infection. If the larynx becomes filled with the membrane, a tube must be inserted or a tracheotomy done. Intubation. — The idea of putting a tube through the larynx in case of laryngeal stenosis was presented by Bouchut in 1858. But v ^--— — Fig. 15. — Intubation Set — Tubes, Mouth Gag, Intubator, Extubator. Trousseau, then at his zenith, combated the proposition and it was not taken up generally, nor accepted by the Academy of Medicine in Paris, before which body Bouchut had laid his suggestions. Hence O'Dwyer, of New York, who in 1886 reported case histories 10 128 DISEASES OF THE RESPIRATORY TRACT and valuable results, is often credited with the introduction of the plan of treatment. The tubes used are so shaped that they fit into the larynx and maintain themselves in situ. They consist of a head, neck, body, and end. The head (see illustration) is expanded so that its over- hanging edges catch and hang on the false vocal cords. The nar- row neck fits in between the glottis muscles, which grasp it tightly. The swollen body fits just underneath the cricoid cartilage, and the pointed end reaches down into the trachea, its blunt point serving to make it easier of introduction. They are made of hard rubber or some noncorroding metal, such as gold or silver. These tubes are introduced by an instrument (called the intro- ducer or intubator) , which consists of a handle with a hollow shaft into which the mandrin of a tube fits. The parts are so arranged that as soon as the tube is in place it may be detached from its mandrin by push- ing on the lever on the back of the handle. In order to facilitate the removal of the tube, a thread is attached by an eyelet to its head, and the end of the thread fastened outside the patient's mouth. To keep the patient from biting the thread, it is slipped between two of the molar teeth. Another instrument (that for removing the tube) completes the essen- tial set, although a mouth gag is a necessary adjunct. The extubator is shaped like the intubator, but has hinged jaws which, when pressed against the sides of the tube's lumen, grasp it so tightly that it may be withdrawn. The patient is held upright before the operator. Young ehil- Fig. 16. — Intubation of the Larynx (CaillS). THE THROAT 129 dren have to be rolled up in a blanket so that they cannot use their arms. The operator puts his left forefinger (see Fig. 16) into the patient's mouth and pulls the tip of the epiglottis forward against the root of the tongue. The tube is passed in the median line along this forefinger until it reaches the epiglottis, and then, Fig. 17. — Technique op Intubation. (Caille, after Trumpp.) by raising the handle of the introducer, the operator directs the tube forward into the larynx. When the head of the tube reaches the level of the end of his left forefinger, the operator uses this finger to push the tube gently into place deeper in the larynx, at the same time, with the right hand, freeing it from the mandrin, and withdrawing the introducer. The threads are then passed be- tween the teeth and fastened to the patient's ear. Should the child not open its mouth readily, the operator must force it to do so by holding the nose. He then slips the mouth gag back into place the first time the child takes breath. While introducing the tube the threads are held by the third 130 DISEASES OF THE RESPIRATORY TRACT and fourth fingers of the right hand. This prevents their being lost or bitten through. As soon as the tube reaches its place in the glottis, the patient is seized with a coughing spell, which, however, soon passes and the patient becomes comfortable. If the tube slips by mistake into the esophagus we have no cough, and notice that the patient swal- lows hard, and that this pulls on the threads held in the right hand. The expert operator needs only a few seconds to put the tube into place; hence the operation makes but little demand on the patient's strength. In this respect it has a great advantage over tracheotomy. The tube should be removed as soon as the danger of suffocation is passed; the sooner the better. After extubating, the physician must stand ready to reintroduce the tube should the glottis seem about to close up. He should watch for this contingency at least half an hour. In general, the tube rarely remains more than three or four days in place. If it is reintroduced, it should not be kept longer than one to two days without another attempt being made to take it out. If the tube cannot be removed by using the extubator in the same general way in which the intubator was used (remember to raise the handle sharply in order to direct the point forward into the trachea) and pulling on the threads, one can sometimes succeed by compressing the trachea from without. To do this, we press the trachea and larynx between the thumb and forefinger, and stroke upward, and then tap the lower end of the tube with the little fin- ger. As soon as the tube seems to give way, we thrust the right thumb and forefinger into the mouth and grasp the head of the tube as it emerges from the larynx (Trumpp). The accidents that may occur are (1) the passing of the tube into the esophagus, (2) letting it slip into the trachea, and (3) the decubitus resulting from the pressure of the tube on the delicate tissues. We have already spoken of the first. Rarely does it cause any serious trouble, for the tube can be immediately drawn back by the threads, cleansed, and reinserted into the trachea. The second accident can only rarely occur. When it does oc- cur, tracheotomy should be done at once, unless the child succeed in coughing the tube out before the operation can be done. THE THROAT 131 The ulcer is most liable to occur in the front wall of the trachea where the lower end of the tube presses against it, hence the shorter the tube the less danger of the ulcer; but, on the other hand, the shorter the tube the more danger of the patient's cough- ing it out and thereby becoming asphyxiated by the recurring stenosis. The avoidance of the decubitus is to be accomplished chiefly by shortening the length of stay of the tube in the larynx. Hence we frequently try to remove the tube as soon as the tem- perature, pulse, and respiration indicate an improvement in the patient's condition, standing ready to slip it back if any signs of suffocation appear. Among other mishaps the following are worth mentioning and providing against: (1) The pushing of masses of the false membrane down into the trachea has happened several times; in one series in three and one half per cent of the cases of intubation recorded. In such cases tracheotomy must be done, unless coughing brings the mass out immediately. (2) The lumen of the tube may be filled with membrane. This rarely happens, because even large membranes may pass through the tube. When it does happen, the tube should be pulled out, hastily cleaned, and reinserted. In view of all these possibilities, whenever we intubate we should always have a skillful nurse or else remain near enough to care for these emergencies, should any arise. The tubes come, of course, in various sizes. O'Dwyer's set was as follows : No. I, for a child one year old. No. II, for a child two years old. No. Ill, for a child three to four years old. No. IV, for a child five to seven years old. No. V, for a child eight to nine years old. No. VI, for a child ten to twelve years old. While the tube is in place, the child can swallow only fluid or semifluid foods, such as custards, ice cream, eggs, etc. Swallowing is easier when lying rather flat, but varies somewhat with the in- dividual. Tracheotomy. — In threatened suffocation, and when intubation is not available, we still have recourse to opening the trachea below 132 DISEASES OF THE RESPIRATORY TRACT Fig. 18. — Tracheotomy Tube. the larynx and inserting a tube from the outside. Such a tube is curved (see illustration) so that the head fastens outside the wound in the neck and the lower end reaches down into the trachea. It must be made of noneorroding material, such as silver or hard rub- ber. A metal plate is usu- ally fitted to the neck of the tube and into eyelets in this plate tapes are fas- tened, the ends of which are tied about the patient's neck. The tubes are usually furnished with obturators to facilitate the insertion. The opening is usually made in the anterior median line just below the cricoid cartilage. When time permits, the skin, super- ficial fascia, and anterior layer of the cervical fascia are carefully divided by a vertical incision extending to one half inch from the top of the cricoid cartilage, the veins and muscles pulled aside with retractors, and the tracheal fascia covering the isthmus of the thy- roid gland and the isthmus itself pushed downward and held with a blunt retractor. A sharp-pointed knife is used to puncture the trachea and then a blunt-pointed knife is used to enlarge the opening. Usually the first puncture is made in the lowest point and the enlargement made by a slit upward. As soon as the trachea is opened, the patient coughs out a considerable amount of membrane and detritus. As soon as this has been expelled, the tube is slipped into place and fastened with the tapes. Fig. 19. — Trocar-pointed Obturator for Tracheotomy Tube. Where time and the surroundings do not permit a careful dis- section, a tube fitted to a trocar-pointed obturator (see illustration) is simply thrust at the proper place into the trachea. In this pro- THE THROAT 133 cedure, of course, we must expect some bleeding and injury to the tissues, but the final results often justify the hasty method. For either operation, the patient lies with a bottle or sand bag under the neck, so that the head is thrown far back and the front of the neck is in fullest extension. The patient's head must be in the median line; that is, the head straight. The skin of the neck is cleansed with soap and water and alcohol, as for any surgical operation. The tube is also boiled and kept in sterile solution until slipped into place. The cricoid cartilage serves as a guide for the higher tracheot- omy, in which the upper three rings are usually incised. The lower location has only the isthmus of the thyroid as a guide. Fortu- nately the high operation is usually sufficiently low to afford breath- ing space in diphtheria. After the tube is inserted, great attention is needed to prevent its becoming clogged. In fact, the inner tube should be removed every day and cleansed in an alkaline antiseptic solution. The physician himself should remove the outer tube frequently enough to be sure of its cleanliness. The tube should not be removed until the patient can breathe with the inner tube removed and the external opening of the outer tube closed with a cork; but, on the other hand, it should not be left in longer than absolutely necessary, because the voice may be impaired if it is left too long. The operation is usually done without an anesthetic. It there- fore requires good assistance and a sure hand. In order to facili- tate the incision of the trachea, a tenaculum is hooked into the cricoid and kept there until the tube is safely in place. Failure to observe this precaution has caused the puncturing of the back wall of the trachea, as well as injuries to the tissues on either side. The hemorrhage may be severe, but usually stops of itself as soon as the venous engorgement caused by the dyspnea is removed by the freer respiration. Should the coughing caused by the opening of the trachea not cease promptly, a few drops of cocain may be swabbed on the mucosa of the trachea. It is well to have a rubber bulb with a tube to fit the tracheot- omy tube always ready to suck out the membranes or detritus if the tube become clogged. Of course, one should be careful not to pump air into the trachea in the hurry of using such a bulb. The 134 DISEASES OF THE RESPIRATORY TRACT nurse should be at hand to wipe away the discharge from the tube as fast as it is expelled, and since the discharge is highly infec- tious, it must not be allowed to dry or reach anyone's clothing. It is best, therefore, to keep carbolic-acid solution on hand and keep the wiping cloths saturated therewith. The diet during the height of an attack of diphtheria is almost necessarily limited to water and thin liquids. As soon as conva- lescence sets in, broths, milk, etc., should be added as rapidly as the patient can swallow them. Prophylaxis. — All children exposed to the disease should be given an immunizing dose of antitoxin, varying from 500 units for a child under two years to 1,000 units for older children. Paralysis. — Diphtheritic paralyses are best treated by simple rest and good nourishment. THE BRONCHI Bronchitis Acute Bronchitis — Here we find an inflammation due to (1) weather changes (physical causes, such as chilling), (2) irritating gases (chemical causes), or (3) the invasion by bacteria, as after a rhinitis or in the course of the bacteremia ; or to a combination of all three. The inflammation is one of the mucosa of the bronchi, with a tendency to spread downward if unchecked, even to the alveoli, and thereby produce a broncho-pneumonia. After the first shock of beginning inflammation, with its irritant dryness, is passed, the reactive discharge into the lumina of the bronchi occurs, and this in turn may form such large masses of fibrin and leukocytes, with the ever-present bacteria, that the bronchi become practically occluded as with plugs. The patient would then suffer from want of air. Again, the smaller bronchioles may be so contracted by the reflex spasms from the irritated mucosa as to shut the alveoli .off from the access of air. Hence we have to do with a local inflam- mation and its consequences rather than a systemic intoxication such as we have, for example, in lobar pneumonia. The treatment is also mainly local. We seek first of all to re- lieve the bronchial membranes from physical and chemical irrita- tion by putting the patient to bed in a light, airy room with pure, cold air to breathe. The temperature of the room should be kept THE BRONCHI 135 even and rather low; that is, between 60° and 65° F. Draughts must be avoided by using screens, but the windows must be kept open. It is better to have no artificial heat at all than to have sulphur, charcoal, or other fumes, for the patient can be kept warm enough even in a cold room under the bedclothes. Secondly, we seek to better the quality of blood supplied to the bronchial mucosa by inducing a pulmonary hyperemia. In weak subjects we do this by applying hot packs to the chest and back (of course taking precautions to prevent chilling during the proce- dure). In robust patients we apply fomentations, alternating the heat and cold. This latter procedure is quite stimulant and needs to be carefully supervised. Next we seek to cleanse the inflamed mucosa by supplying anti- septic moisture. This we accomplish by causing the patient to inhale steam charged with volatile oils, and it is best brought about by erecting over the patient's bed a bronchitis tent and letting the steam from a boiling kettle discharge into this space. To make the tent, we place rods from the head to the foot of the bed about three feet above the patient, one on each side, and a cross rod about halfway down the bed. Sheets are hung over these rods. The front side is sometimes left open for the better observation of the patient. The steam is best generated at some distance from the patient, to avoid vitiating the air he breathes, and conveyed within the tent by a rubber tube. The steam is charged with oil by pouring enough of the latter to form a film over the surface of the water in the kettle. Because it is somewhat more sedative, oleum eucalypti is generally used at the beginning of the attack, and when the secretion is more profuse, or greater stimulation is needed, it is replaced by oleum terebinthinae. Alkalies vaporized in the steam have a tendency to fluidify the sputum by stimulating the activity of the mucous cells. Finally, we give such drugs as may be needed to (1) keep the bowels open, (2) the vasomotors under control, and (3) the secre- tions antiseptic. For the first, calomel and the salines are pre- ferred; for the second, strychnin and camphor serve well; and for the third, hexamethylenamin renders us good service. The com- bination of drugs has to be changed from day to day, because of the need one day of quieting the reflexes, the next of stimulating them, etc. 136 DISEASES OF THE RESPIRATORY TRACT The patient's chief complaint is usually discomfort, or even dis- tress, in breathing. This may be due either to reflex contractions of the bronchioles (asthma), or to the accumulation of exudates in the passages, the accompaniments of the so-called moist stage. The first is relieved by some vasodilator, such as atropin, which para- lyzes the peripheral ganglia ; or the nitrites, which dilate the capil- laries more centrally. Atropin is given in doses (adult) of -j-J-q to -gV grain, best with a needle, as needed. Amyl nitrite is inhaled by breaking under the nose (in a cloth) a pearl containing three grains. Nitroglycerin is given by the needle in -fo of a grain. The fumes of burning stramonium leaves and potassium nitrate are sometimes used, especially for children. (Prepared according to the directions given in our discussion of bronchial asthma below.) The second cause of dyspnea may be removed by giving stimu- lant expectorants. The simplest is the use of hot drinks. Thus often when giving the patient his morning cold rub, by simply giving a cup of hot milk or chocolate, one can excite an expulsive cough sufficient to clear the passages for several hours. Next come ammonium carbonate, ipecac, and apomorphin. Thus one might use the following conventional prescription: IJ Ammonii carbonatis 2.2 grams. gr. xl ; Vini ipecacuanha? 2.2 c.c. TTt xl ; Tct. nucis vomica? 3.0 " TTt 1 ; Tct. gentianse composite 12.0 ' ' 3iv ; Glycerini Aquae aa q. s. ad 240.0 " o v iiJ- M. f. mist. Sig. One to two tablespoonfuls every four hours. Or, better, because simpler and more direct in its application, the following : 5 Apomorphin. hydrochloride . 0.02-0.04 gram. gr. J-f ; Acidi hydrochlor. dil 0.05 c.c. gtt. viij ; Aq. destill 150.0 " gv. Sig. One tablespoonful every two hours. When the vasomotor tone becomes lowered, as is shown by the coldness of the extremities, irregularities of the pulse, etc., it is well to introduce camphor subcutaneously in the ten-per-cent oil THE BRONCHI 137 solution. This requires some four hours to take effect and should be introduced at the first sign of need, in doses of 2 c.c., repeated every six hours. Or, one may use caffein and sodium benzoate in doses of one to two grams subcutaneously for the same purposes. When this failure of the circulation occurs it should arouse a sus- picion of preceding circulatory disease. Consequently our therapy should be directed toward remedying this condition also. The cough of bronchitis fulfills a useful purpose and should be checked only when it exhausts the patient or prevents sleep and rest. Therefore cough sedatives (opiates) should not form a part of the routine prescriptions, but should be given separately and only as demanded. Thus heroin ( T V grain) may be given just before bedtime to insure the patient's falling asleep. In giving opiates we need always to remember their effect on the secretions, and overcome this effect by extra amounts of cathartics and other eliminant drugs. An illustrative prescription for a cough sedative, to be given as needed, is the following : ^ Heroini 0.05 gram. Fl. ext. cascarae sag 0.3 c.c. Tct. gent, co 15.0 " Glycerini 20.0 " Aquae dest q. s. ad 45.0 ' ' Sig. One teaspoonful one half hour before bedtime. If, on the other hand, there is lack of productive cough — if the inflamed area remains obstinately hard and dry — then potassium iodid, two grains every two or three hours, will assist in hastening the catabolic process and in " loosening the cough." The diet during attacks of acute bronchitis should be chiefly fluid, but rather stimulant. Thus hot soups, meat broths, kefir or yogurt, lactone, buttermilk and eggnogs, are better than the neutral fluids used in intestinal disorders. The stomach should never be overloaded, and therefore the three-hour interval between feedings should be chosen. Broncho-pneumonia. — Broncho-pneumonia is essentially an ex- tension of acute bronchitis into the alveoli. Its pathology is the same, therefore, as that of bronchitis, with the addition that some of the breathing space (alveoli) of the lungs has been put out of 138 DISEASES OF THE RESPIRATORY TRACT commission. We have to watch out for and guard against (1) ex- tension of the local process, (2) exhaustion of the heart in its effort to provide aerated blood, (3) exhaustion of the systemic strength because of coughing and other complications (e. g., gastric and intestinal or systemic toxemia), and (4) suffocation. First of all there is necessary pure, cold air and even (65° to 68° F.) temperature in the sick room. What has already been said on this matter in our discussion of bronchitis applies also here. Next the air of the room must be rendered moist and charged with soothing and antiseptic vapors from a bronchitis kettle. With children (and broncho-pneumonia is particularly a children's dis- ease) this form of treatment is the principal one, because it is so difficult to secure the cooperation of children in taking medicines and treatments. The same general principles apply as in bron- chitis : that eucalyptol and turpentine be the chief drugs for medi- cating the vapor. Greater stimulation can be secured by means of ammonia and its fumes. Yeo advocates the addition of bicarbonate of soda to the steaming water to make it alkaline, and thus more effective in loosening the exudate from the walls of the respiratory passages. To summarize: At the beginning of the attack, use a bronchitis tent with oleum eucalypti; as soon as the secretions be- come more abundant, substitute oleum terebinthinre ; if there is still clogging of the passages, add ammonia to the alkalinized steaming water, or to gauze pads held before the child's face. Ammonia may be given internally also, by giving it as the aromatic spirits in doses of one teaspoonful well diluted. This cares for the first indication. We must relieve the heart as much as possible, and the use of Henoch's cold pack will assist in this: A cloth is wrung out in water at 50° to 60° F., folded several times, and wrapped about the thorax. This is covered with dry cotton or muslin and held in place with a binder. As soon as it becomes warm (say in twenty to thirty minutes), it is replaced by another cold compress. This draws the blood to the surface and relieves the engorgement in the smaller circulation. This procedure, of course, would hardly ap- ply for use with the aged, but is particularly good for children. When, in spite of this, the heart seems overburdened, we should begin to use our digitalis freely. (See note on digitalis, p. 417.) Camphor and caffein subcutaneously may also be used, the former THE BRONCHI 139 for nervous excitement and vasomotor weakness, and the latter as a more general tonic. Strychnin is comparable to alcohol in this disorder, and should be used in emergencies to stimulate the spinal centers, and more generally to stimulate the digestive tract. In emergencies emetics may be used to excite a cough, but their weakening influence forbids their continued use. Thus Dover's powders in doses varying from J to 1J grains may be given to chil- dren from three months to five years of age, with \ to 2 grains of ammonium carbonate in a little syrup and water once or twice in twenty-four hours (Yeo). For older patients, the following pre- scription has been recommended : 5 Ammonii carbonatis gr. v ; Ammonii chloridi gr. x ; Vini ipecacuanhas nx v ; Infusi senegas §j. To make one dose. Such a dose may, in cases of need, be re- peated three or four times in twenty-four hours. Of course apomorphin may be resorted to, but it is depressing and should be combined with stimulants whenever given. The excessive cough can, of course, be relieved by an opiate, but the medicated inhalations should be relied upon to allay the bronchial irritation, in order to avoid the depressing effect of the opiates. The gastrointestinal tract should be kept active both for its value in keeping up the patient 's strength and to prevent its push- ing up the diaphragm and crowding the breathing space. The use of carbonated alkaline waters and calomel should be continued throughout the disease. Diarrhea should be controlled by enemata (saline), tannalbin, and the avoidance of fermentable foods. For lividity and other signs of collapse, oxygen, electricity, hy- podermic injections of strychnin and apomorphin, should be used, the last to start up coughing or vomiting, and thus reestablish the aeration of the blood. The drugs may be assisted in this effort by the stimulant action of hot and cold packs to the chest and ab- domen, as recommended elsewhere. The diet must be of the simplest : milk, broths, albumen water, eggnogs, etc. Cold water should be drunk freely. 140 DISEASES OF THE RESPIRATORY TRACT Chronic Bronchitis. — The chronic bronchial catarrhs are espe- cially prevalent in Great Britain (Yeo) and in the cities of the United States. They are due partly to the unfavorable meteor- ologic conditions (changeableness, etc.) and partly to the presence in the air of great quantities of irritant gases (e. g., sulphurous acid), and helped into being by the ever-present bacteria. Gener- ally speaking, then, the inflammation is due to chemical and physical irritation, more or less complicated by the presence of bacteria. The presence of the latter and their effect on the bron- chial membranes usually determine the character of the sputum, whether putrid and abundant or thin and scanty. The indicated treatment is naturally — what is most difficult to secure — a change of residence to a climate more favorable and Fig. 20. — Respirator (to be fastened over the nose). an air more pure. Simple trips to the mountains, or sea voyages, may help the disorder, but permanent relief can only be obtained by a permanent change. Even with a change of residence, sufficient treatment to clear up the existing inflammation is usually necessary. The first object of such treatment would be to check the inflammation and the sec- ond to restore the tissues to as good condition as possible. THE BRONCHI 141 The first is obtained by the use of antiseptics and hyperemia (the former are given by inhalation), the second by breathing exer- cises and hydrotherapy. Thus sending a patient into the pine forest, where the air is pure and the meteorologic conditions favor- able, and providing him with a respirator or turpentine pipe, usu- ally succeeds in checking at least the bacterial growth. These prin- ciples are followed, for instance, in the sanatoria of the Bavarian Alps with great success. The respirator is made of perforated zinc or hard rubber, to fit over the nose, and contains a sponge that is kept moist with tur- pentine. It needs to be worn practically all the time. The turpentine pipe consists of a glass bottle with two tubes, as shown in the illustration. The bottle contains warm water, on which floats a film of turpentine. The patient should carry this about and " smoke " it the greater part of the day. The turpentine is chosen because it is both stimulant (i. e., slightly irritant) and antiseptic, when carried in finely divided form, to the mucosa of the bronchi. It thus fulfills well the conditions demanded for the first part of the treatment. The hydrotherapeutic measures consist in alternating douches, hot and cold fomentations, the drip sheet, etc., all measures to stimu- late a more rapid flow of blood to the parts treated. The " wechsel- douche " may be played on the back and chest for five minutes a day, giving rapid interchange of temperature from 70° to 60° F. and from 120° to 110° F. Where this apparatus is not available, the hot and cold fomentations, one day to the back, the next day to the front of the chest, would do fairly well. After either of these procedures, the skin should be dried with brisk friction and the patient made to rest for an hour. i ' ^^ ^— ~ j- ~ == ~~ Wi j r \ iil i '1 6L, Fig. 21. — Turpentine Pipe. (a) Water; (6) turpentine. 142 DISEASES OF THE RESPIRATORY TRACT Drugs may be used internally to approximate these same re- sults, but their success is but indifferent. Thus guaiacol and am- monium carbonate may be given in the following prescriptions : ^ Creosoti Olei terebinthinae aa TTt xvj ; Glycerini gj. M. f. mist. Sig. A teaspoonful in hot milk t. i. d. IJ Ammonii carbon Sodii bicarbonatis aa gr. xl ; Spts. chlorof ormi TIX clx ; Infusi senegae ad gviij. M. f. mist. Sig. Two tablespoonfuls in hot water every five to six hours (Yeo). A formula for an inhalation that may be used instead of the simple turpentine is the following: IJ Thymolis 3 j ; Acidi carbolici 3ij ; Spts. chlorof ormi §j. M. f. inhal. (Whitla.) Of course other balsams and essential oils may be used, should turpentine, thymol, and carbolic acid prove distasteful to the in- dividual, but our success has been best with the turpentine. During the treatment for chronic bronchitis, the patient should be put on an extra strong diet similar to those mentioned for phthisis (q. v.) and made to live out of doors, best in a forest re- gion free from the dust and smoke of the cities. In addition, the use of mineral waters to stimulate the digestive tract has sometimes proven worth while. Of these waters, those charged with sulphur seem the most successful. When cavities have been formed (bronchiectasis) the treatment is similar but usually more vigorous. In particular, the regular emptying of the cavities by means of emetics (in small doses) must be cared for : for instance, apomorphin and fluid extract of ipecac, the former in one tenth grain, the latter in ten- to fifteen-drop doses, every morning before breakfast. Sometimes the morning cold bath, followed by hot drinks, is sufficient to produce this result THE BRONCHI 143 without recourse to the nauseant emetics. At any rate, the effort should be made to obtain the result without them. To this end, the patient should lie every morning with hips high and shoulders low to promote the flow of the contents of the cavities into the bronchi. This usually brings on an expulsive cough, and the whole mass of exudate is ejected out of the mouth. Bronchial Asthma Asthma may be caused by (1) cardiac weakness, (2) hysteria or other neuroses, (3) by reflex irritation — e. g., from the nose, and finally (4) by chronic bronchitis. The treatment of the former types has been mentioned in our discussion of symptomatic therapy. And since the underlying disorders must be corrected by the appro- priate therapy, and this is discussed in the appropriate sections, therefore only the last type requires mention here. This is one of the most exasperating and obstinate affections with which the physician has to do. Probably the greatest relief may be obtained in the dyspneic attacks in the course of chronic bron- chitis by the intravenous injection of 10 to 120 drops of adrenalin chlorid in 1 : 1,000 dilution. This raises the blood pressure tem- porarily, and, whether by stimulating the right heart or by toning up the bronchioles, at any rate brings relief for considerable time. The injection may be repeated with impunity within an hour or so. The symptomatic treatment follows the lines of the popular use of the atropin group. Thus the dried leaves of the jimson weed (stramonium) may be smoked, or powdered belladonna mixed with a cubeb compound and smoked as a cigarette. A convenient for- mula for such a preparation is the following (Thornton) : Hyoscami foliorum 0.60 gram. Belladonnae foliorum 1.20 ' ' Stramonii foliorum 1.20 " Pruni virginianae foliorum 0.60 ' ' Potassii nitratis 0.60 " Aquae q. s. ad 15.00 c.c. Directions. — Dissolve the potassium nitrate in the water, moisten the leaves, roll into ten cigarettes. Smoke or burn on a plate three to four for relief of asthma. The interval treatment is that of the bronchitis. 11 144 DISEASES OP THE RESPIRATORY TRACT THE LUNGS Emphysema This is a mechanical rather than an inflammatory change. It is caused by compensatory or other efforts to force air out of the lungs while the vesicles are distended; hence prophylaxis is of greater importance than treatment, for the condition, once estab- lished, cannot be removed. All that the physician can do is to guard against and treat the various inflammations to which the condition is liable. Of these, bronchitis is chief, and is, in fact, an almost constant accompaniment of the condition. The principles laid down in our discussion of chronic bronchitis must govern here, also. First, the patient must live, if he is to have a tolerable existence, in an equable climate, such as Egypt, Porto Rico, or California. Second, he must avoid great exertion. Third, he must be temperate in all his habits. For the treatment of acute attacks and exacerbations, the breathing of compressed air (pneumatic cabinet) and the inhala- tion of bronchial sedatives, with the administration of morphin, will have to be resorted to. It will often be found necessary to stimulate the right heart with digitalis. Edema Edema is essentially a overflow of blood from the pulmonary vessels. It may be caused by an increase in blood pressure in the pulmonary circulation, due, for instance, to failure of the right heart, or to a weakness in the vessel walls, so that an ordinary blood pressure proves too great for them. At any rate, the blood serum leaks into the lung tissue. The treatment therefore consists in relieving the local high blood pressure. The most effective method is to remove 200 to 300 c.c. (6 to 10 oz.) from a vein. (See Phlebotomy.) Next we seek to stimulate the contraction of the vascular walls by using intravenously ten drops of a 1 : 1,000 solution of adrenalin. If bubbling rales indicate the presence of considerable fluid in the air passages, diffusible stimulants (e.g., aromatic spirits of ammonia) should be used in teaspoonful doses frequently repeated. THE LUNGS 145 Should the patient recover from the first attack, the underly- ing condition causing it — nephritis, myocarditis, or anemia, etc. — should be looked after in order to prevent its recurrence. Pneumonia Here we have to treat not only a local inflammation with an exudate of fibrin and leukocytes into the air vesicles, but also a constitutional intoxication with the usual effect of such intoxica- tion on the nervous system. The work of the therapeutist must be directed, therefore, not only toward combating the spread of the local disorder, but also toward sustaining the bodily functions and neutralizing the effects of the bacterial toxins until the disease has run its course. Of course this would include, in an ideal scheme, the neutralizing of these toxins by the use of sera from animals immunized to the bacteria causing pneumonia, but as yet we have not developed any sera that are sufficient for the purpose. Hence our work is practically confined to the stimulation of the bodily functions and the protection of the tissues against any accident due to changes in temperature, unwise activity, indigestible food, etc. The local condi- tion is probably best treated by producing about the patient an even temperature, warm enough to pre- vent any drain upon the patient's vitality and yet at the same time permitting the patient to breathe air that is pure and cold enough to be a stimulant to the respiratory surfaces. Where the room temperature cannot be perfectly controlled, the protection to the chest is obtained by applying a jacket made up of uniform layers of cotton (the so-called pneumonia jacket) and sewed on, from the neck to the waist. This produces also a helpful hyperemia about the throat of the patient. Some practitioners try to obtain Fig. 22. — Applying a Clay Poultice. 146 DISEASES OF THE RESPIRATORY TRACT Fig. 23. — Covering the Clay Poultice with Cotton Jacket. the the same effect by applying a thick clay poultice, such as we men- tioned for tonsillitis. This, however, has the disadvantage of requiring changing after twelve or twenty-four hours, while the cotton jacket may remain on for several days at a time, if neces- sary, without injury to the patient. The matter of changing a poultice is of greater importance than would appear at first sight, because patients suffering from such severe dis- ease as pneumonia show such extreme prostration that every effort must be made to keep them from using more strength than is ab- solutely necessary. Hence, also, frequent examination of the chest should be avoided, although we must keep close watch for changes in the patient's condition. The air of the room should be kept at about 68° F. by admit- ting freely the air from out of doors. To prevent draughts, screens should be placed between the bed and windows, and the patient's body protected by a light flannel shirt or by the jacket mentioned above. The air of the room should be kept moist by the use of steam, as mentioned for bronchitis, especially if the climate be a dry one. The nurse should not regulate the temperature by her feeling, but by the consistent use of a thermometer. The constitutional treatment consists first of all in watching the heart and arterial system and stimulating them according to the changing conditions. When, because of the obstruction in the course of the pulmonary circulation, the right heart seems to be overburdened, digitalis is used to drive the blood in greater quan- tities to the extremities, and by means of the prolonged systole refresh the heart muscle. It is best used on the slightest suspicion of the heart's weakening, which should be aroused by a fall in THE LUNGS 147 the blood pressure, in order to allow from twelve to twenty hours for its taking effect. Of digitalis, digitoxin is probably the efficient principle, but this cannot be used hypodermically because so in- soluble. Therefore for subcutaneous medication (and we use sub- cutaneous administration when the stomach is at all upset) we have recourse to digitalinum germanicum, which affords a more rapid action than if the entire drug were used by mouth. In using digitalis, one should always remember its slow action and its lia- bility to cumulative effects ; hence it is best to give the drug early and in heavy doses. Furthermore, we should use it only for a short time and then stop entirely. For instance, if one is using tincture of digitalis, one may give thirty-drop doses every four to six hours for three days and then stop. If one is using Merck's digitalinum germanicum, it may be used even as high as one to two grains (ordinarily one fourth of a grain) at a dose every four to six hours until the emergency has passed. Unfortunately this preparation contains a large quantity of digitonin, which is depressant in its action. Digitalis steadies and slows the heart, compelling the blood to flow through the lungs more rapidly, thus having a tend- ency to give better blood to the lungs, as well as to freshen up the heart. The use of digitalis is therefore justified even when there is no actual collapse of the heart. When the skin becomes clammy and pale, atropin is used in the dosage of ■£$ of a grain (best subcutaneously) to dilate the capil- laries and equalize the blood pressure. This also tends to reduce the burden on the right heart and dry up the secretions clogging the bronchi. Some attention should also be directed toward keeping the fever within reasonable bounds. What these bounds are depends, of course, on the individual patient, and if the patient is bearing the temperature easily, it is ordinarily unwise to reduce the tempera- ture by depressants. The reduction of temperature, when neces- sary, may be accomplished either by cold rubs or antipyretic drugs. Thus acetphenetidin in five-grain doses is used by some to reduce the temperature, but since its effect on the blood is bad, it should be avoided whenever possible. Other physicians use drop doses of the tincture of aconite, especially at the beginning of the fever, every hour as a routine measure for this purpose; but frequent sponging with cool water is a safer procedure than the giving of 148 DISEASES OF THE RESPIRATORY TRACT internal antipyretics, or the ice bag may be applied to the chest if a nurse is not constantly available. The excretory organs must be kept active enough to carry quickly from the body the products of the excited metabolism. For this purpose the saline cathartics and calomel are preferred to the vegetable cathartics. Dr. Galbraith, of New Mexico, has reenunciated the belief, at one time quite prevalent, that pneumonia may be aborted, or at least greatly lightened, in its course by the use of enormous doses of quinin in the first three days of the disease. For instance, in the first twenty-four hours eighty grains of the quinin bisulphate may be given ; in the next twenty-four hours fifty grains ; and in the next, from fifteen to twenty-five grains. If the disease at that time still persist, then he would stop the quinin and proceed along the regular line of symptomatic treatment. In weighing the value of this line of treatment, one should remember that quinin is not a drug that is neutral or negative in all other lines than the one for which it is given, and that its toxic action on the heart and central nervous system might be sufficient to make it dangerous in itself. Therefore one should be cautious about giving this type of treatment in any case except with the most robust individuals. Strychnin acts upon the spinal cord, and if the respiration seems to be getting irregular and shallow, strychnin is the indi- cated remedy. In giving this drug, it should be remembered that its action is rapid and evanescent, although the total excretion lasts from two to eight days. It is better, therefore, to give it in small doses frequently repeated than in larger doses at longer intervals; e - g-> eV °f a grain of the sulphate or the nitrate every two hours rather than ^ of a grain every four hours. To raise the blood pressure and restore the vasomotor tone caf- fein and sodium benzoate hypodermically in one- to two-grain doses may be found necessary. I prefer, however, a neutral oil solution of camphor in 2-c.c. dose (6 c.c. pro die), hypodermically. This needs some four hours for effect, and hence cannot compete with caffein in rapidity of action. Frequently the two drugs may be given together, the camphor to supplement the caffein. Strychnin has the advantage over caffein and camphor in its stimulation of the appetite and digestion, but its evanescence and reaction make it less reliable. THE LUNGS 149 If the simple pneumonia pack does not seem sufficient to bring about the local absorption desired after the crisis, hyperemia may be increased by the use of the alternation of hot and cold cloths or by the application of hot fomentations to the skin of the chest and back. These applications should not be made so as to fatigue the patient, and it is better to leave them out entirely than to run any risk of exhausting the reserve strength, hence they should be used only in those cases of slow resolu- tion where the pa- tient seems otherwise convalescent, but where local stimula- tion is needed. To apply the hot and cold fomentations, the following procedure is suggested: A cloth wrung out in hot water is laid over the consolidated area and leit lor three to live jp IG 24. — Fomentation to the Back of the Chest. minutes. This is fol- lowed by a cold cloth for the same length of time, and so on from thirty to forty minutes. Have the boiling water in a large pail. Fold the cloth about four times. Taking an end of it in each hand, immerse as much of the cloth as possible in the boiling water and when it is thoroughly saturated, twist the ends of the cloth in op- posite directions, thus wringing the cloth without placing the hands in the scalding water. Hastily shake out, smooth, fold to the required size, and place within a dry cloth. The dry cloth should have been previously folded in thirds, so that either one or two thicknesses may be interposed between the hot wet cloth and the patient. To relieve pain renew the application every minute or two. When otherwise indicated, renew the fomentation about every three minutes, having a fresh fomentation ready to apply be- fore removing the one in place. The irritation of the bronchial mucous membrane (shown by a persistent and unproductive cough) is usually relieved by letting 150 DISEASES OF THE RESPIRATORY TRACT the patient have steam to inhale. If the sputum is tenacious and the mucosa needs stimulating, turpentine should be put in the water in sufficient quantity to form a film ; but if the mucosa need more of a sedative effect, eucalyptol is better. Sometimes such a cough — if it be clearly not reflex, as from pleural effusion — is quickly relieved by a Priessnitz bandage or cold compresses over the trachea. In this connection I would reiterate the necessity of having the air of the room fresh and pure, and of protecting the body of the pa- tient from being chilled by this fresh air by means of warmer cover- ings and by screens between the bed and windows, because I believe that the temperature of the respired air has a very decided influence on the disease. Hence for steam inhalations one should arrange the apparatus so as not to vitiate the air of the room (e. g., we may gen- erate the steam outside the room and bring it to the bed in a tube). The condition of the intestines is of immense importance in this disease, therefore from the very beginning one should use thor- ough catharsis. Some men prefer for the initial drug calomel in two- to five-grain doses, others give heavy doses of mag- nesium sulphate or some similar saline cathartic. Whatever is chosen for the initial cathartic, it must be followed up by daily catharsis to prevent fermentation and intestinal toxemia, which might result from stagnation and add other dangers to the disease. For this purpose, one to two grains of calomel daily, administered in one-fourth-grain doses (best as calomel and wintergreen) will be found quite efficient. The diet should be stronger than that of typhoid fever or other enteritis, but should be liquid and easily digested. We give, there- fore, every three hours beef juice (not beef extract), grape juice, egg lemonade, eggnogs, gruels, etc., according .to the patient's di- gestion. If the digestion be bad, then peptonized foods should be used. The amount of food usually given at a feeding varies from four to eight ounces. Water may, of course, be freely given, and acidulated water will prove especially refreshing. For this the following prescription has been often used : IJ Acidi phosphorici 20.0 grams. Syrupi simplicis 20.0 c.c. Aquas 180.0 " Sig. One teaspoonful in water, as needed. THE LUNGS 151 In very robust subjects, the pulse is frequently so bounding and the blood pressure so high that relief by direct interference, such as a venesection or bleeding, is indicated. This should be carried out under aseptic conditions, as indicated in the following paragraphs. Phlebotomy. — Bloodletting has been in use since the earliest de- velopment of medicine. Hippocrates, Galen, and Celsus seem to have practiced it. It is mentioned in the Bible and Talmud. Among the primitive Arabs the term " son of a bloodletter " was one of reproach, and the bloodletters seem to have been suspected of being vain, gluttons, and unchaste. Rhazes (about a.d. 900) praised the procedure. Sydenham and Boerhaave laid great stress on bloodletting. This probably led to an extreme, and it was re- sorted to needlessly. Thus we find the following couplet under the name of Joh. de Mediolano: Exhilarat tristes, viatas placat, amantes Ne sint amantes, phlebotomia facit. The reaction came from the Vienna school, which adopted the ' ' ex- pectant " treatment for most diseases. Thus Dietl, a pupil of Swoda's, objected to its use in pneumonia in 1849. Lately, how- ever, bloodletting is coming into fashion again. Instruments. — One needs only^a small lancet (the old-fashioned lancet was sharpened on both edges, and provided with a tortoise- shell or horn handle, which enabled one to close it and carry it in the pocket) and a sterile gauze bandage two inches wide. Even this latter can be dispensed with and a handkerchief with collodion used instead. Fig. 25. — Median Vein. Place. — The vena mediana in the bend of the elbow is best adapted to the procedure. The places are well shown in the accom- panying cut. 152 DISEASES OF THE RESPIRATORY TRACT Method. — The patient lies on the left edge of the bed. The doctor sits by the bedside so that the patient's left arm is between his own left arm and body. A bandage or compress is drawn twice about the upper arm and knotted on the outside. The doctor fixes the patient's arm with his left hand somewhat distally from the point selected for the opening. He grasps his lancet so that his finger tips are just a few millimeters from the point and sticks it into the vein, either parallel or somewhat obliquely to its course. The skin of the elbow should, of course, be cleansed beforehand for the operation by scrubbing with hot water and soap, followed by alcohol. It should be dry before the cut is made. As soon as sufficient blood is received in the sterile vessel (it is best to have a glass graduate in order to know at each moment how much has been removed) the bandage is removed from the upper arm and a small compress of sterile gauze is applied to the wound. This should be fastened into place with adhesive strips, and should remain in place for twenty-four hours, during which time the arm should be carried in a sling and kept quiet. After this, the compress may be removed and the wound sealed with collodion. The amount of blood to be taken is ordinarily only 100 to 150 c.c. (3 to 4 oz.). In very robust and plethoric individuals the amount may be increased to 500 c.c. The rule is to let 1 c.c. of blood for each pound of body weight. As a matter of historical interest, we quote the following table of amounts from the work of Marshall Hall, published in 1830, from the London Practitioner for March, 1909: I. Augmented Tolerance. — Represented by the mean quantity of blood which flows before incipient syncope: A. Congestion of the hrain: (1) Tendency to apoplexy, 1 (2) Apoplexy from congestion, j B. Inflammation of the serous membranes: (1) Arachnitis, (2) Pleuritis, (3) Peritonitis, (4) Inflammation of the synovial mem- brane and of the fibrous textures of the joints, 40-50 oz. .30-40 oz. THE LUNGS 153 C. Inflammation of the parenchyma of organs: (1) Of the substance of the brain, " (2) Pneumonia, (3) Hepatitis, (4) Inflammation of the mamma, 30 oz. D. Inflammation of the skin and mucous membranes: (1) Erysipelas, 1 (2) Bronchitis, V 16 oz. (3) Dysenteria, J II. Healthy Tolerance. — This depends on the age, sex, strength, etc., and on the degree of thickness of the parietes of the heart and is about 15 oz. III. Diminished Tolerance. — (1) Fever and eruptive fevers 12-14 oz. (2) Delirium tremens and puerperal de- lirium j 10-12 oz. (3) Laceration and concussion of the brain, (4) Accidents, before the establishment V . . 7-10 oz. of inflammation, (5) Intestinal irritation, (6) Dyspepsia 8 oz. (7) Cholera 6 oz. Accidents. — If the blood does not flow, the patient should close and unclose his fist, or rotate his hand. The doctor can help by massaging the veins. If little tags of fat get into the wound, one simply removes them with a knife or scissors. If the patient faints, one simply interrupts the procedure — no evil consequences occur. Thrombosis does not occur when the operation is carried out at all correctly. Only gross carelessness permits the operator to punc- ture an artery. The effect on the blood is to stimulate the blood-building organs and in from two to five days the number of corpuscles has returned to the normal. If the loss of blood reaches one third the total amount in the body, then it may take about fourteen days to secure normal conditions again. 154 DISEASES OP THE RESPIRATORY TRACT Indications. — (1) Septicemia and toxemia. This indication in- cludes even carbonmonoxid and carbonic-acid poisoning. It is indicated also in uremia and diabetic coma. In many of these cases the blood is removed and sterile normal salt solution imme- diately put into the vein. (Release the upper bandage before be- ginning the injection of any solution.) (2) Circulatory disturbances, especially in cases of venous hy- peremia, as in pneumonia, cardiac failure, and pulmonary edema. It is even useful in plethoric conditions of the sedentary and obese. (3) Bloodletting may stimulate the building of the blood ele- ments sufficiently to make it a desirable procedure in gout, chronic rheumatism, and chlorosis. Complications of Pneumonia. — The delirium of pneumonia is best treated by the camphor injections and the application of cold (ice cap or Leiter's coil) to the head. Gastric irritation, vomiting, or diarrhea usually indicates that a mistake in feeding has been made. The intestinal tract should be immediately cleansed with salines (or castor oil) and then feed- ing cautiously recommenced with milk or broth as a basis. Pleurisy The inflammation of the serous membranes lining the lungs leads either to a thickening and roughening of the intrapleural surfaces, or to the formation of bands of adhesions between the two surfaces, or to the exudation of fluid into the pleural sac. This fluid may be serous and sterile, or sero-fibrinous, or sero-puru- lent. From the therapeutic standpoint, the amount, as well as the character, of this fluid is important, because the amount de- termines whether it interferes with the movement of the heart or lungs. And on the character depends whether or not it will be absorbed. Pleurisy is usually secondary to pneumonia and gives more distress to the patient than does the pneumonia itself, thus demanding the specific attention of the physician. The pain in pleurisy is due to the rubbing of the two inflamed and rough- ened pleural surfaces upon each other in respiration; there- fore this pain may be decreased by restricting the respiratory ex- cursions of the pleura and ribs. This is done by bandaging the THE LUNGS 155 lower ribs tightly with adhesive plaster, so that the patient can breathe only with the diaphragm and upper ribs. Then, too, some of the pain may be done away with by using heat locally in the form of hot-water bottles, hot irons, the thermophore, etc. Usu- ally, we try these mechanical procedures before any drugs are given. Morphin is the only drug that is efficient in banishing the pain ; and in cases of pleurisy accompanying pneumonia, it should be given with the hypodermic needle in the dose of J to J grain, ac- cording to the reaction and condition of the patient. Thus, if the patient be a child, the dose should be -fa to J of a grain ; if the pa- tient be an adult and habituated to morphin, the dose should be J to J grain. On the other hand, we find patients whose respira- tion and heart action are readily depressed by morphin even in |-grain doses. If the patient be a stranger to the physician, it is wise for him to give first J of a grain and stay and watch the effect, repeating the dose in one half hour if necessary. For the absorption of the exudate, potassium iodid is a useful drug. This acts simply by hastening the process of catabolism, thus producing a house cleaning in the body. This house cleaning carries with it the cleaning up of the pleural sacs also, but in no wise is the action a specific one. Hence the use of potassium iodid is very frequently without any perceptible result at all ; and then, other measures (chiefly hydrotherapeutic) looking to the produc- tion of a hyperemia in the chest, must be resorted to. Another drug for similar purposes is guaiacol. This is given in a dose of two to fifteen drops rubbed well into the chest or ab- domen. Its action is to produce, when absorbed, a similar catabo- lism to that of the iodids, but it has also an antipyretic action on the nerve centers and an antiseptic action on the tissues through which the drug is absorbed on its way to the circulation. The anal- gesic effect of guaiacol when applied locally in this way should be kept in mind, because it will frequently enable us to avoid the use of morphin or other habit-forming or depressant drugs. Fibrolysin may be used in cases of old adhesions and roughened pleurge to remove the inflammatory tissue and restore the two rub- bing surfaces to their integrity. Fibrolysin hypodermically may be of assistance in bringing about the absorption of an exudate. It should be given in doses of 156 DISEASES OF THE RESPIRATORY TRACT 1.13 c.c. daily for two days, then in double that dose on alter- nate days. In exudative pleurisy drugs are often not sufficient to rid the body of the exudate, hence operative procedures are demanded. The usual procedure is called thoracocentesis, and is described in the following paragraphs. Thoracocentesis. — Even Hippocrates practiced opening the pleural cavity. It seems, therefore, the more wonder that for hun- dreds of years the procedure was not even mentioned in medical writings. It is interesting to note that Hippocrates advocated washing the body with much water before undertaking the opera- tion. This was evidently a striving after asepsis. The opening was usually made in those days with the knife, but preferably with the actual cautery. Bowditch deserves the credit of introducing pleural aspiration into modern practice (1872). In the first half of the nineteenth century the results of the operation had been so unfavorable that few dared to resort to it. Now, thanks to our aseptic methods and the use of the aspirator, the procedure is both easy and without danger. Indications. — The indications for the operation are three : 1. When there is danger of the patient's dying because of fluid in the chest cavity. (This of course demands a careful analysis of the patient's symptoms in order to exclude the other possible causes of the dyspnea and disturbed circulation.) Such danger may lie either in the quantity of the fluid or in its septic or toxic nature. 2. Every great exudate should be emptied even if there is no present danger to life. Trousseau sets the limit at two liters, and stated that if such an exudate remained for some time without re- sponding to energetic medication, it should be removed. In illus- tration of the danger of neglecting such large exudates, Frantzel (quoted by Gumprecht) relates the following incident: When I was clinical assistant at the Charite I was put in charge of a case of pleuritic effusion. I made a careful examination and decided that thoracocentesis was necessary, but because it was late in the even- ing postponed the operation until next morning. During the night the patient suddenly called to the nurse for help, but was dead before the latter reached the bedside. THE LUNGS 157 That is, these great exudates may cause death without any warning sign of dyspnea and special circulatory disturbance beforehand. 3. Delayed absorption is the last indication. The usual time during which we should wait is placed at four weeks. Usually thoracocentesis is carried out for Indication 3 oftener than for the other two together ; e. g., 75 per cent of all such op- erations are done for this reason. Indication 2 has been utilized in 4.5 per cent of the cases in Basle and 30 per cent in Zurich, thus becoming the least used of the three. Pressure at Respiratory Amount Author. Beginning. End of Difference in Removed Aspiration. mm. of Mercury. in c.c. + 8 -10 ± - 6 + 12 - 8 + 30 + 6 -20 10-20 Leyden -1 ± -12 -32 + 28 -12 8-16 + 12 -12 8-16 - 1 - 4 ± -28 -42 + 8 -1 + 30 3,200 + 8-12 -2-3 + 36 1,100 Quincke -< + 16-20 + 5-6 + 2 -1 2,000 2,000 + 10-12 -2-0 2,000 \ + 25 -8-9 1,500 i + 4 -74 1,000 Schreiber < + 20 -24 -30 500 ± -80 90 400 - 6 -6 ±12 250 - 7 - 7 1,600 + o -12 1,500 + 11 -24 2,000 -10 -34 3,200 + o -30 1,500 Keberlet J + 4 -10 1,000 - 8 -24 2,000 - 6 -20 2,000 -16 -26 2,000 ± -16 4,250 -20 -20 1,700 158 DISEASES OF THE RESPIRATORY TRACT It is generally found better not to attempt to remove all of the fluid, but rather to limit ourselves to 1,500 c.c. (three pints), or the amount with the removal of which the patient suffers no inconvenience. The table on page 157 shows the pressure at the beginning and end (measured in millimeters of mercury) within the thoracic cavity. This demonstrates how great the difference in pressure may be and what dangers it may pre- sent. Test Puncture. — Before proceeding to the removal of the pleural fluid it is usually worth while to make a test puncture with a syringe. For this purpose, the all-glass syringe of Hanhart & Ziegler (of Zurich) is best. At any rate, the syringe used must be air-tight and thoroughly sterilized. The needle, of course, should not be boiled, but rather sterilized in two-per-cent formaldehyd solution and then dried out in alcohol. The skin should also, of course, be thoroughly sterilized with soap and water, followed by bichlorid (1:1,000) and alcohol. When everything is ready, the operator holds the syringe in his first three fingers with the piston fast in his palm and plunges it quickly into the selected intercostal space. If fluid is present, some will appear in pulling on the piston. If blood appears, it usually means that the lung has been punctured; if air, then either the needle has penetrated the lung or there is a pneumothorax present. By moving the Fig. 26. — Conditions in which the Aspirating Needle Fails to withdraw Fluid. point of the needle about, one can usually reach the fluid when the first stroke does not touch it, and can at the same time deter- mine whether the point of the needle is in the pleural cavity or in THE LUNGS 159 the lung. When pus appears in the syringe it indicates that a re- section of the ribs rather than an aspiration is demanded. Three reasons for not reaching the fluid are shown in Fig. 26. The Aspirator. — In the old days a simple trocar was used and a fluid exudate allowed to flow out under its own pressure. Now, however, a bottle with a suction pump is attached to the trocar or needle and the fluid withdrawn by negative pressure. Two sorts of needles are in use. The one sort is simply a large hypodermic needle with extra holes on the side. The other is a trocar with a sheath. The former may possibly irritate the lung tissue as it is moved about while in the thorax. The latter, since it has no point to the sheath, is less liable to injure the tissues within the chest wall. On the other hand, it is difficult to secure a trocar to which the sheath fits so snugly that there is no escape of air. A moment 's reflection will show how important this latter point is, especially in those cases in which the needle or trocar must be inserted with the suc- tion in force. Hence the author prefers the Po- tain aspirator with the needle lustration. The graduated bottle in the Potain outfit is quite important be- cause it furnishes a clean receptacle for preserving the fluid, and at the same time is a measure of the quantity withdrawn. There are, however, on the market aspirators without the bottles, which are more easily carried about. For the reason just stated, however, we prefer the bottle type (Potain) to the other shown below (Truax). 12 Fig. 27. — The Potain Type of Aspirator. as shown in the accompanying il- 160 DISEASES OF THE RESPIRATORY TRACT We prefer also the metal pump to either the rubber bulb x or the screw aspirator, because it is more durable and is easily con- trolled. The Place. — It is said that, other things being equal, the best place for inserting the needle is in the fifth or sixth intercostal Fig. 28. — The Teuax Aspirator. space in the anterior axillary line. But, in general, the point must be one where the percussion note indicates the presence of fluid and must be as far as possible from the heart and diaphragm. Fur- thermore, the point on the chest wall should be where it is as thin as can be selected, and the opening made should be favorable for the flow of the fluid. On these points, the following figures will be useful : 1 Gumprecht relates the following incident which shows a possibility from the use of a rubber bulb. The patient was a robust man suffering from serous pleurisy. The aspiration with the needle produced no results; so the attendants began to squeeze the bulb to suck out the fluid. Suddenly the patient began to complain of a severe pain in his chest and became cyanotic. The affected side of the chest had swelled out very noticeably and a pneumothorax was quickly diagnosed. The trouble was found to be in the bulb, which had been turned about and was driving the air into the lungs instead of pumping it out. This was corrected and a part of the air aspirated. The pneumothorax disappeared in a few weeks with no evil results except that the convalescence was some- what delayed. THE LUNGS 161 The course of the lower edge of the lung reaches as follows: At the midsternal line, lower edge of the sixth rib. At the mammillary line, upper edge of the seventh rib. At the axillary line, lower edge of the seventh rib. At the scapular line, lower edge of the eleventh rib. The height of the complementary space is: In the parasternal line, 2 cm. In the mammillary line, 4 cm. In the axillary line, 9 cm. In the paravertebral line, 3 cm. Hence one has considerable latitude even in the normal chest for inserting the needle, especially in the axillary space. The points recommended are: Bowditch, ninth intercostal space (seventh to tenth), scapu- lar line. Dieulafoy, eighth intercostal space, scapular line. Naunyn, eighth intercostal space, just behind the axillary line. Trousseau, seventh intercostal space, on the right sixth axil- lary line. Schuh, fifth to seventh intercostal space. Wintrich, fifth intercostal space, behind the attachment of the serratus anticus. Gerhadt, sixth intercostal space, between nipple and axil- lary line. Frantzel, fifth intercostal space (on right side, fourth), from mammillary line to the axilla. The flow should be slow. The old rule required twenty minutes for a liter. Whether the flow be as slow as this or not, at any rate the slow aspiration runs less danger of bringing on an attack of coughing or other unpleasant results of lung irritation. The aspiration may be repeated daily if need be. Exudates, as a rule, return less frequently than transudates. In general, we may say that the original indications mentioned above are in force also for repeating the aspiration. 162 DISEASES OF THE RESPIRATORY TRACT Double-sided hydrothorax should not have both sides emptied at one sitting. The side containing the greater quantity is opened first, and the next day the other. Hemorrhagic fluid demands great caution. Usually some severe disease lies back of it which of itself would be fatal, so that the aspiration can help but little. The rule is that one should not exceed one half liter in the amount with- drawn. Accidents. — Cough is the most common, hence it is well to inject a dose of morphin hypodermically before the aspiration in any case where there is the least danger of such trouble. The pain caused by the rubbing of the inflamed pleura can also be avoided by using the morphin be- forehand. These pains may last for a day and require additional doses of morphin. Syncope is quite common. In such cases the patient should be laid flat and given brandy or strychnin and the aspiration re- sumed with the patient in the more horizontal position. This danger of syncope should be thought of at the beginning and the patient placed in as easy and as nearly horizontal a position as possible. Sudden deaths have occurred during the aspiration. They have been found to be due to cardiac insufficiency, as a rule. Hence a careful estimate of the cardiac strength should be made before un- dertaking an aspiration. The accident is rare. The clogging of the canula or needle with fibrin is also a rare occurrence, and can be overcome ordinarily by moving the needle. The spasms that have occurred following aspiration and costal Fig. 29. — Points Recommended for the Insertion of the Aspirat- ing Needle. THE LUNGS 163 resection are sometimes due to intoxication from the antiseptic fluid used to irrigate the cavity with ; e. g., in case of empyema. In other cases they seem to be simple reflexes from the pleural irri- tation, and are oftenest encountered in hysterics. There is a record of sixteen deaths in thirty-eight cases of spasm. Pleuresies Bloquees. — Sometimes every physical sign indicates the presence of fluid in the chest, and yet none can be withdrawn through the aspirating needle until one inserts .a second needle unconnected with an aspirator near the first, when an abundance of fluid escapes. Such cases are examples of the pleuresie bloqae of Mosny and Stern (La Presse Medicate, December 11, 1909). The difficulty in aspiration is due to the thickening and stiffening of the thoracic walls — in particular the thickening of the dia- phragmatic pleura — so that when the lung tissue is also thickened and hardened, as is liable to occur in tuberculous and fibrous pneu- monias, the walls do not yield to the negative pressure (vacuum) caused by the aspiration. The fluid therefore cannot escape until it is replaced by air or other substance. The apparatus for replacing the fluid with sterilized air is like the accompanying cut. Here T is of glass in the shape shown, one Fig. 30. — The Mosnt-Stern Apparatus for Aspirating a "Blocked" Pleurisy. end being connected with the needle, B, one with the aspirator, A, and the third with the air supply. The latter consists of two flasks, E and F, connected with rubber tubing. E is empty, F filled with warm sterile water. D is a bulb (of glass) filled with sterilized cotton. Note that E is graduated. To begin we take out the cork 164 DISEASES OF THE RESPIRATORY TRACT / and raise the flask F above E until some water runs into E. We then replace /, and place F on a level with E. The needle, B, is introduced into the pleural sac and a is opened and aspiration is begun. If the exudate is not completely blocked, some fluid will escape through A. As soon as the fluid ceases to flow, a is closed, and c opened. Then / is removed again and the siphon action will cause some water to flow from F to E and drive the air thence through D and C into the pleural sac. The volume of air can be measured by noting the quantity of water in E. We then close c again, open a and begin aspirating anew. As soon as the flow ceases we let in air again, and so on, until we have removed all the fluid we dare. In general, we remove all the fluid present, if thoracic pain and dyspnea do not intervene. Mosny and Stern advise against emptying out the cavities in acute cases where the exudate is rich in polymorphonuclears and endothelial cells (" splenopneumonia "), but urge the evacuation of the exudate in chronic cases where lymphocytes predominate. PHTHISIS General Treatment Tuberculosis of the lungs is not a self -limited disease, therefore it is necessary to make a definite attack on the disease if one is to succeed in its treatment. For example, pneumonia produces re- active antibodies which immunize the body fluids to the disease, and the physician has only to protect the organism until the dis- ease shall have run its course. But in phthisis one must make an aggressive effort to check the disease or the patient will perish. The most successful efforts made toward checking the progress of tuberculosis have been indirect ones rather than direct ; that is, those measures made at increasing the resistant and germi- cidal power of the body tissues and fluids have been more success- ful than antiseptics and germicides applied to the infected tissues themselves. Naturally, however, one is not willing to neglect any means from which he can hope for good results, therefore he would give antiseptics, but at the same time put his chief dependence upon building up the bodily defenses. Probably the weakest point in the body in consumption is the PHTHISIS 165 digestive tract. Therefore the greatest amount of effort must be made to secure increased absorption and assimilation of food, es- pecially fat. In fact, some physicians go to the extent of believing that in furnishing fats to the body one furnishes the real remedy for the disease, and that the essential pathology of phthisis lies in its fat-destroying power. Be that as it may, fats are hard to digest at any time, and naturally worse in times of digestive weakness; consequently, if one attempts to increase the amount taken by tu- berculous patients, it necessitates a complete regulation of the dietary and generally also a stimulation of the digestive organs. Hence our first duty to our consumptive patient is to supervise and regulate his dietary and methods of eating. The principles noted in caring for diseases of the stomach should be remembered here ; that is, a few staple, carefully selected foods should be used instead of permitting a great mass of odds and ends of food to be given the patient. Thus milk and buttermilk can be given in rather great quantities if too many other kinds of food are not mixed in with them. Similarly steak and toast make a diet which one could use for a week or two with very good results ; and then again eggs and vegetables form a good combination to stimulate the digestive function. Food should be given every three hours, and the quantity should be limited only by the digestion of the patient. At any rate, it must be greater than a healthy person would take under like circumstances. Thus a diet of steak and toast at the regular three mealtimes, and four to eight ounces of lactone buttermilk, yogurt, or eggnog, at say ten and four o'clock would be advisable for perhaps a fortnight. Then an egg diet of say three eggs at each of the principal meals and two eggs each at ten, four, and eight o'clock would do for another fortnight. These eggs would, of necessity, be carefully and differently cooked. With the eggs one could allow one vegetable, bread (better, toast or triscuit) and butter, and milk to drink. Another illustrative diet- ary for a patient with a slight hectic fever, living in a tent, is the following : 7.00 a.m. — Hot chocolate (made with full milk). 7.30 a.m.— Cold bath and rub. 8.30 a.m. — Breakfast: steak, toast (buttered), coffee with milk. 10.30 a.m. — Lactone buttermilk, four to eight ounces. 166 DISEASES OF THE RESPIRATORY TRACT 12.30p.m. — Dinner: steak, toast (buttered), cauliflower cooked in milk (or some similar vegetable), rice, custard. 3.30 p.m. — Lactone buttermilk, wafers. 6.30 p.m. — Supper : steak, toast with plenty of butter, tomato and lettuce salad with, mayonnaise dressing, cooked fruit. 8.30 p.m. — Eggnog (two eggs). This would grow monotonous in about two weeks and should then be changed. "We find that if patients live in the open air and live regular lives, they have fewer digestive disturbances than otherwise. It may, however, be necessary at the beginning of the treatment to use gastric lavage and put the stomach into good working order. At any rate, the ingestion of good food is a sine qua non, and the whole life of the patient must be arranged to this end. Further- more, we find that it is much easier to prevent digestive disorders than it is to cure them ; that unless we can secure the full control of the patient's life it is useless to undertake the case. It goes without saying that patients suffering from active phthisis should not be allowed to smoke. The amount of fat given the patient should be as great as pos- sible. I find it very good practice to give an ounce of olive oil three times a day after eating. By securing high grades and giv- ing it (if necessary) with coffee, one can make almost every pa- tient take the oil. Or one may prescribe considerable salad with relatively large amounts of mayonnaise dressing. If given after the meal it rarely interferes with the gastric secretion of hydro- chloric acid. As in pneumonia, so here, the breathing of pure, cold air is ex- ceedingly beneficial. In order to obtain such air, the patient should live out of doors the entire twenty-four hours. A tent is far better than even an open shanty or log cabin. If it is impossible to have a tent out of doors, one can accomplish a similar result (as far as the respired air is concerned) by having a tent bed next the win- dow. This enables the patient's chest and face to be practically in the open air while the remainder of the body is in the room, and it does not chill the interior of the house as it would to have all the doors and windows open. Nor does it create draughts which PHTHISIS 167 would have an unfavorable effect on a weak patient. Where suit- able ground space is not available tents may be placed on porches and roofs, and this in warm weather is preferable to the window tents. The tent should be at least ten by twelve feet, with a board floor raised twelve to eighteen inches above the ground. The sides may be of boards up to thirty or thirty-six inches, but above that they should be of canvas. Small stoves may be put in the tents for warming the air during baths and dressing hours. At other times, the air should be cold and the patient should depend on the bedclothing for warmth. The tents should have the sides raised every day except in inclement weather, and should be kept scrupu- lously clean. The condition of the skin needs careful attention in tubercu- losis, and the stimulation of the skin by cold rubs every morning is very important. If the patient is strong enough to take a cold tub (water at 70° to 80° F.) , well and good. 1 If not, then he should be given a very brisk rub with cold water at the hands of a vigorous nurse. A rub with oil in the evening is also very beneficial, inas- much as the massage, coupled with the application of the oil, keeps it in good order and quiets the patient for the night's rest. Of course, where available, further invigorating hydrotherapeutic procedures may be prescribed for the stronger patients, but they should be selected and supervised carefully and individually. No mass or class prescriptions should be given. During the continuance of the fever the patient should be kept in bed practically all the time. When fever free, the patient should be given mild exercise in the open air. For this those forms should be chosen that lead the patient to breathe deeply and use his chest muscles. For instance, pitching quoits is better than walking. Horseback riding is good for those in whom it does not start up a fever. Driving is good for only the weakest. Working about the flowers and vegetables in the garden is better than loung- ing about the porch. Tennis and hand ball are good, of course, only when they do not excite the fever. No exercise should be 1 Dr. R. T. Sloan states that it is dangerous to order cold baths for phthisical patients because of the danger of (1) irritating old pleuritic adhesions, (2) setting up hemoptysis, and (3) of requiring too great muscular exertion. These dan- gers should be weighed before we order such baths. In my own experience no damage has resulted from such cold baths as I have found it wise to order. 168 DISEASES OP THE RESPIRATORY TRACT taken to the point of fatigue, hence at first it is better to specify particularly the kind and length of exercise each patient may have each day. Ortner gives the following rules, which may serve us as an illustration of a suitable set of exercises: (1) Arms: raising the extended arms over the head from one side, raising the arms over the head from in front, swinging the arms for- ward, up and backward, swinging the arms in a sagittal plane. (2) Legs: raising the leg forward, sideways, backward, spreading the legs, bending the knees. (3) Trunk: bending at the waist, raising oneself from a horizontal position, twisting the trunk, etc. (4) Lungs: slow breathing with the hands on the hips, holding the breath, forced in- spiration, deep breathing with arms stretched backward. The following is an example of a suitable combination of movements: Raising the arms from the sides 10 20 30 times Slow breathing, hands on hips 10 Spreading the legs 6 Rolling the shoulders 10 Holding the breath (thirty seconds) 2 Slight bending of knees 8 Swinging the arms forward, over, and back . 12 Forced inspiration 4 Twisting the trunk 10 Swinging the arms in a sagittal plane 6 Expanding the chest 2 Deep bending of knees 6 The clothing of the patient should be light and airy, not heavy and cumbersome. All the clothing should be changed at night and warm pyjamas donned. Patients should never be allowed to put layer after layer of clothing over the chest or wear chest pads. On the contrary, the chest clothing should be such as to give the freest play to the thoracic musculature, and also ventilate the skin well. The mesh of the underwear is more important than the material. Thus the loosely woven cotton and linen are better than tightly woven woolens. Under the hygienic treatment here suggested, patients soon lose their fear of draughts and exposure to the bra- cing air. 20 30 15 20 8 10 15 20 2 2 16 24 18 24 6 8 15 20 10 16 3 4 9 12 PHTHISIS 169 Climatic Treatment The weight of evidence seems to be that while climate may play an important role in the treatment of consumption, it is not of it- self sufficient to cure the disease; hence to send a patient from a climate in which he may have good care and medical service to one in which he would receive little or none would be unwise. Fur- thermore, wherever possible, the patient should take the treatment in the climate in which he is going to live; that is, he must be immunized to the disease under the actual conditions that will gov- ern his own life. In view of these two facts, the treatment of consumption must for the great majority of our people be given in their home climate, and the discussion of the relative values of recommended resorts will be of practical application to only the wealthy and foot-loose. Of course, the purer the air the better for the patient; hence country is better than city, sea than land, mountain or desert than cultivated plain. The temperature has considerable influence, for the cool, bra- cing weather of Colorado is better than the enervating warmth of the Gulf towns. In fact, some observers believe that the coldness of the climate is essential in climatic cures. But probably of more importance than the average temperature is the range of tempera- ture, and whether the changes are sudden or gradual. This makes inland towns harder for weakened patients than coast towns, even though the best climate inland seems better than the best climate on the coast. Altitude stimulates all the metabolic processes of the body, hence altitude is a desirable quality in favor of a sanatorium in Colorado as against one in Missouri. Altitude is not indispensable, and in fact, unless one can continue to live at that height above the sea, can be thought of only as a temporary stimulation. With many patients change of climate may be helpful, not for the absolute value of the climate itself, but for the stimulation afforded by change of environment. Of course, in calculating this value, one must weigh against it the wear and tear of the extra exertion involved in the change. Our advice is then to seek first of all the conditions under which good treatment may be given, and if the patient's purse 17Q DISEASES OF THE RESPIRATORY TRACT permit it, then select the climate that affords the purest air and greatest stimulation to the particular patient, because some pa- tients have respiratory passages that are better in a relatively moist climate, as that along the seacoast or on an island in the Pacific ; others must have the dry climate of Colorado or New Mex- ico. But these considerations are apart from the treatment of the tuberculosis, and are determined by the diathesis of the individual. The following catalogue of resorts is adapted from the excel- lent text-book of Ortner, edited by Potter. We can learn of sana- toria in the United States resorts by consulting the Directory of the American Medical Association: WINTER AND SUMMER RESORTS ABOVE 3,000 FEET European Davos-Platz, 5,350 feet, much dust and wind in summer, good sani- tary arrangements, sports in winter, large English colony (twenty-six hours from London). Arosa, 5,740 feet, hotels surrounded by hemlocks, six hours by car- riage from Chur. Both these resorts are in Canton Graubiinden, Swit- zerland. Ley sin, 4,757 feet, near Montreux, one hour by rail from Aigle (Can- ton Waadt). St. Moritz, 5,804 feet, in the Upper Engadin, beautifully situated, iron springs, a popular resort for English and Americans. Excellent winter sports. Colder and rather more wind than at Davos. Fewer seriously ill patients, more society. American, etc. (3,500 feet, and over) New Mexico: Santa Fe, 7,000 feet, seventy-five per cent of possible sunshine. Mean temperature 50.5° F. ; extremes, 7° and 89° F. Twelve to sixteen inches of rain. High winds in March and April. Fair hotels. Las Vegas, 6,418 feet. Good hotel at the springs. Albuquerque, 5,200 feet. Even less rain than in above places. Silver City, 5,800 feet. Sandy soil, pine forests, excellent place for out-of-door life. Average rainfall, 12.3 inches. Average number of cloudy days to the year, thirty-seven. Nine miles from Fort Bayard, which was chosen by the United States authorities as offering the great- est climatic advantages for the treatment of tuberculosis. PHTHISIS 171 Eoswell, 3,570 feet. Eddy, 4,000 feet. Good hotel. Alamogordo, 4,400 feet. All three rather hot in summer. Las Cruces, 3,800 feet. Excellent winter climate with marked diur- nal variations in temperature, but the hotel is poor. Arizona : Arizona, with a similar climate to New Mexico, offers fewer resorts with sufficient comforts for delicate invalids. Very marked diurnal variations of temperature, pronounced dryness, two rainy seasons, dur- ing the summer and during the winter, intensely hot summers, mild, sunny, and favorable winters, and annoying alkali dust are the impor- tant general features. Prescott, 5,456 feet. Fair accommodations, excellent climate from September to February. Flagstaff, 6,800 feet. Near pine forests. Colorado : The plateau of Colorado, from 4,000 to 6,000 feet, possesses in general a mountain climate. The Rocky Mountains running from north to south still further diminish the degree of humidity by causing a precipitation of the moisture of the winds from the Pacific Ocean. Hence it offers a much lower degree of humidity, both relative and abso- lute, than would be accounted for by altitude alone. It is also pro- tected from the western winds, but not from the winds from the north and the east. The places in Colorado named below, as well as others with similar climatic conditions, are suited to patients with a considerable reserve of vitality. Those with feeble circulation and poor assimilation will nearly always do better at lower altitudes, in a warmer, moister climate. The same rule is generally applicable to the resorts in New Mexico and Arizona. Denver, 5,196 feet, population, 138,859 (1900), in an arid open plain, fifteen miles east of the foothills and thirty miles east of the main ridge of the Rocky Mountains. Large amount of sunshine, very little rain, a hot summer, cool winter, very dry, good deal of wind and dust. Ar- rested cases in patients of robust constitution who must live in a large town to make their living, will do well, although it is difficult to find work. Colorado Springs, 5,992 feet, ten miles east of Pike's Peak, which is 14,000 feet, population, 21,085 (1900), is nearer the mountains, more winds, alkali dust. Patients require a good deal of vitality to do well. A rather social city for the better class. 172 DISEASES OF THE RESPIRATORY TRACT Glenwood, 5,600 feet, 160 miles west of Denver; in a protected valley in the foothills, less wind and less dust than either of the above; ther- mal springs. Estes Park, 7,500 feet, for summer especially; excellent hotels. Mexico : City of Mexico, 7,400 feet, upon the central plateau of Mexico, is famous as possessing one of the favorable all-the-year-round climates. Accommodations are said to be inferior. South America: The Andes in South America furnish resorts in Peru, Ecuador, Co- lombia, 1,880 to 12,000 feet. The excellent results obtained by sending phthisical patients from Peru into the high valleys of the Andes were largely responsible for the selection of a mountain climate for pulmonary tuberculosis in Europe and North America. Africa : In the north the Great Karoo, 2,800 to 6,000 feet, with a long winter from April to September, offers a winter climate during our summer. The accommodations are said to be inferior. RESORTS AT LOWER MOUNTAIN ALTITUDES For Spring and Fall Switzerland: Montreux, Vevey. Tyrol: Bozen, Gries, Meran. For Summer and Sometimes Winter Months Mendelpass, over 4,200 feet; Brennerbad, 3,900 feet; Gossenpass, over 3,000 feet; Semmering, over 3,000 feet; Neu-Schmecks, Zakopane, Neumarkt, Aussee. Les Avants, 3,232 feet, hot in summer, excellent hotel open in winter. Milder winter than at Davos. Protected by mountains from north and east winds. Any place in the country with plenty of trees. Interlaken, 1,600 feet ; Gleichenberg, 900 feet ; Reichen- hall, 1,400 feet; Velden and Portschach and Millstadt, 1,800 feet. Arizona : Fort Phcenix, 1,080 feet. Tucson, 2,400 feet. Very hot summers, dust showers in winter, beau- tiful scenery. PHTHISIS 173 California : Redlands, 1,350 feet. Hot, dry in summer, noted for its orange groves. South Carolina: Ashville. New York: The Adirondacks. — The Adirondack Cottage Sanatorium, Saranac Lake, 1,650 feet, a worthy monument to the discernment, intelligence, and industry of Dr. Trudeau, is largely responsible for the popularity of the Adirondack range in the treatment of pulmonary tuberculosis. It is planned for patients who cannot afford to pay more than $5 a week, and who are in the very early stages of pulmonary tuberculosis or are at least favorable types; its capacity in summer is 100, 112 by use of tents. Other sanatoria: Sanatorium Gabriel, Paul Smith's, 2,000 feet; capacity, 70; $10 to $18 a week; Stony Wold Sanatorium, capacity, 70; $7 a week; Lake Kushaqua, nine miles from Paul Smith's. Raybrook, State Hospital; capacity, 120. Without much sunshine, with slightly sandy soil, and cold dry winters, the Adirondacks owe almost as much of their fame as a resort for tuberculosis patients to the advantages result- ing from sanatorium treatment as to the climate itself. The summers are apt to be hot, the nights usually cold. Camp life, moderately good fishing, and some hunting add considerable attraction. Sullivan County. — The establishment of the Loomis Sanatorium at Liberty emphasizes the advantages of the dry air on the southern slope of a range of hills in Sullivan County; 2,300 feet; capacity, 140; $10 to $35. Maine, New Hampshire, Vermont: Moosehead Lake, the Rangley Lakes (1900 feet), the White and the Green Mountains offer especially favorable climatic features for patients with pulmonary tuberculosis who are in good enough condition to do well with active outdoor exercise, who do not require sanatorium treat- ment, or who for some reason may be unduly depressed by association with persons suffering from their own malady. In some of the smaller towns very comfortable accommodations can be obtained at low rates. The disadvantages are the difficulty in obtaining proper medical super- vision and the lack of sanatorium treatment. Massachusetts : The Berkshire Hills have been selected for many patients who do not stand so rigorous a winter as that of the Adirondacks. The accom- 174 DISEASES OF THE RESPIRATORY TRACT modations, especially at Lenox, are excellent. It is too warm, there is too much moisture, and the soil is too full of clay to make the climate ideal during the summer months. The Sharon Sanatorium, at Sharon (350 feet, capacity 21, $5 a week), has demonstrated the effect of sanatorium treatment in a climate only moderately favorable. It is sheltered on the north and northwest by thick woods. Massachusetts State Hospital at Rutland (1,000 feet, capacity 250, $4) was the first state sanatorium to be established in the United States. The buildings are on a southern slope, protected on the northwest by wooded hills. LOW ALTITUDES European Damp. — Lake of Garda, Arco, Lake Como, Lake Maggiore, Goritz, North Shore of Lake of Lucerne. Dry. — Egypt, Biskra. Moderately Damp. — Lake Lugano. American Damp. — Florida and Gulf States, shores of the Great Lakes. Dry. — Arizona, New Mexico. Moderately Damp. — Georgia: Summerville and Thomasville (330 feet). South Carolina: Aiken (565 feet) and Camden (200 feet). These four have become favorite winter resorts for people of means. The winters are mild, the soil is sandy, pine trees abound. There are excel- lent accommodations, pleasant society, encouragement for outdoor life. Lakewood, N. J., in a sandy pine belt, is especially favorable for con- sumptives who cannot be sent far from New York. The place has be- come so favorite a fashionable resort during the fall, winter, and spring that the hotel accommodations are particularly good. Moderately Dry. — Texas, inland Southern California, Minnesota, Da- kota, Nebraska, Kansas, Winnipeg. Dry and Warm. — With the Pacific Ocean and its great current on one side and a range of mountains succeeded by high plateaus on the other, California, or perhaps more accurately Southern California, is noted for its mild winters, cool summers, and abundance of sunshine, high humidity, and summer fogs. Individual variations depend upon the latitude, proximity to the coast, and situation with respect to the ranges of mountains running parallel with the coast line. Below Point Conception, halfway between San Francisco and San Diego, the climate is distinctly milder than above it, the mountain ranges shutting out the PHTHISIS 175 northerly winds. The climate of California is especially favorable for people with moderate vitality. They find an opportunity to interest themselves in out-of-door occupations, such as fruit growing. The ob- jections for consumptives are in summer the dryness, dust, and wind; in winter the high degree of humidity, severe cold winds, and the dif- ference between sunshine and shade. San Diego and Coronado Beach, in the extreme southwest corner of California, have the mildest climate and most equable temperature in the state, milder and with less humidity than either Cannes or Men- tone. There is an excellent hotel at Coronado Beach. Los Angeles, 283 feet, fourteen miles from the coast, with a good deal of clay in the soil, is warmer in summer and colder in winter, with less humidity, fogs, and winds than the two above. It is more or less of a business center. The best season is from November to May. Pasadena, 1,000 feet, twenty miles from the coast, is like Los Angeles, though with less fogs and a more inland climate, sandy soil, excellent hotels. Santa Barbara, fifty miles south of Point Conception, one mile from shore, is protected from the north winds and suitable for summer and winter; the climate is similar to that of San Diego. There are two excellent hotels and very capable physicians. Moderately Warm and Damp. — Examples of the moderately warm and damp coast climate are Algiers, Cadiz, Alicante, Malaga (in Spain), Palermo, Catania, all of which have a very even climate; the Ligurian coast (Nervi, Spezia, Rapallo, Viareggio, and Santa Margherita), Pegli on the Riviera, the island of Lussin, the Gulf of Quarnero (Abbazia), Lovrana, Corfu, Ragusa, and the region around Venice. The resorts on the Adriatic are not, however, suited for winter residence on account of the cold, dry wind coming down from the high mountains. They are suitable for the spring and autumn and even for summer, but in Janu- ary and February have an irritating effect on the respiratory mucous membrane. The others are too relaxing in summer, but are suitable for many patients all through the winter. Moderately Cool and Damp. — The moderately cool and damp coast climate is found on the islands and coasts washed by the Gulf Stream : England, France, Norway, etc. The resorts on the North Sea, and to some extent on the Baltic, come under this head, but none of them are important as far as the treatment of pulmonary tuberculosis is con- cerned. Monterey, eighty miles from San Francisco, on Bay of Monterey, a winter resort for Easterners, and a summer resort for San Franciscans, is fairly protected from the winds, and offers a large, well-kept hotel. 13 176 DISEASES OF THE RESPIRATORY TRACT Nantucket, Block Island, Cape Cod, are excellent examples of island climates. Some patients with tuberculosis, notably children with joint and glandular tuberculosis, do extremely well there, especially during the summer. Antiseptic Treatment Thus far we have discussed only the means of strengthening the patient and making him more resistant to the disease. This is not all that needs to be done, for we have at our command agen- cies, some of which make the tissues less habitable for the bacilli, and others which overcome the symptoms produced by the disease. Inhalations. — First of all, we would mention sprays and nebuliz- ers and inhalation respirators which enable us to put finely divided oils and vapors as far as the bronchi. Whether or not these vapors reach the alveoli is uncertain, but their influence on the mucosa of the air passages is certainly good in that it renders these pas- sages more antiseptic, helps remove the accumulations of excre- tions, and soothes the abraded surfaces. The inhalation chambers of the sanatoria are the most efficient, because more successful in saturating the patient with the vapors. In these rooms the patients sit and read or amuse themselves for an hour or more at a time, all the time breathing an atmosphere charged with antiseptic oils and vapors. Next to these inhalatoria in efficiency come the nebu- lizers, with which a patient may sit and inhale the vapor through tubes for ten or fifteen minutes at a time. Then come the inhala- tion respirators, which consist of perforated metal chambers shaped to fit over the nose. These contain the volatile mixtures, and the patient, by wearing one almost constantly, manages to secure enough of the drug to have a positive effect on the air passages. The mixtures used for inhalation may be illustrated by the fol- lowing prescriptions: ^ Iodof ormi gr. xxjv ; Creosoti puri TT\, jv ; Olei eucalypti HI viij ; Chlorof ormi TT\, xlviij ; Alcoholis et aetheris q. s. ad 3j v. M. f. inhal. (Robinson). PHTHISIS 177 IJ Tct. lodi. aetherialis Acidi carbolici aa 3i j ; Spts. vini rectificati ad §j. M. f. inhal. (Coghill). By combining sedative drugs, such as chloretone, with the anti- septic agents, one secures relief from the troublesome throat irri- tations so common to consumptives. Menthol is another drug of this type that is worth using. One may use as a base for such mixtures, when designed for compressed-air nebulizers, the recti- fied petroleums or cotton-seed oils. The following formula illus- trates this type of sedative, but antiseptic, mixture : ^ Chloretone 1.0 gram. Camphor 2.5 grams. Menthol 2.5 " Oil of cinnamon 0.5 c.c. Liquid petrolatum 93.5 " Another but more irritating mixture, one therefore designed for air passages that need stimulation, is the following : ^ PI. ext. cubeb 60 tn. ; Fluid tolu, soluble 60 ni ; Tct. iodin 60 TT\. ; Spts. camphor 60 HI ; Carbolic acid 60 gr. ; Glycerin 1^ fl. oz. Alcohol sufficient to make 4 fl. oz. The drugs used in consumption should be either directly stimulant to the body or else antiseptic. Of the former type, we have strychnin or nux vomica; of the latter type, creosote or guaiacol; and partaking somewhat of the character of each type, the iodids and mercury. Strychnin is probably one of the best drugs to use in consump- tion in that it stimulates the reflex arcs, and thus increases all the bodily powers, such as respiration, digestion, and circulation. It should be given at regular intervals, probably -fa to fa of a grain dispensed in the form of the tablet triturate every six hours for an ordinary case. In cases of weak digestion, it is probably better given 178 DISEASES OF THE RESPIRATORY TRACT as the tincture of nux vomica, in doses of ten drops three or four times a day, because in this form it exhibits more of the local stimu- lant effect on the gastric mucosa than in the form of the alkaloid. Barton Lisle Wright, of the United States Navy, has found that deep (intramuscular) injections of mercury have proven more beneficial than any one type of treatment. His method should therefore be tried in all available cases. His summary of the tech- nique is as follows : The preparation of mercury used is hydrargyrum succinimidum. Just before the injections are to be given distilled water is boiled for at least twenty minutes. A solution is then made so that 0.64 c.c. (til x) will be equivalent to gram 0.013 (gr. £) of mercury succinimid. The syringes and needles are boiled for twenty minutes. Glass syringes and platinum or gold needles should be used whenever possible. The skin of the patient's buttocks is scrubbed with hot water and tincture of green soap, then washed with alcohol, followed by ether, and this in turn by a solution of bichlorid (1: 3,000). The surgeon's hands are prepared as for any operation and sterilized rubber gloves are worn. The patient being in a prone position on the table, the needle is driven deeply into the muscle tissues by a quick downward plunge. If no blood escapes from the butt of the needle, the syringe is put in place and the drug injected. If blood escapes, a vein has been punctured, and the needle is therefore withdrawn and inserted at another place. Begin with -^g- grain of mercuric succinimid, give injections every other day, slowly increase the dose until a slight tenderness of the gums or a slight diarrhea is produced, then reduce the dose until these symp- toms are overcome, and continue the injections until thirty have been given. Then rest for two weeks; at the end of this interval of rest resume injections, using the dose used at the last previous injection, and con- tinue upon this dose as long as the patient continues to improve up to thirty injections; if any untoward symptoms arise or the patient does not appear to be doing well, reduce the dose or alternate injections of mercury with injections of arsenious trioxid, -^ grain, and ferrous citrate, ^ grain, recommended by Harris, of Providence, R. I., for a short time, or arsacetin 1 to 7 grains. Each series of injections to consist of thirty, with two weeks of rest intervening. As treatment progresses, smaller doses of mercury are required. At the end of one year's treatment, a rest of from two to three months should be given, when, if the patient is not cured, treat- ment should be resumed. PHTHISIS 179 When the dose is too large, in addition to the symptoms of mercu- rialization, any one or all of the following may be observed: Rise in temperature, loss of weight, gastric disturbances, excessive increase in cough and expectoration, angina, or an ulcerative stomatitis. Any of the above symptoms being present calls for a reduced dose. The initial injection, if the dose be £ grain of mercuric succinimid or | grain of the bichlorid, is almost invariably followed by a rise of one half degree to one and a half degrees of temperature within three to five hours. It has often seemed that this feature may be of diag- nostic value. 1 The stimulation of the metabolism is best carried on by means of the iodids or other derivations of iodin. Sometimes iodoform in one-grain doses (in gelatin capsules) is given, but this seems to have a rather deleterious effect on the digestive tract, and fre- quently must be laid aside in favor of one of the iodids. Probably in the case of young patients the syrup of hydriodic acid would be better than either potassium or sodium iodid, giving a teaspoon- ful one half hour before meals. The effect of this drug is syner- gistic with strychnin, in that it increases the catabolic processes. Guaiacol and creosote have been used for a long time in pul- monary complaints, probably because they are excreted through the mucous membrane of the bronchi and exercise there an anti- septic effect. It seems to me rather better for the digestive tract if guaiacol be exhibited by rubbing into the skin (in fifteen-drop doses) three times a day. Guaiacol is more readily absorbed when rubbed in over the abdomen than over the chest wall, consequently this point of application is more usually chosen. If the guaiacol is rubbed in combined with an equal quantity of olive oil, it is less likely to irritate the skin than when used pure. To illustrate a conventional method of combining the drugs used in consumption, we quote the following formula, put on the market under the name " volesan ": Creosote carbonate 5 gr. Heroin 2V " Camphor 1 " Balsam tolu 4 " M. f. caps, gelat. no. I. Sig. One capsule t. i. d. 1 From the Navy Medical Bulletin. 180 DISEASES OF THE RESPIRATORY TRACT In commenting on this, we would point out that heroin should be given only when needed to depress the cough centers, therefore, for only a day or two at a time ; hence any such combination as the above could be used only for a short time, and then the prescrip- tion must be changed to meet the new conditions. Therefore, in general, in phthisis, we should give individual drugs and vary them as needed. Tuberculin. — The most direct attack on the disease would be by using the sera of animals immunized to tuberculosis; or, next, by vaccinating the patient with weakened and graduated toxins from the bacilli themselves in order to develop antibodies in the patient's own blood. We have not yet succeeded in immunizing animals to tuberculosis, and therefore cannot use the first method ; and as for the second, it has been in experimental use since Koch worked out a tuberculin in 1890. But the inoculation of the pa- tient with tuberculin is still in the questionable stage and should not be attempted where one does not have adequate laboratory facilities for keeping watch of the opsonic index and regulating very carefully the surroundings of the patient. Trudeau in the Adirondacks has followed out the treatment of consumption by tuberculin for some fifteen years, and his reports are very inter- esting and very encouraging. Nevertheless, one should remember that he used everything that everyone else does in the treatment of consumption, plus the tuberculin. As to the pharmacology of tuberculin, I quote the following from Sollman's " Text-book of Pharmacology ": The original tuberculin from Koch is a sterile glycerin extract of the bodies of tubercle bacilli. Its injection has no effect on normal animals, but even very minute doses cause an intense reaction in tuberculous animals. This is shown by the production of fever, and by acute in- flammatory changes about the nodules. This may lead to the conversion of the nodule into fibrous tissue and may thus effect a cure; on the other hand, it may cause necrosis, and lead to a further dissemination of the tuberculous process. It may be of benefit in lupus and in tuber- culous joints. For this purpose, gradually increasing doses are injected hypodermically into the back. It is well to begin with j^qT c - c -> m " creasing by y-g-W c.c. until -%^-$ c.c. is reached; it is then increased by ^-J-g- c.c. until yJ-q c.c. is reached. Larger additions may then be made. The total dose should not exceed T ^- c.c, as a rule. The dilutions are PHTHISIS 181 made with 0.5 per cent carbolic acid. In pulmonary tuberculosis its use is distinctly dangerous. It should be remembered that it has no direct effect on the bacilli. The greatest value of tuberculin is as a means of diagnosis. A rise of temperature of 1° F. is taken as the index of the reaction. The in- jection should be made between 6 and 8 p.m., and the temperature on the next day taken every three hours. (The normal temperature should have been recorded at the same intervals for two days previously.) The first injection should be y^§-^- c.c. for adults, WoT ^° Wo "o c - c - ^ or cm l~ dren. If there is no reaction, another injection of ^-J-g- c.c. (for children Wo~7 t° toVtt c - c -) ^ s ma de, and if necessary a third injection of t ^-q c.c. (for children yoVo *° "2~oS")- When given in this guarded manner there is practically no danger. A positive reaction is not quite distinc- tive since it is sometimes seen in other affections. The test is also widely used for the detection of tuberculous cattle. Another form of the tuberculin (Tuberculin R.) has been prepared by the extraction of cultures grown on solid media. It is somewhat milder, but no more successful, and it has been found to contain living bacilli, so that its use should be condemned. Symptomatic Treatment Fever. — As we have noted elsewhere, we believe that antipy- retics should not be used unless the high temperature is damaging the patients more than the antipyretics would; hence in consump- tion we must answer the question of damage before we set out to treat the fever. In my own experience I find it rarely necessary to treat the fever. In fact, the temperature curve is to me a valu- able index as to the success of my general and more positive treat- ment; for I find that when the out-of-door life and the cold baths with stimulant food and the drugs named above are doing their work, the fever disappears ; and furthermore, if the fever does not disappear under those conditions, the patient is doomed ; and then the therapeutic indication is simply to make him comfortable. Antipyretics do not assist in combating the disease. Of the antipyretics we prefer acetphenetidin in five-grain doses, or it may be combined, according to Yeo's suggestion, with the hydrobromid of quinin, three times a day. In this connection it should be remembered that if creosote or guaiacol is being used for its antiseptic effect, it of itself has a tendency to depress fever temperatures. Consequently, in those 182 DISEASES OF THE RESPIRATORY TRACT systems of treatment into which gnaiacol enters, other and special antipyretics are rarely needed. Night Sweats. — These are of two sorts: the critical sweat from the daily fever and the sweating of exhaustion. The former occurs about midnight or shortly afterwards, and the latter whenever the patient falls asleep, be it day or night, early or late. The condi- tions under which the patient sleeps have much to do with these sweats, and we find fever among patients sleeping in tents less frequently than among those sleeping in houses. The amount and kind of clothing worn have also their influence, there being less of sweating when the hygienic principles discussed above are fol- lowed carefully. Furthermore, the early morning cold bath and the evening oil rub also do much to prevent the disagreeable sweat- ing so common among consumptives. When we do need to check the sweats by direct drug attack, we prefer to use atropin or its congener, agaricin. The former is given in t Jq- grain just about bedtime, and the latter usually three times a day in the dosage of T -J-^ grain. Needless to say, the exhaustion sweats indicate strychnin, cam- phor, or caffein, rather than depressants. Even the inhibitory effect of atropin on the vasomotor system savors sometimes too much of depression for the patient's good, and in general we would say that night sweats indicate a need for a vasomotor tonic or stimulant (such as the three just named) rather than a depressant or paralyzant, such as Dover's powders or quinin. Cough. — Before starting in to check any cough, we must first determine whether it is a useful or simply an irritative one. Thus patients with considerable sputum are benefited by a coughing spell in the morning. It usually clears out the passages and rids the patient of throat irritation for several hours. The morning cold bath, in which cold water is thrown against the chest and back, will stimulate such a productive cough with its attendant deeper breathing. The irritative cough or hack should, of course, be checked, but checked by stimulant rather than depressant measures. Heroin is, of course, the drug upon which we must depend to depress the medullary cough center, and we should not hesitate to resort to it for a day or two at a time when the patient is going about with a constant hack, or is forming a bad coughing habit. A dose of T \ grain every three hours is usually sufficient. It PHTHISIS 183 should be given separately from the other drugs in order to facili- tate its discontinuance. The dry, hacking cough should be treated by stimulant inhala- tions; e. g., with a mask, or with a nebulizer, or with steam. In general, the most efficient inhalation is steam charged with eu- calyptol, and this can be given so easily that one can find no excuse for not using it. The steam softens the throat tissues, and therefore gets rid of the cause of the reflex. With the nebulizer one should use an oily compound, such as that containing menthol and chloretone, mentioned above. With the mask one must use an alcohol-ether base, for which a prescription is also given above. In hopeless cases, where we simply try to make our patients comfortable, we use morphin, thus both quieting the cough and soothing the mind. Vomiting. — Vomiting can occur only when the stomach has not been put in order at the beginning of our course of treatment and the accumulation of mucus in the respiratory passages has not been cared for. Its occurrence means, therefore, that we have failed to carry out all the necessary points in hygiene. Our reason for making this statement is that vomiting occurs only when mucus either collects in the respiratory passages and the stimulation of the hot food in the stomach excites the dia- phragm to renewed exspiratory efforts, thus bringing the food out of the stomach with the mucus out of the bronchi, or the swallow- ing of mucus has brought about an irritative gastritis that needs only the entrance of food to set up expulsive spasms. When it occurs we need to flush out the stomach either through the tube or with mineral waters (better with simple carbonated waters), and then prescribe light meals every three hours. We should then stimulate the bronchi by using hot and cold fomenta- tions to the posterior thorax daily, and by giving inhalations of steam charged with turpentine three times a day. For a drug to quiet the stomach, bismuth subnitrate (ten grains), suspended in four ounces of water, will prove thoroughly efficient, but this should not prevent our giving, at the earliest possible moment, the gastric lavage, which should be continued until the stomach has regained its tone. Hemoptysis. — Hemoptysis is usually due to some corrosive proc- ess, but may be due to the rupture of varicosities of the lower air 184 DISEASES OF THE RESPIRATORY TRACT passages, and may be simulated by the rupture of a varix in the esophagus. In consumption it is rarely fatal, and may even be beneficial, hence we should avoid alarming our patients in refer- ence to it, and simply teach them to adopt measures of relief when it occurs. The treatment of hemorrhage must be directed toward facilitat- ing the clotting of the blood, and toward preventing such a great loss of blood that the patient will be permanently weakened. Therefore the blood pressure should be lowered, the action of the heart should be slowed and made regular, and at the same time, if possible, there should be a local constriction of the vasomotor sys- tem to decrease the amount of blood flowing through this part. To attain this end, the patient should immediately be laid on his back and the tissue around and about the supposed break in the vascular system chilled as much as possible. This can be accom- plished partly by applying an ice bag to the chest, and partly by letting the patient swallow slowly small pieces of ice. Any vol- untary movement on the part of the patient will probably set up the hemorrhage again, therefore he must be kept absolutely quiet and passive for several hours. Probably as good a drug as any for the continual oozing from a rupture would be styptol, § grain every hour or two for the first two or three days. This also has a tendency to constrict the capil- laries. 1 Morphin also has a beneficial effect in quieting the pa- tient and thus benefiting the condition. Thus Dr. Sloan says: 11 The opiates have been more effectual than anything else in my experience. ' ' The matter of constriction of the arteries has a wider influence than that simply of closing up the break in a capillary, for it also increases the blood pressure, and this increase in blood pressure would tend to break open the capillaries again; hence in hemor- rhage the ideal thing would be to apply locally a locally acting 1 In addition to the vasoconstriction by means of chilling the tissues, we may try the effect of drugs to increase the clotting power of the blood. In this mat- ter, experimentation and clinical experience have not yet reached an agreement, and some of the drugs (e. g., calcium lactate) used in a routine way by many practitioners seem to have no effect when tried out under laboratory conditions. Thus the use of calcium lactate (dose 15 grs. t. i. d.) has not proven efficient in animal experiments (Addis) in shortening the coagulation time of the blood. PHTHISIS 185 vasoconstrictor, and systematically a drug that would lower the blood pressure elsewhere. Thus, if one could apply adrenalin chlorid locally and the nitrites generally, one would quickly stop the leak, but only in the most severe cases is there danger of a fatal issue, hence the question of the ideal is largely an academic one. Aconite and veratrum viride are given by many practitioners in cases of hemorrhage to reduce the blood pressure. For that pur- pose the former is given in doses of one drop of the tincture every hour until the effect is manifest. The latter is used in similar doses of the fluid extract. Probably nothing is quite so alarming to the patient and his friends as the sudden gush of blood from the mouth. This alarm may have a distinctly worse effect on the patient's condition than the hemorrhage itself, hence the first duty of the physician is to reassure the patient and his entourage that nothing horrible is about to occur. On the other hand, the friends should be kept busy doing the few necessary things that need doing — preparing cracked ice, etc. — in order that they may not stand about bewail- ing the condition. The treatment should be continued for two or three days at least, and then the drugs chosen should be those which, like cal- cium, tend to form solid scar tissue. In addition, the saturation of the air passages with iodin and the use of mercury should be adopted more vigorously than before, in order to decrease, if pos- sible, the rapidity of the ulcerative process. But that there is some value in giving lime salts in such cases cannot be denied. Hence we may give calcium hypophosphite for its systemic tonic effect as in the following prescription: 1^ Calcis hypophosphitis gr. iij ; Glycerini ttl xx ; Tincturse quassise rr^ x ; Syrupii aurantii 3 ss; Aquae q. s. ad § ss. M. f. dosis. Sig. Three times a day, one hour after food. (Yeo.) Or, better still, give relatively large doses of calcium lactate and give also a nucleo-albumin such as thyroid extract. Of the former we should order 20 grains every four hours. Of the latter, 3 grains three times a day on an empty stomach. 186 DISEASES OF THE RESPIRATORY TRACT Diarrhea. — When caused by intestinal ulceration, the diarrhea of phthisis is extremely difficult to check. When, however, it is an accidental complication, it can be handled by the usual methods. For this we prefer the albuminates of tannin — tannalbin, tannigen — or the tincture of kino or krameria. On the other hand, the British writers have more complicated prescriptions. For instance, for intestinal ulceration with diar- rhea Yeo recommends: 5 Fluid extract coto rrt lx ; Tincture cardamon co lU lx. Mix and triturate slowly with Mucilage of acacia 3iij ; Simple syrup oij ; Finally, add enough water to make §vj. Give one tablespoonful of the mixture as needed. For diarrhea accompanied by pain, we of course use the tinc- ture of opium in ten- to fifteen-drop doses. Or, if we prefer mix- tures, we may use the following: IJ Ext. opii gr. jss ; Syrup aurantii ov; Elixir gentian, glycerinat., N. F q. s. ad §v. M. f. mist. Sig. One teaspoonful every two hours. Complications. — The chief complications of phthisis are laryn- geal tuberculosis, pleurisy, pneumothorax (or pyopneumothorax), and anal fistula. Laryngeal tuberculosis should be actively treated not only by inhalations and hygienic regulations (chief among which is com- plete vocal rest), but also by expert local surgery. Thus the punch- ing out of the ulcers, or their cauterization with lactic acid (five to forty per cent) has rendered good service ( Casselberry, Journal of the American Medical Association, for August 7, 1909, p. 436), except in the specially nonresistant cases where the body shows no ability to react against the disease. PHTHISIS 187 If pleurisy causes considerable pain, it requires the bandaging of the chest and the application of heat (thermophore). As a general rule it is wiser not to aspirate pleuritic effusions in tuber- culosis, but to put the whole emphasis on the systemic treatment. Pneumothorax, if it causes dyspnea, should be tapped (asep- tically) and enough air removed to equalize the pressure, and the wound sealed with adhesive plaster or collodion. Experience is in favor of not interfering even with a pyopneu- mothorax except where the dyspnea or danger to life absolutely demands it. Then it should be done surgically with a wide open- ing and thorough irrigation. What should be done in case of a fistula in ano depends upon the patient's general condition. If he is improving, it should be treated according to the best surgical methods. If, on the other hand, he still has fever, or is growing worse, it should be let alone and palliative treatment, with phenolated camphor, etc., should be used. In undertaking the treatment of a case of consumption, one should protect himself by demanding that the patient give him at least six months of absolute obedience. Nothing of any per- manent value can be accomplished under that length of time. To have a patient go to a sanitarium, or to change his climate for a month or two, is worse than useless. In the matter of change of climate, this principle should govern : If the patient can change his climate permanently and live in one better adapted to him, it is the best thing he can do ; but if he can go away from home only for a short period of perhaps one or two years, then it would be better for him to stay at home and take open-air treatment in the very climate in which he must live. While the dry Western and South- ern climates of the United States seem to be best adapted to the treatment of this disease, nevertheless successful work has been done in Massachusetts and New York, where the climate is any- thing but equable. Finally, as Osier states, ' ' benefit is usually a matter of months, complete arrest a matter of years, absolute cure a matter of many years. ' ' CHAPTER IV DISEASES OF THE DIGESTIVE TRACT THE MOUTH Stomatitis We are in danger of forgetting that the physician should have charge of the mouth, as well as other parts of the body. The den- tists, on the other hand, are realizing that the average physician knows little or nothing of oral medicine, and are seeking degrees in medicine in order to be able to handle adequately the neglected field. The daily cleansing of the teeth and mouth is an absolute essential to life under modern conditions. This includes the keeping of the teeth in good repair, so that at all times the patient may have a good organ of mastication. At least once a day the teeth and gums should be brushed with a medium hard brush, brushing with water and a powder or paste that (1) cleanses, (2) oxidizes organic deposits, and (3) sterilizes. The mechanical part of brushing the teeth is difficult and demands both energy and patience. It is an art that should be cultivated. The solution of peroxid of hydrogen should also be used now and then for gargling. The following is an illustrative formula for a tooth powder: ^ Strontii perborat 6.00 5jss ; Saccharin 0.20 gr. iij ; Os sepiae pulv 4.00 3j ; Saponis pulv 4.00 3j ; Calcii carbon, precip 30.00 §j ; Olei menth. pop 1.00 gtt. xv. M. f. pulv. (Potter). 188 THE MOUTH 189 It is well to have a good dentist examine the teeth once or twice a year, to fill cavities and to prevent damage from deposits of tartar and similar results of neglect of the daily toilet. Inflammations of the month may be due to (1) mechanical causes, such as injury from broken teeth, hard particles of food, etc.; (2) physical causes, such as hot food; (3) chemical causes, such as caustics and other poisons introduced by mistake; and finally (4), bacterial agents that reach the membranes either with the food or with the air through the nose. The membranes of the mouth are so resistant that unless either the bodily resistance is lowered or mechanical or physical or chemical injury precede, bac- terial infection can hardly take place. Hence, in nursing infants among whom stomatitis is particularly frequent, we must look to the systemic condition coincidently with our local treatment. With older patients who are also subject to the mechanical injuries due to bad teeth and hard food, we must correct the mechanical condi- tions, as well as the bacterial. Acute Stomatitis. — In the acute stomatitis of children, unaccom- panied by ulcers or bacterial growths, we need first of all to remove any irritating agencies such as hard nipples (if the patient be a nursling), irritating teeth, etc. Then we should give food that is nonirritating in temperature as well as in constitution. Cool or cold food will be grateful to such patients. The mouth should be frequently washed out with cool water — boiled water to which twenty-five per cent of glycerin has been added will do as well as anything. The membranes should not be brushed or rubbed so hard as to irritate them. If ulcers occur, they should be touched with the silver-nitrate stick. Cysts should be incised and their walls touched with either the silver nitrate or pure carbolic acid (followed by alcohol). Chronic Stomatitis. — Chronic stomatitis is more often due to gastrointestinal and constitutional disturbances than to local con- ditions. Hence the treatment, while not neglecting the local meas- ures such as cleansing and irrigating the whole oral cavity, should be mainly directed toward putting into order the whole body. The blood should be examined for evidences of anemia, and if there be no patent gastrointestinal disorder, the analysis of the gastric contents after a test meal should be made, and if necessary also an examination of the feces for parasites and defects of pancreatic 190 DISEASES OF THE DIGESTIVE TRACT digestion. When an anomaly is found, it should receive adequate treatment. For the local disorder, treatment along the principles already laid down should be given. The teeth should be brushed after each meal, the mouth and pharynx should be irrigated daily with an antiseptic solution such as the liquor antisepticus N. F., and ulcers touched as often as needed with pure carbolic acid and alcohol. If the membranes seem edematous and relaxed, the application of an astringent such as a five-per-cent solution of tannin in glycerin should be frequently made. Stomatitis from Thermal or Mechanical Injury. — Acute inflam- mations due simply to thermal or mechanical injury should be treated by stopping all food by the mouth if necessary; then the mouth should be kept antiseptic by frequent irrigation with the liquor antisepticus. The pain may be relieved by cocain (two per cent), menthol (five per cent), in glycerin and water, or the use of small pieces of ice. Of course, the subcutaneous use of morphin may be necessary, and should be resorted to if the above simpler remedies are not sufficient. Thrush needs to be treated by rubbing out the patches with strong solutions of sodium bicarbonate. This brushing or rubbing should be done every two hours, care being taken not to injure the adjacent membrane. It is best done with a piece of soft linen wrapped about the finger tip. The reaction of the mouth should be made alkaline by frequent irrigation with alkaline fluids, such as the following mixture: ^ Sodii bicarbonatis Sviij ; Sodii biboratis Sviij ; Sodii benzoatis gr. xx ; Sodii salicylatis gr. xx ; Eucalyptolis gr. x ; Thymoli gr. x ; Mentholis gr. v ; 01. gaultheriie gtt. vj ; Aqme o xv J- The disease is contagious, but may be prevented from spreading by thorough cleanliness, especially of nursing bottles and nipples. Calomel given in doses of one tenth grain as frequently as the age THE MOUTH 191 of the child permits will usually care for the intestinal condition. It may be necessary to feed the child with a tube through the nose while the mouth is sore. Aphthous Stomatitis (Herpetic, Vesicular). — Aphthous stoma- titis should be treated by touching the ulcers with silver nitrate (two- to ten-per-cent solution), and by frequent swabbing of the membranes with one half to one per cent potassium permanganate. Here also the systemic condition demands the first thought — e. g., the excessive use of sweets in the food should be controlled. Diar- rhea and constipation should be treated by alkaline drugs (e. g., bismuth or magnesium sulphate). Ulcerative Stomatitis. — Ulcerative stomatitis requires the use of strong solutions (three per cent) of potassium chlorate. This is somewhat painful and is toxic. Loose teeth must be extracted and suppuration treated with the full strength of the commercial solu- tions of hydrogen peroxid, injected into the abscesses with a good syringe. Ulcers may be treated with silver nitrate (use cocain before making the application ! ) and a soothing mouth wash of glycerin and borax may be at hand for the patient to use as needed. For instance, the following may be employed: I£ Acidi salicylatis oss ; Alcoholis 5iij ; Aquag camphorae gij ; Glycerini ad gviij. M. f. lotio. The internal administration of potassium chlorate (children, 2 grains ; adults, 10 to 20 grains t. i. d. in syrup and water) must be carefully supervised lest it poison the patient (see notes on reme- dies), but it seems worth while because of the antiseptic influence exerted by the drugs as it is being excreted through the saliva. Mercurial Stomatitis. — Mercurial stomatitis requires prophylac- tic treatment in that the mouth should be put into good condition before mercury is given. Solutions of potassium chlorate and hydrogen peroxid need to be used thoroughly and frequently as soon as the red line appears. The mercury must, of course, be stopped. Elimination needs to be stimulated. Thirty to sixty grains a day of potassium chlorate may also be given internally. 14 192 DISEASES OF THE DIGESTIVE TRACT The diet needs to be such as requires no mastication, and should be as nutritious as possible — ground meats, strong soups, eggs, etc. Scorbutic Stomatitis. — Scorbutic stomatitis should not be treated with potassium chlorate, because the stomatitis disappears as soon as the general condition improves. Simple antiseptic and soothing irrigations will be sufficient for the local treatment. Pyorrhea Alveolaris. — Pyorrhea alveolaris is an infection by a variety of staphylococcus. It needs surgical (dental) attention for cleansing out the ulcers and abscesses. The use of vaccines (Hecker) constitutes the most active treatment of the disease. The frequent and thorough brushing of the teeth constitutes both the best prophylaxis and an excellent succedaneum. Noma. — Gangrenous stomatitis and noma depend for their de- velopment upon a very debilitated condition of the system. The moment gangrene appears the patient should receive diphtheritic antitoxin (see diphtheria) and the local necrotic tissue should be thoroughly cauterized under chloroform anesthesia, applying the Paquelin cautery so as to include all the necrotic tissue — that is, cut into healthy tissue. It is impossible to avoid disfigurement and we are satisfied to save the patient's life; hence the treatment must be radical and early. After the cauterization the tissues must be irrigated every two hours with strong solutions of potas- sium permanganate or hydrogen peroxid, and gauze moistened in formalin 1 : 2,000 should be laid over the outside of the gangrenous patch to stop as much as possible of the fetor. Strychnin in full doses should be given every four hours, and every means resorted to for raising the constitutional resistance of the patient. The diet consists of eggnogs and other rich liquids, administered by the nose if need be. The child should be kept from lying on its back in order to avoid the swallowing of the putrid matters and the consequent inhalation pneumonia. Geographical Tongue. — Geographical tongue, or eczema of the tongue, is a chronic and obstinate affection that, however, does not do much damage. The Roentgen ray seems to be the only means of influencing it permanently. It is due to some chronic irritation, such as excessive smoking; hence the first step in its treatment is the removal of such irritation. The disorder is so harmless that were it not for the cosmetic effect it could be safely neglected. THE ESOPHAGUS 193 Leukoplakia Oris. — Leukoplakia oris is generally charged up to the account of syphilis, but appears to have other causes as well. It yields best to painting with the U. S. P. tincture of iodin, with coincident systemic treatment with mercury and the iodids. For instance, the intramuscular injection of mercury succinimid (one fifth grain on alternate days) with fifteen to twenty drops of the saturated solution of potassium iodid three times a day, usually clears up the patches. Smoking and other throat irritations must be given up during treatment. Should papillomata develop, they should be removed by the knife and the wound exposed to the Roentgen ray. THE ESOPHAGUS Inflammation of the Esophagus Inflammation of the esophagus is practically always due to a burn (e. g., carbolic acid, lye) or mechanical injury. The primary indication is therefore for rest, relief of pain, and prevention of (1) sepsis and (2) stricture. The rest is obtained by giving little or no food by the mouth. What is given must (like milk) be entirely nonirritant. In gen- eral, it is better to use nutrient enemata until the raw surfaces be healed over. (For the details of this procedure, see page 203.) The pain is relieved by demulcent liquids and opium. It is better to use opium than morphin (in order to secure its local effect), but frequently the patient cannot swallow at the time when relief is most needed, so that morphin given with the needle will be necessary. When the opium can be used, the following prescrip- tion may be employed (Yeo) : IJ Ext. opii gr. ijss ; Bismuth subnitratis gr. xl ; Emulsionis tragacanth SJss. M. f. suspensio. Sig. One teaspoonful every hour for pain. This serves to relieve pain and prevent irritation, and the con- sequent formation of scar tissue. Its effect will be assisted if a tablespoonful of olive oil be given t. i. d., or if the patient cannot take olive oil, the milk of almonds may be used. Hot fomentations externally may be of some assistance. 194 DISEASES OF THE DIGESTIVE TRACT The mouth must be frequently — e. g., every hour — irrigated with cold water. This is best done by gargles when the patient can carry out this procedure. The milk diet should be kept up for several days, and the change to general diet made gradually, by using such intermediate foods as grain soups, white of egg, etc. Stricture of the Esophagus When in spite of these prophylactic measures a stricture is formed, it requires both local and constitutional treatment. The cautious passage of graduated bougies or dilators serves for the first, and the giving of potassium iodid (10 grains t. i. d.) or of fibrolysin (by the needle 2.23 c.c. on alternate days) for the second. But such strictures must be carefully differentiated from the stenoses due to malignant growths, pressure of tumors outside the esophagus (such as goiter, enlarged mediastinal glands, and aneu- rysms), and spasmodic stricture, for each of these needs its special treatment. Tubage. — For malignant stenoses we may either insert a tube or do a gastrostomy. Yeo describes the former treatment as follows: Mr. Symonds's method (Charles J. Symonds, of Guy's Hospital) is to pass through and retain in the stricture a short funnel-shaped tube, the upper expanded part of which rests on the top of the strictured portion of the canal. It is passed down to the stricture by means of an ordinary conical bougie fitted into the funnel, and after the funnel tube is fixed into the stricture the bougie is withdrawn, a strong silk thread having been previously fastened to the funnel end of the tube long enough to extend beyond the mouth and to be looped over the ear, behind which it is fixed by a piece of strapping. These tubes are made of gum elastic; they are six and a half inches long, the funnel end is one half to three fourths of an inch in diameter; it ends in an ordinary catheter end and eye. Mr. Symonds maintains that this tube has proved of the greatest service in the treatment of malignant stricture of the esophagus, upon which its pressure produces no irritating or injurious effects. It is prevented from slipping down through the stricture by the silk cord attached to it, as well as by the funnel expansion, and by means of the cord it can be easily withdrawn. Its advantages over the long tube pro- jecting from the mouth are obvious: it is not unsightly, it does not interfere with deglutition in any way, it does not irritate the larynx, THE ESOPHAGUS 195 and it does not cause a constant escape of saliva from the mouth. In the first case reported by Mr. Symonds, the patient was kept alive for eight months in comparative comfort, and never felt any inconvenience from the tubes; the stricture dilated considerably, and on post-mortem examination no injurious effect could be traced to its pressure. In the later stages of the disease, it was necessary to remove the tube frequently, as it became blocked with sputum and food. Life has been prolonged for periods varying from four to eleven months by the use of these tubes. The tubes usually do not require changing oftener than every three or four weeks; Nos. 12 or 14 is the size usually worn. They are durable and the same tube and silk have been used for more than three months. Mr. Symonds appears to think that the use of these tubes will generally obviate the necessity of having recourse to gastrostomy, with its attend- ant dangers, and the distress from the excoriation of the skin around the external orifice of the gastric fistula. When a gastrostomy is done, a tube is left in position through which peptonized foods are inserted into the stomach. This pro- longs the patient's life and prevents his suffering for considerable time. (For the technic, see texts on surgery.) The gastrostomy should be done as early as its necessity is foreseen, because it of itself requires some resistance and vitality. Carcinomatous Stricture. — It is, of course, self-evident that esophageal stricture due to carcinoma should not be dilated. Treat- ment in such cases can only be that of relieving the pain and feed- ing by the rectum, except where a gastrotomy may be done to relieve the patient for a short time. The mouth may be kept moist by holding in it a swallow of water or pieces of ice. The teeth and gums need to be cleansed several times a day with hydrogen peroxid or an alkaline antiseptic solution. The pain calls for morphin, the constipating effect of which may be counteracted by using ox-gall enemata. For although no food is taken by the stomach, nevertheless the peristalsis must be kept up to prevent the absorption of putrefying gastric and intes- tinal secretions. The morphin must, of course, be given hypo- dermatically. Some nourishment can be given by rectal enemata, but hardly enough to establish an equilibrium; hence wherever possible a gastrostomy should be done and the patient fed with a tube. 196 DISEASES OF THE DIGESTIVE TRACT The food given by the tube should be in finely divided form, and usually consists of eggs, milk, soups, etc. Sometimes scraped steak, mashed potatoes, and similar foods may be used. Now and then a patient is found who insists on taking a general diet, chew- ing it and then filling his food syringe from the mouth and in- jecting the masticated bolus through the gastrostomy tube into the stomach. While the stricture is still patent, the patient may be fed by the mouth, but necessarily the diet in all such cases must be such as can pass the stricture. To illustrate, I quote the following diet used by Cohnheim: At 7.00 a.m. Lavage and oil treatment. Tea, with 125 grams of cream. 250 grams of milk. A soup made of flour, containing 125 grams of cream and butter. Bouillon with 1 or 2 tablespoonfuls of flour, and 1 or 2 yolks of eggs with butter. Tea, with 125 grams of cream. Any kind of soups, made from cereals or milk. Bouillon with sago or flour and butter. Besides the above, the patient may, if he desires, be given either wine, or wine with eggs, buttermilk with koumiss, fruit juices diluted with mineral water, fruit and vanilla ice cream, puro sanatogen, soma- tose, etc. If the stenosis is slight, semisolids of all kinds, such as the finest puree of potato, spinach, carrots, raw eggs, etc., are indi- cated. In addition, the physician should prescribe a half wineglassful of olive oil, one half hour before the midday and evening meals, if the patient does not have a repugnance toward it. For patients who cannot use the oil, a cup of the milk of almonds may be substituted. Such a diet not only maintains the strength of the patient, but may also cause an increase in weight if the patient takes the proper physical care of himself. I have personally observed, in cases of this kind, an increase of ten pounds or more. The lavage and oil treatment referred to in the above extract is carried out, as follows: Lavage and Oil Treatment. — To wash out the esophagus, the physi- cian should use an ordinary soft stomach tube, No. 8 (American No. 7.00 A.M. 8.00 a 9.00 « 11.00 a 1.00 P.M. 4.00 a 6.00 a 8.00 a THE ESOPHAGUS 197 20) about 90 cm. long, the lower end of which contains two lateral open- ings. The tube should be introduced to the constricted portion of the esophagus, and the stagnating food should be washed out in the follow- ing manner : A small glass funnel, with a capacity of from 50 to 75 c.c, should be connected with the proximal end of the stomach tube, and warm water should then be poured into it and the esophagus thoroughly- cleansed by alternately raising and lowering the funnel, the greatest possible care being taken to remove all mucus and food remnants. Fol- lowing lavage, 30 c.c. of warm olive oil should be introduced. The deeper the cancer is situated, the more warm water and oil can be used. When the carcinoma occupies the upper part of the esophagus, the lavage and oil treatment are generally impossible. One hour after treatment the patient may be allowed to eat. In beginning treatment, the above procedure should be carried out daily, preferably before breakfast, and later on every few days. Patients are considerably relieved by the lavage and oil treatment, and are, as a rule, after a short time able to carry out the treatment alone. Enlarged glands, causing apparent stricture of the esophagus, would, of course, be treated for themselves by using potassium iodid, the X-ray, mercury, etc., according to the nature of the inflammation, and if capable of reduction, be influenced by con- stitutional remedies. If beyond the reach of drugs, the surgeon should be called in. So also aneurysms (q. v.). Spasmodic stricture calls for nerve sedatives, such as the bro- mids (15 grains t. i. d. in solution) or atropin (hypodermically jfo grain t. i. d.). Then hydrotherapeutic measures to tone up the body (alternating sprays, drip sheet, massage, etc.) should be used. The diet must be nonirritant and mineral waters sufficient to keep the bowels freely open must be used. In addition, vigorous local treatment may be instituted, as described in the following paragraphs on cardiospasm. Spasm of Esophagus and Cardia Chronic cardiospasm is to be treated mechanically by forcible dilation. Probably the best method is that wherein a dilatable rubber bag is introduced into the contracted space, and then pres- sure exerted under the control of a mercurial manometer. Thus Cohnheim says: 198 DISEASES OF THE DIGESTIVE TRACT This dilatation is easily accomplished by means of a dilatable rub- ber bag, such as a condom, fastened over the distal end of a small- sized, stiff-walled stomach tube, or an especially contrived rubber bag introduced into the cardia by means of a wire stilet or bougie. The rubber bag should be covered by a silk bag to con- trol and limit its amount of distention during treatment. A mercurial manometer is an essential part of the appa- ratus by which the physician will be able to control the amount of pressure used in distending the cardia within safe limits — namely, six or seven pounds. The normal cardia cannot be safely stretched beyond a diameter of 3.5 cm. The silk bag which covers the rubber balloon should therefore have a maximum diameter, when fully dilated at a pressure of six or seven pounds, of about 3.5 cm. Early treatments should be given with smaller sized bags, these being grad- ually replaced with ones of larger size, at each succeed- ing dilation of the cardia. Either air or water pres- sure may be used to distend the rubber bag. Fig. 31. — Cohnheim's Apparatus for Dilat- ing the Cardia. o O Fig. 32. — Trousseau's Bougies. THE ESOPHAGUS 199 When the contraction is extreme, Trousseau's esophageal bou- gies should be used to open the way for the bag and to measure the distance from the incisors, as well as the diameter of the passage. Another method of dilating the esophagus is that of Plummer, described by him, as follows : The dilator is made by cementing a rubber-dam balloon to one end of a piece of nonelastic rubber tubing in such a manner that the tube just passes through the balloon. The end of the tube is closed with a rubber plug, and a number of holes so punched that its lumen com- municates with the interior of the balloon. A sausage-shaped silk bag is drawn over the balloon to preserve its shape under distention. Several sizes, five inches in length and varying from three fourths to one and one fourth inches in diameter are provided. If the dilator is slightly constricted in its middle third, the tendency for it to slip into the stomach or esophagus is lessened. A flattened steel wire is used as an introducer. Provision for connecting a tube leading to a water tap or pump is made. A section of the tube is doubled. One passage is nar- rowed by inserting a capillary glass tube, and the other section is pro- vided with a stopcock. An altitude gauge is also connected by means of a " T " joint. Having previously determined the position of the cardia, the dilator is introduced sufficiently far for the cardia to engage the balloon at its middle third, and the water turned on at the tap until the gauge indicates the pressure of one or two feet. The stopcock is now closed and the pressure slowly raised to the required point by forcing the water through the capillary tube. The force to be used is to be determined by the tolerance of the patient and the results obtained from former attempts. The pressure used has ranged from five to twenty-five feet, great variation being shown in the ease with which the cardia dilates. In one case the cardia contracted sufficiently to cause obstruction within a few days after each dilatation, until a pressure of approximately fifteen pounds was reached. The reason for the failure to obtain satisfactory results by those who have used the mouth to ex- pand the dilator is at once apparent. Danger of tearing the esophagus is to be avoided by stretching slowly and by having the dilating force under such control that it may be instantly released if severe pain indi- cates any giving way of the tissues of the cardia. Sudden expansion of the dilator, should a tear start, is guarded against by constructing an instrument of rigid tubing, filling the dilator with a noncompres- sible medium, and having the water supply almost shut off by the capil- lary tube. If a compressible medium like air is used, dilatation of the cardia from a small caliber to the full size of the dilator can take place 200 DISEASES OF THE DIGESTIVE TRACT without materially lowering the pressure, and therefore should the tis- sues begin to give way, a large rent in the esophagus might suddenly occur. To provide against further accidents, dilators of increasing size should be employed, but this is no safeguard unless sufficient pressure is used to give assurance that each successive size is extended to its full diameter. Two or three dilatations have been sufficient, as judged by the results obtained, to completely paralyze the circular musculature of the cardia. Recurrence of the dysphagia will depend largely upon the ability of the dilated esophagus to regain its normal size and tone. Relapses are to be expected in some of the cases. THE STOMACH Gastralgia Gastric pain may be caused by either one of two general patho- logical conditions. First, it may be caused by erosion and ulcera- tion of the mucous membrane over considerable surface of the stomach, thus exposing the sensory nerve endings. That is usually the accompaniment of hyperacidity. Second, it may be due to the distention of the viscus by gas. This is usually the accompaniment of an acidity or atony. In the first type the epigastrium is tender to pressure, in the second case it is sometimes tender and some- times not. If the pain be due to erosion or ulceration, the treatment dis- cussed under hyperacidity is indicated. If, on the other hand, it is due to the presence of gas, temporary relief may be obtained by causing this gas to pass off. Thus, hot drinks usually stimulate the pylorus to open and the consequent peristalsis then carries the gas through the intestine, or else causes belching, which brings the gas up through the mouth. Ginger and other stimulant stomachics have a like influence in starting up the peristalsis. If the pain, however, is quite severe, morphin may have to be resorted to to relieve the patient while the physi- cian proceeds with some causal treatment, such as gastric lavage. But in either case it may be profitable to the future well-being of the patient to have a thorough gastric lavage, which would clean off and revitalize the mucous membrane. Or, on the other hand, the use of mineral waters until the gastrointestinal tract is thor- oughly cleansed may be sufficient if gastric lavage be not feasible. THE STOMACH 201 Where such gastric pain from gas distention is habitual, a carbon- ated alkaline water should be given regularly, preferably on an empty stomach, until the condition is relieved. For instance, in the morning at least half an hour before breakfast, and if neces- sary at a similar interval before the other meals also. If the trouble be a simple one where the mucous secretions of the stomach need merely some stimulation, a simple carbonated water is suf- ficient; but if the whole intestinal tract be relaxed, carbonated alkaline waters would be better. The quantity varies with the strength of the water. Usually it ranges between four and eight ounces. The waters should be sipped rather than gulped, and where the whole system seems relaxed and flaccid, hot rather than cold. Anacidity As will be noted, the above measures remove the results of the abnormality in the gastric secretion, that is, they constitute the symptomatic treatment. The causal treatment, on the other hand, is as follows : Whether functional or organic, anacidity is most satisfactorily treated by giving dilute hydrochloric acid 1 one half hour after meals. The dose should be 15 to 30 drops in plenty of water. The condition can be helped considerably by active bodily exercise in the open air, and also by massage and friction baths. It will frequently, however, be necessary to give the acid in some combination that will obviate the necessity of the patient's measuring out his own medicine by drops (as in charity and tene- ment house work). In that case, a prescription with the bitters would be useful, e. g. : ^ Acidi hydrochlor. dil 15.0 c.c. Tinct. gentian, co 30.0 " Ext. fl. cascarae sag 8.0 " Glycerini 90.0 " Aquae destill 60.0 " M. D. S. : One dessertspoonful in water thirty minutes after eating. 1 The officinal drug is a 10 per cent solution of the strong acid. The normal acidity of the gastric juice gives a test of total acidity between 40 and 65 mm. of decinormal sodium hydroxid solution. 202 DISEASES OF THE DIGESTIVE TRACT Hyperacidity Fats, when given before other foods, have a tendency to check the secretion of the gastric juices, therefore the best treatment of hyperacidity is the use of olive or other oil in tablespoonful or larger doses just before meals. Where the oil is not palatable the following prescription may be used (Cohnheim) : 1J Tct. belladonnas folior 5.0 c.c. Olei amygdalae dulcis 30.0 ' ' Vitelli ovi unius Aquas destill q. s. ad 200.0 " M. f. emulsio. D. S. : A tablespoonful t. i. d. just before eating. For the relief of pain, which usually occurs at the height of gastric digestion, bismuth subnitrate in 20-grain doses, or soda in 1- to 2-grain doses, in water will be found efficient. Illustrative Case Histories (from Cohnheim 's text) : Case I. Frederick B., a tailor, thirty-one years old, had for two years suffered from pressure in the stomach after eating solids, and had an inclination to diarrhea. There had been an exacerbation of the symp- toms for two weeks, after he had eaten currants. Patient's appetite was poor, except for highly seasoned foods. He was emaciated and pale. He had catarrh of the apex of the right lung. The greater curvature of the stomach reached to the umbilicus. The microscope showed the test breakfast to be poorly digested. The total acidity was 20. Treatment. — Kissingen water, a diet of semisolids, and hydrochloric acid. Five weeks later pressure in the stomach had almost entirely dis- appeared, and patient was discharged. Case II. Mr. R., a merchant, twenty-seven years old, was a heavy smoker. The patient had suffered periodically for a year and a half from cramplike pains in the stomach, two or three hours after meals, which were always relieved by eating again. He had always had a hearty appetite. Treatment. — Half a wineglassful of olive oil was prescribed in the morning and a cup of milk of almonds at noon and in the evening before eating. Belladonna, combined with an alkali, was given twice daily after meals. The patient was immediately free from discomfort in the stomach. The after treatment consisted in the use of Vichy water. THE STOMACH 203 Gastric Ulcer We have already made some mention of ulcer of the stomach in connection with onr study of the pathological conditions of mucous membranes, and we have seen that bismuth subnitrate, orthoform, and atropin represent the types of drugs to be used to quiet the pain and protect the abraded tissues. The condition demands ab- solute rest, both of the body in general and of the digestive func- tion in particular; therefore patients suffering from round ulcer of the stomach are, whenever it is possible, put to bed and given no food whatever by the mouth for perhaps a week. All nourish- ment during this time is given by the rectum in the form of nu- trient enemata. Peptonized milk and eggs are used for this pur- pose. To make these enemata most effective, the rectum should be cleansed with an enema of one to two pints of sodium bicarbon- ate solution one hour before the injection of the nutrient enema. After the rectum is emptied, the patient lying on his left side, the enema should be put in through a rectal tube, slowly, in order to avoid irritation which would cause it to be expelled before it has had time to be absorbed. The solutions used for nutrient enemata should be dilute in order to conform to the laws of endomosis. They should be as thoroughly predigested as possible in order that they may resemble the chyme that is absorbed from the upper intestinal tract. The agent for the predigestion is usually pan- creatin. Enough soda is added to the powdered pancreatin to make the solution alkaline, in order that it may afford the best conditions for the development of the ferment action. 1 The inter- val between two nutrient enemata is usually six hours. The typical composition of a nutrient enema (Boyd and Robertson ) is: Yolks of two eggs; 30.0 (1 ounce) pure dextrose; 0.5 (7 grains) common salt; pancreatized milk sufficient to make 300.0 (9 ounces). During the second week, feeding by mouth may be begun. The only food allowed at first is liquid, and this is given in two- to five- ounce doses every three hours. At first milk may be used diluted with a carbonated water, such as Vichy. Later, the fresh, undi- luted milk may be used; then milk with bread soups, tea with 1 Pancreatinizing powder may be purchased ready for use. The two best known are Fairchild's and Wyeth's. 204 DISEASES OF THE DIGESTIVE TRACT cream, cocoa cooked with cream; then oatmeal, rice, corn meal, or wheat gruel may be given for variety. Butter may be used freely. For such patients as can take them, raw eggs may be given in the first food by the mouth, instead of the milk; but because so many people are nauseated by the thought of taking raw eggs, the prac- tice cannot be made general. The next week something more substantial may be added, and so on, until finally after about six weeks the patient reaches a fairly normal diet — at least a diet that will maintain the normal equi- librium. The essential part of all these treatments is the rest in bed, and more failures probably result from the patient's getting up too soon than from any other one cause. The patient must avoid for several weeks coarse breads, fried potatoes, acids, pastries, cabbage, cheese, goose, duck, fat pork, ham, bacon, eel, salmon, legumes, etc. The bismuth and the orthoform are used in this course of treat- ment only when the pain renders some sedation necessary, as at first, before the rest has succeeded in quieting the gastric pain. The bismuth is used in doses of 1 gram (15 grains), suspended in water, and the orthoform similarly in a one-per-cent suspension. Another prescription to quiet pain, to be used after eating, is the following : ^ Ext. belladonnas folior 0.2 Magnesii oxidi Sodii bicarbonatis aa 25.0 M. D. S. : One teaspoonful, one or two hours after food, two or three times a day. Still another combination of drugs suitable for relieving the pain of ulcer is the prescription from Cohnheim given above in our discussion of gastric hyperacidity. Cancer of the Stomach Cancer of the stomach is, of course, a surgical disease and should be treated by excision or exclusion whenever possible. Many cases of inoperable cancer will, however, be found in every man's practice, and these demand the most painstaking care. Many years ago, Professor Friedreich, of Heidelberg, thought THE STOMACH 205 he had found in condurango bark a specific against cancer, because it seemed to stimulate the appetite of the patient and enable him to take food and for a short time often gain in weight. The drug has turned out, however, to be only another of the stimulant stomachics. Nevertheless, it is useful in cases of inoperable can- cer, when given in connection with the other indicated remedies. The first of these is arsenic. It is used for the sake of building up the body to greater resistance. It is sometimes injected directly into the tumor in the hope of securing thereby its caustic effect, but in case of cancer of the stomach this is, of course, impossible ; therefore it is given either by the mouth as Fowler's solution, or 3*0 grain arsenious trioxid pills, or injected every other day in doses of 0.05 grams of arsacetin into the muscles of the back. The diet in cancer of the stomach should, of course, be such as to pass through the pylorus. When this is closed, nothing remains but rectal alimentation and the frequent use of gastric lavage. When, on the other hand, the pylorus is open, one can still feed by mouth by having recourse to predigested foods. Painstaking attention should be given the condition of the bowels and no con- stipation or clogging permitted. An illustrative prescription for use in such a case of gastric cancer would be : If Fl. ext. corticis condurango 2.0 Fl. ext. cascaras sagradas 0.5 Acidi hydrochlorici diluti 1.0 Glycerini 5.0 Essentia^ pepsini 5.0 For one dose, to be given about thirty minutes after food. In this prescription, the cascara is used for its laxative effect, the hydrochloric acid to supply the lack of acidity always found in gastric cancer, and the glycerin and essence of pepsin form a synergistic vehicle. The taste of the medicine thus prepared is rather bitter, and for that reason patients should take it in water if the bitterness prove disagreeable. Pyloric Stenosis This is a surgical condition and comes to the physician only for diagnosis or when an operation is out of the question. Here 206 DISEASES OP THE DIGESTIVE TRACT gastric lavage is absolutely necessary to keep the stomach free from fermenting food stuffs, and should be done at first twice a day, at morning and at night, until no detritus is found in the returning water. After the lavage, 50 to 100 c.c. of warm olive oil may be introduced into the stomach. This may be done through the tube, but preferably by drinking. There should be only two meals a day, and these should be fluid, but should contain as much of albumin and oil as possible, and in such condition as will most easily pass the pylorus. In benign stenosis the stomach can sometimes digest meats and albuminous foods when they are ground fine; but in malignant stenosis the gastric secretions are too weak to do this. The only drugs that should be used in this condition are anti- fermentatives and antiseptics to check the fermentation caused by the stagnation of the food in the stomach, and the antispasmodics to relax the pyloric sphincter as much as possible. Therefore we give the bismuth subnitrate as antifermentative and sedative, and belladonna as an antispasmodic. Sometimes the use of olive oil with the tube obviates the necessity of any other medication. On the other hand, we find cases requiring the use of papain and other digestants to assist in preparing the food for the duodenum. Pa- pain should be given in such a case in doses of 5 grains soon after eating. Portal Congestion Frequently dyspepsia is due to the congestion of the mucous membrane throughout the portal circulation. This causes a faulty secretion of the digestive juices and also a feeling of discomfort and weight. The taking up of so much blood in the splanchnic area leaves the extremities cold and the skin clammy and pale. The best treatment is a hygienic one wherein by massage and exercises these blood vessels are stimulated to contraction and the blood is driven into other parts of the body. Cold baths, the alternating hot and cold douche over the splanchnic area and over the back, combined with drugs that will stimulate the peristalsis, seem to be valuable in obtaining relief. The patient should have regular hours of sleep, as regular hours of eating, and should not attempt to rob the digestive tract of its due share of blood after meals through intense mental activity. THE STOMACH 207 The drug treatment is chiefly by means of the stimulating sto- machics (bitters), varying according to the acidity of the stomach contents and the tone of the stomach wall. I use for such bitters chiefly the compound tincture of gentian, condurango, and berberis. Functional Gastric Disorders In functional gastric disorders, suggestive therapeutics com- bined with hygienic regulation of the life usually bring about a cure. The regulation of the diet must proceed on the principle of stimulating the stomach and proving to the patient the soundness of the organ. In general, forced feeding combined with a rest cure is the plan adopted. The drug most used for the stimulation of the stomach is valerian (or its derivative baldrian), which seems to have a desirable general as well as local effect. The tincture is often made the vehicle for other and stronger drugs. Thus, for a case of nervous atony with constipation, we might give the fol- lowing : ^ Acidi hydrochlorici diluti 10.0 Ext. fl. cascarae sagradse 6.0 Tct. Valeriana? q. s. ad 100.0 M. D. S. : One teaspoonful in water or milk one half hour after eating. Finally, we must remember that many gastric disorders are caused by troubles than can be removed, such as those of vision and mastication, as is most interestingly shown in the following case history from Harry Campbell's book of essays on treatment: A man, thirty-five years old, was a great sufferer from indigestion, and he had become pale, emaciated, nervous, and irritable. He went to the Continent and consulted several specialists there. They drew off the contents of the stomach at various intervals after each meal, and examined them chemically with a view to discovering the power of the stomach to digest different articles of diet; those which were not prop- erly digested were removed from the dietary, until finally the patient was restricted to three or four. The amount of fixed and free acids was also estimated, and special drugs were administered in order to correct certain defects that the calculation revealed. The result of this very scientific treatment was that the patient lost weight, and that he got more anemic, more irritable, and more nervous than ever. When 15 208 DISEASES OF THE DIGESTIVE TRACT I saw this patient he was a veritable skeleton. I found that he had astigmatism (he was a great reader), and that his teeth were not as good as they might be. These errors were at once corrected, and then, as he was in a very exhausted state, I had him put to bed and fed up. There was no need to be very particular about his diet, for from the very beginning he digested his food quite well now that the sources of irritation, in the eyes and teeth, were removed, and he was no longer scouring the Continent in search of doctors. Gastric Dilatation The dimensions of the stomach are not to be given exactly be- cause so mnch depends upon the tone of the musculature and the history of the individual. The vertical distance from the greater to the less curvature in the middle of the stomach is usually stated to be 9 to 11 centimeters. At least such is the ordinary distance beyond the cardia which the sound or stomach tube must pass before it reaches the lower wall. The capacity of the stomach has been stated by different authors, as follows : Ewald 250 c.c. to 1,680 Luschka 1,500 c.c. to 2,000 Schuren 2,430 c.c. Vierordt 2,980 c.c. Beneke 3,800 c.c. Brinton 3,130 c.c. Soemmering 2,500 c.c. to 5,500 Henle 2,500 c.c. to 5,500 Ost 2,533 c.c. to 2,700 These figures have been gathered for the most part from cadavers, and are therefore too high. At any rate, we would have to say that anything above 2,500 c.c. is abnormal, and that therefore the normal capacity of the stomach should not exceed 1^ to 2 liters. For instance, the stomach that at the post-mortem examination held 3,060 c.c. of water, during life reached almost to the sym- physis and therefore belonged to the worst degree of dilatation. At the present time we understand the expression " dilatation of the stomach " to mean that form of gastric disturbance in which the stomach is unable to empty itself of its contents, with a resulting persistent stag- nation of food. The location of the greater curvature is in itself irrel- THE STOMACH 209 evant in the diagnosis of dilatation of the stomach. The question is not as to the size of the stomach, but only as to its motor function. The term " gastrectasis " originated at a time when physicians had not learned to recognize the initial stage of the affection, but only its final stage — dilatation of the organ — and this was considered the most significant symptom of the disease. When we use the expression " dila- tation of the stomach," therefore, we must from the outset be clear that we mean only the symptom of an actual disease rather than a dis- ease per se. To make the condition quite clear, a comparison of the stomach with the heart is very applicable, for just as acute dilatation of the ventricles of the heart may arise from valvular insufficiency, so acute dilatation of the stomach may occur from overloading the organ, as a result of errors in diet, or from paralysis of the nerve-muscular apparatus. On the other hand, chronic dilatation of the stomach is without exception the result of an ob- struction at the pylorus or du- odenum, just as hypertrophy and dilatation of the ventricle re- sults from valvular affections. Hence the primary factor is al- ways an obstruction which causes stagnation of the food, this in turn producing dilatation of the stomach. Every dilatation of the stom- ach is therefore a vitium py- lori or duodeni (obstruction) in the stage of disturbed com- pensation. As has already been men- tioned, it is necessary to differen- tiate between acute and chronic forms of motor insufficiency of the stomach. Acute dilatation is extremely rare, and in general corresponds to acute gastritis after indigestion or to ileus which is located high up in the intestine. (Cohnheim.) Fig. 33. -poche sous-pylorique of Chapotot. The result of gastric dilatation and gastrectasis is to be seen in the accompanying illustration following Chapotot, showing the 210 DISEASES OF THE DIGESTIVE TRACT pocket which is below the level of the pylorus, and therefore not to be emptied in the usual manner. Gastric Lavage The use of the gastric sound reaches back into the time of Greek antiquity, but was not brought into prominence until in the time of the Roman emperors, when their banquets demanded the fre- quent emptying of the stomach in order that the banqueters might take more food. The means for emptying the stomach were first the sticking of the finger into the throat to cause vomiting. The finger was succeeded by the use of a feather, and this in turn by a glove finger, the lower two thirds of which were filled out by wool and the upper third left empty for the insertion of the physician's finger. This in turn was succeeded by the lorum vomitorum, which, on account of its fearful taste, produced the desired effect. This was a sound doctored with vile-tasting compounds, which when put into the throat immediately caused vomiting. In the second half of the seventeenth century there was developed the stomach brush, which consisted of a long pliable fish bone, on the lower end of which were fastened pieces of linen or silk, or even wire, for scraping out the inside of the stom- ach. Then a regular brush was used, but since this sometimes brought on hemorrhage or asthmatic attacks, it was soon laid aside. Fig. 34. — Original Method of Gastric Lavage Without the Help of a Physician. THE STOMACH 211 In 1716 Fabricus ab Aquapendente invented his silver canula for inserting into the nose of patients suffering from lockjaw. This was improved upon by John Hunter, who used a hollow bou- gie or catheter. Along in the beginning of the nineteenth century, Bush and Juke performed gastric lavage by means of a syringe and rubber tubes, but it was not until 1870 or later that the soft rubber tube was introduced into England, from which it spread to different parts of the world. Scientific gastric lavage was developed by Kussmaul in 1867. The instruments, however, had been developed at different places and different times, and were simply brought into systematic and logical use by Kussmaul. At first a pump was used for emptying the stomach of its contents, and this was succeeded by the use of the siphon. The ac- companying illustration, taken from a publication in the early part of the '70s, shows the method used at the Jena clinic under Gerhardt for pa- tients who were able to pass the tube themselves. We now use improve- ments on this method, but the same principle. Of stomach tubes there are on the market practically two types, as shown in the accom- panying illustrations. The one depends upon the siphon principle, the other (Ewald's) upon the suction exerted by the rubber bulb to remove the stomach contents. These tubes are marked by a ring at the point which should be between the teeth when the end has reached the stomach. The caliber of the tube should be governed by the diameter of the narrowest point in the esophagus — the point opposite the cri- Fig. 35. — Ordinary Type of Stomach Tube With Funnel and Bulb. 212 DISEASES OF THE DIGESTIVE TRACT coid cartilage. This varies considerably. Thus von Hacker found it to be 16 mm., Mackenzie 19J, both measures being from large- sized adults. Manton, however, found a diameter of 14 mm. ; hence it is unwise to use a tube over 13 mm. in diameter. The passage of the tube by the cricoid with its projecting ring is accomplished best by having the patient swallow. This draws the cartilage forward, away from the verte- bras. When this does not succeed, we can push the larynx forward by in- serting the forefinger, as shown in the accom- panying illustration. The length of the esophagus is given by various authors thus: Krause, 21.6 to 24.4 cm. ; Luschka, 28 cm. ; Laim- er, 25 to 26 cm. ; Moro- sow, 24.5 to 25 ; Sappey, 22 to 25.5. Rosenheim, on the other hand, says it is T 5 g- of the length of the trunk. The distance of the front teeth to the upper end of the esophagus is usually 14 to 15 cm., hence the mark on the stomach tube, to show the point that should rest between the teeth, should be the sum of the two lengths; that is, 40 to 42 cm. from the lower end. One can estimate on the patient approximately the distance from the incisors to the cardia by using Kussmaul's method. This is to pass the sound or tube from the mouth along the cheek, un- der the ear, and down the back to the height of the tenth thoracic vertebra, for this represents the level of the cardia. The begin- ning of the esophagus is similarly represented by the level of the sixth cervical vertebra. Gastric lavage should be used whenever there is pyloric Fig. 36. -Pulling the Larynx Forward Before Inserting the Tube. THE STOMACH 213 stenosis, or gastric fermentation, or mucous gastritis, and also after the ingestion of poisons. It is of great value in cases of gastric neurosis, atony, etc., being useful even in many cases of gastric erosion and ulcer. In case of carcinoma ven- triculi it can be used, but only with, great caution, lest the tube perforate the wall. It is contraindicated in case of aortic aneu- rysm on account of the danger of rupturing the weak vessel walls. The tubes should be of soft rubber and have an opening on the side as well as at the end. To insert the tube with the patient sitting in an ordinary chair, one should stand behind and to his right. The patient's head should rest against the operator's left chest, with the operator's left arm encircling the head and his left hand supporting the tube at the patient's lips. With his right hand the operator then pushes forward the tube to the uvula, and as the patient swallows, pushes it gently forward into the esophagus. The tube is then carried downward by successive swallowing movements until it reaches the stomach. Should this method not succeed, the operator may stand in front of the patient and insert his left forefinger and press for- ward the larynx and then pass the tube by the side of his forefinger with his right hand. The tube should be moistened thoroughly in cold water or glycerin before being introduced. As soon as the stomach is reached the funnel end of the tube should be lowered over a basin and the patient asked to press as at stool. This usually brings up some of the gastric contents. This part is usually set aside for laboratory examination, and then the real lavage begun. For this the funnel is raised to the height of the patient's head and the solution poured slowly into the tube. The air in the tube may cause some difficulty at first, but this may usually be overcome by raising the funnel until the tube is nearly vertical. Because of the blockade cause by air and its unpleasant effects when forced into the stomach, care should be taken to pour the solution in a steady stream until the quantity desired has reached the stomach. When sufficient quantity has been poured in, the funnel should be quickly lowered (with the water still in it to start the siphon action) over the basin to empty it out again. 214 DISEASES OF THE DIGESTIVE TRACT The process of filling and emptying should be repeated until the water returns clear. As to the quantity of solution to be used for each filling, few figures generally applicable can be given, for everything depends Fig. 37. — Stomach Washing, when it is Necessary to Pull Forward the Tongue (Caille). upon the irritability of the stomach. In general, one should use enough to dilate the organ somewhat, but not enough to give dis- tress. Frequently the patient will vomit up the solution outside the tube as soon as the stomach is nearly full. This, of course, is un- pleasant, but does no damage. It gives a limit for the next filling. Before passing the tube the patient should be warned of the feeling of suffocation and told that there is no danger, and that he has only to take long, forced respirations to overcome this dis- comfort. Of solutions to be used simple warm water is best for all general THE STOMACH 215 purposes. When the presence of microorganisms has been demon- strated in the stomach salicylic acid in the strength of one fourth per cent may be used. When morphin has been ingested potassium permanganate in 1 : 1,000 to 1 : 4,000 dilution may be used in order to oxidize the morphin still within the stomach. When the stomach is coated with mucus warm alkaline mineral waters (Waconda, White Rock, Congress, Sulpho-Saline) should be used. In general, it is best to use the tube either early in the morning or late in the evening. In cases of fermentation, the evening hour is better because it insures a good night's rest. When a mucous gastritis is present the morning hour is better, in order to free the stomach of mucus preliminary to the ingestion of food. Once a day seems sufficient for most cases. In chronic cases patients should be taught to use the tube themselves. Then they may either use the ordinary tube and have some one help them to pour the water and place the basins, or they may secure an apparatus like that shown in the accompanying il- lustration and perform the lavage alone. Whenever the holes in the tube become blocked with food par- ticles it is usually better to withdraw the tube, cleanse it, and re- Fig. 38.— The Ewald Tube (Shortened). insert it than to try to dislodge them by pouring in extra water or similar maneuvers. In withdrawing the tube one should compress it between the thumb and finger (as one does a catheter), so that none of the contents can escape until it is safely in the basin. One should also withdraw it very quickly; usually one single pull is sufficient. 216 DISEASES OF THE DIGESTIVE TRACT Needless to say, the patient should rest after the treatment. The tube should be cleansed out in hot water immediately and then hung up to drain. It should not be boiled. To use the Ewald tube, we pass the tube separated from the bulb, and then attach the latter compressed. Its expansion sucks the stomach contents upward into it. If it becomes filled, it should be detached, emptied into sterile glass vessel (if the contents are to be examined), and reattached compressed. Lavage with this in- strument is very slow, because one can put in so little fluid without refilling the bulb. 39. — Esophageal Stricture. An obstacle to the passage of the stomach tube. The presence of esophageal diverticula may cause some diffi- culty in passing the stomach tube, as is indicated in the illustration from Gumprecht on this page. In such cases the measurement of the height at which the obstruction is met should next be under- taken, to make sure that it is within the limits of the esophagus. THE LIVER Although the diseases of the liver are usually considered among those of the gastrointestinal tract, nevertheless they differ in their pathology from other intestinal diseases, because the liver is essen- tially a separate gland, and therefore influenced by, and influen- THE LIVER 217 cing, in a more involved and obscure way, the general systemic metabolic processes. The liver, for instance, acts as a filter to separate out the poisonous products of intestinal digestion, as well as the waste products of metabolism. It also provides the bile which influences intestinal digestion; hence, whenever the organ does not do its work properly, or is inflamed, we have not only the local discomfort and interference with digestion, but we have also the direct poisoning of the body from the absorption of the by-products of digestion. Among these systemic effects we find mental and nervous depression, changes in the blood, and brady- cardia. Whether these changes are caused by the absorption of the coloring matter of the bile, or of the bile salts, or of the pep- tones, is immaterial to this issue, because the general process is the same. Only when we come to a discussion of antidotes for this toxemia does it become necessary to know which product of the liver's activity (or lack of it) we must neutralize. Icterus The most common symptom of liver disorder is icterus, or jaun- dice. That it is a symptom and not a disease entity is very im- portant for us to realize in order that we may not seek to treat the jaundice for itself, but may institute the proper investigations to establish the causation of the symptom and thus diagnosticate the real lesion. Icterus (that is, the discoloration of the skin and mucous membranes) is, of course, due to the absorption of bile by the blood and the deposit of the coloring matter along the capil- laries. Usually such absorption occurs only when an obstruction of some sort prevents the flow of bile into the duodenum. Some- times, however, toxic processes may be at work, causing the ab- normal absorption of bile by the blood. Cases of the latter type are, fortunately, rare, for they indicate a condition upon which bur therapy has little effect. Of the causes of obstruction, the most common is the lodgment of gallstones in the common duct. Then follow inflammation of the biliary passages, inflammation of the duodenum in and about the outlet of the common duct (so as to block the outlet), and tumors large enough to compress the ducts. (This compression of the ducts is also increased by tight dress- bands and corsets.) 218 DISEASES OF THE DIGESTIVE TRACT Fortunately the skin usually begins to regain its normal color as soon as the obstruction is removed. Only after repeated attacks do we find a permanent discoloration of the skin or the develop- ment of xanthoma; therefore we do not need ordinarily to combat the coloring process or seek agents to decolorize the tissues. Hence the treatment of icterus is the treatment of the under- lying cause ; but, on the other hand, we often must seek some relief for the symptoms caused by the toxic constituents of the bile, such as the tendency to capillary hemorrhage, the vomiting, the itching, the sleepiness, and the other nervous symptoms. For in- stance, for the tendency to capillary hemorrhage we may use cal- cium salts (although late researches indicate that they do not affect the coagulability of the blood), stypticin (cotarnin hydro- chloride adrenalin (intravenously), etc. The favorite calcium salt is the lactate, because of its lack of irritation. This may be given in fifteen-grain doses as frequently as desired. Ordinarily, the interval varies from two to four hours. This raises the calcium content of the blood and neutralizes the bile acids or coloring mat- ters which seem to be paralyzing the vasomotor tone of the smaller blood vessels. Stypticin may be given in doses of three fourths of a grain every three hours (if the stomach will retain it) . The maximal daily quantity is nine grains. Its effect is still more problematic than that of the lime salts. Adrenalin chlorid may be introduced (slowly, drop by drop) into a vein in doses of ten to even twenty- five drops. The effect is, temporarily, at least, good, in that the blood pressure is raised and the vasomotor centers stimulated. Thyroid extract, three grains three times a day, given with calcium lactate, twenty grains three times a day, has caused the coagulation time to fall in a case of gallstone disease from eight to two and a half minutes within a few days, and therefore seems, for the pres- ent at least, the most promising therapy for the tendency to capil- lary hemorrhage. The pruritus is best treated by sweat baths. Of such baths the hot-air cabinet yields results the most pleasantly and quickly. The patient should be wrapped loosely from the neck down in three or four layers of cotton blankets or Turkish toweling and kept in the cabinet with a temperature of 225 to 275° F. for thirty to forty- five minutes. Ice-water cloths should be kept on the forehead and the pulse and respiration carefully watched. Should the pulse run THE LIVER 219 to 120 per minute, the heat should be turned off at once. At the close of the bath the patient should be sponged off in warm water and put to bed. The purpose of these baths is to remove from the skin and its glands the irritant matters causing the itching. The general effect of these sweat baths is also good in that it helps Fig. 40. — Electbic Bath Cabinet Room, Illinois Westebn Hospital for the Insane, Watertown, Illinois. eliminate the toxic matters from the body and stimulates the slug- gish metabolism. The depression of the nervous system calls for the stimulation of the emunctories — skin, kidneys, and bowels. The use of cam- phor (ten-per-cent solution in a sterile neutral oil) subcutaneously in doses of 6 c.c. pro die may give symptomatic relief. But the use of hot baths, mineral waters, and diuretin (the latter in doses of one half to one gram t. i. d.) are attended with more permanent effect. We may substitute, but with less effect, electric-light baths, hot-tub baths, and steam baths, given in sufficient strength to cause free perspiration. Summarizing now our drug treatment, we have the following: We treat primarily the lesion causing the jaundice, as outlined in the following pages. The jaundice itself we treat chiefly by stimu- lating the elimination of the bile. Thus in uncomplicated cases we might prescribe (in addition to the physical therapy) the fol- lowing: 220 DISEASES OF THE DIGESTIVE TRACT t IJ Diuretin 0.5 gram. Calomel 0.03 " M. f. chart, no. I. Da tales doses no. X. Sig. One powder three times a day. Should we need to stimulate the skin elimination by drugs, we give pilocarpin hydrochlorid subcutaneously in doses varying from ■fa to J grain. This drug should be given only by the physician himself and repeated only as needed (usually twice a day), be- cause of its depression of the heart. The maximum daily dose is f grain (0.04). Should we discover the need of stimulating the whole body as well as the digestion, we might prescribe the following mixture: Tji, Tct. nucis vomicae 10.0 c.c. Magnes. sulphatis 30.0 grams. Diuretini 10.0 " Elixir simplicis 90.0 c.c. M. D. Sig. One teaspoonful in four ounces of water three times a day. The diet and the general conduct of the case must be governed by our diagnosis of the causative disorder. Of the diseases of the liver, some are beyond our power to af- fect, therefore we need spend little time in the consideration of such conditions as acute yellow atrophy, malignant neoplasms, amyloid, and fatty degenerations. On the other hand, we need to study thoroughly the treatment of gallstones, biliary inflamma- tions, and other remediable conditions leading to the disturbance of the liver functions. Hepatitis Cases of primary general inflammation of the liver are rare; more often we find an inflammation of the bile passages and the extension from them into the liver substance of the inflammatory process. The treatment for such conditions calls for the general unload- ing of the gut — and the stimulation of the excretion through skin and kidney also — and the physiological rest of the liver by giving THE LIVER 221 foods making little or no demand upon the hepatic function. To attack the causes of the condition, the best we can do is to give by the mouth drugs that will disinfect the hepatic passages (as far as that can be done by drugs) and increase the flow of fluid through the secreting cells. We need also to furnish to the in- testine the product of which it is deprived by the disorder of the liver functions, hence a prescription for hepatitis would be illus- trated by the following: J^ Phenylis salicylatis 0.2 gram. Fellis bovis inspissatae 0.2 " Hydrargyri chloridi mitis 0.01 ' ' M. f. caps, gelat. no. I. Da tales doses no. X. Sig. One capsule every three hours. In place of the salol one might use hexamethylenamin in the same dosage, since both of these drugs have antiseptic properties while circulating in the body fluids. The diet must be liquid and yet albuminoid in character. Thus vegetable soups, predigested milk, custards, eggnogs, etc., given every three hours, illustrate the general prescription. The reasons for these requirements are that the presence of albumen seems to prevent the precipitation of bilirubin and the formation of gall- stones (Robson). The liquid food creates less disturbance and is more easily digested than the solid foods. The frequency of the meals tends to stimulate the formation of bile, or at least its dis- charge into the duodenum. The patient should be kept in bed in order to limit the combus- tion of tissue and the consequent labor of the liver. Synergistic with the bed rest is the stimulation of the emunc- tories. Hot baths, diuretics, and laxatives should be used care- fully, yet adequately. In general, calomel is the best cathartic in this condition, because its action is antiseptic as well as cathartic. It is best given in small and frequent doses, rarely exceeding two grains for the total daily dose. Inflammation of the Biliary Passages In this condition we find faulty secretion of the bile, the pres- ence of detritus, and microorganisms in the ducts, and consider- 222 DISEASES OF THE DIGESTIVE TRACT able congestion of the mucous membranes. The stimulation of the circulation (active hyperemia) through the liver and biliary passages is therefore the first indication. This can best be brought about by deep massage, by the local application of hot and cold water (fomentations or sprays) in alternation, and the use of the thermophore. The food and drink of the patient should be regulated so that there is no stagnation in the duodenum. This means that the food should be nutritious, but not so bland that it would not stimulate the peristalsis, and that the meals should not be large. For exam- ple, a semisolid diet of eggs, milk, broths, scraped steak, etc., proves effective in most cases. Fresh grapes and other fruits can usually be given in addition. Mineral waters or other cathartics should be used to keep the peristalsis active. Of the mineral waters, the group known as alkaline cathartics (see list of waters) are best adapted to this class of cases. This water should be taken on an empty stomach, and where the patient is debilitated, as hot as can be well borne. Usually a wineglassful one half to one hour before breakfast, and another in the middle of the afternoon, will prove sufficient. Of the other cathartics, calomel in daily doses of one grain has proven of most worth. The old-time list of cholagogues has gradually been decreased, until now the only accepted cholagogue is bile. The apparent cholagogic effect of calomel is probably simply due to its inhibition of fermentation in the intestine, thus preventing the breaking up of bile in the intestine. As far as drugs needed to treat the local inflammation are con- cerned, the most useful are ox gall, to stimulate the flow of the bile ; salol or hexamethylenamin, to sterilize the biliary passages; and pancreatin, to assist in the digestion of the food in the duodenum. Ox gall is to be given in doses of 2 to 5 grains (0.1 to 0.3) sev- eral times a day, salol in doses of at least J gram (5 to 7 grains) three times a day. It should be remembered that the bile salts, when given in large quantities and absorbed into the system, pro- duce a digitalis effect on the heart. If the ox gall and pancreatin be confined in a salol-covered capsule or pill and this given about two hours after meals, probably the best results are obtained. A prescription illustrating this arrangement would be: THE LIVER 223 ^ Pancreatin 0.1 gram. Ox gall 0.3 " Calomel 0.01 " Make one keratin-covered capsule. Dispense twenty such pills. One group of men of merit is enthusiastic in recommending sodium succinate 1 in a dose of 5 grains every three hours for several months as an efficient treatment of chronic inflammation of the gall ducts and bladder. Whether or not such a treatment is ef- ficient, I am as yet unable to say. Another group of men is using a pill of the following com- position : I£ Acid sodium oleate 1J gr. Sodium salicylate If " Phenolphthalein ^ " Menthol T V " Sodium oleate 2 (that is, soap) probably has a similar influence to the sodium succinate in the above medication and works toward fluidizing the contents of the biliary tract. The sodium salicylate acts as an antiseptic, the phenolphthalein acts as a cathartic, while the menthol has a stimulant and analgesic effect upon the sffomach. 1 Succinates. These belong to the oxalate series, but are practically nontoxic. They are slowly absorbed from the intestine and entirely broken up in the sys- tem. Whether or not, after being absorbed, they have a valuable influence on the biliary tracts is as yet unproven. The dose is (0.3) 5 grains every three hours, continued for weeks and months. 2 Sodium oleate. This should not be confused with the officinal oleates, about which S oilman has the following to say: " Oleata. Solutions of bases (metallic or alkaloidal) in oleic acid. They are not definite chemic compounds, as the name would imply. The rationale of their use is that a substance is not absorbed by skin from aqueous, but from oily, solutions. Many substances, again, are not soluble in oils, but dissolve in oleic acid. The oleates therefore constitute a useful class of preparations when it is desired to secure the absorption of a drug through the skin. Many are diluted with olive oil. Five are officinal — four being oleates of alkaloids, the fifth of mercury." The claim is now made that this soap, sodium oleate, is one of the normal products of the mucosa of the biliary tract, and that this justifies its use in inflammations of the gall ducts. 16 224 DISEASES OF THE DIGESTIVE TRACT A variation of the above prescription is the following, which sells nnder the name of probilin : ^ Acid, salicylic 0.02 Natr. olein 0.08 Natr. stear 0.04 Phenolphthalein 0.01 Camph. menth 0.03 Excipien. q. s. ad pill no. I. Sig. Three or four pills several times a day. The use of hot fomentations over the liver region will help to overcome the pain and stimulate the local circulation. When jaundice is present, the use of a general hot bath is to be pre- ferred. Massage of the abdomen, when carefully supervised, is helpful. This should include the kneading and rolling movements. These treatments should not be prolonged enough to exhaust the patient, nor so vigorous as to cause pain; hence a prescription for two treatments daily, each lasting ten minutes, is usually sufficient. The patient should be kept in bed, or at least on a couch, for the reason given above. He should be encouraged to drink water between meals up to ten or more glasses a day. When such treatment does not succeed within a few weeks, #t is usually justifiable to perform a laparotomy and drain the in- flamed ducts or bladder. Chronic Cholecystitis When such biliary inflammations become chronic, they center in the gall bladder and we have the series of indefinite and puz- zling symptoms belonging to this disease. Thus there are epigas- tric pain, flatulence, irregularity of bowel action, headaches, at- tacks of vomiting, etc., symptoms that might be caused by several different lesions. The diagnosis once reached, an attempt at medicinal treatment should be made, but should this prove inef- fective, the patient should promptly be turned over to the surgeon. The treatment is essentially that outlined above, except that the use of large amounts of water need be emphasized. The sys- temic treatment by hydrotherapy and massage is usually essential THE LIVER 225 to a cure, hence such patients find it most profitable to enter a sanatorium, where the diet may be regulated and mechanical and physical treatments thoroughly given. Gallstones Gallstones are usually due to the stagnation of the bile in the gall bladder. The stimulus to calculus formation is usually bac- terial infection, a condition that frequently accompanies stagna- tion. Of bacteria, the bacterium coli commune is the most com- mon, and the bacillus typhosus somewhat less frequent but more virulent. The process is probably somewhat as follows: Bilirubin is precipitated by a biliary inflammation as a bilirubinate of lime ; about this as a nucleus layers of cholesterin are formed until either the chemical conditions change or the stones become so large that they rub on each other and thus prevent further growth. Probably contributing causes are long intervals between meals, sedentary life, and portal congestion induced by the lack of exercise and the lack of deep breathing, which usually accom- panies it. Gallstones often give no symptoms of their presence until they are forced into the ducts. There, of course, they produce intense pain (biliary colic), and also, if in the common duct, jaundice. In case of such a colic, the pulse is small, the face is pale and pinched, the skin cool, and the forehead bathed in perspiration. The pain may be sufficient to cause syncope. Chills may occur and the tem- perature rise to 102° or 103° F. This, however, usually indicates the presence of an additional cholecystitis. As soon as the stone has passed into the intestine, the attack ceases and the patient feels as well as ever. The indications for treatment are the relief of pain and the dilation of the passages. The first calls for morphin in full doses and the second for atropin and heat, hence the subcutaneous in- jection of \ grain of morphin sulphate and -^ grain of atropin sulphate is the first procedure after the diagnosis is clear. Then the heat should be applied locally and hot water in large quan- tities given by the mouth. The latter does good even if the patient vomit it up immediately. In such case, some more should be drunk as soon as the patient can do so. Sometimes it is necessary 226 DISEASES OF THE DIGESTIVE TRACT to anesthetize the patient with chloroform during such an attack, so great is the distress. During the interval the patient should be treated as for inflam- mation of the biliary passages. Should a second or third attack occur, he should be referred to a surgeon for drainage of the gall bladder. The use of olive oil to dissolve the stones is fallacious. On the other hand, it is a very good laxative and the soaps formed from it may be of use in stimulating the flow of bile in the ducts. It should be given after meals, unless the patient is suffering from gastric hyperacidity. (In the latter case, it should be given as directed in the discussion under that head.) Mineral waters are, of course, valuable, and patients suffering from cholelithiasis are often very much benefited by a stay of a few weeks at some springs. While there they should take plenty of the lighter waters rather than smaller quantities of the heavier ones. Hepatic Gummata Hepatic gummata and other conditions due to tertiary syphilis should be treated by a vigorous administration of the iodids, par- ticularly of the potassium iodid, using from 20 to 60 grains three or more times a day, in addition to the general treatment for the obstruction and other symptoms as outlined above. Such conditions seem to yield more quickly if mercury be given simul- taneously, as, for instance, intramuscularly in the form of the suc- cinimid (-£■ grain on alternate days deep into the glutei). Cirrhosis This condition is practically hopeless of restituo ad integrum; but, on the other hand, the patient can be made more comfortable than he would be without treatment. The whole life of the pa- tient should be regulated so that there be as little call made upon the liver functions as possible and drugs given to relieve the vari- ous symptoms of the disease as they arise. Thus if the patient lead a quiet life, spending a great deal of time outdoors (for instance, on horseback or driving), eat small meals of nutritious food, with very little of alcoholic stimulants or tobacco, the disease THE LIVER 227 may of itself cease to progress and cause very little trouble for months or years. The chief complication in these cases is the portal congestion, with the consequent dyspepsia. This needs to be handled along the lines mentioned in discussing stomach troubles, but with the addition of mineral waters, which through their active irrigation of the stomach and upper bowel tend to keep the mucous mem- branes in much better condition. The vomiting may be restrained somewhat by the use of dilute hydrochloric acid, and the edema may be controlled by the use of diuretics, such as diuretin x and calomel, or by means of hot-air baths, or by the use of pilocarpin (hypodermically in J-grain doses). The diet may be, at first, at least, exclusively of milk ; but usu- ally buttermilk, thin oatmeal gruel, or thickened milk soups, and jellies may be added. Vegetables and fruits, when well cooked, may be added for relishes. Animal food should be forbidden ex- cept at rare intervals. No alcoholic or other stimulant should be permitted. Considerable attention should be paid to the clothing and every precaution taken against chilling the body and deranging the circulation. Such chilling also puts an extra load on the kid- neys, and this in turn affects the liver. Hence in cases of cirrhosis well-to-do patients can with profit move to some equable climate such as California or that along the Mediterranean coasts. The ascites accompanying liver cirrhosis may require mechan- ical removal (i.e., paracentesis abdominis). For this the patient is braced up in bed, and after cleansing the hypogastrium with soap and water and alcohol, a small trocar is thrust into the peri- toneal sac in the median line between the navel and pubic arch ; or, if the patient lie somewhat on one side, then into the more de- pendent side at about the same level. The place for the puncture is selected by its dullness on percussion, and since the intestines tend to float on top of the fluid, selecting a dull point on the de- 1 For example, the following prescription may be employed : 1^ Diuretin 0.5 gram. Calomel 0. 01 " M. f. chart, amylac. no. 1. Da tales doses no. x. Sig. One powder t. i.d. 228 DISEASES OF THE DIGESTIVE TRACT pendent side usually keeps us clear of harming the bowel. The trocar is, of course, sterilized before using. The fluid should be collected in a clean basin and carefully measured. Fig. 41. — Manner of Holding Trocar. Should the patient feel faint, stimulants should be adminis- tered, such as aromatic spirits of ammonia and strychnin. If the fluid flow slowly, all may be removed that will come. In chronic peritonitis, some good seems to result from the fre- quent removal of the fluid, but in hepatic cirrhosis the only value of the operation is the relief from pressure symptoms. In fact, the drainage of the body fluids caused by the refilling of the peri- toneal sac has in some cases seemed to weaken the patient very perceptibly. The reinjection subcutaneously of this fluid in 3-c.c. doses has been advocated by Audibert and Monges in La Presse medicate for February 2, 1910. This should be accompanied by a chlorid-poor diet. (See Nephritis.) Abscesses op the Liver Liver abscesses call for operative treatment, the best of which is to open and drain ; hence in cases of chills and rigors due to the presence of solitary abscesses one should not waste time with drugs, but should call upon a surgeon to evacuate the pus. Hydatid Cysts Hydatid cysts may be aspirated and part of the fluid with- drawn. This would serve to fix the diagnosis even if it did not kill the embryo (which, however, it usually does). But probably THE INTESTINES 229 the best method is to have a surgeon do a laparotomy and clean out the cyst radically under the guidance of his eye. THE INTESTINES Enteralgia Enteralgia, or colic, is a symptom of various gastro-intestinal disorders and should lead us to seek out the lesion, and never per- mit us to content ourselves with relieving the pain. It may be due to irritation of the nerve ends in the intestine or reflexly to the irritation coming from other centers or from disorders of the nerve trunks themselves. Thus colic may be brought on by the irritant ac- tion of hard masses in the intestine, such as food, scybala, gallstones, or even worms (colica verminosa) . Again, as in gastralgia, it may be due to the distention of the bowel, either through impaction or gas (colica natulenta) . The latter follows the abnormal fermentation of starchy foods (e. g., green apples and also overripe fruits) . Cathar- tics may " gripe " the patient and cause colic. Abdominal chilling causes colic (colica rheumatica). On the other hand, we find colic in tabes dorsalis, uterine and ovarian inflammations, and lead poi- soning. Of course some cases of colic are due to simple hysteria. Hence, before treatment is begun, we must decide whether we have to remove irritant masses from the intestine or check re- flex pains. In the former cases it is always wise to use an enema to empty the lower bowel before any cathartic is given by the mouth. At the same time we may relieve any nerve spasm present by giving atropin mixtures. Thus the following mixture, recommended by Yeo, illus- trates a conventional combination of carminatives and sedatives • I> Tinctura? belladonna? oss ; Tinctura? cardamoni composite 3vj ; Spiritus ammonia? aromatici ^ __ ,_.. Spiritus chloroformi ) Sodii bicarbonatis 3 j ; Aqua? carui 1 ad §vj. Sig. Two tablespoonfuls every hour until relieved. 1 For this caraway water, which is not officinal in U. S. P., may be substituted aquae menthae piperitae or the aquae aurantii florum in the same dosage. 230 DISEASES OP THE DIGESTIVE TRACT Before such a prescription is given, however, if there is any reason to suspect that the offending material is still in the stomach, we should give an emetic and remove it. Thus T V grain apomor- phin hypodermatically would be the first thought in such a case. Following the drugs for immediate relief, one should use gentle cathartics for two or three days to make sure that the bowels are kept thoroughly emptied. Of these cathartics, calomel in J-grain doses (given every half hour until four to six are taken) and the salines (e.g., magnesium sulphate, 15 to 20 grams in water) are the best and least dangerous. In many cases the pain and distress will be so great that mor- phin must be given. In such cases it is better to give it with the needle and in a dose just large enough to dull the pain, but not large enough to check peristalsis; hence J grain should be the initial dose. The colic of infants is generally due to improper feeding, hence the food should be changed or peptonized until it can be cared for by the imperfect apparatus of the particular child under treat- ment. Rarely, indeed, can we prepare food for a class of infants; it is the individual that we must satisfy. The colic of hysteria is sometimes best relieved by asafetida or valerian. The former may be given by enema or by the mouth ; the latter is given as the ammoniated tincture of valerian in teaspoon- ful doses every half hour until relief is obtained. Lead colic is best treated by administering the sulphates (in order to precipitate the lead as it is excreted into the colon), as, for instance, in the following prescription (Yeo) : If Magnesii sulphatis j _- ^ Sodii sulphatis ) Acidi sulphurici aromatici 3 j ; Syrupi zingiberis o ss ; Aquse cinnamoni ad gxij. Sig. Pour teaspoonfuls every hour until relieved. Obstruction of the bowel requires early surgical interference, hence if the use of heat externally and by hot drinks, together with atropin, does not give relief, the surgeon should be called in. Irri- tant cathartics should not be used when there is a suspicion of THE INTESTINES 231 intussusception (invagination). On the contrary, the bowel should be unloaded with copious enemata. The atropin usually makes the use of morphin unnecessary. Enteritis Usually nonspecific enteritis is due to dietary indiscretions lead- ing to the injury of the mucous surfaces by excessive fermentation or putrefaction. Again it may be due to the pathogenic bacteria that have worked their way into the bowel with the food. The disease therefore calls for the rest not only of the body as a whole, but also of the intestine itself. Therefore the patient should be put to bed and practically no food given by the mouth until the acute attack has subsided. The intestinal mucosa should be irrigated thoroughly by having the patient drink freely of weak mineral waters. If the inflam- mation be very acute, these mineral waters should be of a simple alkaline variety rather dilute ; but if the inflammation be subacute, then the more stimulant carbonated waters may prove more useful. They should be taken at least twice a day, preferably at 9 a.m. and 4 P.M. Sufficient antiseptic drugs should be used to check the fermen- tation in the intestine, as well as the development of the specific organisms causing the trouble. For this purpose salol (two and one half grains) with calomel (one tenth grain) will prove very effective. For example: ^ Phenylis salicylatis 0.2 Hydrargyri chlor. mitis 0.01 M. f. tabella no. I. Da tales doses XXV. Sig. One tablet every hour. One should expect, after forty-eight to seventy-two hours of the salol and calomel treatment, to find the stool green and inoffensive to the smell. In addition, one can use milk soured by the lactic-acid bacillus (e. g., lactone buttermilk) to assist in this action, the giving of this preparation to begin as soon as the milk causes no pain. If there be blood in the stool, indicating considerable erosion and ulceration, bismuth subnitrate should be given in sufficient quantities (e. g., ten grains stirred up in water taken on an empty 232 DISEASES OF THE DIGESTIVE TRACT stomach at bedtime, early in the morning, and again during the day as needed) to coat over the abraded surfaces. Or, if one wishes to avoid the astringent action of the bismuth and secure a laxative effect, one may use olive oil (e. g., one half wineglassful at bed- time), if there be no great infection still present. The first food should be thoroughly predigested, or else there should be given with the food some digestant. Of these the best are the pancreatin compounds. For instance, diazyme or holadin are recommended as being particularly efficient. As in biliary troubles, so here, pancreatin ferments should be given about two and one half hours after meals. Lactone buttermilk, kefyr, yogurt, or koumiss may be given early in the disease in four- to eight- ounce quantities several times a day. Later, when the patient takes his three meals of mixed foods, such preparations may be given between meals; as, for instance, at ten o'clock, four o'clock, and at bedtime. For weeks the food should be nonirritating and should consist mainly of milk, steak, rare roast beef, tender fowls, mealy (dry) baked potatoes, toast (oven dried), fruit juices, etc. Sometimes there is considerable discomfort because of the for- mation of gas and the distention of the intestines. "When this can- not be relieved by high enemata with ox gall or other simple means, then the rectified oil of turpentine in five-drop doses, either on sugar or in a capsule, will usually be found sufficient to excite the peristalsis and carry off the gas. Asafetida in five-grain doses has also proven of value in such conditions. The cure of the tendency to distention comes only with the reestablishment of normal digestion. If there be a diarrhea and other indications of relaxed mucous membrane, medication in the form of albuminate of tannin (tan- nalbin) will be found useful. This should be given in the dosage of one half to one gram (five to fifteen grains) every two hours for three or four doses, then after each diarrheal stool. For the ileocolitis of infants, a writer {Medical Fortnightly, September 25, 1908) recommends: ]$ Tct. cinnamoni 3 j ; Inf usi simarubre giij ; Syrupi aurantii q. s. ad g jv. Sig. One teaspoonful every four hours for an infant eight months old. THE INTESTINES 233 This prescription for simaruba illustrates our tendency to add to our materia medica strange and fanciful preparations. Probably the standard drugs would be just as successful rightly combined and assisted by careful dieting and care. Flatulence Sometimes the abnormal formation of gas is the only indication of trouble in the intestinal canal, and it may be difficult, there- fore, to persuade a patient to undergo a course of vigorous dieting and intestinal cleansing. But in such cases the least that can be done is to require the patient to use nonfermentable foods (avoid- ing particularly those containing starch) and to drink water freely in order that there be something of a cleansing of the bowel. A course of mineral waters is usually more helpful than the plain drinking water. Of mineral waters, the alkaline cathar- tics are the ones most generally useful, and if there be any constipation, stronger waters, such as the Veronica, would be indicated. In the way of drugs, turpentine may be used to stop the fer- mentation and stimulate the peristalsis. Asafetida has considerable reputation for the relief of this disorder, having been used by the Hindus long before the time of Christ. This may be given in a pill of three to five grains, or as a suppository of similar size. Its effect seems to be due to its carminative and nerve-soothing action rather than to any particular local influence. Of course no cure can be accomplished if we cannot regulate the life and diet of the patient. When we can do this, we follow the principles laid down in our discussion of enteritis, except that frequently we need to give more bulky foods. In such cases we order salads, greens, sweet potatoes, and other vegetables rich in cellulose, mixing them with the other articles mentioned under Enteritis. We would avoid irritating spices, alcoholic drinks, etc. Even tobacco may have to be tabooed. The general habits of life of such patients should be active in order to stimulate and control the general circulation. In par- ticular, we should seek to drive the blood from the viscera to the extremities, and for this wood chopping would constitute an ideal combination of movements. For those then who will not or cannot 234 DISEASES OF THE DIGESTIVE TRACT chop wood, tennis, active movements such as running, jumping, etc., are desirable. Typhoid Fever Typhoid fever is both an enteritis of specific origin and also a bacteremia with all the constitutional effects implied by the term, hence the treatment must observe the general principles laid down for cases of enteritis, and also combat the prostration and the tendency to the formation of secondary foci presented in septicemias. The patient is put to bed; no food is given that would in any way irritate the intestine or form a favorable medium for the growth of bacteria. Or, to put it positively regarding the food, one should feed the patient three to eight ounces of unfermented grape juice or sweet milk every three hours. Should the sweet milk prove indigestible (this can be seen by the presence of thick curds in the stool), either predigested milk or buttermilk should be given. 1 If the patient can take additional food, the order of indulgence should be cream, toast, raw eggs (or eggnogs), lactose, etc.; but it should be remembered that the stools must be green and inof- fensive, there must be no gas pains or other disturbances due to the administration of too great an amount of food or to the general atony of the digestive organs. Some physicians advocate the feeding of patients ill with typhoid fever sufficient food to maintain their weight during the disease. Sometimes this may be done, but usually the ill effects accompanying the procedure, the relapses and prolongation of the convalescence limit sharply the number to which the method may be applied. An adult at rest produces about 30 calories of heat for each kilogram of his body-weight. At complete rest it may go as low as 22 calories (Johannson). Typhoid patients are rarely at com- plete rest, hence their heat production may be put at 30 calories. In addition, ten per cent should be added for the dynamic stimula- tion of metabolism by food (Rubner). Now if in fever the heat 1 See Virginia Medical Semi-monthly, April 9, 1909, and Archives of Internal Medicine, December 15, 1909. THE INTESTINES 235 production be increased from ten to sixty per cent (Krehl), we must estimate the outgo of energy in typhoid fever at about 53 calories per kilogram (Shaeffer and Coleman). If, now, food affording 60 to 90 calories per kilogram of body- weight be given to patients ill with typhoid fever, the excretion of nitrogen may be kept within the amount ingested, especially if the greater part (all but 10 to 1.5 grams, which should be of nitro- gen) is given in the form of carbohydrates (Shaeffer and Cole- man). The foods used in the experiments leading to the above conclusion by Shaeffer and Coleman were the following: Food Used. Protein. Carbo- hydrate. Fat. Milk (by volume) Cream (by volume) Butter (by weight) Toast Eggs (weighing about 60 grams, gross) One egg Lactosi Somatose Liebig's meat extract Per Cent 3.3 2.0 11.0 12.0 7.2 gm. 12 . 4% nitrogen 9.2% nitrogen Per Cent 5.0 3.0 60.0 100.0 Per Cent 5.0 30.0 85.0 9.0 5 . 4 gm. The fats proved indigestible, and an amount of protein greater than 10 to 15 grams afforded no greater benefit. In order to supply this greater amount of food, Houghton (American Journal of Medical Sciences, January, 1910) uses the following vegetable soup. One can carry out the principle by combining in the dietary with this soup eggs, cream, toast, milk, and grape juice, at two-hour intervals. The Preparation of Vegetable Soup. — Sixty grams each of green or canned French peas, white dry beans, potato, rice, and noodles, and 15 grams of carrot are boiled in water at least four hours. Sufficient water should be added to make one liter, which is suf- ficient for four feedings. The whole yields 760 calories, of which 6.3 per cent is protein, fat less than 0.2 per cent, and 43.9 per cent is carbohydrate. When ready to use, stir up sediment and allow the patient to eat all (including noodles), with the exception of the pea and the bean skins. Onion may be added for flavor if desired. 236 DISEASES OF THE DIGESTIVE TRACT % The drugs to influence the local condition are salol and calomel, used as indicated in our discussion of enteritis. Fre- quently physicians content themselves with giving dilute hydro- chloric acid, 15 to 20 drops in three to four ounces of water every four hours. This may be sufficient for uncomplicated cases, but it is better practice to secure the better intestinal conditions afforded by salol and calomel at the beginning of the treatment and thus be ready for any emergencies that may arise. The drinking freely of pure water is of great value. Thus the use of 4 ounces of water every half hour has often proven its worth. In this condition, on account of the presence of the ulcers in the ileum, it is important that no active peristalsis of the small intestine should be produced; therefore nearly all active catharsis should be brought about by colonic irrigation, using ox gall, if necessary, to stimulate colonic peristalsis. The colonic irrigation should be continued until the stools are free from offense. If the pulse become weak and irregular, showing a relaxed vaso- motor system, camphor should be used hypodermically, as indi- cated in our discussion of heart diseases (6 c.c. of the sterile ten- per-cent solution pro die). Camphor may also be given in the delirium accompanying typhoid, i. e., typhoid mania. Cold baths should be given frequently enough to stimulate the vasomotor control and also to keep the fever within reasonable limits. What such limits are depends upon the individual. Some patients can bear with impunity a temperature of 102° or 103° F. Others are extremely sick if the temperature goes above 101° F. The cold bath or sponge should be ordered according to the indi- vidual peculiarity of the patient. Under cold baths we do not necessarily mean tub baths, because the cold tub (Brand bath) is not usually necessary in typhoid. Probably just as good results can be obtained by the use of the cold sponge bath, and this with- out any danger to the patient. The technic of such a bath we have discussed at length under Fever. In case of perforation of the bowel, the only possible salvation is by means of immediate laparotomy. In case of hemorrhage, the foot of the bed should be elevated, ice should be packed over the abdomen, and tincture of opium in ten-drop doses should be given by the mouth, and also bismuth THE INTESTINES 237 subnitrate or tannalbin in 10- to 15-grain dosage if more active astringents are needed. In order to prevent hemorrhage the calcium salts have been recommended. Thus Sir A. E. Wright recommends citric acid and salts to make the blood more fluid and calcium salts to make it more coagulable ; e. g., calcium lactate, 15 to 20 grains t. i. d. 1 "We give usually calcium lactate in 15- to 20-grain doses every four hours, and thyroid extract, 3 to 5 grains t. i. d., on an empty stomach, whenever we fear hemorrhage or find the coagulation time becoming abnormally long. The prevention of the spread of the disease is an important part of the treatment. To this end the urine and stool should be covered with fresh milk of lime and let stand for a half hour be- fore being thrown into the closet or privy. All body and bed- clothing should be soaked in a five-per-cent solution of liq. cresolis co. of the Pharmacopeia for an hour or more. Dishes should be boiled. Nonwashable materials must all be disinfected with for- maldehyd. The disease spreads by the careless disposal of the feces, therefore patients should be kept under surveillance until three bacteriologic examinations of the stools, six days apart, prove negative. The last is Koch's rule, and it is one worth observing whenever we have the opportunity to study the stools bacteri- ologically. Colitis Colitis may be due to the presence of parasites, such as the ameba ; bacteria, e. g., bacillary dysentery ; to poisoning, e. g., excretion of the metals into the colon; and to nervous and nutri- tional disturbances, e. g., mucous colitis, membranous colitis. Thus we find that inflammation of the colon may result from stag- nation and putrefaction of the bowel contents (autointoxication), irritation from the ingestion of nonliving elements, and finally to the injury due to the presence of living organisms. The last type of colitis (mucous colitis), however, seems to have been so varied in its manifestations that some workers have classed it among the symptoms of general nervous derangement, while others believe that it is due to local irritation brought on by non- 1 See The Practitioner, July, 1906; Quarterly Journal of Medicine (London), January, 1909. 238 DISEASES OF THE DIGESTIVE TRACT hygienic living. In our judgment mucous colitis is due to both the nervous weakness and the local irritation. Thus women unhappy in their home lives, who have not been careful in the selection of their food or the ordering of their lives, constitute the majority of our patients suffering from mucous colitis. To cure such pa- tients it is necessary both to make them more contented and hygienic in their lives and also to relieve the local inflammation. Such patients suffer attacks of excruciating pain, followed by the discharge of feces containing mucous shreds and strings more or less bloodstained. We find that we need to inculcate in these patients a calmer outlook on life — more of stoicism, perhaps — in order that they may not be upset by their daily worries. Sometimes, in order to ac- complish this result, we must change their environment tempora- rily; for example, put them in a pleasant sanatorium for a few weeks. Secondly, we must stimulate their general metabolism by cold and hot baths and massage. Many of these patients have skins so particolored that it is evident that their bodies are full of the waste products of metabolism. With such patients the hot baths (either in the hot-air cabinet or in the tub) on alternate days should be used to start up increased elimination. But cold rubs should also be given mornings to stimulate the vasomotor system. At first such cold rubs must be given by an attendant; later the patients learn to give themselves fairly adequate treatments. The diet must be highly nutritious but bland. In this our ex- perience differs from that of von Noorden. We give steak and oven-dried toast, milk, buttermilk, eggs, and olive oil. Of the last we try to use at least two ounces daily. The meals may be at the usual hours, provided a lunch, e. g., of lactone buttermilk or yo- gurt, is given between each two meals. Laxatives should be given to prevent the stagnation of the feces and the formation of scybala, characteristic of this disorder. Min- eral waters (preferably of the heavily mineralized type, such as Veronica, Saratoga Congress, etc.) should be used once or twice a day on an empty stomach. In addition, phenolphthalein should be used in sufficient quantities to insure two evacuations daily. This should be given at night, and, if given in tablet form, should be well chewed before being swallowed. One or two grains a day may be needed. THE INTESTINES 239 Usually the use of ox gall and pancreatin to promote intes- tinal digestion is of assistance at the beginning of treatment. Thus capsules containing one to two grains of ox gall and similar amounts of pancreatin should be given two hours after meals. Finally, the colon should be irrigated daily with normal salt or soda solutions. This irrigation should be done with the thirty- inch soft rubber colon tube. If it is done right, the procedure is of much value, otherwise it is useless. To carry out the procedure, the patient should lie on the left side on a Kelly pad, with knees drawn up. The tube should be lubricated with petrolatum and gently inserted. As soon as resistance is met, the water should be turned on in order to belly out the gut in front of the tube, and the tube pushed forward with a gentle rotatory movement until it has reached beyond the sigmoid flexure. The flow of the solution should be stopped if either it gives pain or the colon is visibly dis- tended. The patient should hold the solution for fifteen to twenty minutes before trying to expel it. Longer retention is helpful rather than harmful. i The prognosis in these cases is poor unless one can secure the conditions necessary for carrying out the treatment for a long time or until the colon have recovered its ability to absorb and trans- mit without the excretion of the tenacious mucus, hence we should be careful at the beginning to stipulate the conditions of cure as well as its difficulties. Toxic Colitis. — The use of arsenic is always attended with the danger of poisoning from its excretion and reabsorption in the large intestine. The other metals are subject to the same dangers as far as the local irritation of the bowel is concerned ; hence when- ever patients are being given the metals it is well to prescribe colonic irrigations as well as laxatives to insure the daily cleansing of the bowel. This same precaution would be useful with workers in lead and other metals. When the inflammation is already present, the first indication, of course, is to stop the ingestion of the irritant. The next is the thorough flushing of the bowel by water and salines per os and per rectum. When considerable tenesmus is present, olive oil should be freely administered both per os (after food) and per rectum (warm, with the patient lying with elevated hips). The 17 240 DISEASES OF THE DIGESTIVE TRACT use of atropin will assist in overcoming much of the discomfort resulting from the irritation. This may be administered as the tincture of belladonna per os in ten-drop doses, or subcutaneously in doses of y-^ to ^V grain of atropin. The putrefactive and bacterial inflammations require first of all rest, then irrigation; that is, the patient should rest in bed a goodly share of the time during the acute attack. The diet also should be of such a type as to afford rest to the colon. For in- stance, the foods mentioned above (lean meats, eggs, milk, etc.) are usually chosen as the basis of the diet. Food containing cellulose should not be used until the acuteness of the attack is past. The irrigation should be given both by drinking ten to fifteen glasses of water daily, e. g., one every hour, as well as by the daily colonic flushing. The solutions for the latter should not be at all stimulant or irritant — the normal saline or soda solutions are gen- erally best ; but to be effective they must be put in high up. While the bowel is irritated (shown, for instance, by the passage of blood- stained feces) starch or oil enemata or tannin solutions may be needed, the first two to coat the denuded areas, the last to act as an astringent (two-per-cent solution). After the acute stage is past, " greens " of beet tops, chard, etc., may be added to the diet to act as a nucleus of a mass for sweeping out the colon. In the way of drugs, two types may be indicated. Either there may be need for the antifermentatives and antiseptics, such as salol and hexamethylenamin, or the intestinal ferments, such as pancreatin and papain, to carry the food beyond the reach of the putrefactive organisms. Should the digestants be used, they should be administered at least an hour before meals. Which type should be used may be decided upon by examining the stools to ascertain whether the intestinal digestion seems complete, and whether evidences of putrefaction (skatol, indigo) are present; for, if there be evidences of lack of digestive power, holadin and bile salts, or some similar preparation, should be used. If putre- faction be pronounced salol or hexamethylenamin should be ad- ministered. We shall consider parasitic colitis under the general head of Intestinal Parasites following. THE INTESTINES 241 Intestinal Parasites In general for the treatment of this disorder it will be found necessary to give a diet that will free the bowels of as much food detritus as possible, in order to leave the parasites exposed to the action of such drugs as may be given. The drug treatment is directed toward intoxicating the worm without giving sufficient of the drug to intoxicate the tissues of the host. It is well, there- fore, to give the drug in such a way that as little as possible of it is absorbed; as, for instance, after the bowel has been cleansed by catharsis and just before more cathartics are given. For the dif- ferent kinds of parasites different drugs are used. Another method of attacking the parasites is shown by the late reports of the successful use of papain. This, of course, consti- tutes an effort to digest the parasites without any particular effort at specificity. Of this drug, one would use five grains in gelatin capsules every three hours, taken with a glass of water. Tenia. — The tenia are usually most efficiently removed by us- ing preparations of the male fern. The night preceding the planned medication, the patient should be given a very light meal. Sometimes it seems best to make this meal of salads, sardines, and mixtures of cellulose and oil m order to stimulate the peristalsis and carry down in the general mass the parasites also. The next morning, before breakfast, 8 c.c. of the ethereal extract of the male fern are given in divided doses; that is, 2 c.c. in gelatin cap- sules every fifteen minutes. Fifteen minutes after the giving of the last capsule a brisk saline cathartic, or calomel and jalap, is given. The use of castor oil for this purpose is a questionable procedure, because the oil tends to make the male fern more easily absorbed, and thus there is a liability to systemic intoxication ; but nevertheless the oil is frequently given — one tablespoonful floated on a cup of black coffee. The stools should, of course, all be care- fully collected and examined by washing them through a fine sieve to see if the head of the worm as well as the body has been brought away. If the head cannot be found in the sieve, it is well to repeat the treatment after the lapse of a fortnight. Instead of the ethereal extract of male fern, it is often easier in America to secure the oleoresin. We should then use the fol- lowing prescription: 242 DISEASES OF THE DIGESTIVE TRACT IJ Oleoresinae aspidii 8.0 Da in capsulis gelat. no. IV. Sig. One capsule every fifteen minutes, followed by a wineglassful of Pluto water (or one ounce of Epsom salts). Ameba Coli. — This parasite usually inhabits the cecal end of the colon, and because it burrows underneath the mucosa is very difficult to dislodge. Daily high (thirty-inch tube) colonic flush- ings with a 1 : 500 solution of quinin bisulphate will be found best to begin with. Later the strength of the solution should be re- duced to 1 : 1,000. If there is a dysentery, solutions of tannin (two per cent) may be employed in alternation with the quinin. Large meals of greens (for instance, beet tops) seem to have some value in acting as a mechanical brush to cleanse the intestines of the parasites; otherwise the diet should be light (small meals at short intervals). In particular, the food should be such that no masses be formed in the intestine in which the parasites could burrow. Calomel, one grain a day in divided doses, seems to be of assist- ance in removing the parasites in some cases. In others, powdered thymol, ten grains a day in capsules, has been successful. Ipecac in salol-covered capsules, in doses of sixty grains a day, has given great satisfaction in the British army and in the Philippines. 1 It may be given also in divided doses. But in spite of all these meas- ures, it is sometimes necessary to perform a caecostomy and insert a permanent catheter and thus secure the opportunity to irrigate 1 "The detailed method of its administration is, I believe, of the greatest im- portance, the lack of which stands as explanation in part for the failures reported in many quarters. First of all, the drug should be administered only in pill form, coated to the extent of about one eighth inch with phenylsalicylate (salol). The patient must be put to bed for the first two weeks' treatment and his diet restricted to liquids, or at most light solids. This absolute rest in bed with re- stricted diet is particularly essential to the details of the plan. Castor oil may be given as the initial purgative and then each evening, after a three-hours' fast, the salol-coated pills are administered. A start may be made with 40 or 60 grains, depending on the length or the severity of the infection, but each sub- sequent evening the dose is reduced 5 grains until the limit of 10 grains is reached. Following this I have been in the habit of continuing with 10 grains each day for the next two weeks." — Simon, in The Journal of the American Medical Asso- ciation, p. 1529, Nov. 6, 1909. THE INTESTINES 243 the colon satisfactorily from above. Here one uses the same solu- tions as for the irrigation from the rectum. The Hook Worm. — The uncinaria occupy the duodenum and are therefore best reached by drugs given by the mouth. Thymol is regarded practically as specific, although male fern is also quite efficient. The former is given powdered in capsules to the amount of thirty grains within three hours, followed by brisk catharsis, according to the following prescription: Tfr Thymolis pulv 2.0 Pone in capsulis no. III. Sig. Take one capsule on empty stomach, every half- to three-quarter-hour, and follow the last dose with one ounce Epsom salts in four ounces water. The treatment should be preceded for a day or two by a prelim- inary dieting to clear ^the intestine of fecal masses and fermenting foods. During and after the administration of the thymol, coffee should be given to prevent collapse, because thymol is apt to cause collapse if absorbed by the intestinal walls. It is therefore im- portant that the patient be carefully watched during the exhibition of the drug and that it be followed by a cathartic to prevent any such dangerous prostration. The constitutional conditions accompanying uncinariasis are combated by the exhibition of iron in the form of Blaud's mass (five grains three times a day). Because Blaud's mass deteriorates with age, it is better, when one is not sure of obtaining freshly pre- pared pills, to order the saccharated ferrous carbonate in cap- sules, thus: j^ F err i carbonatis saccharati 15.0 Da in capsulis gelat. no. L. Sig. One capsule t. i. d. Pin Worms. — Pin worms, or seat worms, are usually found in the lower colon and in the rectum. They may be removed, there- fore, by thorough irrigation from the rectum. Salt solution is usually quite efficient for such irrigation, although quinin bi- sulphate solution may be needed (1:1,000). The favorite drugs for use by the mouth are calomel and san- tonin. These are given in doses of one half grain of each every fifteen minutes until three or four doses are given, followed, if necessary, by a saline purge. 244 DISEASES OF THE DIGESTIVE TRACT IJ Hydrargyri chloridi mitis 0.12 Santonini 0.12 M. Da in capsulis (vel tabellis compressis) no. IV. Sig. One capsule (or tablet) on an empty stomach every fifteen minutes. Round Worms. — These occupy the small intestine and are most easily removed by santonin and calomel. On the night preceding the treatment, the food should be limited in quantity and should consist largely of oils or salads, then in the morning, on an empty stomach, one half grain each of santonin and calomel should be given every fifteen minutes until four doses are taken. This is usually sufficient to expel these parasites. Enteroptosis The sinking of one or all of the viscera of the abdomen is prov- ing to be a causative factor in many cases of constipation, gastric dilation, and nervous disorders, hence it deserves some attention. As a rule, enteroptosis seems to be due to congenital conditions, and is found chiefly in long, narrow-chested (phthinoid) indi- viduals with weak abdominal musculature. The condition de- velops into one of pathologic importance when disease or lack of exercise robs the patient of his reserve strength. The organs then sink down until they receive some support from below; that is, practically into the pelvis. This, of course, interferes with their function and also causes discomfort by dragging on their support- ing ligaments. The treatment must first of all seek to restore strength to the musculature and ligaments. During this time the disturbed func- tion must be performed by artificial aid (digestants, bandages, etc.). Finally, when necessary, mechanical supports must be used to keep the organs in place. For the first, the general condition of the patient must be improved. Usually it is necessary to put the patient to bed and give considerable massage to the abdomen to relieve the organs of their congestion and restore them to their pristine vitality. Such a course of treatment lasts ordinarily from four to six weeks. THE INTESTINES 245 The bed rest and dieting are important in relieving the fatigue and securing a new general vigor for the entire body. The result of the treatment is generally a restoration of tone to the circulation (that is, the hands and feet lose their tendency to be cold and clammy) and a feeling of fitness for living before absent. The massage develops strength in the muscles and restores some part of their contractility to the ligaments. Only when such measures fail should abdominal supporters, such as belts and corsets, be resorted to, for these permanently weaken the ligaments and make the patient entirely dependent upon such outside support. In this same category comes sur- gical interference, such as suspension and gastroenterostomy and bowel exclusion. Such operations are the final resort, after we have failed to establish a hygienic life and muscular com- pensation. During the treatment it is usually necessary to use saline laxa- tives, diuretics, and even vasomotor tonics to overcome the portal congestion, with its accompanying indigestion and constipation. Pancreatitis We are just beginning to learn something of the diseases of the pancreas, and we find that they are of two types. Either there is an inflammation of the parenchyma of the organ, or there is a cyst formation due to the obstruction of its ducts. Inflammatory material may be brought there by the blood, but usually it is de- rived from the duodenum through the duct. In the treatment, drugs should be used to keep the duodenum free from stagnation in and about the opening of the duct. Pan- creatic extract must be supplied per os to take care of the food for the body while the pancreas is out of commission, and also drugs should be used to check any fermentation of bacterial growth within the limits of the gland. These indications are met in the same manner as the correspond- ing inflammations of the gall bladder. Thus mineral waters are given, as are also ox gall, some preparations of pancreatin, salol, hexamethylenamin, and calomel in practically the same way. For instance, the following prescription will be found useful at the onset and while the pain is pronounced: 246 DISEASES OF THE DIGESTIVE TRACT tf Fellis bovis . . 0.1 Pancreatini 0.1 Hexamethylenaminse 0.05 Acetphenetidini 0.1 Hydrargyri chlor. mitis 0.01 M. f. caps, gelat. no. I. Da tales doses no. XV. Sig. One capsule every two hours. Holadin with bile salts would also prove effective in the place of the two first ingredients, or, where there is little pain and fever, they might constitute the only remedy given. Peritonitis Peritonitis is a bacterial inflammation originating usually from the discharge of intestinal contents into the peritoneal sac. This occurs chiefly through the perforation of ulcers, as in typhoid fever, peptic erosion, etc., but may also occur through the transmis- sion of bacteria through the intestinal wall without open perfora- tion, as in case of intestinal tuberculosis. Similarly, pelvic peri- tonitis is a frequent accompaniment of infection of the uterus and tubes, due to the escape of the infectious material into the peri- toneum, as from gonorrhea or puerperal fever, hence in nearly all cases peritonitis is secondary to some other localized inflamma- tion, and occurs only when the primary infection has not been suc- cessfully checked. This causation logically makes the treatment of peritonitis largely symptomatic, although sometimes surgical interference may seem to assume the appearance of causal treat- ment; for real causal treatment must be directed toward combat- ing the primary lesion. The symptoms usually are intense abdominal pain, distention and tympanites, obstipation, rapid and shallow respiration, vom- iting, scanty urine, etc. The patient lies with knees drawn up, pale and anxious countenance, either rapidly sinking into a coma or tending toward delirious excitement. In perforative peritonitis successful treatment demands imme- diate laparotomy and closure of the perforation, with a subsequent drainage (perhaps also with a saline flushing) of the peritoneal THE INTESTINES 247 sac. 1 Even in other cases the surgical interference may be justi- fied ; but, if done at all, it should be done at the beginning of the inflammation, hence an early and sure diagnosis, with quick de- cision, adds much to the prospect of success. The treatment, whether with or without a laparotomy, demands (a) rest, (6) the application of heat (or cold), (c) the flushing of the system with normal saline solution, and (d) gastric lavage and the relief of vomiting and shock. Rest should include bodily rest as well as the rest of the in- testines, hence the patient is kept quiet and no food given by the stomach. If there be no danger of shock, ice is applied to the ab- domen; if there be weakness indicating a liability to shock, heat is applied. This both relieves the pain and relaxes the intestines. Heat is best applied with the thermophore, but where that is not available, hot fomentations may be used. The patient should be allowed to lie in any position he desires, so long as he be kept quiet. The salt solution supplies the body with fluid and tends to promote diuresis, as well as diaphoresis. In this way it removes toxins from the system ; it is, therefore, the most important aggres- sive treatment in this disease. It should be given by the rectum, and, as long as the patient can retain it, as much as a pint every hour. If the patient seems unable to retain it the continuous proc- toclysis of Murphy (see Fig. 42) should be resorted to. In this method the solution is allowed to run into the bowel at just above body temperature, with the reservoir just high enough to permit an interchange of fluid between the bowel and reservoir, as the force of bowel peristalsis varies. This irrigation also prevents thirst and shock, thus doing much to assist the body to fight the 1 The following is Mayo Robson's summary of the plans of surgical inter- ference : " (1) The removal or repair of the cause with or without irrigation of the peritoneal cavity; (2) drainage of the site of operation by a split rubber tube containing a strip of gauze, and of the peritoneal cavity by a tube in the pelvis, assisted by the reclining posture, which he has for years advocated after all abdominal operations; (3) rapidity of operation; (4) avoidance of unnecessary exposure and handling of the viscera; (5) the prevention of shock; (6) the free administration of saline fluid by the rectum; (7) rectal alimentation and the stoppage for a time of mouth feeding; and (8) the avoidance of opium and some- times the administration of repeated small doses of calomel subsequently to operation." 248 DISEASES OF THE DIGESTIVE TRACT disease. Whenever it is impracticable to use the bowel, the saline solution 1 should be introduced subcutaneously into the loose tis- sues of the chest and flanks. For this the solution (and vessels) Fig. 42. — Appaeatus for Continuous Proctoclysis. The cylinder is for the purpose of keeping the solution at an even temperature. must be sterile and the fluid kept at about 110° F. One pint may be introduced at a sitting; thus two or three pints may be intro- duced in twenty-four hours. The distressing vomiting and peristaltic frenzy are kept in abeyance by careful gastric lavage. For this the patient does not need to be upright, but should swallow the tube in his usual posi- tion in bed. Only enough water should be used to secure a good cleansing of the stomach. For vasomotor stimulation and control, the subcutaneous in- jection of camphor dissolved in sterile oil, and also of strychnin, will prove useful. Of the former, 6 c.c. should be used daily; of the latter, -^ grain every four hours. Opium should be used only as a last resort. It masks the symp- toms and checks excretion, hence it does not, like the above meas- ures, tend toward cure while affording relief. 1 See note on normal solutions on p. 453. THE INTESTINES 249 In cases of pelvic peritonitis one may, in addition to the above, flush out the vagina (and the uterus, if circumstances permit) with one-fourth-per-cent lysol solution at 110° to 120° F. This irriga- tion may be done twice a day. In cases of tuberculous peritonitis we find very different con- ditions, and must proceed differently. Thus one should use ex- ternally iodin or iodoform ointment (Yeo). This is made of one half grain of iodoform dissolved in a dessertspoonful of cod-liver oil. It should be well rubbed into the abdomen three times a day. At the same time iodoform should be given by the mouth, accord- ing to the following prescription: IJ Iodof ormi gr. ss ; Ext. nucis vomicae " J ; Mentholis " i- M. f. caps, gelat. no. I. Sig. One capsule three times a day after food. The presence of the iodoform, even when given only by inunction, is to be demonstrated in the urine in from two to four hours' time (Still) either as iodin or iodid, hence the well-known remedial in- fluence of the iodids on tuberculosis is brought to bear to its fullest extent when given in this way in tuberculous peritonitis. If medical treatment for tuberculous peritonitis does not show improvement in four to six weeks, a laparotomy should be done and the peritoneum drained. The mere entrance of air into the sac seems to be sufficient to stimulate the tissues toward repair, therefore some operators leave rather large drainage tubes in the wound in order to continue this influence. In other cases of tuberculous peritonitis guaiacol (equal parts of guaiacol and olive oil) seems to be very effective when rubbed into the abdomen ; in fact, in nearly all cases of peritonitis the in- unction of guaiacol will be found to give great relief, both from the pain and the high fever. It should be applied from three to six times a day. When the peritonitis is not extremely acute, and where the patient can take food and medicine by the mouth, it is wise to pre- vent fermentation and distention in the intestine by giving salol in full doses. This also renders the body fluids less efficient as 250 DISEASES OF THE DIGESTIVE TRACT culture media, and in that way tends toward shortening the time of inflammation. Diseases of the Rectum Hemorrhoids. — The first indication here is to secure relief from pain; the second is to get rid of the cause of the pain, namely, the dilated capillaries and local congestion. The first is brought about by the application of some local analgesic, such as atropin, menthol, or phenolated camphor. Even cocain, eucain, or quinin hydrochlorid and urea may be injected under the mucosa in very dilute, e. g., one-half -per-cent, solution, and thus afford the con- ditions necessary for the surgical treatment of the disorder. Probably some form of radical treatment like complete excision is the most satisfactory and efficient method. The palliative meth- ods of treatment by the use of suppositories containing tannin, belladonna, and alum, or similar drugs, will do only for subacute and very mild cases. It rarely, however, is a profitable method of treatment. We suggest, then, that the patient be put on a table or solid bed and the rectum either swabbed with the following solution or a tampon saturated with it packed against the inflamed surfaces : ^ Morphinae 1.0 Atropinae 0.1 Glycerini 10.0 Aquas 10.0 After about ten minutes we may proceed to inject eucain in two per cent, cocain in two per cent, or quinin hydrochlorid and urea in one-half -per-cent solution along the line of incision. The following is Dr. Heitzman's description of his operation, which is a useful one for office work for the removal of hem- orrhoids : After the preparation of the patient, the tumors are exposed suc- cessively and held between the thumb and finger or with forceps. An incision is then carried in the long axis of the bowel through the mu- cous membrane, care being taken not to wound the blood vessels. The blood vessels being now exposed, they are grasped with forceps and trac- tion applied. This, as a rule, will liberate the vessels; if not, the use of a small blunt spoon or curette will materially assist in breaking up THE INTESTINES 251 the inflammatory adhesions of the connective tissue. When by this method the hemorrhoidal vessels are thoroughly exposed through the cut in the mucous membrane, a ligature of small-sized catgut is applied above and below. Now the vessels are extirpated with scissors or knife. The incision in the mucous membrane is closed with like suture ma- terial. I have found, however, that unless the incision is large it heals just as readily without suturing, being hermetically sealed with blood clot. Should too much redundant tissue remain it may be removed, carrying the incision in the form of an ellipse and closed as before. It is surprising, however, how much the mucous membrane will shrink after removal of the vessels. The only dressing used is a sterile pad over the anal region. The operation is best performed without the use of sponging, a drip of boric-acid solution being employed to keep the field clean. Limitations. — The operation is not applicable to the friable or capil- lary form, nor to the so-called connective tissue or cutaneous hemor- rhoids. Superiority of the Operation. — It is at once thoroughly surgical as well as simple. There is little hemorrhage during the operation, and the danger of secondary hemorrhage is reduced to a minimum. It is a comfortable operation for the patient; there is practically no pain. The edges of the wound are thoroughly coapted, causing prompt healing and the absence of a cicatrix. Tl*e cause is removed, not merely a bunch of mucous membrane, as is often the case with other operations; therefore the probabilities of recurrence are limited, more so than with other operations, to say nothing of unfortunate sequelae such as I have mentioned. Fistulse and Fissures. — We have practically considered these in our discussion of the inflammations of mucous membranes, but in order to make the subject more complete, we recapitulate the dis- cussion here. The first indication is to stop the irritation due to the broken mucous membrane and the exposure of the sensory nerves, and the second is to cover over the abraded surface in order that it may heal without interference. Whenever we can reach the fissures with a probe or swab we should apply either silver nitrate or carbolic acid in full strength, destroying any germ life present, forming an eschar, and thus preventing the spreading of the in- flammation to the surrounding healthy mucous membrane. Where a caustic action is not desired, atropin may be used to deaden the sensory nerves, applied in a one-per-cent solution. 252 DISEASES OF THE DIGESTIVE TRACT If there be a considerable surface abraded and exposed, which cannot be easily treated with a probe, as, for instance, in the am- pulla recti or in the upper part of the anal canal, then tannin in a ten-per-cent solution will be found useful for injection. Such in- jection should be put in slowly and allowed to remain in contact with the tissues as long as possible. For this very reason supposi- tories and soothing ointments are preferred to simple injections in such erosions, because they not only keep the drug in contact with the inflamed area a long time, but they also protect the surfaces from irritation. The following is the formula of a commercial suppository : J$ Opium, powdered 1 gr. Ichthyol 2i " Tannic acid 1 " Extract belladonna J ' ' Extract stramonium \ " Extract hyoscyamus J ' ' Extract hamamelis £ ' ' Phenol i " Excipients in sufficient quantity to make one suppository. This illustrates the tendency to include in such a prescription all possible sorts of drugs — " shotgun prescribing." Another prescription, and one much more logical, is: ^ Bismuth subnit 6.0 grams. Resorcinol 0.5 " Balsam peruv 1.5 " 01. theobrom 19.0 " Ung. cerat 2.5 " M. f. suppos. no. XII. This avoids the use of morphin, atropin, and similar systemic drugs. In caustic action there are three stages to be distinguished : the simple hyperemia, the inflammatory necrosis, and the chemic solu- tion. The scab (eschar) is liquid or hard and dry, according to the chemical combination formed by the particular caustic in use. Solid scabs prevent the deeper penetration of the drug. In general, it may be said that the metals give hard scabs, while the alkalies THE INTESTINES 253 give soft ones. It may also be stated that the acids act by with- drawing the water. Sulphuric, trichloracetic, and nitric acids act by carbonizing the tissue, because they break up the molecules, thus separating the hydrogen and oxygen. Silver nitrate forms a hard scab, phenol a soft one. For these reasons in rectal work silver nitrate or pure crystal- line phenol (or phenol liquefied by heat, never phenol in aqueous solution) are the caustics generally used. After using phenol, one should always touch the parts with alcohol in order to remove the excess. It is generally good policy to precede such cauterizations in the rectum by the application of a local anesthetic, as noted above. 1 It goes without saying that inaccessible fistulse should be made accessible by the use of the knife under an anesthetic and then treated with the caustic or the diseased tissue excised, as may seem best to the operator. The spasm of the sphincters that nearly al- ways accompanies abrasions of the anal mucosa needs to be over- come at the beginning of the treatment. This may be accomplished by dilation under an anesthetic or, more slowly, by the use of belladonna suppositories. As soon as the dilation is accomplished, the use of the silver nitrate to coat over the denuded areas will, in most cases, prevent the return of the spasmodic contraction. Defecation is a painful process for these patients, therefore, wherever possible, this should be alleviated by using daily oil enemata. Where such local treatment is not possible, mineral waters or saline laxatives should be given to keep the stool soft. Pruritus Ani. — This condition is most often due to a lack of nutrition of the tissues due to the changes of old age, but it may also accompany the eczema ani due to the irritating secretions of chronic diarrhea ; hence the first step is to correct the bowel condi- tion. This is best done by daily irrigations with quinin bisulphate and tannin solutions (the former in 1 : 1,000, the latter in two-per- cent solution). At the same time papain and a tannin albuminate should be given by the mouth. 2 1 The student will find much valuable information and suggestion along this particular line in Hilton's "Rest and Pain." 2 ]$ Tannalbin 0.1 gram. Papain 0.2 " M. f. caps. no. I. Da tales doses no. XX. Sig. One capsule one hour after each meal. 254 DISEASES OF THE DIGESTIVE TRACT The application of high-frequency currents and the bidet spray will then tend to restore the nutrition of the skin. Such treatments should be given at first daily, gradually lengthening the interval as the relief is obtained. Finally, for symptomatic relief, ointments may be used. For instance, an excellent ointment for this affection contains: IJ Camphor 4 gr. ; Menthol 3 gr. ; Carbolic acid \ dr. ; Boric acid Calomel aa 10 gr. ; Zinc oxid q. s. ad 1 oz. But the painting of the inflamed area with a two-per-cent solu- tion of nitrate of silver will be more successful than the use of ointments. This painting may be repeated every day or every other day, as needed. CHAPTER V DISEASES OF THE CIRCULATORY SYSTEM THE HEART This discussion includes the disorders not only of the heart muscle itself, but those also of the pericardium and the endo- cardium, together with the cardiac neuroses. The Neuroses Probably one of the most painful diseases classified under heart disease is the so-called angina pectoris. This seems to be simply a nervous spasm of the coronary blood vessels. Since it is a nerv- ous spasm, the therapeutic indication is for a drug that shall in- hibit the nerve centers that cause such a spasm. The drug ordi- narily used is a nitrite, either in the form of the amyl nitrite or nitroglycerin. The former is inhaled in the dosage of three drops, usually by breaking in a handkerchief a glass pearl containing that amount; the latter is injected hypodermically in the dosage of y^ to ^o of a grain. Another drug that will help in this condition is atropin, injected hypodermically in y^-grain to -^pgrain doses. The nitrites act more quickly than atropin, hence it is useful some- times to give both the nitroglycerin (glonoin) tablet and at the same time the atropin. Palpitation is another troublesome cardiac neurosis. This may be due to reflexes from the viscera, to pressure from neighboring organs, and to mental conditions; hence to treat palpitation one must locate the cause of the nervous excitement. Of the reflex conditions causing cardiac palpitation, perhaps enteroptosis is the one most frequently found at fault. In other cases the patient's indigestion seems to be sufficient to cause the trouble ; and in general we find that the splanchnic and abdominal 18 255 256 DISEASES OF THE CIRCULATORY SYSTEM sympathetic nerve centers are being irritated by some such strain- ing and stretching of the tissues whenever the palpitation is the result of a visceral reflex. Here atropin, to relieve the cardiac excitement, would be the first drug to consider. Its use is gener- ally sufficient to relieve the symptom; then comes in the causal treatment — a matter that, as in the case of enteroptosis, is not so easy. This involves, for instance, the correction of the visceral ptoses and allied conditions. Hence in most cases the physician must content himself with giving remedies to relieve the attacks of palpitation and advising in general terms the correction of dietary and hygienic errors, and the use of appropriate gymnastic exercises. In the case of palpitation due to simple acute gastric distention we should empty the stomach if the danger be great. This may be done with the stomach tube or apomorphin ( T V grain subcu- taneously). In milder cases, twenty to thirty drops of dilute hy- drochloric acid, well diluted in water, will be found sufficient to relieve the distention. If the palpitation be due to the pressure of tight clothing the remedy is obvious. In the palpitation due to general nervousness, the bromids will be found useful. Fifteen grains of sodium bromid in a half glass of water will ordinarily be sufficient to depress the excited spinal centers sufficiently to allow the normal cardiac rhythm to reap- pear. If more prompt action is desired (for the bromid action might not appear within an hour), the bromid could be profitably given with the ammoniated tincture of valerian, e. g. : Sodii bromidi 10 Ext. fl. Valerianae 10 Arom. spts. ammon 40 Aquaa destill 40 Sig. One dessertspoonful, well diluted, every hour until the patient is quiet. To summarize the above : The treatment of palpitation must be considered under the heads The Immediate Relief and The Re- moval of the Cause. Thus, while we secure temporary (and neces- sary) relief by means of atropin or the bromids, we must not forget THE HEART 257 that these drugs should not be given for any length of time, but should remember that they should be replaced by dietetic, hygienic, or other drug treatment, as each case may demand. In a similar way tachycardia and bradycardia must be pro- ceeded against. Thus in the tachycardia of exophthalmic goiter heart tonics and depressants are nearly useless, having at most an evanescent effect. On the other hand, drugs that combat the toxemia producing the tachycardia permanently affect the condi- tion. Therefore, instead of using aconite, ammoniates, or digitalis for such a patient, one would better use the quinin hydrobromid recommended by Forchheimer or the thyroidectin recommended by other observers to overcome the hyperthyroidism lying at the basis of the disorder. Rarely is the tachycardia so acute that the delay of the few days in which such treatment would take effect would prove fatal. Pericarditis Whenever the pericardium is inflamed there may be an effusion into the pericardial sac, and this may interfere with the regularity of the action of the heart. When there is no such effusion the ap- posed surfaces are dry and irritated, or even adherent. We must therefore see to it that the pain is relieved, that the heart's action is kept regular and even, and that the exudate is absorbed, or, in the other case, the serous surfaces rendered smooth. The pain connected with the compression and rubbing due to the exudate would, of course, best be handled by morphin in J- to ^-grain doses subcutaneously. If the irritation cause a cough heroin in ^-grain doses should be substituted for the morphin. The most important aid to promoting cardiac regularity is physiologic rest, and this is obtained by keeping the patient re- cumbent, with an ice bag over the chest. In applying such an ice bag it is well to remember that the rubber should not touch the bare skin, but that there should be a layer of cloth between. Neither should the whole weight of the bag of ice rest on the chest, but it should be supported by some sort of cradle above the pa- tient. The first application of ice to the chest usually gives some discomfort in nervous patients, and not until the lapse of about one half hour at least does the relief begin to appear. This treat- ment is usually sufficient to secure rhythmic cardiac action. Only 258 DISEASES OF THE CIRCULATORY SYSTEM when we have cyanosis, small and rapid pulse, and the other signs of cardiac weakness do we really need to resort to cardiac stimulants. The drug that best serves to promote the smooth action of the heart is digitalis, given preferably subcutaneously in the form, for example, of Merck's German digitalin (dose one tenth to two grains) or by the mouth in the form of the tincture, twenty to thirty drops every four hours. As soon as the pulse rate is within normal bounds and the heart action rhythmic, the drug should be stopped. The internal administration of digitalis is so nauseant that it is liable to upset the stomach, already badly affected by the disturbed circulation. The drug best adapted to promote the absorption of the exu- date is an iodid, which, as noted elsewhere, promotes catabolism, thus hastening the breaking down and absorption of pathological formations. It should be given in five- to ten-grain doses (in satu- rated solution or in a carminative vehicle) three times a day. Fi- brolysin, to absorb the adhesions, may also be tried after the active inflammation has somewhat subsided, but its effects are appar- ently as uncertain as those of the iodids. It is given subcutane- ously in doses of 2.23 c.c. on alternate days. The pericardial exudate is frequently great enough to demand the operative removal of the fluid. Even a moderate amount may demand such removal if the circulatory compensation be broken. The use of thymol (Gussenbauer, 1884) and other drugs for re- moval of such large exudates has only an historical interest, and we now place our dependence entirely upon mechanical inter- ference. The normal pressure in the pericardium is — 3 to — 5, measured in mm. of mercury ; therefore it requires only a few hun- dred centimeters of fluid within the pericardium to make the intra- pericardial pressure positive, unless, indeed, the sac have lost its elasticity; for, after all, it is the tension rather than the amount that counts. Purulent exudates require, of course, the resection (under ether) of the ribs and a wide opening of the sac, with consequent irrigation. Making a trapdoor of the fourth or fifth costal car- tilage with the muscular tissue in the third intercostal space as a hinge, thus enabling one to push aside the internal mammary artery, is the best procedure. After cautiously opening the sac, THE HEART 259 it should be irrigated with warm saline or boric-acid solution. This irrigation may need frequent repetition. The technic of pericardial paracentesis varies but slightly from that used in draining the pleural sacs. A preliminary puncture with a hypodermic needle should always be made. Such a punc- ture should be made with the smallest possible trocar or needle, in order to injure the heart as little as possible. It is advisable to make a vertical incision through the skin along the left margin of the sternum in order to be freed, as nearly as possible, while mak- ing the puncture, from the motion of the chest wall. In choosing the point for inserting the needle, one should bear in mind that the internal mammary artery is between 2 and 40 mm. from the left margin of the sternum; one should therefore punc- ture the thoracic wall either against the ster- num or at least an inch away from it, especially in the fifth intercostal space. Furthermore, the pleura must be avoided. The thoracic wall is 20 mm. thick over the heart. The accompany- ing illustration shows where the margin of the pleura may be found. From this it may be seen that the best place for inserting the needle is the fifth intercostal space close to the ster- num, and that the point of the needle should be sternum. The dangers of the operation are: (1) Injuries to the lung and pleura and their infection from the needle; (2) air has sometimes been let into the sac (this, however, is not apt to happen with the apparatus shown in our discussion of thoracocentesis) ; (3) sud- den deaths have occurred, but it is questionable whether they can Fig. 43. — The Various Limits of the Left Pleura. directed toward the right under the 260 DISEASES OF THE CIRCULATORY SYSTEM be charged to the operation. At any rate, they would probably be due to the nervous shock rather than to mechanical interference with the cardiac action; (4) the heart has been injured by too quick or careless insertion of the needle. When this happens it is usually the right ventricle that is injured; fortunately such in- juries are rarely fatal. The quantity removed has varied from zero to 3,500 c.c. West's table shows the results in eighty-four cases, as follows: 150 c.c. -300 -450 -600 -900 -1200 -1500 More than 1500 13 cases 15 9 8 12 11 4 11 cases The success of the operation is hard to estimate, because the disease causing the exudate is usually fatal of itself, and the re- moval of the exudate simply eases the heart action and makes the patient more comfortable; nevertheless even this result is worth the effort. For the insomnia of pericarditis morphin (or, in compensated cases, a bromid) is the proper hypnotic. For the rheumatism or other infection underlying the pericar- ditis we proceed as if the pericarditis were not present. Fre- quently, however, we cannot discover the primary disorder. In such case we would advocate giving hexamethylenamin to render the body fluids as sterile as possible; dose, five grains three times a day. Myocarditis When the heart muscle is attacked the first indication must be to relieve the heart of all extra work, therefore the patient is kept recumbent and absolutely at rest. Generally digitalis is used in this condition to keep the action of the heart as nearly regular as possible, and ice is applied externally to assist in securing this result. Some writers believe that a fatty degeneration of the heart is a contraindication for the use of digitalis, but others use it in all conditions demanding a slower and stronger ventricular contraction. It is very important in all these cases to diet the patients care- THE HEART 261 fully in order that there be no disturbance of the stomach, causing it to press against the heart and thus mechanically hinder its ac- tion. Moreover, any other irritation of the splanchnic and vagus nerves interferes with the heart action. The principles upon which such dieting proceeds are: (1) The amount of fluid ingested should be reduced to the minimum; (2) the heavy meal (if such a meal be necessary) should be in the middle of the day; (3) the food should be simple and of but slight variety (not heterogeneous), and of the more nutritious sort; (4) as little of chlorin as possible should be given in the food. The " Karel cur," which consists essentially of rest in bed and 200 c.c. of milk five times a day, is a type of this treatment, in which the food, though fluid, furnishes the minimum amount of fluid necessary for daily consumption. If the myocarditis be due to the invasion of the muscle by microorganisms, then antiseptic drugs, such as salol, hexamethyl- enamin, guaiacol, and the like are used in the effort to render the blood as poor a medium as possible for the growth of these bacteria. Some therapeutists use collargol, which is a colloidal silver. It is a black crystalline substance, soluble in fifty parts of water. It should be used intravenously, or, if the infection is not very severe, it may be used in the form of a fifteen-per-cent ointment by in- unction. Its success is very doubtful. "When the condition is a chronic one the iodids are given in order to assist in the building of new and better muscle by stimu- lating the general bodily metabolism. Sometimes the physician contents himself with a routine pre- scription like the following, which, in our judgment, is of question- able value, but is often used where we, on the other hand, should prefer to put our reliance upon something more specifically di- rected toward affecting the varying condition of the patient from day to day. Thus on one day we might have to use diuretin to stimulate the diuresis, on another pay all our attention to overcom- ing digestive disturbances, etc. ; but because there is considerable argument for having a routine prescription, we quote it, as follows : T£ Pulv. fol. digital, titr. Pulv. bulb, scillae aa 1.0 Rad. et ext. gentian q. s. ad pil. no. XXX. Sig. One t. i. d. 262 DISEASES OF THE CIRCULATORY SYSTEM Endocarditis If it is the endocardium which is attacked, we have either a leakage in the valves or the formation of vegetations within the cavity, or both. Here, also, the first indication is absolute rest with the application of cold, by means of ice bags, to the chest ; and also a very careful attention to the gastrointestinal tract. Thus small doses (three grains in broken doses) of calomel given daily and the occasional use of mineral waters will be found of value in all these cardiac conditions. Digitalis is the first thought in cardiac disease involving arrhythmia, and it may be given by the mouth either as a tincture in twenty- to thirty-drop doses three times a day or hypodermically as Merck's German digitalin in one-tenth- to two-grain dosage. In severe cases of infective endocarditis the use of vaccination has been found worthy of trial. The best cultures from which to make the vaccines are made from the patient's blood. The twenty- four-hour-old cultures are washed down and killed by heat and then injected subcutaneously in the dosage of one half million germs or over, according to the patient's resistance. Careful at- tention must be given to the patient's reaction and no second dose given until the patient's condition warrants it; that is, until the ' ' positive phase ' ' of the reaction is present. This is usually indi- cated by an improvement in the pulse, temperature, and general feeling of the patient, and occurs from two to five days after the injection of the vaccine. In these cases where streptococci may be found in the blood- stream the use of polyvalent antistreptococcic serum is warranted (see notes on remedies). When patients suffering from leaking valves have overcome the initial loss of circulatory equilibrium, it is a good therapeutic point to try to strengthen these valves by very carefully graduated exer- cises and passive movements (Schott or Nauheim treatment). The beginning treatment of this type is by the use of carbonic-acid baths, which, through the skin stimulation, seem to have a very good effect on the heart muscle. They are ordinarily made by dis- solving to each 10 gallons of water at 95° F. 3 pounds of sodium chlorid, 4J ounces of calcium chlorid, 2 ounces of soda bicarbonate, and 3 ounces of commercial hydrochloric acid. The first bath THE HEART 263 should usually last only five minutes, but the length of time is increased daily. The temperature of the first bath is, as indicated, at 90° to 95° F. The temperature of succeeding baths is gradu- ally reduced from day to day until 50° F. is reached. The patient is, of course, lifted on a sheet into the bath tub and out of it, in order that there be no exertion on his part. Rock-salt baths (2J to 7-| pounds of rock salt in 75 gallons of water) may be substi- tuted for the carbonic-acid baths in some cases. Here the tem- perature begins at 95° F. and the bath lasts about ten minutes. For ambulant patients suffering from valvular lesions con- siderable attention should be given to the character of the under- wear. The loosely woven linen mesh seems to be a favorite in our changeable climate, and the woolen better adapted to the moister (but more equable) climate of England and the Continent. The diet needs to be carefully chosen to prevent fermentation and dilatation of the stomach, hence starchy foods should be re- duced to a minimum and carefully dextrinized (triscuit, shredded- wheat biscuit, etc.). Following the carbonic-acid baths, resistance movements are valu- able in gradually increasing the cardiac power. Thus the patient lies with his legs straight out and tries to keep them so while the physi- cian either lifts the leg or bends the knee, putting but little effort into the movement at first, but gradually increasing the strength applied to different muscles and joints from day to day. These two things are practically the essence of the Nauheim treatment. The following pulse tracings show the effect of the Nauheim treatment by means of carbonic-acid bath and resistance exercises. Figures e to I show the consistent development of one patient. (Quoted from Th. Schott, Herzkrankheiten, 1890.) (a) Before the bath : Pulse rate 94, blood pressure 120. (6) After a carbonic-acid bath at 88° F. lasting 15 minutes: Pulse rate 72, pressure 140. (c) Tracing made before exercise: Pulse rate 80, blood pressure 125, 264 DISEASES OF THE CIRCULATORY SYSTEM (d) After 30 minutes of resistance movements: Pulse rate 95, pressure 160. (e) Tracing made before any treatment: Pulse rate over 150, blood pressure 82. (/) Tracing made on the next day after a 1% carbonic-acid bath at 92° F. lasting 10 minutes. (g) Same patient, after 8 days of baths: Rate 144, pressure 95. J\AAJUU\A^ (h) Same on 9th day after 3^ hour of resistance exercise: Pressure 110. 00 Same on 14th day: Rate 108, pressure 115. 0*) After 3 weeks: Rate 108, pressure 125. (k) Before resistance exercise: Rate 102, pressure 130. (l) After the resistance exercise: Rate 92, pressure 145 THE HEART 265 Illustrative Case Histories (quoted from Hofmann) : Case I. — Tradesman, fifty-two years old, healthy until May, 1907. Attacked then with dyspnea and pains in the chest, which became worse when he walked and at that time were specially noticeable between the shoulders. Since the patient was a heavy eater and moderate drinker the first thing done was to cut down his rations one half and to forbid alcohol; then digitalis was prescribed. This improved his condition, but the middle of May, 1908, the same symptoms recurred because the patient had stopped following the prescriptions. The legs swelled to the knees, the abdomen was distended, and the shortness of breath reached the stage of dyspnea when the patient attempted to go upstairs. At this time the following status was found: well nourished, successful looking man 168 cm. tall and 85 kg. weight. Light cyanosis, especially on undressing or other exertion. Lungs sound but with scattered rales over the bronchi. Cardiac dullness reaches the middle of sternum, tones pure, but muffled. Pulse 120, small, easily compressed. Liver reaches 7 cm. beyond ribs, abdomen distended, ascites present. Edema reaches from feet to middle of abdomen. Urine medium concentration and free from albumen and sugar. Diagnosis: myocarditis. Treatment: The Karel treatment was prescribed (bed rest, 200 c.c. milk three times a day) which in spite of his abhorrence of milk the patient carried out. On no day did the patient drink the prescribed amount of fluid, still the amount of urine on the second day reached 2,000 c.c. On the fourth day the amount was even greater, and the edema and ascites had dis- appeared. The liver was now normal in size, and the pulse had fallen to 90. After seven days the patient felt so well that he left his bed and went to work. Loss of weight, 11 kg. In seven weeks he had a relapse with dyspnea, edema, and ascites, as before the " Karel cur," which the patient refused to take again. A diet in which but little salt was found was ordered — coffee with milk, meat, bread, butter, potatoes, fruit, without salt. This diet brought about just as good a result as the milk treatment and in just as short a time. This, with the following prescription, has kept the patient in good order since that time : ^ Pulv. fol. digital titr. Pulv. bulb, scillse aa 1.0 Ext. strychni 0.3 Pad. et ext. gent. q. s. ad pil XXX. Sig. One pill t. i. d. Case II. — Engineer, fifty years old, always healthy, suffered from light attack of diabetes in 1904 which did not affect his general health. Pulse 266 DISEASES OF THE CIRCULATORY SYSTEM was even then small and rapid (100). In June, 1907, he became short of breath and had pains which radiated into left arm. Improved under treatment of bed rest and digitalis. The patient had a liking for well- salted food, and would add 15 to 20 grams of salt to his already well-salted food. At that time his status was : well nourished, 160 cm. tall, weigh- ing 84.5 kg. Rather pronounced cyanosis, which increased upon move- ment. Lungs sound. Cardiac dullness extended to right. Systolic mur- mur at apex, which is pronounced on movement but disappears when patient is quiet. Liver reaches navel. Abdomen distended. Ascites plainly evident. Edema of legs, scrotum, and belly wall. Urine shows trace of sugar and albumen, no casts, a few white corpuscles. Treat- ment : " Karel cur " : one liter of milk daily in five portions, which are not all drunk. In three days increased diuresis had caused the edema and ascites to disappear. General feeling excellent. Then a mixed diet, poor in salt, was ordered and patient permitted to leave his bed for short periods. In fourteen days patient was cured, for there was no trace of circulatory disturbance. Pulse 90; cardiac tones pure; no edema; no shortness of breath. Loss of weight 12.5 kg. The Heart in Constitutional Diseases When the heart seems to be about to collapse in the course of different constitutional diseases, such as typhoid and pneumonia, different drugs are used, according to the character of the primary disease. Thus in typhoid fever, because the type of the poison is convulsant or similar to strychnin in its action, probably the most satisfactory medication for the circulation is camphor, and this, when used in the form of an aseptic neutral solution (ten per cent in olive oil) in dosage of 6 c.c. pro die, proves to be efficient not only in giving a more even circulation, getting rid of a good deal of dicrotism, but also in quieting the mind and relieving much of the nervous twitching. In pneumonia digitalis will be found the best drug to be used (as indicated in the discussion of that disease) in rather large quantities for a few days. If the disease be diphtheria or some disorder that relaxes the blood vessels and dilates the capillaries, then caffein may be better indicated than digitalis, because this acts more upon the vasomotor system than it does upon the heart muscle itself. This is usually given in the form of the citrate in doses of from two to eight grains. In nephritis, either acute or chronic, the heart is always af- THE HEART 267 fected. If the nephritis be toxic, then from the very beginning the heart would suffer from it. If the nephritis be simply one of the interstitial character, the heart does not show any result of the strain until later in the disease. Probably the best drug to steady the action of the heart and help increase the amount of excretion through the kidneys is one of the double salts of theobromin. For instance, diuretin in doses of one gram three times a day will prove very efficient in giving not only something of the caffein action of the heart, but also to increase gradually the diuresis. Of course digitalis may be added to the diuretin, and one in that way gets a more certain -effect upon the heart muscle, as well as the control of the vasomotor system. In adolescence the heart frequently does not grow as rapidly as does the remainder of the body, and therefore is relatively in- sufficient. In such conditions, the principle of resistance exercises should be adopted and the patient gone over thoroughly to ascer- tain what exercises are the most particularly indicated, then should be given exercises, diets, and baths that will from day to day stimulate the heart to increased activity and growth. More can be hoped from this sort of hygienic treatment than from the use of drugs, although digitalis is often used in these conditions. The following exercises (from Poynton) illustrate the above statements regarding resistance movements: Schott Movements. — 1. Arms extended in front of the body at the level of the shoulders and palms touching. The patient slowly moves them outward until in a line with one another against the gentle re- sistance of the operator. This done, they are slowly brought back to the original position. 2. Arms dependent. Patient flexes forearm until hand touches shoul- der, and then returns to original position. One forearm is flexed at a time. 3. Arms dependent, then slowly swept round in the arc of a circle until the thumbs touch above the head; then back again. 4. Arms dependent, hands meeting over abdomen, and the first phalanges pressed together against one another. In this position the arms are raised to the level of the head, and then returned to the same position. 5. Arms at attention, then slowly raised forward to the vertical po- sition and back again. 6. The same movements as No. 1 with the fist clenched. 268 DISEASES OF THE CIRCULATORY SYSTEM 7. The same as No. 2, but with the fist clenched. 8. Flexion of the trunk to a right angle without flexion of the knees, and return to the original position. 9. In the erect 'position rotate trunk without moving the feet, first to one side, then to the other, then back to original position. The op- erator will place one hand in front of the advancing shoulder, the other behind the retreating one. 10. In the erect position, flex the trunk laterally, first to one side, then to the other, and return. 11. Erect position. Hands dependent, arms extended. Make a com- plete revolution of first one arm, then the other. 12. Erect position. Arms extended, hands against thighs. Move up- ward and backward without flexion of the trunk, and return to the original position. 13. Erect position. Stand supported by hand on the chair. Flex thigh to abdomen, and back again. 14. Same position. Keep the leg stiff, and bend the whole limb first forward, and then backward. 15. Erect position. Flex and extend leg on thigh. 16. Erect position. Abduction and adduction of the lower ex- tremity. 17. Erect position. Arms abducted to the horizontal line, rotated forward and backward to their extreme limits. 18. Flexion and extension of the wrist. 19. Flexion and extension of the ankle. All these movements are made slowly against the slight resistance of a skilled assistant. The movement is repeated according to the judg- ment of the operator, and rest is allowed after finishing each group. The condition of the patient is carefully watched and the exercises varied accordingly. Special Symptoms. — In heart disease there are many symptoms due to the disturbed circulation, but symptoms that do not call for heart tonics per se. Thus insomnia, due to the inequality of the blood supply to the brain, should be treated with the bromids rather than the cerebral depressants. Fifteen to twenty grains of sodium bromid should be given in hot milk two hours before bedtime. The dyspnea is best treated with small doses of the opiates until one can restore the equilibrium of the circulation. The epigastric pain is best handled by the application of cold, THE BLOOD VESSELS 260 either by means of the ice bag or the coil through which cold water is flowing. In other words, these symptoms should be treated symptomat- ically until one can restore the physiologic tone to the circulation by means of rest and vasomotor tonics. THE BLOOD VESSELS Arteriosclerosis The most that can be hoped in this condition is to stop the progress of the disorder and relieve the symptoms. A restitutio ad integrum is still beyond our therapy, though we still dream of fibrin and scar-tissue dissolving drugs which shall rid the vessels of their inelasticity and friability. The disease is due to strain and overwork or to such constitutional diseases as syphilis, hence any measures to check the progress of the disorder must call for a change in the habits of life of the patient, as well as the use of positive influences to bring about the necessary tissue changes. The symptoms resulting from arteriosclerosis are the headache due to the inabilty of the vessels to accommodate themselves to the vary- ing conditions demanding dilation and constriction; nephritis, which almost always results from arteriosclerosis; the heart be- comes degenerated and the patient suffers attacks of angina pec- toris, and finally the scene is usually closed by the cerebral vessels breaking down and the patient suffering a fatal stroke of apoplexy. In order to break down the pathological formations in the walls of the blood vessels, potassium iodid is usually exhibited. This is particularly efficient where the arteriosclerosis is due to syphilis, and in such a case should be given in immense doses. In ordinary cases, however, ten to fifteen drops of the saturated solution are given three times a day, and with little perceptible result. The high blood pressure existing in arteriosclerosis can some- times be beneficially influenced for short periods of time by the use of sodium nitrite (five grains in solution three times a day). However, the system soon becomes immune to this drug and the blood pressure returns to its former state. Therefore one has the best prospects of success in such condi- tions by putting the patient into an institution where hydrotherapy 270 DISEASES OF THE CIRCULATORY SYSTEM may be given in addition to the drug medication. This life, since it combines massage, the application of electricity, and very careful oversight of diet and exercises, will in a great many cases prove sufficient to check the progress of the disorder. Naturally, any such course of treatment must be carried on for several months in order to accomplish any results. For patients who cannot afford to go to a sanatorium, one must prescribe relief from overwork, additional sleep, additional out-of- door exercise, hot tub baths, Turkish baths, restricted diet, etc., as the environment may permit. The hours of work must be so rigorously cut down that the patient will awake refreshed in the morning. At the beginning of the treatment, a nap or siesta after the noon meal will be needed. The out-of-door exercise should include something more than walking. For, while walking over the country road is good, walking over the pavements is bad. Golf, of course, is excellent. Driving and riding where possible are to be encouraged. Gardening is helpful. Tennis is usually too vigor- ous. The diet must be restricted to what the patient really needs and what he can easily digest. Prolonged mastication of the food and the use of plenty of water between meals will assist in the utilization of a suitable diet. The nephritis and other symptoms resulting from the arterio- sclerosis are to be treated symptomatically. Thus in nephritis the salt-free diet and the hot-air baths will be the most potent remedies. The former is obtained by using milk and cream as the diet (four to six ounces every two or three hours), and the latter can be arranged for even at home by making a cabinet out of a bed, as has been described elsewhere. The angina pectoris requires the administration of nitroglyc- erin and atropin. The retrosternal pain requires similar treat- ment. All such pains, however, demand the adoption of hygienic and dietary measures to reduce the strain upon the heart and blood vessels. The nitroglycerin (y^-g- gr.) and atropin (y^j- gr.) may be given together subcutaneously. Apoplexy Cerebral hemorrhage usually occurs as a final result of arterio- sclerosis, although it may occur without any arteriosclerotic condi- THE BLOOD VESSELS 271 tion. The therapeutic indication, of course, is for a line of treat- ment that shall stop the exudation of blood into the brain and that shall also promote the absorption of the blood already exuded. The first is usually obtained by putting the patient in bed and packing the head in ice. The use of heat to the feet at the same time may be advantageous, in that it tends to reduce the intra- cranial blood pressure. The promotion of absorption is to be looked for through a general stimulation of all the metabolic processes. Thus the internal administration of the iodids will tend here, as in the case of other exudates, to cause the absorption of the material lying outside of the vessel walls ; hence a prescription for a man suffering from apoplexy (but without pain or other dis- comfort) would include nux vomica, an iodid, and a cathartic, as, for instance, the following: 1$ Tct. nucis vomica? 15.0 c.c. Potassii iodidi 10.0 grams. Ext. fl. cascarae sag 5.0 c.c. Elixiris gentian, glycerinati (N. F.) . . . . 200.0 c.c. Sig. One dessertspoonful three times a day. The use of massage and oil rubs should not be neglected whenever it is practicable to give them. Varicose Veins Probably the best treatment for chronic varicosities is surgical, because in such conditions the venous walls have lost their power of recuperation and constriction and had better be removed at once. The apparent reduction of the varicosities produced by the application of elastic bandages and similar supports is at best only temporary. It should be resorted to, therefore, only when the more radical treatment by the resection of the dilated vessels is impracticable. Beginning varicosities can be helped by using digitalis to con- strict the vessels as well as stimulate the heart. Whether or not it would be possible to overcome a congenital tendency to varicosity by such medication is impossible to say. But such varicosities as are induced by constricting bands and prolonged standing on the feet could be warded off if the bands (garters, for instance) be 19 272 DISEASES OF THE CIRCULATORY SYSTEM removed and the patient be given employment less exhausting. In such cases the use of digitalis or of adrenalin (intravenously) should be tried. The insomnia in such cases (due to the hyperemia of the brain when the patient lies down) can be helped by using digitalis to constrict the blood vessels. Inasmuch as digitalis is slow of action, one should give the drug in the afternoon at, say, four o'clock, unless one use the quicker acting digitalin, or digalen, hypodermically. Varicose Ulcers These are usually due to the flooding of the tissues with the exudate from the neighboring varicose veins. Therefore the first indication for their successful treatment is the relief of the vari- cosity, or at least the draining of the tissues of the superabundant supply of serum. This indication is interpreted by a German physician, Schweninger, to mean the cutting of trenches around about the ulcer, thus shutting it off from any direct blood supply. Ordinarily, however, this draining of the tissues is accomplished by the use of tight bandages combined with a stimulant cleaning off of the ulcer surface. The irritation accompanying ulcers may be relieved by the application of zinc oxid ointment (twenty per cent). The infection of the floor of the ulcer is removed by rubbing it with gauze wrung out in 1 : 1,000 bichlorid-of-mercury solution. After the tissues dry, powdered iodoform is sprinkled on the raw surfaces and protective bandages applied. Relaxed Vessels This condition forms a menace to the general health, particu- larly when the vessels of the portal circulation are affected. In such cases it results in indigestion, headaches, cold extremities, insomnia, and a general feeling of discomfort in and about the abdominal cavity. In fact, some writers believe that most cases of " the blues " are due to portal congestion. The treatment should proceed along two lines: (1) The pa- tient's life should so be regulated that all the abdominal muscles are stimulated into activity, and (2) the circulation of the skin and in the extremities should be stimulated so that the blood is kept THE BLOOD VESSELS 273 from stagnating in the portal tract. Both of these things are ac- complished by deep breathing, massage over the epigastrium and abdomen, and by bending exercises (Abrams). The general outline of life given above for beginning arterio- sclerosis would apply here, except that here the exercise may be much more vigorous and the use of cold baths more often indi- cated than hot ones. In fact, the morning rub with cold water and exercises so vigorous that the perspiration rolls out are the best procedures. There is also the internal line of treatment. The blood pressure in the splanchnic area may be increased quite materially by the use of digitalin (the alkaloid) hypodermically. Ergotoxin, or even the crude drug when prepared for subcutaneous use, will prove useful. Even when the fluid extract of ergot has been given by the mouth it has yielded results worth while. Adrenalin used intra- venously or intramuscularly would have a less lasting effect and therefore would not be as useful here as the subcutaneous injection of digitalin or ergot. Styptol (or stypticin) in three-fourth-grain pills (three or four times a day) should also be thought of, but since it has a tendency to produce a contraction of the capillary walls alone where a more general contraction would be more bene- ficial, it is not as efficient as one of the above. Camphor used hypodermically as a neutral oil, ten to twelve per cent, or even by the mouth, would increase the blood pressure in the splanchnic area, and would therefore be decidedly valuable. The effect of caffein would be less, but it might be used in combination with the other drugs for its blood-pressure-raising effect. It should be given as caffein citrate in doses from two to eight grains. The use of the alternating hot and cold douches and fomenta- tions would be helpful in any systematic treatment of this disorder. In the use of the hot and cold fomentations, a cloth is wrung out in water as hot as can be borne and laid over the abdominal area, or along the spine, and after about three minutes the cloth is re- moved and ice is rubbed over the same area for perhaps a half minute ; then a fresh hot cloth is applied. This treatment is usually somewhat safer if applied to the back than the front of the trunk, because when applied to the abdomen the shock to the system is so great that it may cause trouble if the patient be not fairly robust. 274 DISEASES OF THE CIRCULATORY SYSTEM In applying the douche, the patient is sprayed with a current of water at, say, 60° to 70° F., and then as soon as he has reacted to it, with one at 100° to 120° F. The force of the current and the heat of the water are both regulated according to the resistance of each patient. Capillary Hemorrhage Capillary hemorrhage may be due either to the relaxation of the capillary wall or to the lack of coagulability of the blood itself. In the first type, astringents or constrictors are called for; in the second, coagulants. In detail, the treatment is the following : When it can be reached locally, as in the case of uterine or nasal hemorrhage, hemorrhage may be treated by the application of styp- tics. Adrenalin applied locally in 1 : 1,000 solution is, of course, the least damaging to the tissues, and in ordinary conditions will prove sufficient. Should it not prove sufficient, resort may be had to the iron salts which produce a searing of the superficial tissues. Thus, the liquor ferri chloridi, a thirty-eight-per-cent solution of the salt, will be found one of the strongest styptics, but should be applied very carefully, because it is corrosive and will injure any tissues or material touched. It should be applied on a wooden applicator. In the nasal hemorrhage of pernicious anemia the liquor ferri chloridi has proven the most efficient. The bleeding points should be touched with the solution and then the entire cavity packed with absorbent cotton. In the uterine hemorrhage of endometritis, thorough curettage seems to be the only efficient treatment. The intra-uterine appli- cation of styptics is merely temporary, and yet very painful. In the hemorrhage of icterus and similar states, the calcium salts have long been used, but with doubtful effect. Addis has shown that calcium does not increase the coagulability of the blood (British Medical Journal, April 24, 1909), yet we find many cases in which the coagulation time is reduced by the administration of large doses of calcium salts. The best results are obtained when we use a nucleo-protein such as thyroid extract with the calcium. Thus we would give 15 grains of calcium lactate and 3 grains of thyroid extract three times a day — the former after meals and the latter on an empty stomach. THE BLOOD VESSELS 275 The subcutaneous injection of gelatin has been used for many years in cases of capillary hemorrhage, but the difficulty of freeing the gelatin from tetanus bacilli has depressed the ardor of those who would otherwise use it. On the other hand, the thoroughly sterilized preparations of gelatin have generally lost their styptic effect, and for that reason are equally useless. The best method of preparing gelatin in order to render it germ free and yet retain its styptic power is perhaps to take 4 to 5 grams of the best white gelatin and dissolve it in 200 c.c. of warm, sterile seven-tenths-per-cent solution of sodium chlorid. This solu- tion is thereupon sterilized for four successive days, a half hour each day in steam vapor at 100° C. The solution must be com- pletely clear. In case it is not it should be boiled up with some solution of egg albumen and filtered until it is completely clear. The sterile solution should be kept in bottles with glass stoppers, sealed with glazed paper or rubber caps. Before using the bottles containing the solution should be warmed to the proper tem- perature. For injection, one uses one of the larger syringes (25 c.c.) . The fluid is injected either in the glutei or between the shoulder blades very slowly and in quantities of 150 to 200 c.c. The best method is to insert the needle, and when no blood shows, attach the syringe and slowly drive in the fluid gelatin. The syringe is then detached from the needle, refilled, and its contents injected, and so on, until the total quantity required has been put within the subcutaneous tissue. There is considerable pain connected with the operation, for which, of course, one should apply heat, either with cloths wrung out of hot water, or the thermophore. The injections may be repeated daily until one is sure that the hemorrhage has ceased. Gelatin can also be injected directly into bleeding hollow or- gans, such as the stomach and bladder, or into the joints, and good effects have been seen from it. Purpura Purpura is probably due to changes in the blood itself, brought about by toxins and hemolysins. Thus we find purpura in cases of icterus of long standing. Here the hemorrhage is due to the action of the absorbed bile. Likewise we find purpura in severe strepto- 276 DISEASES OF THE CIRCULATORY SYSTEM coccic infections. Hence the disease should not be looked npon as idiopathic and our treatment limited to the symptoms. On the contrary, it should be regarded as merely a symptom and the cause searched out and causal therapy instituted. The treatment of the symptom is by means of calcium and thyroid extract, as mentioned under capillary hemorrhage. The symptomatic treatment calls also for careful dieting, so as to keep the bowels active and also so as to secure the maximum efficiency of the food values ingested. Thus milk, eggs, fruit juices, rare steak, carefully dried toasts, etc., should be prescribed and chosen. Cathartics must be avoided, because of their liability to set up intestinal hemorrhage. Hemophilia Hemophilia is, of course, treated symptomatically. Adrenalin, either locally or intravenously, according to whether the bleeding is local or general, should be our first thought. The injection or application of gelatin may also be employed with success. Thus bleeding from the bowel would be best handled with gelatin ene- mata. The essential element seems to be pressure or constriction at the point of hemorrhage, therefore the use of the corrosive styptics seems needlessly destructive. Scurvy Scurvy seems to be due to the deprivation of the body fluids of elements supplied by citric acid and uncooked albumen. Hence the treatment requires that the patient be kept absolutely quiet (children may be packed in cotton) and the diet arranged to sup- ply the missing elements. Orange juice, lemon juice, fresh milk, raw vegetables, and beef juice should be employed in such form and quantity as is best taken by the individual patient's stomach. The mouth must be cleansed frequently and freed from infec- tion by the use of hydrogen peroxid and other antiseptics (see Stomatitis). The anemia may call for iron — or at least a diet rich in beef. Rectal enemata are best to keep the intestines open, and even these must be gently given. Most cases get well when given the appropriate care and diet without the administration of special drugs. THE BLOOD 277 THE BLOOD Primary Anemia This pathological condition demands first of all some influence that shall stimulate the blood-building organs to throw out into the blood stream an increased supply of hemoglobin or blood corpus- cles. To make this stimulation most successful, there should be an attempt made to ascertain the cause of the condition, and if this consists in some fault in the mode of living, it should at once be corrected. If it is due, as is frequently the case, to systemic intoxi- cation, or to the presence of intestinal parasites, or the loss of blood from intestinal ulcers, then the treatment necessary for the cor- rection of the causal condition should at once be instituted. Con- sequently no case of primary anemia should be considered idio- pathic until all the means of diagnosis have been exhausted and the search should cover the gastric contents and feces as well as the blood and urine. Chlorosis. — In this condition there is a lack of hemoglobin or iron in the blood ; therefore the indication is for an increased sup- ply of iron in the diet. This is brought about in the simplest way by feeding the patient Blaud's mass or else saccharated ferrous carbonate in five-grain doses three times a day. Either one of these is superior to most of the other inorganic preparations in that it does not discolor the teeth or irritate the mucosa. Inasmuch as Blaud's mass is effective only when the carbonate is of the fer- rous rather than the ferric type, it is particularly important to have the preparation fresh and active. Blaud's pills should there- fore be freshly made for each prescription. Nowadays the follow- ing prescription would be just as satisfactory as the Blaud's pills: 3J Ferri carbonatis saccharati 0.3 M. f. capsula gelat. no. I. Da tales doses no. L. Sig. Take one capsule after each meal. "\Ylien chlorotic patients are suffering from hyperchlorhydria or other diseases of the intestinal tract, it may be necessary to give iron in the form of the organic salts. These are less corrosive and less irritant. Ferrous carbonate rarely ever, however, gives rise to gastric disturbances, but in some cases the albuminates will do the 278 DISEASES OF THE CIRCULATORY SYSTEM work better and should then be chosen. As far as experimental research can demonstrate, the inorganic preparations are absorbed in the duodenum just as quickly as are the organic. Therefore on account of the increased cost of the organic form of preparation, the inorganic preparation should be used wherever applicable. The albuminates most used are Gude 's peptomangan, ovof errin, ferratin, etc. The former has become almost a patent medicine, so widely and thoroughly has it been advertised. On the subject of these preparations, we would quote the " New and Nonofficial Remedies of the American Medical Association, ' ' as follows : Organic Iron Preparations: The term, "organic iron" ("masked" or "nonionic" iron), is confined by modern usage to those organic com- pounds of iron which do not give the chemical tests of the metal (blue color with potassium ferrocyanid, blue-black color with hematoxylin, etc.) until the structure of the molecule has been destroyed by reagents. The resistance to this destruction varies greatly; some (such as hemo- globin) require incineration or the action of concentrated acids, while others give the iron tests after treatment with even fairly dilute acids. The organic compounds occurring naturally in animal and vegetable tissues (which are often termed " food irons ") belong generally to the more resistant class, while the iron of the synthetic preparations is usu- ally liberated fairly readily. This does not, however, constitute a sharp line of distinction between the two classes, nor is there any good evi- dence that they differ in therapeutic action. Until this difference is es- tablished all organic iron preparations, whatever their source, may be placed in a single class. It is evident, however, that an organic iron (chemically) which is destroyed by two-tenths-per-cent hydrochloric acid at the body temperature, cannot be classed as an organic iron in the therapeutic sense. It should also be emphasized that salts of iron (which gives the iron tests directly) are classed as organic iron whatever the acid radicle. True albuminates, peptonates, etc., of iron are therefore inorganic. Organic iron preparations are used to increase the hemoglobin in conditions of anemia. Bunge supposed that only organic iron could be absorbed and assimilated by the body, the reputed action of inorganic iron being altogether indirect, and due to its local effects on the ali- mentary canal. This theory was modified by Abderhalden to the effect that inorganic iron, while it could not be converted into hemoglobin, nevertheless stimulated the assimilation and conversion of organic iron. Later work, however (Tartaskowski), seems to prove conclusively that inorganic iron is assimilated and converted into hemoglobin, and is in THE BLOOD 279 so far therapeutically fully equal to organic iron. Many authors, how- ever, still adhere to the theories of Bunge and Abderhalden. At all events a real difference exists between the organic and most of the inorganic preparations, namely, in the local irritant and astringent action of the latter, and the absence of these effects in the organic com- pounds. These actions may be desirable in some cases and undesirable in others. It should also be remembered that organic iron may often be administered in sufficient amount, and most economically, by select- ing a dietary rich in iron, such as red meats, egg yolks, green vegetables, whole wheat, etc. Pernicious Anemia. — In this type of primary anemia, it is the blood corpuscles that are attacked. They show an abnormal lia- bility to break down, and we find therefore a number of patholog- ical forms on every blood slide. If possible, the hemolytic toxin causing such a breakdown should be removed from the body. As we have indicated above, this toxin frequently originates in the intestinal canal; therefore a thorough cleansing of the intestines often brings about a rapid improvement in the condition of the patient. This cleansing should be given both by cathartics, with calomel as the preferable one, and also by colonic flushing with quinin bisulphate and normal salt solution. To stimulate the bone marrow, lymphatic glands and spleen (in short, the hematopoietic organs) to an increased activity in supplying corpuscles, arsenic is given in extremely heavy dosage (60 to 120 drops of Fowler's solution pro die). The prescription follows : 5 Liquoris potassii arsenitis §ij. Sig. Begin with 10 drops in water three times a day, and in- crease by 1 drop each day until the dose is 20 drops. The X-ray applied to the long bones and over the spleen for five to ten minutes on alternate days will be found helpful. In this disease there come, no matter what type of medication is employed, periods of remission, and these should not be mistaken for cures. Whenever we use metals such as arsenic and iron for any length of time, we should keep in mind that they are excreted 280 DISEASES OF THE CIRCULATORY SYSTEM chiefly through the mucous membrane of the large bowel. This renders necessary frequent colonic irrigation. If there are no pro- tozoa to be eliminated from the colon, simple saline solutions will be sufficient for such irrigations. Needless to say, the patient must keep his bed and avoid all work and worry while undergoing treatment. Secondary Anemia Here ordinarily the drain upon the system has been stopped before we begin treatment for the blood loss and one has only to deal with the resultant loss of blood substance. This loss is usually made good by giving iron in the form of Blaud's mass, or saccha- rated ferrous carbonate (5 grains three times a day). In some cases it is advantageously combined with jV grain of arsenic trioxid in order to secure a stimulation of the hematopoietic organs. The stomachics are indicated here to promote the absorption and stimu- lation of food. Naturally, one should be very careful while giving iron and similar astringent drugs to keep the peristalsis active by laxative food, mineral waters, etc. Leukemia In the leukemic diseases it is chiefly the number and forms of the white blood cells that show the progress of the disorder. Leu- kemia seems to be essentially a disease of the blood-building organs, therefore the treatment is similar to that employed in pernicious anemia, with more emphasis placed on the stimulation of general bodily functions. Since the disease seems to lie in the blood-build- ing organs, there is needed an increased supply of the blood ele- ments and constituents which these glands would normally furnish. Hence an attempt has been made to better the condition by giving thyroid extract, bone marrow, pituitary extract, etc. In some cases this has seemed successful. When exhibiting such glandular prod- ucts, the same principles should be followed as are laid down for giving of thyroid extract for hypothyroidism. Thus the extracts must be given under conditions which are the best for their absorp- tion from the duodenum (e. g., three hours after and one hour before eating). The dosage of the thyroid extract is ordinarily from 2 to 5 grains. Thus : THE BLOOD 281 1$ Glandularum thyroidearum siccarum 0.2, M. f. capsula no. I. Da tales doses no. XX. Sig. One capsule on an empty stomach three times a day. Arsenic is freely used in leukemia either in the form of Fowler's solution, or hypodermically in the form of atoxyl, arsacetin, or soamin. The X-ray and the high-frequency current are also used to stimulate the bodily activities. In caring for the leukemic patient one should not forget the stimulant effect of cold douches, hot and cold fomentations to the spine, hot and cold sprays (Wechsel douche), etc. Trypanosomes These parasites inhabit the blood and lymph currents. Those of the African sleeping sickness seem to be found most constantly in the lymphatic glands. The medication up to date has not been successful. It has been found that the use of arsenic in extremely heavy doses is sufficient to inhibit the organisms and prevent their development, but it has been noted that in the case of " the sleep- ing sickness " in Africa that within six months after the discon- tinuance of the drug the disease sometimes recurs. Arsenic should, therefore, be used hypodermically in the form of sodium cacodylate, or atoxyl, or arsacetin. This permits the injection of relatively large quantities and thus keeps the system saturated. Ehrlich, of Frankfort, has been long engaged in the develop- ment of remedies to combat this condition. He has worked on the anilin dyes, because he has found them to inhibit the parasite with- out injuring particularly the host. The best that he has yet de- veloped is called the trypan red, but this drug changes temporarily the color of the skin and hair of the patient who is taking it, and is otherwise unpleasant. Hence the arsenic still seems the best treat- ment that we have for the condition. The injections are made subcutaneously on alternate days, using as much as the patient will bear ; for example, 25 minims of a ten-per-cent solution of atoxyl, or the same amount of a one-per- cent solution of arsacetin (i. e., begin with ^ grain (0.02) and increase to 10 grains (0.65)). CHAPTER VI DISOEDEES OF THE GENITO-UEINAEY SYSTEM FUNCTIONAL DISORDERS OF THE KIDNEY Uremia Uremia is the term given to the complex of symptoms re- sulting from the intoxication of the body by the waste products which normally are excreted by the kidneys. Hence the treat- ment of uremia is the treatment of symptoms rather than of a definite pathological condition, while the treatment of the under- lying lesion would be governed by the principles discussed under that head. The symptoms are those referable to a severe intoxication; therefore we find delirium, convulsions, or coma, according to the severity of the attack and the reaction of the patient. The symp- toms due to the disturbance of the digestive and circulatory symptoms are also pronounced, but may be looked upon as second- ary to the nervous symptoms. Hence the first need is to stimulate all the emunctories of the body and secure a freer elimination of the stored-up combustion products. For this purpose we use sweat baths for the skin and saline cathartics for the bowels. The former eliminates the more of the fluid, the latter of the solid elements, hence both should be used. The sweat baths may consist of hot packs (for technic, see In- dex), hot tub baths, or best of all, hot-air cabinet baths. The dry hot-air bath is to be preferred because it produces more profuse perspiration than the other types. The most satisfactory saline is magnesium sulphate. This should be used in tablespoonful doses every two hours until the bowels move freely. 282 FUNCTIONAL DISORDERS OF THE KIDNEY 283 It will greatly aid in this process of elimination if normal salt solution be injected freely into the rectum or under the skin. For the former, the continuous inflow (according to Murphy's method), and for the latter 250 to 500 c.c. under the skin of the chest, flanks, or thighs furnish the best methods of procedure. Naturally more solution can be put into the body through the colon than through the skin, hence this is the procedure of choice. In very alarming conditions, a vein may be opened and 200 to 500 c.c. of blood removed, and then a similar amount of warm sterile salt solution allowed to flow into the vein (intravenous infusion). (Be sure that the solution is a " normal " one. See Index.) The drug treatment must be aimed at the underlying lesion. In acute suppression of the urine, for example, one might use atropin to relax the renal tissues. In chronic nephritis one can sometimes see good results follow the administration of macerated kidney substance — either the fresh kidney chopped up fine and preserved in glycerin, or the commercial preparation called nephritin. The action of this substance is explained as antidotal to the toxins already absorbed. Of the fresh kidney substance one uses a tea- spoonful every four hours on an empty stomach. Of nephritin one uses five tablets every two hours. In many cases the subcutaneous injection of morphin gives surprisingly quick relief. This is purely empiric and symptomatic, and to be used only when more direct action is not possible. Anuria. — Of the conditions producing uremia, the total sup- pression of the urine (anuria) is the gravest. This may be due to changes in the nerve control or to pathological changes in the kid- ney. Hence, no effective causal treatment can be used until the diagnosis is complete. The symptomatic treatment is the same as for uremia from other causes — elimination and sedation. The anuria may be due to a spasmodic contraction of the vessels of the kidney. Here the drug that will overcome this nervous spasm is indicated. The most rapidly acting drug of this group would be the nitrites (hypodermically, as nitroglycerin ^V grain, 0.001 gram), but probably the more efficient one because acting more on the nerves and less on the vessel walls would be atropin in the dosage of y^-g- of a grain (0.002 gram) hypodermically, repeated hourly until effective. If the anuria be only intermittent the bro- 284 DISORDERS OF THE GENITO-URINARY SYSTEM mids might be sufficient if given in dilute solution in 15-grain doses repeated in four to six hours if necessary. On the other hand, if the anuria be due to a relaxed condition of the kidneys so that the blood pressure is weak, and the glomeruli so relaxed as to be inactive, vasoconstrictors are indicated. Of these, digitalis stands first, especially in the form of digitalin ( Ger- man, Merck) given hypodermically in doses of ^ to 2 grains. Diuretin, since it belongs to the xanthin group, will also be found of use in this condition, given in doses of 1 gram in dilute solution three times a day. Other drugs that might be tried to overcome this vascular re- laxation are the fluid extract of ergot, styptol, or stypticin, and adrenalin. All these are vasoconstrictors and would tend to raise the blood pressure and relieve the renal congestion. The fluid extract of ergot may be given in dosage of 1 fluid dram per os, or of the aseptic preparation 1 to 2 c.c. hypodermically. Styptol or stypticin would have a tonic effect in more chronic cases. The dose by the mouth is § grain up to twelve doses pro die. Adrenalin may be used intravenously in dosage of 10 to 25 drops of the 1 : 1,000 solution for emergency service. If, on the other hand, the anuria be due to pathological changes in the kidney, it is best to relieve the kidney of all work, and stimu- late the skin and bowels to eliminate as much as possible of the waste products. Here drugs are of less use than baths, saline infusions, etc., the eliminant procedures mentioned under uremia. Oxaluria Oxaluria demands attention in that its continuance irritates the passages and may lead to the formation of calculi. Hence, the supply of oxalates in the food should be decreased (e. g., rhubarb, tomatoes, pineapples, apples, strawberries). The excessive use of sweets and carbohydrates should also be forbidden. The next step is to correct the digestive irregularities leading to the formation of oxalates. This is usually accomplished by cor- recting the condition of gastric subacidity (q.v.). In general, 15 to 30 drops of dilute hydrochloric acid in plenty of water about thirty minutes after each meal furnishes sufficient acidity to over- come the lack of normal secretion. INFLAMMATIONS OF THE KIDNEY 285 Phosphaturia Phosphaturia usually bespeaks nervous strain, and therefore calls for some regulation of the patient's activities. The amount of phosphates in the urine may be decreased by giving calcium car- bonate in 1 or 2 grain doses two or three times a day. INFLAMMATIONS OF THE KIDNEY Acute Inflammations Acute inflammations of the kidney are due to both toxic and rheumatic causes. In the majority of cases direct causal medication is not possible. Rather, our efforts must first be directed toward relieving the kidneys of their ordinary work, and secondly toward the elimination of the body's waste products through other channels. To bring about these results, the diet must be regulated so that foods making great demands upon the kidneys are not ingested, and the bodily activities must be reduced so that there is a smaller consumption of the nitrogenous tissues. And finally, vicarious elimination must be established through the skin and bowels. The kidneys seem to have the greatest difficulty in eliminating creatinin and phosphoric acid, hence all superfluous protein should be removed from the diet of the patient suffering from acute nephritis. In particular, we must avoid meat broths and soups. For this reason, milk has become the staple diet of patients suffer- ing from acute nephritis. Even this should not be given in exces- sive quantities, because we must save the kidneys from eliminating the extra fluid. Therefore, in acute nephritis from a pint to a quart of milk may be given daily for four or five days. In order to save the kidneys from the evil effect of the phosphorus in the milk, 15 grains of calcium carbonate should be given two or three times a day. To prevent the distress from the thirst, the patient should be given small pieces of ice as frequently as needed. Such starvation diet must be kept up for four or five days, an interval usually sufficient to overcome the acuteness of the inflammation. The patient must be kept in bed and protected from chilling influences. Not only so, but he should be given a daily sweat bath, either in the hot-water tub, the hot pack, or the hot-air cabinet. 286 DISORDERS OF THE GENITO-URINARY SYSTEM The bowels must be kept active with saline cathartics or with enemata containing ox gall and magnesium sulphate. The pain is best relieved by the subcutaneous injection of atro- pin. If this is not efficient, morphin may be used. Hematuria. — Renal hemorrhage is relieved by ergot. This should be given subcutaneously. Therefore some nonirritating aseptic preparation, such as Parke, Davis & Co. 's, Mulford's, or Burroughs, Wellcome & Co.'s should be used. Otherwise, ergo- toxin intravenously or intramuscularly would be the choice (^hr to T V of a grain). 1 If hematuria be the only symptom of renal disorder, it may indicate a need for calcium salts, that is, for a rise in coagulability of the blood. Of course if the disorder be due to calculus, surgical interference is called for (nephrotomy). In all cases of bleeding the use of hexamethylenamin (5 grains t. i. d.) is a wise prophylactic against renal sepsis. Hemoglobinuria. — Hemoglobinuria (as distinguished from hema- turia) may be due to toxic causes or to chilling of the body tissues, sometimes at considerable distance (e. g., the feet) from the kid- neys. Of the former the most frequent causes are potassium chlo- rate, guaiacol, coal-tar products, solanins, and some acids. Methem- oglobin also may be due to the ingestion of potassium chlorate and the coal-tar products. Hematoporphyrinuria. — Hematoporphyrinuria may be caused by sulphonal and trional. Naturally, the first step in the treatment of any one of the uri- nary disorders is to remove the cause by stopping the ingestion of the toxic drug or the continued chilling of the body. The second is to keep up the supply of oxygen to the tissues until new blood cor- puscles can be formed. The inhalation of oxygen may therefore be necessary. At any rate, tissue consumption must be reduced by means of bed rest and mental quiet, and the patient given fresh air under the best conditions for the hours and days during which the fresh blood is being formed. 1 Since the above paragraph on Hematuria was written, evidence has appeared to show that adrenalin administered intramuscularly is better than ergot for hematuria: One c.c. of the 1:1,000 solution is injected deep into the glutei, and may be repeated in one or two hours. INFLAMMATIONS OF THE KIDNEY 287 Chronic Inflammations Chronic Inflammations of the Kidney. — Before our treatment can be most effective, we must know whether the inflammation is of the parenchymatous or interstitial type. Our reason is that the regimen of the patient constitutes the most important part of the treatment, and this must vary with the type of the inflammation. The aim of all the treatment must be, of course, to protect and rest the renal tissues, to relieve and sustain the heart, and at the same time to nourish the patient satisfactorily. Thus foods that pass the kidney with difficulty must be avoided. In interstitial nephritis considerable fluid may be used to flush out, as it were, the kidneys. But in parenchymatous nephritis the quantity of fluid must be reduced. The amount of solids excreted daily must be watched as the index of the nutrition of the patient as well as of the efficiency of the kidneys. Of urea the urine of a healthy man should contain daily not less than 12 grams. This represents 85 to 90 grams of proteid food. A healthy man excretes from 13 to 17 grams of so- dium chlorid daily, although his actual need probably does not go much above 3 grams ; hence it is not the amount of fluid excreted, but rather the amount of solids that shows whether waste products are being retained in the system or not. Of course in studying these amounts, one must take into consideration the amount of food ingested before deciding whether or not the bodily equilibrium is being maintained. In parenchymatous nephritis, with scanty urine and edema, the reduction of the amount of fluid allowed the patient has a benef- icent effect on the edema as well as the quantity of urine, decreas- ing the former and increasing the latter. The minimum amount of fluid pro die is 1,500 c.e. (three pints). This takes into account the fluid in the food as well as that in the beverages. Not only is the fluid output increased, but the work of the heart is lightened under this reduction of fluids in appropriate cases. In this way the dry diet fulfills all the conditions laid down for the treatment of such cases. But where the heart is laboring and the kidneys seem unable to handle the excretion of the ordinary dietary products, the pure- milk diet is indicated. Two and a half to three pints of milk di- 20 288 DISORDERS OF THE GENITO-URINARY SYSTEM luted with sodium citrate, sodium bicarbonate, or Vichy water is the standard prescription for the adult. This diet gets rid of the excess of chlorids and similar irritants, but will not do for all cases or for any length of time, because it does not furnish sufficient heat energy to maintain the body in equilibrium. Thus, a man of 125 to 150 pounds needs some 2,400 calories of heat energy. This would require the ingestion of some 3^ quarts of milk. Not only would this amount of milk be objectionable on account of the amount of the fluid, but also on account of the amount of protein thereby thrown into the body, 137 grams of albumen or 22 grams of nitrogen, that is, an amount double what is needed to maintain the protein balance. To obviate the difficulty, von Noorden x gives a milk diet made up of 1,500 c.c. of milk and 450 c.c. of cream. This amounts to 2,100 calories and 55 grams of protein. The heat energy is found in its 70 grams of sugar and 165 to 170 grams of fat. This diet does well for those convalescing from acute nephritis, and those suffering from parenchymatous nephritis. Milk is also poor in iron, hence a simple milk diet will not do for any length of time. Of iron a healthy man needs some .04 grams daily; but even the 3J quarts of milk just mentioned con- tain only 0.12 grams, hence extra iron must be supplied to pa- tients living on a milk diet. On the other hand, milk is rich in phosphorus, and phosphoric acid is difficult for the kidneys to ex- crete. Hence, when giving an exclusive milk diet, one should add calcium carbonate or similar substance to precipitate the phosphoric acid in the intestine — e. g., 20 grains calcium carbonate t. i. d. Many suggestions have been made for diets giving all the ad- vantages, but none of the disadvantages, of the pure-milk diet. Thus Gouget prescribes 2 liters of milk, 250 grams of rice, 250 grams of grapes, and 750 c.c. of Vichy water. Arrowroot and sago may be substituted for the rice. Now in any form of nephritis where there is great edema it has been found that a diet poor in chlorids brings about a reduction 1 Forchheimer uses for similar reasons the following diet: Oatmeal jelly, made from 120 grams (4 oz.) of oatmeal 932 calories Milk, 1,000 c.c 893 " Sugar 205 " 2,030 calories INFLAMMATIONS OF THE KIDNEY 289 of the edema. Hence, a milk diet is advantageous in dropsy for this reason also. The following are illustrative diets (Achard and Widal) that contain less than 2 grams of sodium chlorid: 1 1. Milk . . . Potatoes Eggs . . . Meat . . . Barley . Sugar . . Butter . 2. Bread (made without salt) Meat Legumes Butter Sugar 3. Potatoes Meat Butter Sugar 4. Potatoes Meat Butter Rice 5. Bread (made without salt) Meat Butter Sugar 1,000.0 300.0 2.0 300.0 200.0 50.0 40.0 200.01 200.0 250.0 50.0 40.0 1,000.01 400.0 80.0 100.0 1,000.0 300.0 50.0 125.0 500.0 400.0 80.0 100.0 I This affords 2,274 calories. This affords 2,200 calories. This gives 3,132 calories. (2.595 calories.) (3,037 calories.) 1 To ascertain the salt cod tent of an ordinary diet the following figures will be useful. The following foods contain per kilogram: Milk 1 . 15 grams of salt Butter 1.0 Eggs 1.5 Rice 0.1 Potatoes 0.5 " Oatmeal 0.4 Peas 0.6 Cooking vegetables in pure water reduces their salt content one part in the thousand. 290 DISORDERS OF THE GENITO-URINARY SYSTEM 6. Bread (made without salt) . 200.CT Potatoes 700.0 Milk 50.0 Butter 1,000.0 7. Bread (made without salt) . 200.0 Potatoes 300.0 Rice 100.0 Sugar 100.0 Butter 25.0 (2,450 calories.) (1,889 calories.) In nearly every case of nephritis we must forbid the use of more than 100 grams of protein pro die (=25.0 of urea). So also should we forbid all alcoholic drinks, spices, caffein, and nicotin. In the regulation of the patient's activities, we must also seek to spare the kidneys and circulatory apparatus, hence patients suf- fering from nephritis must avoid great exertion both of mind and body. They must take life easy; they must not confine themselves indoors, but must lead a varied existence, seeking as much as pos- sible of gentle out-of-door exercise. Of drugs we should make sparing use, reserving them for the time when stimulation or inhibition is required. We call upon them, therefore, to affect various symptoms. Thus to increase the quantity of urine in nephritis where there is no hematuria or sign of overstimulation, the sodium salicylate salt of theobromin has proven the most generally useful drug. This goes under the trade name of diuretin, and should be given in solution in doses of one half to one gram (five to fifteen grains) three times a day. Solutions of diuretin are best made with warm fluids; otherwise we are apt to have a cloudy preparation. When, on the other hand, there is a spasmodic contraction or great irritation in the kidney, we should use atropin in y-J-g-- to -jV grain doses (or ten drops of the tincture of belladonna). For similar purpose, in less acute cases, the bromids may be used in one-gram doses in solution. Most of the popular diuretics are valuable chiefly for the fluid they contain. In all cases of nephritis great assistance may be derived from INFLAMMATIONS OF THE KIDNEY 291 the stimulation of excretion through the skin and bowels, as was suggested for acute inflammations. Hot-air baths and massage will do much toward lightening the work of the heart and kidneys. Hot-air baths may be given in bed by constructing an inclosed air space about the patient's body and running into that space air heated by the bedside. Thus wooden rods are extended from the foot to the head of the bed, some ten to eighteen inches above the patient's body and about three feet apart. Over these blankets are placed and tucked in so as to form a closed space extending from the patient's shoulder to his feet. Heat is generated in an alcohol or gas lamp and led into the cabinet through metal pipes. The patient should lie on a flannel blanket, under which is a rub- ber one. Sweat baths should, in general, be stopped when perspiration has stood on the patient's forehead for ten minutes. When pos- sible, the patient should then be briskly rubbed with lukewarm water and dried with a rough towel. Since a sweat bath lowers resistance to changes of air, an ambu- lant patient should rest in a warm room for at least an hour after the bath before exposing himself to any temperature changes. Suppurative Inflammations For suppurative inflammations of the kidney, in addition to the nonpharmacal procedures just outlined, hexamethylenamin should always be given. Its dose is five grains three or four times a day, either as a powder or in solution. Salol may also be used to render the urine antiseptic, but the antisepsis is decidedly weaker than that produced with hexameth- ylenamin (Sollman, Journal A. M. A., September 5, 1908). But in suppurative cases, wherever medicine does not afford speedy relief, surgery should be resorted to and the kidney irri- gated and drained. To ascertain whether one or both kidneys are affected, a cysto- scope should be used and the ureters catheterized. Only for a short time should we wait after making our diag- nosis before we call in the surgeon, because experience has shown that the prognosis in suppurative inflammations is exceedingly poor, and that the chances for recovery in the hands of a 292 DISORDERS OF THE GENITO-URINARY SYSTEM skillful surgeon are better than when the disease is treated by drugs alone. Degenerative Inflammations Amyloid Kidney. — Amyloid kidney calls for a search for the cause. If suppuration or active syphilis can be demonstrated, it should be dealt with energetically, the former by operation, the lat- ter by potassium iodid in sufficiently large dosage. The kidney lesion must be treated just as any chronic inflammation is treated, by keeping the patient quiet and ordering the diet so as to relieve the kidney of unnecessary strain. Hydronephrosis. — Hydronephrosis is simply a result of the ob- struction of the ducts, hence the chief treatment is surgical — a ne- phrotomy to find the obstruction and, if possible, to remove it; a nephrectomy for a hopelessly atrophied kidney. The symptoms may be relieved by aspiration, but this is at best a measure for only temporary relief. Renal Calculus We might say almost the same for calculus as for suppurative inflammations, for unless our medication succeeds very promptly in quieting the disturbance the surgeon has a better chance of suc- cess with his mechanical treatment than we with our indirect methods. Whenever we diagnose the presence of calculi or of " gravel," uric-acid solvents are indicated. Probably the most effective of these are the piperazin group (lycetol, lysidin) and the hexameth- ylenaminae. We should not expect, however, to secure the solution of large concretions already formed; hence it is advisable to re- move by surgical means calculi already formed and then adopt such medical treatment as shall prevent their re-formation. For this purpose hexamethylenamin will prove most effective ; it should be given in doses of three to five grains t. i. d. Where an effort must be made to eliminate per vias naturales concretions already formed, atropin has proven quite helpful, because it anes- thetizes the mucosa and relaxes the tissues of the whole urinary tract. INFLAMMATIONS OF THE BLADDER 293 INFLAMMATIONS OF THE BLADDER Cystitis Inflammations of the bladder are more often ascending than descending. In like manner they yield more readily to irrigation from the urethra than to drugs passing downward through the ureters. Ordinarily, however, sedative and antiseptic drugs are applied from both directions. We give drugs by way of the kid- neys in order to prevent the spreading of the infection upward as well as because it is generally easier to persuade patients to take drugs by the mouth than to permit thorough vesical irrigation. By the mouth we give the balsams, atropin, or bromids to quiet the irritation, and hexamethylenamin or salol to render the urine antiseptic. Of the balsams the sandalwood oil has the best reputation. It is given in capsules (to avoid irritating the stomach) in 5- to 15- drop doses several times a day. It is best given with milk or food. Atropin may be given in t Jq- -grain doses, or as the tincture of belladonna in 5- to 10-drop doses. Sodium or potassium bromid may be given in solution in water or in some pleasant vehicle in 15-grain doses. Three times a day is usually often enough for this drug. Hexamethylenamin is given in five-grain doses every four to eight hours. It may be given in solution, powder, or in tablet form. Salol is usually given as a tablet containing two to five grains. Thus in severe cases we would give five grains every four hours. For irrigation through the urethra we use potassium perman- ganate in 1 : 4,000 solution, or lysol in one-fourth- to one-half-per- cent solution, or a silver albuminate in five-per-cent solution. It is well to fill the bladder quite full of the solution and empty it twice or thrice and then fill it again, remove the catheter, and let the solution run out through the urethra. Such irrigation should be repeated daily, or even twice a day in severe acute cases. In chronic cases the interval may be longer. In acute cystitis we must also relieve the pain and discomfort. This is accomplished best with atropin and, where that fails, with morphin. Next we must render the urine less irritant. For this purpose 294 DISORDERS OF THE GENITO-URINARY SYSTEM we increase the amount of fluid drunk by the patient. Hexa- methylenamin and methylene blue are given freely both for their soothing and their antiseptic effects. Then, as soon as the condition will permit, we introduce a care- fully sterilized and well-lubricated rubber catheter and irrigate the bladder with the appropriate solution. If the causative organism be the gonococcus, we use a silver albuminate (naturally less freely than we would the cheaper lysol). If the organism be simply one of the ordinary streptococci or staphylococci, lysol does well. Fur- ther along in the case potassium permanganate would be the anti- septic of choice because of its greater stimulation of the cells of the mucous membrane to regeneration. In chronic cystitis a careful study should be made to determine the cause — whether, for example, it is an obstruction in the ure- thra, as that due to an enlarged prostate, whether it is due to some inaccessible focus of suppuration, or whether it is due to a lack of reaction on the part of the body to some infection, such as gon- orrhea. In any case, the urine is rendered antiseptic and then the causal treatment is begun. Enlarged prostates are massaged or treated locally, or removed; abscesses are drained, and the patient's re- sistance raised by vaccination with weakened cultures of the infecting organism. At this point we may con- sider the technic of catheteriza- tion of which we have spoken in the preceding pages. Catheterization The female urethra is about two inches long, and therefore requires no particular technic in the way of catheterization. The chief emphasis in carrying out this operation needs to be laid on asepsis and gentleness. Probably beginners will have the great- est difficulty in dealing with female patients in finding the external orifice of the urethra, and one should hunt for it by starting from Fig. 44. — The Sinus Prostaticus. INFLAMMATIONS OF THE BLADDER 295 the clitoris and looking just below that for a minute depression or a collapsed opening. The glass catheter is the best for female pa- tients, for it can be thoroughly sterilized by boiling and shows when it is not clean. The male urethra, on the other hand, varies between 13 and 35 centimeters in length. Sappey's investigation made the average length 16 centimeters. Naturally the length may be increased by stretching the membranous parts. The diameter of the dilated urethra varies ; it measures in the pars pros- tatica from 10 to lOf milli- meters; in the pars membra- nosa, 9 millimeters; in the pars bulbosa, lOf millimeters ; the ex- ternal orifice, 8 millimeters. It will be noticed that the external orifice is the narrowest and the part that is least capable of being dilated. There- fore, when instruments have passed this orifice they will meet in the normal urethra no further resistance from the size of the lumen. When they do meet resistance, it is probably because the instrument is being pushed into the pocket just in front of the Fig. 45. — Obstruction at the Mouth of the Urethra. Fig. 46. — Obstruction Offered by the Sphincter. Fig. 47. — Catheter Obstructed by the Sinus Pocularis. prostate, called the sinus pocularis. Just before the catheter passes into the bladder it will meet some resistance from the sphincter muscle which keeps the bladder closed. It should be remembered 296 DISORDERS OF THE GENITO-URINARY SYSTEM that the pelvic floor is made up of a resistant membrane (triangu- lar ligament) through which the urethra passes. Therefore the beginner should try, by gentle means, to make the catheter fol- low the normal course instead of trying to force it through this ligamentum trigonum. The bladder normally con- tains from 250 to 500 c.c. of urine. Thus in a healthy twenty- seven-year-old man with a pres- sure of 14 to 16 centimeters, the quantity taken by the bladder was 250 c.c. A twenty-six-year- old man with 12 to 13 centi- meters pressure took 600 c.c. In a case of retention of urine in a thirty-six-year-old man, with a pressure of 14 to 16 centimeters, the bladder took 900 c.c. of fluid. In a case of hypertrophy of the prostate with a pressure of 9 to 10 centimeters, the bladder content was 4,200 c.c. In a case of urine retention in a ten-year-old girl, with a pressure of 11 to 12 centimeters, the urine in the bladder was 450 c.c. In a case of paraplegia in a twenty-nine-year-old woman, with a pressure of 28 to 30 centimeters, the amount of bladder content was 1,200 c.c. In a case of retention of urine during a course of typhoid fever, with a pressure of 25 to 28 centimeters, the amount of fluid was 2,100 c.c. Fig. 48. — Method of Pushing Cathe- ter Out op the Sinus Pocularis. IPs ^ Fig. 49. — Metal Catheter for Normal Cases. Soft catheters are usually passed with less damage to the mem- brane of the urethra, at least by beginners, than are the metal catheters. For that reason they are to be preferred until one be- INFLAMMATIONS OF THE BLADDER 297 comes thoroughly proficient. However, as soon as one meets obstructions in the course of the urethra, it will be necessary to use a metal instrument, and in using such an instrument one should Fig. 50. — Metal Catheter for Enlarged Prostates be careful to observe the natural curvatures in the body. In the first place, one should use a different curve for a normal individual than for a patient troubled with hypertrophied prostate. In the latter case there should be a much greater curve. To carry out the operation, the physician should stand on the left side of the patient, holding the penis parallel with the surface of the abdomen, introduce the catheter (lubricated with aseptic Fig. 51. — Position for Passing Catheter Under Pubic Arch. oil) gently, and force it down slowly over and around the pubic bone. As soon as it glides under the pubic bone, the instrument should be raised so that its point will look in the direction of the 298 DISORDERS OF THE GENITO-URINARY SYSTEM axis of *the body. This point should hug the front wall of the urethra in passing through the prostate. This avoids the sinus pocularis. After safely passing this danger, there will be a feel- ing of obstruction from the sphincter muscle, and a gentle but persistent pressure will cause this to give way and the catheter to slip into the bladder. The mouth of the catheter should then be Fig. 52. — Position of Catheter After it has Entered the Bladder. depressed so that the urine may flow into the vessel held for it by the attendant. As soon as the flow checks up, the operator should press over the bladder area with his free hand to keep the flow going until the bladder be entirely empty. When the bladder is empty one should close the mouth of the catheter with his finger and withdraw the catheter quickly but gently, following the same course and using the same precautions that he used in inserting the instrument. It is unsafe ever to use a catheter without boiling it and taking it direct from the very water in which it was boiled, for the chief danger to be feared from the use of the catheter and from bladder irrigation lies in the introduction of sepsis; therefore not only should the catheter be thoroughly sterile, but also the whole area that is liable to be touched by the operator. In particular, the lu- bricant used for the mouth of the catheter should be thoroughly sterile. One of the easy things for a physician to do is to stick his dirty finger into a bottle of vaselin and rub it on the catheter, and then close up the bottle of vaselin ready to use again in the INFLAMMATIONS OF THE BLADDER 299 next case. This, of course, is a sure method of ultimately produc- ing sepsis. By obtaining aseptic lubricant in collapsible tubes one may avoid this tendency. Vaselin may be sterilized by setting the bottle containing it (with the cork replaced by cotton) in boiling water for ten minutes after using each time. Before inserting the catheter the whole penis should be thor- oughly washed in hot water and soap and the glans penis in par- ticular cleansed with mercuric bichlorid (1:1,000). This same technic applies also for irrigating the bladder. First one should insert the catheter and empty the bladder. When the bladder is empty one should attach the tube of the irrigator to the mouth of the catheter and put the irrigating can just high enough to secure a regular flow. As soon as one half pint to a pint has been injected the solution should be allowed to flow out through the catheter. If this shows considerable detritus, the operation should be repeated in the same way. When the last filling of the bladder has been made, the catheter should be removed with the operator's finger checking any flow from its mouth and the patient instructed to hold the solution in the bladder for ten to fifteen minutes. This will lessen the danger of sepsis, because the anti- septic solution in flowing out will help to disinfect the entire urethra. Enuresis Enuresis is a symptom demanding a most thorough study as to its causation. Sometimes it is due to bad habits of life, some- times to peripheral irritation in and about the urethra, sometimes to psychic causes. Thus children should be taught to be regular and careful in defe- cation and urination, to empty the bladder before going to bed, not to eat inordinately just at bedtime, etc. The external genitals must be kept scrupulously clean. The clothing must not be irritating. Suggestive therapy will greatly help the patient to gain control of the sphincters after the physical causes are removed; that is, the encouragement of the patient to believe that he can and will control his urination. The use of cold baths and sprays assist in toning up the skin reflexes. Thus every morning a cold spray or rub should be given ; if necessary, more than one daily. 300 DISORDERS OF THE GENITO-URINARY SYSTEM The food of the patient must be given regularly, and he must not be allowed to overload the stomach nor yet to become over- hungry. The bedclothing at night should not be so warm that the pa- tient sweats under it. The air of the sleeping room should be cold and pure. All cystitis (and enuresis almost always causes a subacute cys- titis) should be thoroughly treated by irrigations with antiseptic solutions and the administration of hexamethylenamin. Finally, for the irritability of the sphincters, atropin should be given in ^ to y-J^ grain t. i. d. Where the difficulty seems rather a lack of tone, the faradic current should be applied with one pole in the rectum or vagina and the other (sponge) over the bladder or over the spine. These treatments may be daily or on alternate days, and should be graded to the patient's resistance. INFLAMMATIONS OF THE URETHRA Inflammations of the urethra demand antiseptic irrigation. This is partially supplied by the urine when made antiseptic by hexamethylenamin; but, to be efficient, additional irrigation is needed. This is furnished by daily irrigations with the Valentine irrigator or similar apparatus and, when the bladder is also in- volved, by irrigations through a catheter into the bladder whence the solution flows through the urethra after the catheter is re- moved. Usually the bladder is filled twice and the solution allowed to escape through a catheter before the final filling is done and the catheter removed. Before the irrigation of the urethra, when that alone is in- volved, the patient should be caused to urinate in order to remove the detritus present. Then the solution should be injected into the urethra, either with a piston syringe or with an irrigator, just enough to fill the urethra, but not enough to distend it or force the virus into the posterior urethra. Naturally the injecting and emptying should be repeated several times at a treatment, and the treatment, in acute cases, repeated several times a day. In chronic cases the treatments are given at greater intervals. The Valen- tine apparatus enables one to use a larger quantity of the fluid and INFLAMMATIONS OF THE URETHRA 301 regulate the force of the flow. To use it one should take a catheter or douche point small enough to let the solutions flow back outside it and insert it with the water flowing and gently push it for- ward for an inch or so, or just far enough to cover the affected area, and then run a pint or quart of the solution through the catheter. The operator needs to protect himself with rubber gloves and apron. The instruments should be sterilized both before and after using. The solutions used with the irrigators or douches are lysol (one fourth to one half per cent), hot nitrate of silver (1: 5,000), hot boric-acid solution (five per cent), permanganate of potash (1:4,000). For use with the piston syringe the albuminates of silver (e. g., argyrol, protargol) have been found best. These are used in strengths varying from five to ten per cent injected slowly and retained for several minutes. For the female urethra we cannot use irrigation effectively, but a similar effect is obtained by inserting bougies of cocoa butter mixed with the desired antiseptics. This dissolves in situ and thus medicates the membranes thoroughly. If now the urine be made antiseptic by the administration of hexamethylenamin it will wash out thoroughly the detritus and inhibit the bacteria. During the entire course of an acute urethritis, it is wise to keep the urine antiseptic and bland with hexamethylenamin and sandalwood oil. Chronic Inflammations Chronic inflammations of the urethra may be accompanied by stricture, and this furnishes an additional reason why the treat- ment needs to be local. The passing of sounds frequently enough to secure a permanent dilation of the stenosis, together with such antiseptic treatment as is necessary to clean out the infection, con- stitute the usual treatment. The solutions are practically the same as those for acute urethritis. Chronic Gonorrheal Urethritis In chronic gonorrheal urethritis (gleet, etc.) one follows the most logical line when he vaccinates the patient with weakened virus taken from cultures made from the urethral secretions. 302 DISORDERS OF THE GENITO-URINARY SYSTEM I am indebted to Dr. R. B. Brewster for the following sugges- tions on the vaccine treatment of chronic gonorrhea: Chronic gonorrhea is often a mixed infection. In fact, many cases of the so-called chronic gonorrhea are not gonorrhea at all, but are chronic inflammations due to various other bacteria, the gonococci having long since died out leaving only the associated bacteria in their place. Since these other organisms are less toxic than the gonococcus, they give rise to less reaction, both systemic and local. This may be the reason why they are so apt to become chronic. Vaccine treatment is not indicated in any acute infec- tion, but when the body fails to develop a general immunity after developing a certain amount of local immunity, a vaccine may be brought into use to make all the body tissues assist in the immuniz- ing process. As long as there is systemic reaction " autovaccination " is taking place. When systemic reaction, as evidenced by pain, fever, swelling, is gone, but a discharge persists, it is wise to give vaccine therapy a trial. If microscopic examination of the urethral discharge shows the gonococcus to be the etiologic factor a stock vaccine may be used, of which we give a dose of 20,000,000 organisms subcutaneously every fifth day. Either dose or frequency or both may be gradu- ally increased if we keep within limits that will cause a very slight local reaction at the point of inoculation. The staphylococcus and pneumococcus are often found in the urethral discharge either separately or in conjunction, and still more frequently a short bacillus unknown to me. This bacillus has been found so frequently that I believe it to be a definite etiological factor. When these or other organisms are found it is practically useless to try stock vaccines, since the organisms are in varied com- binations and their strains are often very different from the stock vaccines in everything but morphology. For these cases an " au- togenous " vaccine should be used. The method is briefly as fol- lows: Have the patient present himself in the morning before he has urinated. Wash out urethral meatus with sterile water and open the meatal lips, reach into urethral canal with sterile plat- inum loop. Make smears on slide for identification purposes. Plant secretion on agar slants. Make six plants on as many tubes, distribute evenly over surface and incubate twelve hours. Exam- INFLAMMATIONS OF THE URETHRA 303 ine microscopically and compare with slide so as to know what organisms you have to deal with, then wash off growth in 5 or 10 c.c. sterile normal salt solution. Hermetically seal this bacterial emulsion in a test tube, shake to break up clumps, and subject to 60° (Centigrade) water bath for one hour. Now pour into a bottle containing 30 c.c. sterile physiological salt solution to which has been added one fourth of one per cent lysol or carbolic acid. All methods of standardizing vaccine by making bacterial counts of the emulsion are laborious, and the results are so unre- liable that many have discontinued making such counts, but de- pend upon a microscopic estimation of the gross growth upon agar to determine what the dilution shall be — i. e., whether the sterilized emulsion shall be put into 25, 30, 40, or 50 c.c. of diluent nor- mal salt solution. The only standardization worth while is the amount of reaction in the patient. Commence with a small dose and increase it gradually until you get a mild local reaction of soreness and brawny induration over an area less than one inch from point of puncture. So successful have the vaccines been that a failure is always laid to a failure to secure the proper organism ; hence another vac- cine is made in an attempt to get the true etiologic organism. Naturally saprophytes are more easily cultivated than parasites, hence the latter are sometimes hard to secure. It is almost im- possible to get cultures of gonococcus to grow, hence a stock vac- cine should be used, when this is the offending organism, by every- one unprovided with a complete laboratory. Cultures that have been kept growing for years on artificial media can be secured, and they are comparatively easy to handle, but it is well-nigh impossible to carry freshly secured culture of gonococcus to a second genera- tion in a test tube. Unfortunately for the vaccine therapist the cervical discharge in the female is strongly antiseptic, and although bacteria are found plentifully in smears, cultures can rarely be obtained. Hence the alleviation of cervical, uterine, and tubal infections can only be brought about when we have stock vaccines that are more efficient than they are at present. 21 304 DISORDERS OF THE GENITO-URINARY SYSTEM GENITOURINARY INFLAMMATIONS IN THE MALE Inflammations of the Prostate Inflammations of the prostate also demand local treatment — if pus be present it must be drained out, otherwise the irritation may be allayed by the application of belladonna (atropin) and soothing oils to the walls of the urethra at the points nearest the gland. External applications of heat and cold are also helpful. Internally we give sandalwood oil and hexamethylenamin. In detail, the tenesmus and dysuria are relieved by giving inter- nally sandalwood oil (5 drops) and tincture of belladonna (6 to 10 drops). Since the former is irritating to the stomach, it is best given in capsules and after meals. The latter may be given in water or other vehicle. Bitterness is its only drawback. The in- Fig. 53. — Treatment of the Prostate Through the Urethra (Overall). fection is combated by making the urine antiseptic with hexa- methylenamin (3 to 5 grains t. i. d.). Acute cases cannot be treated by passing instruments through the urethra. Hence we must GENITO-URINARY INFLAMMATIONS IN MALES 305 have recourse to hot baths (sitzbader) . Hot cloths (fomentations) also afford some relief. Guaiacol and similar analgesics may be applied externally over the perineum to relieve some of the distress. The patient must lie in bed and use only a light diet of nonirri- tating food. In chronic cases the local treatment with electricity is worth trying. For this the galvanic current is used and treatments begun with strengths of 5 to. 10 milliamperes for one to three minutes. This may be combined with cataphoresis wherein a drug in ointment form is applied to the prostatic area of the urethra before the electrode is inserted, and then the negative pole inserted at the proper place and the current turned on. To diagnose and treat this condition, as well as the others of the urethra, one should master the use of the cystoscope. Otherwise he cannot locate and evaluate local erosions and inflamed areas. For the ointment the ung. belladonnas of the Pharmacopeia will do as well as more expen- sive preparations. One may use the rec- tum for securing access to the prostate when the urethra is too inflamed for such service, and massage of the pros- tate through the rec- tum has proven very efficient ( Forchheimer ) . For this treatment the patient assumes the knee-elbow position and the physician inserts the forefinger of his right hand (protected by a rubber glove) and kneads the enlarged glands. At first the treatment must be very short and gentle. After a few treatments they may be prolonged to two to five minutes. Fig. 54. — Treatment of the Prostate Through the Rectum (Overall). 306 DISORDERS OF THE GENITO-URINARY SYSTEM If after a week's energetic treatment the enlarged gland is not reduced, the surgeon should be called upon to do a prostatectomy. The drawing off of residual urine with a catheter should be taught the patient only as a last resort. When it is so taught, great emphasis must be laid on asepsis, both in the way of cleaning the catheter, in using only sterile lubricants, and in washing the penis. It is better to have a prostatectomy done and permanent relief thereby obtained. Inflammations of the Epididymis and Testes Inflammations of the vas deferens and epididymis are usually secondary to urethritis and prostatitis. Only in the case of tuber- culosis, mumps, and influenza does it appear primarily in the deeper structure. The condition demands first of all rest. The patient should re- main in bed and the whole scrotum should be raised and supported by bandages so that there is no strain on the ligaments, and the return flow of blood is free and unhindered. If there is great pain, heat should be applied by means of the thermophore, antiphilogistin, or moist hot cloths. If no pain, cold should be applied to check the extension of the inflammation. There is little or no direct drug therapy. One may, however, secure some sedative effect by applying menthol and guaiacol oint- ments locally. Internally one may give hexamethylenamin and laxatives (e.g., calomel). The addition of an orchitis to the epididymitis hardly changes the therapy. Here the swelling makes the bandaging more im- portant. Tuberculosis demands surgical interference and the removal of the diseased tissue. Functional Disorders The functional disorders, spermatorrhea and impotence, de- mand a study of their causation. If, as is usually the case, they are functional, systemic treatment (especially suggestive therapy) is called for. The habits of the patient must be corrected — all ex- cesses in work, play, venere, and baccho must be checked. Obesity GENITO-URINARY INFLAMMATIONS IN FEMALES 307 must be treated. Constipation and indigestion must be relieved. On the other hand, out-of-door exercise and wholesome pabulum for the body and mind must be provided. Should there be a tendency to local congestion, local cold baths and rubs should be prescribed. Should there be a sort of ischemia, means for producing a local hyperemia should be exhibited. Of drugs, strychnin for its general tonic effect, ergot for its stimulant effect on the smooth muscles, and yohimbin to congest the pelvic viscera, may be exhibited. Or, if the patient be nervous, the consistent use of the bromids may bring about a functional cure. In general, however, it is the hygiene of body and mind that is most needed by these patients, hence the chief duty of the physician is to examine each patient thoroughly from head to foot and ascertain, if possible, his whole curriculum vitas before out- lining his therapy. Then, after all, it may be simply friendly counsel and encouragement that is most needed. GENITO-URINARY INFLAMMATIONS IN THE FEMALE Endometritis Inflammations of the uterus are due to infection by way of the vagina and require local treatment. The patient must be quiet, the bowels kept free, and the diet light. Pain is usually not severe if the patient remain quiet; hence the greater part of the treat- ment is directed toward keeping the drainage free and checking a spread of the inflammation. For the former, antiseptic douches are used at least once a day, with practically the same solutions that we named for cystitis. The vagina may have to be swabbed out daily with hot sponges under the guidance of the eye (specu- lum). If there seem to be a gathering of pus, this of course must be drained. Otherwise no active operative interference is at- tempted until the process has become circumscribed or chronic. To prevent the spread of the inflammation, we depend upon rest and cold. The former keeps the blood current from pick- ing up extra infection, and the latter inhibits the activity of the inflammation. Cold is best applied by an ice bag over the hypogastrium. 308 DISORDERS OF THE GENITO-URINARY SYSTEM The use of hexamethylenamin or salol to render the body fluids less hospitable to bacteria is generally approved. When the acute stage is over, the question of the value of dila- tion and curettement should be brought up. Its purpose is to remove the foci of infection from the endometrium, and to free the uterus from adhesions and scar tissue. The reflexes of the patient may demand some sedation. For this, valerian and the bromids seem most successful. The former may be given as the ammoniated tincture in 1 or 2 c.c. (-J dram) doses. It is well to use plenty of fluid in the vehicle, and glycerin with the simple elixir may be added to make the dose a teaspoonful and then the whole is given in hot milk or water. The bromids may be given in doses of 1 gram (15 grains) in water or hot milk. Either drug may be repeated in four hours if needed. Salpingitis There is little hope of medicinal treatment for inflammations of the tubes. If they be distended with pus, some method of drain- age should be sought, for the tubes can hardly be expected to be- come patent again after such a suppurative inflammation. On the other hand, chronic inflammations with thickening may be treated by the application of ichthyol to the vaginal vault (ten per cent ichthyol-glycerin suppositories). This drug stimulates the local tissue building to the extent of softening scar tissue and relieving the tension of adhesions. The use of heat over the hypogastrium to induce local hyperemia is also of benefit. In addition to the local measures (especially in the chronic forms of the disease) the ordering of a quiet life, the providing of free saline cathartics, the use of massage and hot baths will all tend to shorten the time of recovery. The relief of the pain must first be brought about by analgesics. But in a day or so, the causal therapy (either the evacuation of the pus or the hyperemia) will also relieve the pain and the other most troublesome symptoms. Oophoritis The ovaries are so inaccessible that therapeutic measures must be more or less systemic to affect them. Thus the application of GENITO-URINARY INFLAMMATIONS IN FEMALES 309 heat or cold is less effective than in the corresponding lesion of the male, but such measures do have an effect and should not be for- gotten. The source of the inflammation is generally from the tubes, and therefore liable to be complicated with a more or less circumscribed peritonitis. On the other hand, there are inflammations of hema- togenous origin which give rise to symptoms more or less neuralgic in character. In view of the inaccessibility of the organ, the decision as to the presence of pus must rest on the leukocyte count rather than on the result of digital examination. When pus is present the desirable procedure is to drain it with as little destruction of the functions of the ovaries and tubes as possible. Hence, a conservative surgeon should be called into the case. When pus is not present, the treatment is medical. The patient must go to bed. Heat must be applied to the lower abdomen until an active hyperemia is produced. If great tenderness exists, guaia- col and methyl salicylate may be applied in conjunction with the heat. As usual, they may be used in strengths of twenty to fifty per cent in oil or ointment. The bowels must be kept active, both by cathartics (calomel or salines) and hot enemata. The diet should be light. If great pain persists, the coal-tar derivatives seem more effective than morphin. Bartholinitis Inflammations of the glands of Bartholin need the same general treatment that similar inflammations elsewhere would require. Thus pus must be evacuated and the interior cleansed with hydrogen peroxid or some other antiseptic. The chief need is to keep the gland open and draining, rather than any particular drug application. Similarly the cervical glands should be opened and drained whenever distended or inflamed. These are sometimes obliterated with phenol or nitrate of silver after cleansing. CHAPTER VII DISOKDEKS OF THE NEKVOUS SYSTEM INTRACRANIAL DISORDERS Intracranial disorders demand in general the reduction of bodily activity to the minimum. Therefore, the patients are put to bed in quiet, darkened rooms, and cold applied to the head and back by means of ice bags or Leiter 's coils. Next, the intestinal tract is cleansed from all debris by thor- ough initial purging with calomel and the salines or castor oil. The emptying of the bladder also must be carefully supervised and catheterizing done when there is a well-grounded suspicion of retention. The diet is restricted to those substances that make the least demand on the digestive apparatus, such as peptonized milk, cus- tards, junkets, eggs, etc. The food should be given in small quan- tities and at frequent intervals. The skin is carefully looked after with frequent rubs with oil or alcohol, as the condition may warrant. Severe pain is usually relieved by acetphenetidin or the other coal tars. Intracranial congestion, when not sufficiently relieved by the cold, may be treated by the application of a leech (or a cup) be- hind each ear (particularly efficacious with children). Aggressive therapy is possible only when we can open the skull and mechanically repair the lesion, when we can give a specific drug (as the iodids in tertiary syphilis), or when we can inject an antitoxic serum. Hence the diagnosis of the cause of the dis- order is of the utmost importance, and no test should be omitted — e. g., the Wassermann reaction for syphilis, the lumbar puncture (Quincke) for microbic infections, or the study of the retina for neoplasm and pressure symptoms. 310 INTRACRANIAL DISORDERS 311 Prophylactically much can be done to avoid cerebral complica- tions. Thus in diseases where there is danger of thrombosis and embolism, every effort should be made to prevent the dislodging of the clot. In particular, such patients should not be allowed to move until all danger of embolism is past. In another class of cases, such as purulent inflammations of the sinuses and middle ear, free opening and drainage of the pus should be undertaken before it has had time to penetrate to the meninges. In septi- cemias the head should be kept cold and the patient very quiet to prevent the localization of secondary foci in the intracranial vessels. The use of hexamethylenamin in septicemia would find justification if it did nothing more than render the cerebrospinal fluid resistant to infection. Encephalitis can be treated only by the general measures just named (rest, cold applications, etc.), except where an abscess can be made out. Whenever this is done the abscess should be opened and drained. Hemorrhage requires measures to lower the blood pressure within the skull and measures to promote the absorption of the exudate. The first is obtained usually by dilating the blood vessels of the lower extremities, and by doing venesection (whenever not contraindicated by the underlying disease). The latter is sought by promoting the general metabolism. Of drugs for this purpose, potassium iodid is the most popular, and this is frequently given in immense doses (see Syphilis). The food must be nutritious. The emunctories must be kept active. For reawakening the dam- aged nerve centers, strychnin is the best drug (e. g.,iV grain every four hours) . For the principles of treatment when arteriosclerosis is the cause of the hemorrhage, see that section. Tabetic Processes. — The tabetic processes (e. g., in paresis) in the brain substance are regarded as hopeless. The giving of potas- sium iodid in large doses sometimes seems to have an influence for good. Embolism. — Embolism may sometimes be helped by increasing the flow of blood to the head (to overcome the ischemia and its consequent softening of brain substance). To accomplish this the patient is laid on a bed with head low and feet high. Strychnin and potassium iodid are used to stimulate the circulation and tissue building. 312 DISORDERS OF THE NERVOUS SYSTEM Neoplasms. — Neoplasms require surgical treatment. When that is unavailable the quiet life of an arteriosclerotic (q. v.) should be enjoined. Sunstroke. — Sunstroke leaves results that can be removed only by hydrotherapeutic and hygienic treatment carried on for a long time. That is, by means of massage and baths we endeavor to reju- venate the brain tissues along with the other tissues of the body. The principle of procedure is the familiar one of combining hot and cold baths, exercise and rest, and regulating the food to develop to the maximum the process of tissue repair. Hydrocephalus. — For hydrocephalus little can be done. The puncture of the ventricles and of the lumbar cord will relieve the temporary danger of death, but it seldom saves the child from be- coming imbecile or idiotic. Infantile Cerebral Palsy. — Infantile cerebral palsy may be treated by the iodids and strychnin, but the results are very dis- appointing. It has been suggested that prophylactically one could do much by giving pregnant syphilitics a thorough course of the iodids. Meningitis. — Ordinarily meningitis is divided into two varieties, the tuberculous and the nontuberculous type. The former is re- garded as being always fatal, and the latter is so in more than three fourths of the cases; hence the therapy of the condition is largely palliative. The patient should of course be put into bed and the head packed in ice in order to decrease the amount of irri- tation of the cerebral centers. The chilling of the tissues seems to have a good effect in inhibiting the rapid multiplication of the microorganisms, as well as in giving some comfort to the patient. In the way of internal antiseptics, hexamethylenamin, salol and guaiacol are generally used, the two former given in the dose of 5 grains every two hours for the adult. For children, smaller doses in proportion should be given. The guaiacol should be given ex- ternally (15 grains in the fifty-per-cent oil solution rubbed in on the abdomen three times a day). For the stimulation of the vital processes as long as possible strychnin is used. This may be given hypodermically in ^ of a grain every four hours for an adult. The intestinal canal must be kept free. For this purpose calo- mel is probably the best drug. The preliminary cleansing may re- INTRACRANIAL DISORDERS 313 quire a saline purge, but after that a grain of calomel daily in divided doses will prove sufficient, unless the patient be too coma- tose to take drugs per os. In this case enemata with ox gall would help keep the intestines clear. A prescription embodying the above is as follows : 1J Hexamethylenaminse 3.00 gms. Tct. nucis vomicae 0.70 c.c. Ext. colocynthidis compositi 0.05 gms. Glycerini 50.00 c.c. Elixiris gentianse glycerinati 50.00 c.c. M. D. S. : One teaspoonful every three hours. Or, if a capsule or powder be preferred, the following might be used: 1^ Phenylis salicylatis 6.00 gms. Strychninae sulph 0.04 ' ' Hydrargyri chloridi mitis 0.20 " M. f. capsular (vel. chart.) no. XX. The lumbar puncture referred to above is of sufficient impor- tance to devote some space to its discussion. Upon it we must often depend for our diagnosis of the lesion, but its use has also been of immense importance in relieving the intracranial pressure in hydrocephalus and tumors, and it has also enabled us to replace inflammatory spinal fluid by fresh sterile saline solution. Lumbar Puncture. — Quincke introduced, in 1891, lumbar punc- ture as a method not only of diagnosis but also of treating cerebro- spinal meningitis. In that year he reported 22 cases in which he had made 42 punctures. Piirbringer reported 45 cases in 1895 in which he had made 100 punctures, and in 1896 Lenhartz re- ported 150 punctures and later 230 in 126 patients. The method is, of course, of particular use with children, but the technic should be at the disposal of the general practitioner because it is applicable to the treatment of tetanus, as well as for the spinal analgesia with novocain and stovain. Anatomy. — The lower end of the spinal cord (conus terminalis) reaches in adults the level of the arch of the first or second lumbar vertebra. In children it reaches a little lower, usually to the third 314 DISORDERS OF THE NERVOUS SYSTEM lumbar vertebra. From this point downward the dnral sac (cis- terna cerebrospinalis) is filled with the cerebrospinal fluid in which the scattered bundles of nerves which compose the cauda equina float freely, so that when a needle is inserted into this space the nerves are not injured thereby. The subarachnoid space communicates with the brain ventricles by means of the foramen Magendie, and also two additional open- ings in the roof of the fourth ventricle. The foramen Magendie may measure as much as 6x8 mm., but the two other openings are very much smaller. Because of these openings there should be free communi- cation between the lumbar space and the lateral ven- tricles of the brain. In- creased pressure in the one place should show itself in the other almost immedi- ately. When this does not occur it is due either to the obstruction of the passages or to a change in the character of the fluid. The ligamentum denticulatum keeps the membranes lining this space under normal con- ditions apart. The space- between the arches of the third and fourth lumbar vertebrae is the largest, although that of the fifth, while some- what flatter, is usually somewhat broader. These openings usually measure 18 to 20 mm. in width and 10 to 15 mm. in height. However, they be- come smaller with age, therefore it is much harder to find the 5th space Fig. 55. — The Spaces for Lumbar Punctures. INTRACRANIAL DISORDERS 315 opening in adults than it is in children. For this reason it is necessary with adults to insert the needle at a greater angle than with children. Technic. — It is usually preferable to have the patient lie on one side, although it is easier to have the patient sitting with the body bent forward on the hips as far as possible. A line is drawn be- tween the two cristas ilii. This line usually passes over the spinous process of the fourth lumbar vertebra. Therefore we should locate with the finger the next spinous process above, and when dealing with, children, insert the needle under this third process. With adults and with some children it is necessary to begin the insertion •J to 1 cm. to the side of the median line and then direct the needle upward and medianward until it reaches the free space under the spinous process. Usually the needle penetrates the muscles and fascia easily, and if one has directed it right one feels at the dis- tance of 5 or 6 cm. in adults (less in children) that the resistance to the movements of the needle has lessened, and if one now re- moves the mandrin, fluid usually begins to escape. Before insert- ing the needle the skin must be thoroughly disinfected as for any operation, with soap and water, alcohol with sublimate, or iodin. AVith patients suffering from tetanus it is usually necessary to chloroform them before the body is relaxed enough to slip the needle under the spinous process. The first drops of fluid may be bloody. These should be caught in a sterilized test tube, and as soon as the fluid begins to run clear a second test tube should be substituted for securing the rest. It is best to have these test tubes graduated in order that one may know exactly how much fluid he has taken out. Under ordinary conditions 20 to 30 c.c. will flow out spontaneously. Under in- creased pressure as high as 75 to 100 c.c. may flow. But the removal of this latter amount may be accompanied by the danger of terrific headaches and spinal pains. If the fluid does not flow freely, one should have the patient sit up for a moment until it does start, or else one should reinsert the mandrin of the needle to see that the lumen of the needle has not been clogged with coagu- lated fluid or by a nerve fiber. Instruments. — One may use the ordinary aspirating needles, but one should remember the danger of breaking such needles if one by accident hits the bone; therefore when possible the instru- 316 DISORDERS OF THE NERVOUS SYSTEM ments devised by Quincke himself should be used. The outfit usually consists of two (Quincke) needles about 1\ cm. long and from T 6 o- to 1^ mm. in diameter. These needles should be fitted with small steel mandrins pointed at the anterior ends the same way that the needle is pointed. Second, there should be several wide gradu- ated test tubes sterilized ready to receive the fluid. Third, it is wise to have instruments for measuring the pressure, and this in the Quincke outfit consists of a thin rubber tube to one end of which is attached a metal connection fitting the canula or needle, and to the other end of which a narrow glass tube on which is marked the millimeters to indicate the height of the fluid therein. The flow of the fluid should occur by drops. If it starts to flow out under pressure one should check it every moment or two in order to prevent too sudden a change of pressure within the spinal canal. On the oher hand, one should not aspirate in case the fluid does not flow, but should make sure that the needle is within the proper space and is free from clots. In some cases it is necessary to withdraw the needle and reinsert it. At the close of the work one withdraws the needle quickly and seals the opening with cotton and collodion. The greatest difficulty comes from the striking of the bones. This may break off the needle or bend it. When one hits a bone one should not withdraw the needle completely, but should with- draw slightly and move the point about in search for the open passage ; then, of course, if an open passage be not found, the needle may be entirely withdrawn and a new insertion made. There is some danger lest one push the needle across the spinal canal and through the anterior wall of the lumbar sac into the body of the vertebra in front. In this case the fluid flows only after one has withdrawn the needle somewhat. The normal fluid contains \ per mille (Jacobi 0.2 to 0.5 per mille) of albumin, and in the case of meningitis the albumin may rise to 1 t 8 q- per mille (" one per mille means inflammation, ' ' Jacobi) and brain tumors to 2y 2 o per cent. As soon as this in- crease in albumin occurs, coagulation is more rapid and fluid may coagulate even while running out. The specific weight is about 1.002 to 1.009, and reaches in pathological cases as high as 1.011. Sugar is found in very small quantities normally, but is much increased in tumors. The finding of microorganisms in the SPINAL DISORDERS ■ 317 fluid is, of course, of great diagnostic value. The normal fluid is clear. In using lumbar puncture for the introduction of drugs into the spinal canal one should be careful either to withdraw as much fluid as one introduces or should use the spinal fluid itself to dis- solve the drug (e.g., novocain). To avoid this necessity we often make our solutions so concentrated that we need to introduce only a few drops, as in the case of magnesium sulphate when injected for tetanus. To secure relief from too great pressure we should let just enough flow out to make the pressure normal (5 to 35 mm. of mer- cury or 40 cm. of water). This usually requires not more than 30 c.c. SPINAL DISORDERS Chronic Pachymeningitis. — Chronic pachymeningitis should be treated surgically. Laminectomy should be done over the affected area and the meninges irrigated with corrosive-sublimate solution. (Horsley.) Myelitis. — If myelitis be due to the pressure of an abscess, the latter should be opened and drained, otherwise the patient should be kept very quiet, with just enough gentle massage and electrical treatment to keep the skin and muscles of the affected area from atrophying. It is wise to strap the patient to a board or frame in order to facilitate treatment. The worst that can be done is to use the so-called osteopathic movements; for by keeping the spine at rest there is a chance that the process will heal, but by moving the spine we simply damage the tissue and cause the disease to spread. The use of hexamethylenamin and strychnin in these disorders is justified. If the underlying process be tuberculosis, the appro- priate regimen should be adopted (see Phthisis). Anterior Poliomyelitis. — Anterior poliomyelitis should be treated by electricity, the iodids, and strychnin, to promote tissue repair, cell regeneration, and renewal of function. The electrical current should be just strong enough to stimulate gently, not strong enough to injure. Thus 30 milliamperes of the constant current for five minutes a day is regarded as the maximum. Of course the bowels and bladder require constant watching, especially if the innerva- 318 DISORDERS OF THE NERVOUS SYSTEM tion be damaged. Sometimes in this disease the supply of nutri- tion to the affected areas of the spinal cord may be reestablished during the fever by stimulating the general bodily processes, at the same time keeping the patient as quiet as possible, with ice applied along the backbone. Sometimes also the symptoms of this disease are caused by intestinal intoxication, and in such cases complete relief may be obtained by active catharsis, followed by careful dieting and antisepsis of the intestinal tract. For the recovery of the motion in the parts of the body sup- plied by the affected nerves, it is important that those muscles be kept quiet in the days immediately following the attack ; and thus, instead of giving active massage and movements, the muscles should be incased in cotton batting and restrained from all activity. Later on, electricity and massage may be used with good effect. The use of iodids here, as in other nervous diseases, to bring about the absorption of the exudates and the reestablishment of the normal tissue has become routine treatment. For children, 5 grains of the potassium iodid three times a day will be sufficient. Finally, the stimulation of the regenerative powers is influenced by strychnin, and therefore this drug should also be used. For instance, we might combine the medicines as follows: ^ Tinct. nucis vomica? 10 Potassii iodidi 7 Elixiris gentiana? glycerinati (N. F.) 60 Sig. One teaspoonful three times a day. For stimulant electricity the sinusoidal current seems to have proven most effective. The one electrode should be applied to the feet and along the affected muscles, while the other electrode should be placed at the back of the neck. If the former be a roller, mas- sage can be utilized with the electricity. Tabes Dorsalis. — It is not to be hoped in this condition to restore function to the affected nerve trunks. Therefore, the best that can be done is to establish function through the development of new nerve paths. This consists in teaching the patient to use the af- fected muscles carefully and slowly, one action at a time, just as one would teach a baby to walk. The nerve tissues involved may sometimes be helped by the SPINAL DISORDERS 319 exhibition of the iodids and by the regular application of high- frequency currents. Both of these measures simply mean a quick- ening of the metabolic processes in the area of the affected nerves. The pains have to be treated symptomatically with the coal-tar derivatives or opiates. The use of electricity and massage some- times is sufficient to keep such pains under control. Optic nerve atrophy and similar dystrophies seem benefited by strychnin. In general, tabetics do best in sanatoria, where they may have the advantage of freedom, and on the other hand have carefully directed exercise, diet, and treatment. If everything goes well, the disease may after months of treatment be arrested and the patient live in comparative comfort for years. The principle upon which such treatment is laid down is that of developing new conduction paths between the brain and the periphery. This is accomplished by passive movements : i. e., mak- ing a set of muscles perform a set of movements over and over until they do it almost automatically. This is practically the method by which we all learn to use our muscles in our infancy and childhood. Hence painstaking oversight and appropriate ma- chinery are necessary for the successful treatment of tabetics. Tetanus. — Tetanus may be treated by the injection of magne- sium sulphate in twenty-five per cent solution, 4 c.c. at a dose. Injection should be between the third and fourth or between the fourth and fifth lumbar vertebras. For instance, insert the needle 2 cm. to the side of the median line on a level with a line extend- ing between the highest points of the iliac crests. No solution is in- jected until a few drops of clear (not blood stained) cerebrospinal fluid have escaped. The injections lessen the rigidity and the suffering, and should be repeated as soon as the rigidity becomes extreme. The magnesium sulphate employed should be the pure salt, such as Squibb 's, and the solution should, of course, be steril- ized by boiling. The following case histories illustrate the value and applica- bility of this therapy (from Medical Fortnightly for April 10, 1909; Dr. A. P. Heinecke, of Chicago) : Case I. — Robinson, G. Cany. Treatment of tetanus by intraspinal injection of magnesium sulphate. (Jour. A. M. A., 1907, Vol. XLIX, p. 320 DISORDERS OF THE NERVOUS SYSTEM 493.) Male, eleven years ; weight, 67£ pounds. Contusion of scalp. Pre- vious immunization, none. Played considerably around stable. Ex- cised supposed wound of entrance. Chloral hydrate, gr. 30, sodium bro- mid, gr. 60, every twenty-four hours for the first two weeks. On the eleventh day of the disease patient was anesthetized. Ethyl chlorid used as a general anesthetic. Three c.c. of a twenty-five-per-cent solu- tion of magnesium sulphate injected in subarachnoid space. On the next day repeated injection using 3^ c.c. On the fifteenth day of disease injected in same locality 4 c.c. of same solution. Recovered. Author states that the intraspinal injections of magnesium sulphate produced marked lessening of the very severe symptoms for a number of hours. The muscular rigidity was never so severe after each injection as it had been before. Case II. — Miller, Robert T. Treatment of tetanus with subarach- noid injections of magnesium sulphate. (The Am. Jour, of the Med. Sciences, 1908, Vol. CXXXVI, p. 781.) Male, seven years; weight, 60 pounds. Period of incubation, seven days. Previous immunization, none. Lacerated wound of left hand. Antitoxin daily for fourteen doses varying from 1,500 to 7,000 units. Sedatives for a short time. Copious saline enemas and infusion. Eleven lumbar punctures made within thirteen days. Approximately 25 c.c. of a twenty-five-per-cent solution of magnesium sulphate being injected into the meninges at each puncture. Recovered. "Of the value of the treatment of magnesium sulphate, no one who witnessed this case has any doubt. The muscular paralysis following each injection lasted from eighteen to twenty-nine hours. It involved all muscles, except those of head, neck, and dia- phragm. The injections were followed several times by respiratory col- lapse, lasting from eleven to fourteen hours, and the pulse dropped though not to a dangerous degree. Case III. — Henry, John Norman. (International Clinics, 1908, series 18, Vol. IV, p. 1.) Male, nine years. Period of incubation six weeks. Previous immunization, none. Abrasion of skin of back by kick of horse. Lumbar puncture 3 c.c. of twenty-five-per-cent solution of mag- nesium sulphate injected in subarachnoid space. Five days later sub- arachnoid injection repeated. Recovered. The case was a severe one. Made excellent recovery. Each injection was followed by a relaxation of the rigidity. NEUROSES The neuroses require more general bodily treatment than do most of the localized or organic nervous diseases. This is due to the NEUROSES 321 fact that a neurosis is essentially a symptom, or symptom-complex, the cause of which is only dimly understood. Hence we must try to influence all the bodily processes that could in any way have an influence on the symptoms. We have to use shotgun rather than rifle methods. "We need, therefore, to increase the patient's weight if he be emaciated, or decrease it if he be obese. We need to regulate the diet, the mastication, the environment, and the habits of the pa- tient. We must prescribe the exercise and rest, the baths and the rubs, the sleeping hours and the working hours — all this in order to furnish to a deranged nervous system a better body or body machinery upon which to work. Because arsenic stimulates the nutrition of the nervous system we use arsenic in most neuroses. In other cases the catabolic power of the iodids seems more to be desired. Again we need the stimulant power of strychnin or the depressant action of a bromid. Anemias must be corrected by the administration of iron. Irri- tation from faulty vision must be helped by well-fitting glasses. Reflex irritation from a hooded clitoris, an adherent prepuce, or an anal fistula must be searched out and relieved. In short, we must not rest until we have corrected all the abnormalities of the body and done everything to soothe and help the mind. Mania This condition is usually due to an exaltation of the cerebral centers. Therefore those drugs are indicated which have specific action in depressing the cerebral centers. Of these, scopolamin (hyoscin) stands foremost. It should be used hypodermically in y-J-jj- of a grain to -^ of a grain every four hours if needed. Hyos- cyamin and atropin are less specific in action and should be used only when there is an accompanying excitement of the peripheral nervous system. It should be remembered that -j-J-g- grain of hyoscin is combined with J grain of morphin for an anesthetic. The result of the giving of such a combination is profound sleep, which may sometimes be very desirable to secure in mania. In such sleep the patient's respiration may be reduced to four in the minute, and may become stertorous in character. The skin of 322 DISORDERS OF THE NERVOUS SYSTEM the face is cyanotic, due to the dilation of the skin capillaries. As long as the pulse is regular and not below 50, and the respira- Fig. 56. — The Permanent Bath for Quieting Mania. (Clow's System.) Fig. 57. — The Permanent Bath in Use in a Hospital for the Insane. (Clow's System.) NEUROSES 323 tions keep up from 4 to 8 in the minute, little danger is ordinarily to be apprehended from this depression of the res- piration. Whenever possible, the so-called permanent bath is preferred for quieting mania. The patient is put in a tub and a heavy canvas cover fitted about his neck and arms in such a way that he cannot leave the tub or injure himself. Patients are left in such baths if necessary for twenty-four hours or more. The water is, of course, kept at a constant temperature by regulating the in-and- out flow, so that the patient soon falls asleep under its admin- istration. Soothing rubs and the application of heat will also be found helpful for quieting maniacs. The administration of food and the stimulation of the emunc- tories should not be neglected with these patients. The use of gavage by a tube through the nose may have to be resorted to. In such cases, warm broths, peptonized eggs and milk are used. The cathartic salts meet the needs for relieving the system of waste products better than the other cathartics, because they would carry off the detritus which in health would pass through the kidneys or the skin. Chorea This is a functional disorder, and usually due either to an over- use of some part of the nervous system or an intoxication of some region of the central nervous system. Thus girls at school, where they have become excited about their work and pursued it too vigorously, are quite often subject to attacks of chorea, or children who do not care for the regular evacuation of the bowels and blad- der, and, on the other hand, eat inordinately and at all times of candy and delicacies, are also liable to the disorder. (This type of chorea should, of course, be carefully differentiated from that type which depends upon congenital weakness.) In general, therefore, chorea is best treated by putting the patient absolutely at rest in bed, and in giving at first depressants, and afterwards tonics, until the equilibrium of the body is reestablished. For pre- liminary depression, acetanilid has been recommended, although since it is a coal-tar product one should be very careful in its use 324 DISORDERS OF THE NERVOUS SYSTEM and not permit it to affect the circulation. Hyoscin or hyoscya- min would be found useful, which, depending upon whether the choreic exaltation seems to psychic or lower down. Hyoscyamin for medullary or lower exaltation should be given in the dose of y-J-g- of a grain three times a day. The hyoscin for exaltation of more psychic character could be given in tJ-q of a grain. The nutrition of these patients is usually improved by the use of arsenic and iodids. The arsenic is for the purpose of stimulating the nutrition of the nervous centers, while the iodid hastens the processes of metabolism. For such purposes, Donovan's solution, which contains the arsenic iodid as well as the mercuric iodid, would probably be most indicated. This should be used in ordi- nary patients in the dose of 5 drops three times a day. The drug is more effective if given before meals. Where anemia is present, iron should be used, and in general the character of the drug depends upon the findings in the blood examination. As soon as the patient has overcome the worst twitching, he should be put into out-of-door life — made either to lie on a couch (well wrapped, of course) in the sunshine, or if more vigorous, given plenty of active exercise. Epilepsy The pathology of this condition has not yet been fully worked out. It is probably some interference with the cerebral centers. When the interference is in the cortex, we have the Jacksonian type of epilepsy, which is usually successfully treated by surgical interference. When the lesion is deeper in the brain the only line of treatment possible at present seems to be the depression of the nerve centers and reflex arcs. The drug that has proven most effective for this purpose is the bromid, which probably in most cases would better be given in the form of the sodium salt rather than that of the potassium, because the sodium salt is less destructive to tissue in its action. Patients suffering from this disease should be kept out of doors in as pleasant surroundings as possible and every effort made to increase their bodily strength. Thus the farm colonies which are now used by the more progressive of the state governments for NEUROSES 325 the care of their epileptics form a great advance over the old-fash- oned asylums, with their lack of light and air. In treating epilepsy great stress must be laid on keeping the digestive tract active and clear. The chief liability is to constipa- tion and intestinal autointoxication ; hence, in giving the bromids, it is well to combine them with stomachics and cathartics, according to the need of the individual patient. The following prescription will serve to illustrate the point: ^ Sodii bromidi 20.0 gms. Ext. fl. cascaraa sag 7.0 c.c. Tinct. gentian, co 30.0 " Glycerini 60.0 " Aquae 90.0 " Sig. One dessertspoonful t. i. d. There are constantly being added to our materia medica new compounds and forms of nerve depressants, such as sabromin, bro- mural, which may be used when for some reason the ordinary bromids are inapplicable. Hysteria So far as we know, hysteria is purely a functional disease. It seems to be due to a labile condition of the central nervous sys- tem, so that slight stimuli (even so slight that the normal organism would react without damage) cause in the hysteric a complete alteration of the mode and characteristics of their lives. For this reason, as far as drugs are concerned, the treatment is one of de- pression of the reflex arcs. It is not yet clear why it is, but valerian and the aromatic sedatives seem to be more useful for this than the simpler bromids. Thus the tincture of valerian (which is a twenty-per-cent solution) given in teaspoonful doses has proven quite effective even when other drugs that seemed to have a reason- able basis for their administration have failed. Even more ef- fective than the plain tincture is the ammoniated tincture, also a twenty-per-cent preparation, given in a 2-c.c. dose, well diluted. Bromural and veronal, which seek to combine the actions of the bromids and valerian, would also be useful. 326 DISORDERS OF THE NERVOUS SYSTEM But it is in hysteria that psychotherapy finds its true field. Psychotherapy includes suggestion, persuasion, reeducation, hyp- notism, and the other intangible therapeutic measures advocated at different times and under various names. In its essence psychotherapy seems to be the transference of the patient's attention from his bad feelings and weaknesses to points on which his feelings seem good and he appears otherwise strong. It centers his attention on his hopes rather than his fears. It teaches him to be thankful for what he has rather than to mourn for what he has not. How this change of thought affects the body processes can, of course, only be theorized about; but, in general, we may say that it does enable all the metabolic processes to act more easily and uniformly, and that this in turn makes the mind feel better. The difficult part in psychotherapy lies in the securing of the patient's attention and belief. It is to this part that the manifold procedures and methods are really directed. In general, we may say that it is essential that the patient listen to the physician, and that he will do this only when he consciously or unconsciously as- sumes a receptive attitude toward the physician. For this reason some psychotherapeutists secure the attention of their patients by unusual actions and motions, by exhibiting bright objects upon which the patients must fix their attention, or even by putting the patients to sleep (hypnotism). We may even say that unless the patient can and will fix his attention successful treatment is impossible, hence the insane and imbecile are not amenable to psy- chotherapy. Wherever possible, acute cases should be treated by isolation and quiet, bland diet (e.g., milk), and cheerful suggestions from the nurse and doctor. The patients must be made to feel that they have the sympathy of both nurse and doctor, that everything is being done for their benefit, and that they will get well if they will only resign themselves to the doctor's direction and attention. Such patients improve in nutrition, weight, and feeling under this regime. The isolation is possibly the most important part of this treat- ment, because it gives them rest and also frees them from harmful suggestions from ignorant and thoughtless comrades. It meets a need which we all feel now and then — a need of seclusion, of re- NEUROSES 327 treat from the world, of freedom from responsibility and care. 1 This isolation is, of course, best brought about in a hospital in a private room with a special nurse, but it may be done fairly well at home if one can secure the proper nurse. For, after all, it is the nurse who makes or breaks our treatment of this class of cases. She must be a woman who has lived and thought as well as have received the technical training of a nurse. It is better not to at- tempt the isolation, treatment at all than to try to use an incom- petent nurse. The milk diet is usually kept up for a week, or until the diges- tion and defecation are normal and the patient is relieved of the many somatic disturbances accompanying the disease. We usually give four to eight ounces of full milk, or milk mixed with car- bonated water, every three hours. The daily visit from the doctor is quite important. At this visit the doctor should encourage the patient, point out his im- provement, and tell him that his nervous troubles are curable and will gradually disappear. With some patients we use reeducation ; that is, we try to explain and persuade, showing them their real condition and teaching them how to overcome the pathological tendencies. With others we must work through the emotions rather than the reasoning faculties; that is, we employ suggestion. We tell them that they are going to get well and use every opportunity to force home that suggestion. Hypnotism is therefore needed in the few cases where we can- not use reeducation or waking suggestion. We hypnotize by fix- ing the patient's attention and then suggesting sleep, meanwhile providing all the conditions helpful to somnolence, such as quiet, comfort, warmth, etc. As soon as the patient is completely passive we give our therapeutic suggestions, repeating them until they become fixed in the patient's mind. We must repeat the seance before the patient can quite return to his old condition of thought and feeling, be it in a few hours or a day or two ; hence hypnotism is used more in those cases where the patient visits the doctor's office and where the latter is not able to control the environment of 1 Its value is beautifully shown in Robert Herrick's admirable tale, " The Master of the Inn," published by Scribners, which every student of medicine should read. 328 DISORDERS OF THE NERVOUS SYSTEM the patient. Its danger is that it tends to make the patient more dependent upon the doctor, rather than more independent. There- fore, if we believe that the doctor's mission includes the moral one of making his patients stronger and better, we must conclude that hypnotism is distinctly inferior to reeducation. 1 Hypnotism. — Dr. Munro thus outlines his usual speech to a patient when he uses a small vial of water : Take this chair, please. Now, I will explain to you what I am doing and what I wanted with you. Do you see this little bottle of medicine ? This is a sample of a preparation that I am introducing to the physi- cians, known as " Somno- Analgesic Compound." " Somno " means sleep producing and " analgesic " means pain relieving ; so then this is sleep- producing and pain-relieving medicine. It is used by rubbing it on the forehead just as you see me rub it on mine. You notice it does not harm me and it will not harm you. Now I have explained to the phy- sicians here that in order for this remedy to have its effect it must be applied in a certain way, and that is the way that we get our patient to do and to be while the medicine is applied that determines its effect. I want you to take a seat in this chair, lean your head back against the wall, relax ' every muscle, close your eyes slightly, and breathe through your mouth, just as if you were going to sleep. Then, as I apply the remedy, you will soon get quiet all over, then get drowsy and sleepy, and go to sleep, and awake feeling better. Now see here, my man, don't resist the effect of the medicine ; just sit here, and let it have its effect. The same author gives the following outline for his method when he uses no object: All right, take this seat. Lean your back against the wall. Close your eyes lightly and breathe through your mouth and think of going to sleep. Now, as I apply this remedy, you will soon become quiet all over and get drowsy and sleepy, and go to sleep, and awake feeling better. I will talk to you to help you concentrate your mind. Now, as I apply this remedy, you will get sleepy, sleepy, sleepy, sleepy, so-o-o-o sleepy. Now go to sleep, sleep, sleep, sleep. Now you feel quiet all over. Your muscles are relaxed. Everything 1 As an illustration of the actual methods used by hypnotists, I quote the following examples from a text-book on the subject by Munro. NEUROSES 329 is dark to you. You do not hear anything but my voice. You are drowsy and sleepy, so-o-o-o-o sleepy. You feel the sleep coming over you. You are going to sleep, sleep, sleep, sleep. By the time I count ten you will be fast asleep. One, two, three, four, five, six, seven, eight, nine, ten, and you are asleep, fast asleep, sound asleep. By the time I count five more you will be sound and dead asleep, just as you are in the dead of night when sleeping soundly in your own bed. One, two, three, four, five, and you are asleep, fast asleep, sound asleep, dead asleep. Don't wake now until I tell you. Every second your sleep will become sounder and sounder and deeper and deeper. Sleep on quietly until I wake you. Now you will not hear anything or feel anything or know anything except what I tell you. Sleep on quietly until I awaken you. After the patient is asleep usually something is done to com- plete the effect — to convince him, so to speak, of the operator's power. Dr. Munro 's method is as follows : Sleep on quietly. When I count three this arm will be stiff (raising his arm), so stiff that you cannot take it down. One, two, three; your arm is stiff and you cannot take it down until I tell you. Now when I rub this medicine on your arm three times it will be dead and have no feeling in it. Now I pinch this arm (thrusting a pin through a fold of the skin), but you do not feel it; there is no feeling here at all; this arm is perfectly dead. The therapeutic suggestion is then given; given in simple lan- guage, slowly and distinctly. If necessary, the suggestion is re- peated several times before waking the patient. For waking the patient some suggestion as the following is given : Now, my man, when I count three you will open your eyes and be wide awake. You will be feeling good all over. You will remember nothing that has been said or done, and will find that you never felt better in your life, and will always be glad that you came up here. One, two, three, and you are awake. The following case history from Barker (Am. Jour. Med. Sci., October, 1906) illustrates the use of reeducation in the treatment of neuroses : 330 DISORDERS OF THE NERVOUS SYSTEM Reeducation. — Case History: insomnia, incapacity for work; fear of insanity; obesity; rapid cure; weight reduced twelve pounds. Mr. P., aged fifty-six years, married, was admitted November 18, 1905, complaining of nervousness, inability to sleep, and fear of going insane. His mother had died insane, and one of his brothers had also been insane. In childhood the patient suffered from measles, scarlet fever, and whooping cough. At twelve years he passed through an attack of typhoid, and at fifteen had malarial fever. He denies venereal infec- tion. His habits have been good as regards alcohol and tobacco. The patient states that he has always been a nervous man, and that for the past nine or ten years, dating from a period of worry over ill- ness in his family and certain business troubles, he has been much more nervous and sleepless; has found himself incapable of attending properly to his business affairs. For the past two or three years he has been seriously incapacitated, often being compelled to stay away from his business, that of a storekeeper, for days at a time. He ascribes this incapacity to general lack of interest and energy. Lately he has been growing irritable, worrying easily over small matters, though he knows that it is nonsensical to do so. He thinks that his memory is somewhat impaired, and states that he suffers from insomnia nearly every night. He always feels worse in the morning, whereas before going to bed at night he sometimes feels in perfect health. The appe- tite has been variable. The bowels move regularly. On examination the patient is found to weigh 185 pounds, though he is not a tall man. Patient does not look ill, and mentally he seems clear. The pupils react to light and accommodation. There is no glandular enlargement. The lungs are normal. On examination of the heart the point of maximum impulse is not easily visible or palpable. The deep cardiac dullness extends 8.5 cm. to the left of the middle line in the fifth intercostal space. The heart sounds are normal, and the pulse is regular in force and rhythm. The radial artery is not palpable. The abdomen is pendulous, owing to the large amount of fat in the abdominal wall. The examination of the abdomen is otherwise nega- tive. The knee kicks are present, but not overactive. Cremasteric and plantar reflexes normal. No objective disturbance of sensation. Sta- tion good; Romberg's sign negative. Examination of blood: red blood corpuscles, 4,830,000; white blood corpuscles, 5,800; hemoglobin, eighty per cent; no parasites. A careful ophthalmoscopic examination was made by Dr. Bordley and the disks were found normal. The patient had some esophoria. NEUROSES 331 The patient was told that he was too fat, and that his weight should be reduced. He was also informed that a majority of his symptoms were of nervous origin, and that they were curable. He was encouraged to think that there was no reason why he should go insane. During the first few days he was kept in bed, upon a low milk diet, after which he 9 was placed upon a reducing diet. Erom day to day he was encouraged as to his progress and told that we believed he would get well. After a time he was given regular room gymnastics, nearly all of the muscles being exercised in this way. Later still, he was made to walk, the dis- tance being increased each day until he walked five miles every day. He was then advised to take a few Turkish baths before going home. The reducing diet contained 140 grams of proteid, 30 grams of fat, and 112 grams of carbohydrates, so that he received some 1,320 calories a day. He lost twelve pounds in weight in the seven weeks, regained energy and courage, and was discharged November 18th feeling per- fectly well. Some months later his brother entered the hospital for treatment, and reported that the patient had been perfectly well ever since, and was doing his work with entire satisfaction to himself and his family. It would not be surprising if he should relapse later, as the case seems to fall in the group of the " periodical depressions." The results of the psychotherapeutic treatment of hysteria by Charcot in Paris and Barker in Baltimore (treatment continued for several months) show about fifty per cent of cures. That is, the suggestive therapeutic method requires a long continuance of treatment to insure permanency in the results. Hydrotherapy. — Hydrotherapy has also been called into use for hysteria. The following case from Baruch's text-book shows the difficulties as well as the success that may attend the work. A. F., aged fifteen years, was brought to the Hydriatic Institute July 19, 1892, by his father, who said that on March 21, 1892, on the day of his daughter's burial, the boy " fainted." Ten days later he fainted in school, and again two days later. The family physician in- vestigated the case at school, concluding that it was a form of epilepsy. The boy was kept from school and put on potassium bromid. The at- tacks becoming more frequent a prominent neurologist was called in consultation ; the same treatment was continued. He continued to have attacks every day, and very often twice a day, lasting from five to ten minutes. At first he lay unconscious without any movement whatever; then the attacks became violent, frequently requiring several men to 332 DISORDERS OF THE NERVOUS SYSTEM hold him down and prevent him from doing himself bodily harm. The former consultant was again called in and made an unfavorable prognosis. Several neighboring physicians who had been called during the attacks gave him hypodermics of morphin. Patient also received electrical treatment from his own physician. Status Prcesens. — Face pale, covered with acne, eyes restless, hand • tremulous, appetite fair but capricious, gastric oppression after meals, bowels constipated. Patient appeared to be brominized. Treatment. — Resorcin, three grains in a half pint of hot water, an hour before lunch and dinner. He was ordered to be at once well scrubbed with soap and water. This was followed by a wet pack (sheet wrung out of water) at 70° F., reduced two degrees; this to be followed by a rain douche at 90° F., twenty-five pounds pressure, gradually reduced during thirty seconds to 75° F. August 20th : This treatment had been used daily, the temperature of the douche being reduced two degrees every day. He had a slight attack five days after treatment was begun ; none since. He was ordered to Long Branch to take surf baths. September 29th: Patient has called on me several times, reporting steady improvement. He was discharged cured. The patient has re- mained well. False Angina. — Mr. D., merchant, aged forty years, weight 190 pounds, of robust appearance, has suffered for several months from agonizing pains in the precordial region whenever he attempted to walk briskly, especially after meals. He was completely disabled from busi- ness. His family physician regarded the case as one of angina pectoris, and this diagnosis was confirmed by an eminent consultant. He was advised to use amyl nitrite pearls for the attacks and give up business. In consequence of this decision he became melancholic, and when he applied for treatment he was a picture of woe. He gave a gouty his- tory ; urine normal but loaded with urates ; digestion impaired ; pulse of high tension. He was restricted to a nonmeat diet, put upon glonoin and strychnin. A wet pack, water at 60° F., was ordered daily for one hour, followed by rapid ablutions with water at 50° F. ; a wet compress to be worn all day, wrung out of water at 60° F. No preparatory treat- ment to ascertain his reactive capacity was needed, because he was a robust man of splendid physique. The aim of treatment was the enhancement of tissue change, a calming effect with stimulating sequel. This was happily accomplished because the patient was careful and frightened. He did not neglect treatment. In three months the fre- quency and intensity of the attacks had so far diminished that I per- mitted him to take a journey of some weeks. On his return dyspeptic NEUROSES 333 symptoms were more pronounced. He was put upon chopped beef, pre- ceded by a pint of hot water, for breakfast and dinner; oysters and hot milk for luncheon. Four months later he was entirely free from pain and had lost some flesh, but was able to bear the worries of business. Although five years have elapsed he remains in good health. These case histories illustrate perhaps better than a descrip- tion the necessary features of the successful treatment of hysteria. Nothing that does not make a profound impression on the patient will succeed, hence the treatment must be vigorous, aggressive, and compelling, no matter whether psychotherapy, hydrotherapy, or pharmacal means be employed to restore the patient to health.' Neurasthenia This disease will form the bulk of many a young doctor's ini- tial practice, and his success in handling these sufferers will greatly influence his general success in practice in that locality. The first indication is for rest and the second for graduated exercise. The first restores normal function to the body, the sec- ond redevelops the power and self-confidence of the patient. These sufferers are usually afflicted with a congenital disposition to en- teroptosis. This makes necessary medication to correct dyspepsia and constipation, and also stimulation of the digestive processes. The following case histories from Baruch are instructive, both as to the condition of the patients and the methods of successful treatment : Case I. — Neurasthenia Psychopathica. — Mrs. , aged forty years, from San Francisco, has four children; perfectly well for eighteen years. Since birth of last child, seven years ago, has been ill. At that time, her husband being very sick, great demands were made upon her. "Went to the World's Fair in 1893 in charge of a party, but found her- self suddenly incapable of continuing and was compelled to return home. During the next three years she spent most of the time away from home on account of " distressing nervousness." She now went to Japan on account of her husband's health. She " could not account for her great depression during the sojourn in this interesting country, and constantly trembled at the thought of resuming her role in life, because she had misgivings as to her ability." On her return in October, 1895, to use her own language : " I was careless, forgetful, indifferent to everything, 334 DISORDERS OF THE NERVOUS SYSTEM and excitable, restless, and fickle-minded to a distressing degree. My ordinary duties became a burden, a decision on any point, however trivial, was an impossibility." She took a partial rest cure at home, but found it necessary to go to a private sanatorium. She was nervous, dis- tressed, dissatisfied without cause, felt she was of no use to anyone, a detriment to those nearest and dearest to her, and she was therefore will- ing to live apart from them. She " remained away a whole year without feeling maternal ambition, lost interest in everything. She had mas- sage, steam and shower baths triweekly; she lived and dragged herself wretchedly, feeling that she had sacrificed her position in the home." On her return home she suffered unspeakably; was now, as she had always been since her illness, subject to insomnia. She again felt im- pelled to leave home and went to relatives. Her uterus was now curet- ted. She felt better until she got up ; then " doubts, fears, questions as to the best course to pursue," returned ; she " felt that she had lost her grip." Her hearing being much impaired added to her mental dis- tress. She now came to New York. October 5, 1897 : Mrs. — presented herself in order to try systematic hydrotherapy as a last resort. She stated that her " life during the past year has been spent in idleness, dreading the coming of sunshine in the morning and of the darkness at night; the thought of her husband and children deserted was maddening; sorrow had taken the place of peace, irresolution was her bane." She presented no organic disease; weight, stripped, 107 pounds ; nutrition much below par, appetite poor, sleep im- perfect. Ordered careful regulation of diet, exercise, rest, and a grad- ually developed hydriatic treatment, patient being placed in charge of a nurse. October 7th: A preparatory douche, 95° to 85° F., produced an hys- terical attack. October 20th: Becoming gradually accustomed to the treatment, she took to-day a circular douche, 95° to 90° F., of one minute, followed by Charcot (fan) douche, 78° F. for ten seconds. Her weight has increased three pounds. Mental condition unsatisfactory. Nurse is suspicious of suicidal intent. October 22d : Lost one pound in weight and is much distressed by the fact. Ordered hip bath 85° F. for five minutes, followed by fan douche to back, 78° F. for ten seconds, to be reduced daily one degree. November 13th : Took the same hip bath followed by fan douche, 74° F. for ten seconds. He gained four pounds, but expresses no satisfaction over gain. Is extremely despondent, sighing, and irresolute. NEUROSES 335 November 28th: Hip bath, 85° F. for eight minutes, followed by jet douche to back, 65° F. for fifteen seconds, and fan douche, 70° F. for ten seconds. Has lost two pounds; greatly dejected by the loss. December 5th : Treatment continued with daily reduction of douche temperature and increase of duration. To-day she took a jet douche to back, 58° F. for twenty-two seconds, and general fan douche, 65° F. for ten seconds. Weight increased three pounds without remark by patient. December 12th: Weight increased two pounds, total increase being eight pounds. Mental condition better. Patient " sees some ray of hope." The hip bath was now ordered alternated with perspiration bath to stimulate tissue change. The urine had become scant, with an increase of urates and phosphates. January 1, 1898 : Under this treatment she did not improve. She was saddened over a loss of three pounds. January 25th: She has continued regular treatment. Took to-day hip bath, 85° F. for seven minutes, followed by jet douche. Her weight is 113 \ pounds, a gain of 6 \ pounds. Her complexion is good ; appear- ance bright; mental condition decidedly improved. There was a linger- ing degree of dissatisfaction, but I deemed it advisable to send her home with the injunction to her husband to insist upon occupation. June 8th : Frequent reports have reached me stating that Mrs. — is a changed being ; she is cheerful, active, and " the life of the house." Case II. — Neurasthenia Gastrica — Home Treatment. — Miss W., daughter of an Ohio physician, aged twenty-three years, was referred by Dr. Frank H. Bosworth, the well-known rhinologist. Pale, emaci- ated, despondent, the picture of woe and despair, she was brought into my office by her sister. She had been ill three years ; suffering first from fainting fits at the menstrual period; afterwards from violent pains in the right hand, traversing the body and concentrating in the epigas- trium. For these her father (a physician) has been compelled to admin- ister morphin for a month. Her stomach became irritable and had con- tinued so up to the present time; she vomited and spat up nearly all her food, mostly the solids. Sea baths did not improve her. She studied hard and grew worse. She lived on milk and farinaceous mush, and her stomach was regularly irrigated without improvement. She grew worse, became emaciated; she took peptonized milk for a month but vomited it; meat produced the same effect. She now lived on grapes, which agreed with her; had tonics, pepsin, and all possible medication which her father and brother could muster, without avail. 23 336 DISORDERS OF THE NERVOUS SYSTEM She was sent to Dr. Bosworth, who is a friend of her brother. After she had been in the city three weeks without improvement, the doctor sent her to me. She now vomited every day. She traced her ailments to painting lessons, but I drew from her the history of a potent psychical factor as a cause, in the sudden violent insanity of the favored nurse of her childhood which occurred just previous to her attack. The stom- ach was washed out twice a week to remove mucus and fermenting material, which were not abundant and ceased after a few irrigations. She received general faradization daily, and every morning she was treated with the dripping sheet at 60° F., while standing in warm water, with three effusions of 50° F. upon the sheet, after which she was well dried and sent into the open air. Under this systematic management she improved slowly; vomiting ceased entirely; she went to the seaside greatly improved. On her homeward journey she called to tell me that she had grown stout and felt perfectly well. Two years later she wrote me that despite reverses which necessitated her adopting teaching as a means of livelihood, her health had remained perfect, and that I would scarcely recognize her as the same person. These case histories demonstrate the importance of having the patient in an institution where the influences of environment, etc., can be regulated and controlled. They demonstrate also the fact that the principles of treatment outlined for hysteria apply here also, hence we simply refer the reader to that section. Neuralgia Neuralgia may be treated by the peripheral stimulation of the suffering fibers or by the depression of the sensorium. The former is brought about by the application of heat, electricity, or blisters to produce a local hyperemia; the latter is sought by giving the coal-tar analgesics, morphin, or the bromids. A third method is the blocking of the nerve trunk by injecting alcohol, salt solution, etc., as has been already described with reference to sciatica. Still another treatment for obstinate neuralgia is the pulling out of the entire nerve, as is most frequently done in case of trifacial neuralgia. A favorite prescription for the temporary neuralgia that may be relieved by analgesics is the following, because its relief seems more lasting than that from the ordinary analgesics: NEUROSES 337 IJ Quininse bisulphatis 0.4 Sodii bromidi 1.0 M. f. chart, no. I. Da tales doses no. III. Sig. Dissolve one powder in two ounces of hot water and drink. Repeat in one hour, if needed. The value of this prescription lies in its general nerve-depressant power, thus reducing the response to irritation rather than pro- ducing a feeling of relief by simply depressing the sensorium. Intercostal neuralgia usually demands a course of treatment with the hot-air cabinet or some similar means of producing a local hyperemia of the thorax coupled with diaphoresis. In general, it is wise to treat the patient suffering from neural- gia of any sort by complete rest. Next it is wise to keep the air of the room uniform and nonirritant, because of the dangers from changes of temperature or draughts. Then, too, elimination should be thoroughly carried out both through the bowels and kidneys. Thus a prescription for a subacute neuralgia would assume the following type: IJ Magnesii sulphatis 10.0 Acetphenetidini 0.3 Potassii iodidi 0.5 M. f. chart, no. I. Dissolve in four ounces of hot water and drink. Later it would be well to substitute a salicylate for the acet- phenetidin (in a dose of 0.5 to 1.0) and let the patient use it regu- larly three times a day for a week, preferably on an empty stomach. Neuritis Neuralgia is to be distinguished from neuritis by the fact that in the latter we have an inflammation of the peripheral nerve, while in the former we have only the peripheral pain; the lesion may be central or even elsewhere in the periphery. Neuritis requires, first of all, rest. No massage or osteopathic treatment should be permitted until the inflammation has been reduced. Then massage (very gentle friction at first) and weak 338 DISORDERS OF THE NERVOUS SYSTEM electric currents will hasten the cure. At first the limb should be laid gently in warm sand bags, to secure the benefits of rest and hyperemia. Only quite late in the disease should passive move- ments and cold rubs be employed. The salicylates are used in quite heavy doses in the beginning to quiet the pain and bring an end to the inflammation. Sodium salicylate in gram doses or aspirin in half-gram doses should be given every two hours until the patient feels relief or the ears begin to ring. If the stomach will not tolerate the salicylates, guaiacol and methyl salicylate should be applied externally along the course of the nerve and driven in by heat or by an impermeable bandage. Following the salicylates, the iodids may be used with good effect. Thus potassium iodid, in ten- to fifteen-drop doses of the saturated solution, or ten drops of Donovan's solution (to secure an additional effect from the arsenic), should be given three times a day. Of course the elimination of waste products through bowel and kidney should be carefully attended to. Beri-beri is essentially a multiple neuritis, and as such is treated according to the above principles. The salicylates are given as noted above, at the same time heart tonics and general stimulants, until the system begins to respond. The bowels should be kept free. Prophylactically one can do much by using a diet rich in ni- trogenous elements (Osier) whenever one has to live in a sus- pected neighborhood. The Japanese secured good results in their navy by forbidding the consumption of raw fish. In addition to the simpler neuritides considered above, we have several forms of toxic neuritis, such as the alcoholic, the arsenical, that following infectious diseases, etc. The treatment is, however, essentially the same : rest in bed, elimination, the giving of the sali- cylates and analgesics, aud later the use of massage and electricity (here faradic or interrupted current instead of the galvanic is used). CHAPTER VIII DISORDERS OF THE GLANDS THE LYMPHATIC GLANDS Acute Lymphadenitis. — Acute lymphadenitis is usually confined to the cervical glands. Its treatment requires the correction of gastrointestinal disturbances, the stimulation of the skin reaction, and the local application of guaiacol or iodin. We therefore prescribe calomel in sufficient strength to keep the bowels active. We order cold rubs of the chest, neck, and back twice a day. A fifty-per-cent oil solution of guaiacol is rubbed into the glands every four hours. After the tenderness has moderated we use iodin (ten per cent in saponated petrolatum) rubbed in twice a day. The patient should sleep in a room with the windows wide open, so that he breathe pure cold air. The food should be bland and nourishing, but should not be in great variety or quantity. Pseudoleukemia, or Lymphatic Anemia (Hodgkin's disease). — Pseudoleukemia does not call for the operative removal of the swollen glands unless done in the very earliest stages of the dis- ease. On the other hand, the use of the X-ray seems to have a very beneficial effect on the course of the leukemia. So, also, does the administration of large doses of arsenic (hypodermically, as arsacetin). Hence the treatment is chiefly symptomatic and means the con- trol of all the patient's activities in order to increase his strength and vigor. Syphilitic and Venereal Buboes. — Syphilitic and venereal buboes require a line of treatment that shall both disinfect, if possible, the contents of the glands and provide a stimulant to the regeneration of the glandular walls. The pain of this type of swollen glands is very slight and is usually relieved by the general treatment for 339 340 DISORDERS OF THE GLANDS the condition. The drug used must be one that will be readily absorbed through the skin, and which, when absorbed, will pro- duce a local analgesic as well as a stimulant effect. Probably guaiacol, since it is both antiseptic and analgesic, rubbed on in the form of a fifty-per-cent oil solution, meets these conditions best. The inunction should occur several times a day. Phenolated camphor is also sometimes effective. Very resistant buboes usu- ally yield to the X-ray. The application of chloral hydrate has been tried for many years, but is rarely successful. Sometimes a solution of iodin (five to ten per cent) in saponated petrolatum x may be successful when well rubbed in. This vehicle is necessary for iodin, because in order to be at all useful the drug should not confine its action to the superficial layers of the epidermis, but must reach the glands; hence the ordinary tincture of iodin is well-nigh useless. The use of mercurial ointment is not without effect, but, since it is not analgesic, and, on the other hand, is dirty, it is not a popular remedy. The application of heat by means of cloths wrung out in hot water or of the thermophore will do much to bring about a re- generation of the glands. Tuberculous Glands. — Tuberculous glands (scrofula) demand first of all the constitutional treatment that is usually afforded to consumption. The patient should live in the open air and his digestion and excretion should be thoroughly stimulated, as out- lined in the therapeutics of consumption. In addition, the appli- cation of the sunlight directly to the glandular surfaces will be found very helpful, wherever it is not possible to extirpate the glands completely. For this purpose the patient should lie (with the face covered with a white cloth, if necessary) on a couch so as to permit the direct sunlight to reach the glands. The most successful treatment, therefore, is to be found in those climates where the sun is bright and not hidden by frequent clouds. Some- times the same effect as that produced by sunlight, that is, that 1 Saponated petrolatum — formula : Liquid petrolatum 60 . Oleic acid 30.0 Spts. ammonia 15 . THE SPLEEN 341 obtained by the passage of a strong galvanic current through the glands, will be found to check their growth. Thus the positive electrode, with a gold or platino-iridium needle, thrust into the glands electrolizes much of the pathological material. The strength of the current should be about thirty milliamperes. The guaiacol inunctions mentioned for acute lymphadenitis may be used here also ; but whatever the treatment employed, it should be remem- bered that the primary object is the strengthening of the con- stitution of the patient, and that the local treatment will be successful only when the bodily resistance to tuberculosis will be strong enough so that the disease cannot invade any other part of the body. This same principle applies when one discusses the matter of extirpation, because extirpation is useless unless the bodily resistance be raised ; therefore it is generally wise to insti- tute the correct hygienic treatment, and then, having increased the patient's weight and raised his resistance, remove the inflamed glands. THE SPLEEN Splenomegaly. — This may result from chronic malaria or may be the accompaniment of some of the leukemias or pseudoleuke- mias. Quinin has been noted for a long time for its power to reduce the size of the spleen. Methylene blue has a similar effect. But any treatment directed toward relieving the condition must take into consideration the constitutional results necessary to bring about such a change, because splenomegaly is only a symptom and does not constitute the entire disease. Arsenic to stimulate the formation of red corpuscles in the bone marrow is probably the most used drug for splenomegaly, and, in order to avoid injuring the stomach, is now being given hypodermically in the form of arsacetin (twenty-five minims of the ten-per-cent solution on alternate days). The X-ray applied for ten minutes on alternate days will also have a beneficial effect in decreasing the size of the spleen. The patient should, of course, be kept quiet and the diet regu- lated. This is the more necessary because in most of the conditions accompanied by splenomegaly there is a hyperemia of the mucosa of the stomach and intestines, and this in turn produces indiges- tion. The use of dilute hydrochloric acid to overcome this indi- 342 DISORDERS OF THE GLANDS gestion and of cathartics to keep the bowels in order is therefore usually necessary. THE ADRENAL BODIES The most common disease of the adrenal bodies seems to be tuberculosis. Aside from this we find ordinarily only a nonspecific interstitial inflammation. The most prominent symptoms are due to the loss to the body of the normal secretion; therefore the primary indication is to supply to the body secretions thus lost to it. As for attacking the process in the glands, very little can be accomplished, hence the treatment is one of general constitutional stimulation plus the ad- ministration of adrenal extract. The glandular extracts, when given for such a purpose as this, should always be used when the stomach is empty and there is little danger of their being broken up by the gastric juices. Prob- ably the crude adrenal extract for such conditions would be better than adrenalin or any one of the active principles. The dose varies from two to five grains a day, given in water, about two hours from mealtime. THE PITUITARY BODY In two cases of exophthalmic goiter treated by me with pituitary sub- stance both were relieved of tachycardia, nervous distress, and headache. In a psychosis that looked much like catatonia, in which both physical and mental decay had progressed apparently to the limit, the ingestion of this agent resulted in complete mental restoration and fairly good physical vigor. This case also had most intense vasomotor spasm, with hot flashes, that had previously resisted suprarenal treatment. These waves of heat and redness both ceased after exhibition of pituitary substance. In a case with endocardial, myocardial, and vascular changes due to an arteriosclerosis in a woman of seventy years of age, in whom the pulse was more than 130 and the eyes protruded and great distress ex- isted, six grains of the substance lowered the beats to 90 and gave much comfort. A case with mitral regurgitant and aortic obstructive mur- murs, with a pulse rate of 120, received one cubic centimeter of the extract from the posterior lobe of the pituitary gland. In twenty-four hours the pulse rate was 80, and the patient in a week's time showed THE THYROID GLAND 343 marked strength and tone in the cardiac action. In several cases of irregular heart action, attended with a feeling of oppression, much com- fort has been observed following the use of the gland substance. In a case of conjunctivitis, caused by a cinder, the extract of the posterior portion dropped on the congested surface could be seen to contract the blood vessels quite rapidly. (R. A. Bate, M.D., American Practitioner and News, March, 1909.) To be sure of getting a prime quality I applied to Parke, Davis & Co., who kindly placed at my disposal a pure and uniformly potent preparation. I found that the extract produces first a slight lowering of the blood pressure, and then gradually a marked increase. A renal turgescence usually followed the intravenous injection of pituitary ex- tract in dogs, cats, and rabbits. This was registered on the oncometer, and there was, as a rule, certain parallelism between its curve and that of the blood pressure. In the case of cats the diuretic effect of the extract after intravenous administration was marked. I emptied the bladder of a cat to which morphin and curara had been given, and noted that the viscus was refilled in a very short time after the injection of two centimeters of the extract. When emptied the second time, the organ was again rapidly refilled. In experiments on the extirpated arteries of cattle — the coronary, carotid, and femoral arteries — I found that a contraction takes place ; but in the case of the renal artery (periph- eral section) there is relaxation. A mydriatic effect is produced on the extirpated eye of the frog. These quotations show the trend of thought regarding the in- fluence of the pituitary body, hence in diseases of that gland (e. g., genital infantilism) we need to supply pituitary extract, and also use such general constitutional treatment as shall best keep the patient in good general health (i.e., symptomatic treatment). Bell (British Medical Journal, December 4, 1909) has used in- fundibular extract 1 in 1 c.c. doses with good results in postpartum hemorrhage, in intestinal paralysis, and in local conditions re- quiring a great rise in blood pressure. THE THYROID GLAND There are two types of pathological conditions connected with diseases of the thyroid gland. The first is an increase in the 1 Prepared by Burroughs, Wellcome & Co., of London. 344 DISORDERS OF THE GLANDS secretion of the gland producing nervous tremor, exophthalmos, etc., and the other is a decreased secretion of the gland producing thyroid myxedema, thickening of the skin, etc. The first is called hyperthyroidism and is a characteristic of Graves's disease; the second is hypothyroidism and is a characteristic of cretinism. In the former case measures must be taken, if possible, to de- crease the activity of the gland and to neutralize the effect of the excessive secretion. The first is usually accomplished by surgical means, the second by giving drugs that will antagonize the action of the thyroidin in the nervous system. Some good effects have been reported for this latter purpose by using thyroidectin, that is, the serum of thyroidectomized goats. The sedation of the sym- pathetic Aervous system may also be accomplished sometimes by the use of aconite (four drops of the tincture three times a day). Again, the tincture of digitalis to quiet the heart may be useful. But, in general, the best we can do will be to watch the individual symptoms day by day and counteract them by the appropriate drugs as they arise. Probably no two patients would require the same drugs. Forchheimer (pp. 434 et seq.) advises the routine administra- tion of quinin hydrobromate in doses of 0.3 gm. (gr. v) in gela- tin-coated pills four times a day. He adds ergotin, 0.065 gm. (gr. j), if the quinin does not show good results in forty-eight hours. In case of hypothyroidism (cretinism or myxedema) the ex- tract of the thyroid gland should be administered. The dose will vary from two to five grains pro die. It should be given on an empty stomach with water and under conditions that prevent its being broken up by the gastric juices. An interesting study of endemic goiter has been published by Robert McHarrison in the Quarterly Journal of Medicine for April, 1909. Herein the conclusion is reached that endemic goiter is due to living organisms taken in with the drinking water. Cures were effected by the use of intestinal antiseptics. For this pur- pose powdered thymol (ten grains night and morning) seemed particularly effective. CHAPTER IX DISORDERS OF METABOLISM GOUT Gout is evidently due to the inability of the excretory organs to free the body of the waste nitrogenous compounds. This may be due to an excessive supply of such bodies, or to a weakening of the excretory apparatus, or both; hence we find the disease in those who eat as if woodchoppers and yet live sedentary lives, and also in those who live in the cold and damp, thus inhibiting the excretory processes. Its causal treatment, therefore, consists in adjusting the pa- tient's life so that his food shall equal his ability to consume and excrete. To do this the excretory power of the kidneys should be studied day after day on diets containing various amounts of ni- trogen — measuring the urine and its contained nitrogen — until we find the limits of renal toleration. In some cases it would be necessary to raise the patient's mus- cular work in order to secure a complete combustion of the food consumed. In other cases it will be necessary to restrict the diet, limiting the meat and insisting upon a thorough mastication of the food taken. Alcohol and similar stimulants need to be prohibited in all gouty subjects. The symptomatic treatment of an attack follows the general lines. The painful joint is raised to a level with the rest of the body, anointed freely with guaiacol (fifty per cent in olive oil) and swathed in impermeable bandages. Morphin (J grain) or colchicin (-fa grain) is given hypodermically, and as soon as the patient's condition permits a free catharsis (calomel or salts) is brought about. The use of hot baths and massage to secure the absorption of the exudates is next in order. 345 346 DISORDERS OP METABOLISM As an illustrative dietary for a gouty subject we give here that of Porchheimer : Breakfast — Small cup black coffee, two eggs, crisp fried or broiled bacon, toast, fruit. Luncheon — Fish, oysters, vegetables, fruit, milk, bread. Dinner — Meat, vegetables, salad, fruit, bread. ARTHRITIS Inflammations of the joints are still very properly called " rheumatic," because we know nothing surely about their etiol- ogy and pathogenesis, hence the treatment is still empirical and symptomatic. Of the two chief theories on which methods of treatment are based, the one implies that the disorder is essentially an acidosis of the body fluids, the other that it is an infectious process; there- fore adherents of the former belief give alkalies in great quantity, those of the latter coal-tar antiseptics. The former theory suf- fered greatly in the downfall of the humoral pathology and in the rise of the cellular pathology and the germ theory of disease, but of late has secured added strength because the treatment based on it has seemed to succeed in cases where the salicylates and other coal tars have failed to cure. In general, then, we must admit that we have no specific or causal remedy for rheumatism, and must treat it essentially along symptomatic lines. The pain of the acute febrile arthritis requires immobilizing the joints and the application of heat. Thus we pack the joint in hot sand bags, or prop it up with soft pillows and apply the thermophore. The swelling and tenderness are greatly benefited by the in- unction of methyl salicylate (oil of wintergreen) in twenty -five- to fifty-per-cent olive-oil solution and then wrapping the joint with bandages of flannel or absorbent cotton, and covering with waxed paper or oiled silk to retain the heat. Or, if a thermophore is to be used, the oil may be applied gently directly to the skin and the light then turned on without the bandage. The systemic condition is most quickly influenced by giving ARTHRITIS 347 sodium salicylate in one-gram (fifteen grains) doses every two hours for eight doses. This should be discontinued sooner if the patient complains of ringing in the ears. When the patient cannot take sodium salicylate alone in pow- ders or capsules, we may sometimes succeed in giving it as a part of an effervescing mixture/ or we may Tiave to turn to acetphene- tidin or the other coal-tar analgesics. These have to be given in full doses and at frequent intervals to keep down the pain until the local treatment shall have had time to relieve it. When the condition has become more or less chronic we bring into play local hyperemia. For this we use by preference the local application of dry hot air for about forty-five minutes each day. The vacuum apparatus, when at hand, is also useful, but the latter is more often used for ankylosis than for the inflamma- tion itself; that is, it is specially adapted for assisting in bringing about a renewal of joint motion after the inflammation is past. During the fever of acute arthritis we must have the patient wear a bed gown or pyjamas of absorbent material, in order to avoid the discomfort from the clammy sweat and the real danger of his becoming chilled by his moist clothing. Alkaline washes (sodium-bicarbonate solution) sometimes assist in keeping the skin free from moisture and irritation. The skin of the groins and elsewhere where excoriations are liable to occur should be kept covered with a soothing powder (e.g., talcum). The diet needs to be very nutritious, although very digestible, for the patient develops rapidly an anemia if not kept to the highest point of nutrition. 1 Formula A (National Formulary). Fine Powder. Sodium salicylate, in fine powder 50 parts Saccharated sodium bicarbonate (N. F.) 475 " Saccharated tartaric acid (N. F.) 475 " Formula B. Granular Powder. Sodium salicylate in fine powder 50 parts Saccharated sodium bicarbonate (N. F.) 475 " Saccharated tartaric acid (N. F.) 237 . 5 " Saccharated citric acid (N. F.) 237 . 5 " One heaping teaspoonful equals about 0.3 gram or 5 grains. This powder will not entirely dissolve, but if taken while effervescing will carry the insoluble material along with the fluid. 348 DISORDERS OF METABOLISM To guard against the endocarditis, which arthritis often brings on, all patients suffering from inflammatory rheumatism must be kept from moving more than absolutely necessary, even though the attack seem very light. When the heart murmur is detected an ice bag should be applied to the chest at once and the regimen for heart disease instituted. The alkaline treatment referred to above calls for sufficient alkalies of one sort or another to keep the urine alkaline. Sodium and potassium citrate (1 to 2 grams every hour) are the favor- ite forms. But Garrod gave twenty grains of potassium bicarbonate every three to four hours, night and day, together with heavy doses of quinin, until the temperature dropped. Another variation is that of Puller, who dissolved ninety grains of sodium bicarbonate and thirty grains of potassium acetate in three ounces of water and added one ounce of lemon juice to render it effervescent. This was continued until the urine became alkaline. A compromise between the salicylate and alkaline methods is obtained by using doses of twenty grains of sodium salicylate and thirty grains of potassium bicarbonate, dissolved in two ounces of water, every two or three hours. This may be made effervescent by adding lemon juice or twenty grains of citric acid. When the temperature falls the dose of salicylate should be decreased to ten grains, and when the urine becomes alkaline the mixture should be given at longer intervals (Yeo). In obstinate cases of rheumatism bathing in hot sulphur water has given good results. But in default of the opportunity to give these the use of the hot-air cabinet or the electric-light bath will show improvement worth while. The most popular sulphur baths are those at Mt. Clemens, Mich., and Hot Springs, Ark. Massage and passive exercises, carefully regulated, are also beneficial. The physician should prescribe these as carefully as he does his drugs to see that the most good is done, or at least that no damage is done on account of ignorant zeal. Arthritis deformans must be treated along the lines of chronic rheumatism. In addition, the use of electricity and heavy doses of arsenic (e. g., arsacetin intramuscularly) will be needed to check the progress of the disorder. This is a matter of months; there- fore institutional treatment is advisable. Such treatment should DIABETES MELLITUS 349 include baths, passive movements, high-frequency currents, pleas- ant surroundings, and arsenic. DIABETES MELLITUS The problem of the treatment of diabetes mellitus will not be solved until we know more of its etiology. We know that it may be due to lesions in the pancreatic gland and also to lesions in the medulla. We believe that it may be caused also by exhausting the tolerance of the organism for sugar either by overindulgence in the ingestion of sugar or by some inefficiency in the work of the liver. We do not know the interaction between the thyroid and the pancreas well enough to evaluate the influence of the for- mer gland in glycosuria. Hence practically our present line of treatment is simply to raise the tolerance of the organism for sugars. This we seek to do by ascertaining the amount of carbohydrates any given patient may ingest without glycosuria, and then, by increasing the vigor of his body and carefully regulating the amount of carbohydrates in his food, seek to increase gradually the limit of tolerance until the patient may live a relatively normal life without glycosuria. The use of drugs, except to relieve particular symptoms, has been disappointing. This includes the opiates as well as the vari- ous glandular preparations, hence the drug treatment is practi- cally confined to the treatment of symptoms. The following items will serve as illustrations: The itching is usually relieved by simple local applications and by hot baths and massage to raise the skin resistance. In con- nection with such hot baths (e. g., the use of the hot-air cabinet) daily rubs should be taken with cold water. If vesicles and sores appear on the skin a dusting powder of calomel (ten per cent) and starch is usually sufficient to heal them if the systemic re- sistance can be raised. For the pruritus itself a menthol ointment (see Pruritus) is usually sufficient until the care of the skin brings about an improvement. The constipation is best relieved by the use of phenolphthalein with pancreatin and papain, the purpose being to stimulate in- creased peristalsis and at the same time an increased digestion of the food. Thus a capsule made up of one half to one grain of 350 DISORDERS OF METABOLISM phenolphthalein, two grains of pancreatin, and two grains of papain should be given two hours after meals. The thirst is relieved by the use of lemonade or other acidu- lated drink. The diet basis is meat, fats, and green vegetables. We must, of course, supply at least 2,000 calories of heat energy, and the animal economy will not permit us to supply this exclusively of protein. We may use fats freely up to the point where their pres- ence obstructs digestion. The accompanying tables, from the Bul- letins of the Agricultural Department of the United States Govern- ment, show the content of the various foodstuffs in carbohydrates: Table I Composition of Food Materials, Edible Portion Food Materials. average Meats, etc. Beef: Neck Chuck ribs " Ribs " Brisket Cross ribs Shoulder average Shin Plate Navel Sirloin average Socket Rump average Round " Leg Top of sirloin .■ Flank Fore quarter Hind quarter Side without kidney fat Liver Kidney Heart Tongue Kidney fat Marrow (leg bone) Veal: Shoulder. average Per cent. 62.0 58.0 48.1 47.4 43.9 63.9 73.8 44.4 47.6 60.0 57.1 48.2 68.2 72.1 42.2 27.4 54.1 55.7 54.8 Nutrients. Per cent. 38.0 42.0 51.9 52.6 56 36 26 55 52 40.0 42.9 51.8 31.8 27.9 57.8 72.6 45.9 44.3 45 30 24 43 36 68.831.220.2 Per cent, Per cent. 17.5 23.5 35.6 37.2 41.6 15.6 2.3 39.4 36.5 20.5 25.2 35.6 10.1 5.7 43.7 59.9 27.7 26.3 27.1 5.4 4.8 26.2 18.0 94.6 92.8 9.8 Per cent sa Per cent 1.0 0.9 0.9 0.8 0.8 1.0 1.2 0.8 0.8 1.0 1.0 0.8 1.2 1.2 0.8 0.7 0.9 0.9 0.9 1.5 1.2 1.0 1.1 0.2 1.3 1.2 »T3 > a — 50.7 38.7 55.2 54.7 53.5 51.8 56.2 56.7 64.7 54.8 55.1 60.9 57.9 52.7 67.4 74.6 50.3 72.2 69.3 72.0 72.5 66.2 69.6 68.6 62.7 73.8 58.1 49.8 52.8 58.6 84.0 12.1 41.5 41.2 62.4 61.3 47.8 45.3 46.5 48.2 43.8 43.3 35.3 45.2 44.9 39.1 42.1 47.3 32.6 25.4 49.7 41.9 50.2 47.2 41.4 16.0 87.9 58 5 58.8 37.6 Per cent. 18.1 14.2 18.4 16.2 18.3 15.0 15.8 17.0 16.9 16.9 17.5 19.2 17.5 18.9 19.0 18.1 18.9 18.6 24.2 18.3 21.5 16.0 24.4 22.3 21.2 24.7 23.9 22.9 17.2 21.7 14.9 Per cent 22.4 47.2 25.9 27.3 19.0 35.0 45.0 29.9 27.5 28.7 29 23 24.8 15.3 25.1 25.8 19.1 22.5 13.2 13.4 2.6 32 2.0 4.2 5.4 1.4 8.7 5.2 13.2 14.5 10.5 26.6 33.0 17.1 4.4 1.8 82.8 39.1 42.8 15.8 Per cent Per cent. 0.9 1.0 0.8 0.8 0.9 0.5 0.9 0.9 0.9 0.9 1.4 1.8 1.4 1.4 1.2 1.7 1.0 0.8 2.0 3.0 3.4 6.8 0.3 4.2 2.7 2.2 3.0 Calo- ries. 1,280 2,255 1,435 1,455 1,140 1,755 2,195 1,580 1,475 1,525 1,580 1,355 1,375 1,000 1.410 M25 1,155 1,295 1,155 905 510 1,680 540 635 620 520 810 655 875 1,015 720 1,370 1,655 1,220 745 335 3,510 1,960 2,065 1,015 352 DISORDERS OF METABOLISM Table I. — Composition of Food Materials, Edible Portion — (Continued) Food Materials. Fish, Shellfish, etc. Fresh Fish: Sturgeon Red horse Herring Alewif e average Shad " Smelt " Whitefish Cisco California salmon average Salmon " Lake trout " Brook trout " Pickerel " Pickerel, pike Muscalonge Eel, salt water average Mullet Mackerel average Spanish mackerel Pompano Bluefish Butterfish Black bass average Yellow perch " Wall-eyed pike Gray pike Striped bass White perch average Sea bass Grouper average Red snapper " Porgy Sheepshead " Red bass Kingfish Weakfish Blackfish average Hake Cusk Haddock average Cod " Tomcod Pollock Halibut average Turbot Flounder average Lamprey eel Skate Per cent. 78.7 78.6 69.0 74.4 70.6 79.2 69.8 76.1 63.6 63.6 69.1 77.7 79.7 79.8 76.3 71.6 74.9 73.4 68.1 72.8 78.5 70.0 76.7 79.3 79.7 80.8 77.7 75.7 79.3 79.4 78.5 75.0 75.6 81.6 79.2 79.0 79.1 83.1 82.0 81.7 82.6 81.5 76.0 75.4 71.4 84.2 71.1 82.2 Nutrients. Per cent 21.3 21.4 31.0 25.6 29.4 20.8 30 2 23.9 Per cent 18.0 17.9 18.5 19.2 18.6 17.3 22.1 19.1 17.4 Per cent. 1.9 2.3 11.0 4.9 9.5 1.8 6.5 3.6 17.9 21.6.13.4 18.211.4 19.0 18.6 18.6 19.6 19.3 19.3 >> . -Pa Per cent 26.6 18.2 31.9 27.2 21.5 30.0 23.3 20.7 20.3 19.2 22.3 24.3 20.7 20.6 21.5 25.0 24.4 18.4 20.8 21.0 20.9 16.9 18.0 18.3 17.4 18.5 24.0 24.6 28.6 15.8 28.9 17.8 20.6 18.6 19.0 17 20.4 18.7 18.4 17.3 18.3 19.0 18.8 18.9 19.2 18.5 19.5 16.7 18.7 17.4 18.5 15.2 16.9 16.8 15.8 17.1 21.7 18.3 2.1 0.5| 0.6 2.5 9.1 4.6 7.1 7.6 1.2 11.0 1.7 0.8 0.5 0.8 2.8 4.1 0.5 0.6 1.0 5.1 3.7 0.5 0.9 2.4 1.3 0.7 0.2 0.3 0.4 0.4 0.8 5.2 12.914.4 13. 9j 0.6 14.9 13.3 15.31 1.4 ^S Per cent 1.4 1.2 1.5 1.5 1.3 1.7 1. 1.2 1.1 1.4 1.3 1.3 1.2 1.0 1.6 1 1 1 1 1.0 1.3 1.2 1.2 1.2 1.4 1 W T3 cS O 1 1 1 1 1 1.3 1.4 1.2 1.2 1.2 1.2 1.1 1.0 0.9 1.2 1.2 1.0 1.5 1.1 1.3 1.3 0.7 1.1 Calo- ries. 415 430 810 565 745 400 685 505 1,080 965 820 440 365 370 470 725 555 640 790 665 405 795 450 380 365 355 460 525 370 375 400 560 520 230 385 425 400 310 325 325 310 335 440 560 850 285 840 345 DIABETES MELLITUS 353 Table I. — Composition of Food Materials, Edible Portion — (Continued) Food Materials. Fish, Shellfish, etc. — {Continued) Preserved Fish: Desiccated cod Salt cod average Boned cod Salt mackerel Smoked haddock Smoked halibut average Canned mackerel Canned salmon average Canned sardines Canned tunny Canned salt mackerel average Canned smoked haddock Shellfish, etc.: Oysters in shell average Oysters, "solids" " Canned oysters average Long clams from shell " Long clams, canned Round clams from shell Round clams, canned Scallops average Mussels from shell Lobster from shell average Lobster, canned " Crayfish Crab Crabs, canned average Shrimp Terrapin Green turtle Dairy Products. Milk Butter Cheese, full cream average Cheese, skim milk Oleomargarine Vegetable Foods. Potatoes average Sweet potatoes " Red beets " Turnips " Carrots " Onions " Squash, flesh " Pumpkin, flesh " Per cent. 2.9 23.0 21.5 10.6 0.2 12.9 1.9 1.0 Per cent. 15.2 53.6 54.3 42.2 72.5 49.4 68.2 61.9 56.4 72.7 43.4 .7 Nutrients. Per cent 81.9 23.4 24.2 47.2 25 37 29.9 37.1 43.6 27.3 46.3 25.7 12.9 12.8 14.7 14.2 15.5 13.8 017.0 319.7 2,15.8 8 18.2 7J22.3 2.18.8 1122.9 0|20.0 8 29.2 5 25.5 20.2 87.013.0 10.589.5 30.269.8 41.358.7 11.089.0 78.921.1 71.128.9 88.511.5 89.410.6 88.611.4 87.612.4 88.111.9 93.4 6.6 Per cent 74.6 21.4 22.2 22.1 23.7 20.6 19.9 20.1 25.3 21.5 17.3 21.8 6 1 6.3 7.4 8.7 14.6 18.7 17.0 17.8 16.5 25.6 21.0 18.5 3.6 1.0 28.3 38.4 0.6 1.1 1.4 0.9 0.9 Per cent. 1.9 0.4 0.3 22.6 0.2 15.1 8.7 15.7 12.7 4.1 26.3 2.3 1.2 1.6 2.1 1.0 1.3 0.4 0.8 0.2 1.1 1.9 1.1 0.5 2.0 1.5 1.0 3.5 0.5 4.0 85.0 35.5 6.8 85.0 0.1 0.4 0.1 0.2 0.4 0.3 Per cent a -» 4.7 0.5 1.8 8.9 0.4 17. 9i 26. 1 8.8 8.2 8.9 10.1 0.210.1 O.ll 4.9 Per cent. 5.4 1.6 1.7 2.5 1.5 2.0 1.3 1.3 5.6 1.7 2.6 1.6 2.0 0.9 1.3 2.6 2.3 2.7 2.8 1.4 1.9 1.7 2.5 1.3 3.1 2.0 2.6 1.0 1.2 0.7 3.0 4.2 4.6 3.0 1.0 1.0 1.1 1.0 1.0 0.6 0.7 0.7 Calo- ries. 1,470 410 425 1,365 450 1,020 735 1,035 1,005 575 1,430 505 230 260 300 240 275 215 285 345 285 350 395 335 415 370 520 540 365 325 3,615 2,070 1,165 3,605 375 530 195 185 205 225 215 110 354 DISORDERS OF METABOLISM Table I. — Composition of Food Materials, Edible Portion — (Continued) Food Materials. Vegetable Foods. — (Continued) Cucumber average Cabbage, entire " Cabbage, inner leaves " Cauliflower. " Lettuce " Spinach Rhubarb, stems Asparagus average Tomatoes " Green peas j String beans average Lima beans, green Okra Green sweet corn Egg plant Peas Peas, canned average Haricots, verts, canned " String beans, canned " Stringless beans, canned " Haricots flageolets, canned " Haricots panaches, canned Little green beans, canned Wax beans, canned Lima beans, canned average Baked beans, canned " Red kidney beans, canned Corn, canned average Artichokes, canned " Sweet potato Okra, canned average Brussels sprouts, canned Tomatoes, canned average Asparagus, canned " Pumpkin, canned " Squash, canned " Macedoine, canned " Succotash, canned " Mixed corn and tomatoes, can'd " Mixed okra and tomatoes, can'd " Apples, flesh " Cherries, flesh Strawberries average Blackberries Whortleberries Cranberries Grapes, Catawba Lemons average Per cent. 96.0 90.5 93.1 90.8 93.1 92.4 92.7 94.0 96.0 78.1 87.2 68.5 87.4 81.2 92.9 83.9 85.4 95.1 94.3 93.9 81.6 86.1 93.8 94.7 79.7 67.2 72.7 75.4 92.5 68.4 94.4 93.8 93.7 94.4 92.7 86.6 93.1 76.2 Nutrients. Per cent. 4.0 9.5 6.9 9.2 6.9 7.6 7.3 6.0 4.0 21.9 12.8 31.5 12.6 18.8 7.1 16.1 14.6 4.9 5.7 6.1 18.4 13.9 6.2 5.3 20.3 32.8 27.3 24.6 7.5 31.6 5.6 6.2 6.3 5.6 7.3 13.4 6.9 23.8 87.512.5 91.8 83.2 86.1 90.8 88.9 8.2 16.8 13.9 9.2 11.1 82.417.6 87.612.4 74.825.2 89.3,10.7 Per cent 0.8 2.4 1.5 1.6 1.6 2.1 0.8 1.8 0.8 4.4 2.2 7 2 2 1 3 1 1 4 3 1 1 4 7 7 2.8 0.8 1.3 0.7 1.5 1.3 1.5 0.7 0.5 1.3 3.5 1.7 1.2 0.3 1.1 1.0 0.9 0.7 0.4 1.6 1,0 Per cent. 0.2 0.4 0.2 0.8 0.5 0.5 1.2 0.2 0.4 0.5 0.4 0.7 0.4 1.1 0.3 0.8 0.2 0.1 0.1 0.1 0.1 o.i 0.2 1.3 0.3 0.1 1.0 0.2 0.1 0.1 0.3 0.9 0.4 0.2 0.4 0.8 0.7 2.1 3.0 0.9 1.7 0.9 ■eg Per cent. 2.5 5.3 4.6 5.0 3.7 3.1 4.4 3.3 2.5 16.1 9.5 22.0 9.5 14.2 5.1 14.2 9.7 2.6 3.5 3.5 12.5 9.2 3.4 3.0 14.4 20.3 18.5 19.6 5.0 29.2 3.6 3.4 4.2 2.8 6 12 4 18 9 5 15.9 11.4 6.9 7.5 13.5 10.9 21.3 8.3 £S Per cent. 0.5 1.4 0.6 0.8 1.1 1.9 0.9 0.7 0.3 0.9 0.7 1.7 0.7 0.7 0.5 0.5 1.1 1.1 1.2 1.4 1.2 1.0 1.5 1.2 1.6 2.2 1.6 0.9 1.7 0.8 1.2 1.3 0.6 1.2 0.5 0.4 1.0 0.9 0.9 1.6 0.2 0.6 0.6 0.6 0.4 0.2 0.6 0.5 Calo- ries. DIABETES MELLITUS 355 Table I. — Composition of Food Materials, Edible Portion — (Continued) Food Materials. Nutrients. 2S IS Vegetable Foods. — {Continued) Banana, pulp Pineapple Watermelon, flesh or pulp Nutmeg melon, flesh or pulp Rice average Beans, dried " Maize meal " White hominy " Oatmeal " Pearl barley Rye flour average Wheat " Graham flour " Entire wheat flour " Cracked wheat " Buckwheat flour " Buckwheat farina " Buckwheat groats Wheat bread average Graham bread Rye bread Boston crackers Soda crackers Pilot (bread) crackers Oyster crackers Oatmeal crackers Graham crackers Starch Sugar, granulated Molasses Per cent. 66.3 89.3 91.9 76.4 12.4 12.6 15.0 13.5 7.8 11.8 13.1 12.5 13.1 13.0 10.4 14.6 11.2 10.6 32.3 34.2 30.0 8.3 8.0 7.9 3.9 4.9 5.0 2.0 2.0 24.6 Per cent. 33.7 10.7 8.1 23.6 87.6 87.4 85.0 .5 92.2 88.2 86.9 87.5 86.9 87.0 89.6 85.4 .8 .4 67.7 65.8 70.0 91.7 92.0 92.1 96.1 95.1 95.0 98.0 98.0 75.4 Per cent. 1.4 0.4 0.9 1.4 7.4 23.1 9.2 8 14 6 11 11 13.6 11.9 6.9 3.3 4.8 8.8 9.5 8.4 10.7 10.3 12.4 11.3 10.4 9.8 Per cent. 1.4 0.3 0.7 0.2 0.4 2.0 3.8 0.4 7.1 0.7 0.8 1.1 1 2 1 1 0.6 1.7 1.4 0.5 9.9 9.4 4.4 4.8 13.7 13.6 Per cent. 29.8 9.7 6.2 20.5 79.4 59.2 70.6 77.4 68.4 78.1 78.7 74.9 71.7 70.0 74.6 76.1 84.8 83.4 56.3 53.3 59.7 68.7 70.5 74.2 77.5 69.6 69.7 97.8 97.8 73.1 Per cent. 1.1 0.3 0.3 1.5 0.4 1 4 4 7 5 8 4 4 4 6 0.9 1.6 1.4 2.4 1.8 1.1 2.5 Calo- ries. 640 200 160 415 1,630 1,615 1,645 1,620 1,845 1,635 1,625 1,645 1,625 1,640 1,680 1,605 1,650 1,665 1,280 1,225 1,285 1,895 1,900 1,795 1,855 2,035 2,050 1,820 1,820 1,360 To establish the tolerance for sugars we may adopt the method of Von Noorden, which is somewhat as follows : At 7.30 a.m., before breakfast, the patient urinates and the urine is thrown out. Then he takes for breakfast a cup of black coffee with perhaps a raw egg stirred up in it. Then at ten o'clock he urinates and a sample of the urine is used for qualitative analysis. This analysis is imme- diately made, for upon it depends all further procedure. If it contains no sugar or diacetic acid (iron-chlorid test) then we pre- scribe a diet for the day that shall contain 100 grams of bread or 500 grams of milk. Thus, as soon as the result of the test is learned, black coffee, 1 to 2 eggs or meat, with 30 grams of bread. 356 DISORDERS OF METABOLISM At noon— Bouillon with egg, 200 to 250 grams meat or fish, green vegetables, such as spinach, lettuce, cabbage, cauliflower, etc., prepared without flour, and 40 grams of bread, buttered ad libitum, and 20 to 30 grams of cheese. At 4 p.m. — Coffee or tea and an egg. At 6 p.m.— Meat or fish, with green vegetables, and 30 grams bread with butter. If milk be used instead of bread as the test food containing carbohydrates, it should be divided up among the various meals. No alcoholic drinks should be taken during these tests. The entire urine passed during the day, including that passed at ten o'clock and that passed next morning up to 8 a.m., should be carefully collected and measured. From this a sample should be taken for quantitative tests. If in this second examination sugar be found in the urine, the amount of bread for the succeeding day must be decreased to 50 grams (or 200 c.c. milk) and the meals ordered as on the preced- ing day. If, on the other hand, no sugar is found, then the quantity of carbohydrate added to the diet may be increased, say by 20 grams of bread, and so on, until sugar appear in the urine. This establishes the threshold of tolerance. Now, returning to the ten o'clock sample examined on the first day: If sugar be present, then the day's rations should include only 50 grams of white bread. If even this produce sugar, a smaller quantity should be tried the next day. If the first test show a positive iron-chlorid reaction, then the treatment for acidosis should be at once undertaken. This con- sists in giving 15 to 20 grams of sodium bicarbonate pro die, dis- tributed as is most convenient. The diet during the giving of the alkali may be the same as if the acidosis were not present, with this exception — that the amount of protein should be restricted. The general rule for the giving of carbohydrates is that the total daily amount should be below the threshold of tolerance. For instance, when the giving of 120 grams of protein produces sugar in the urine, the amount allowed should not exceed 80 grams. In the bad cases, where there is little or no tolerance for sugar, DIABETES MELLITUS 357 the diet should be selected from foods that contain at the most only a trace of carbohydrate. Thus Liithje recommends as an illustrative dietary: 200 c.c. of cream. 6 eggs. 100 grams of butter. 50 grams of cheese. 50 grams of ham. 50 grams of pork. 100 grams of spinach. 200 grams of veal. 50 grams of green salad (lettuce) . 200 grams of roast beef. 500 c.c. of bouillon. And, in addition, tea, coffee, or mineral waters as beverage. This affords some 3,000 calories of heat energy. If even on such a restricted diet as the above sugar is still present in the urine, the amount of protein should be cut down. The limit to which the protein may be reduced is seventy to eighty grams a day. It is just such cases that show an intolerance for sugars derived from protein, but are able to take some carbo- hydrate sugar. In such severe cases it is well to introduce frequently vegetable days; that is, days on which only vegetables and fats are given. If, however, it is impracticable to use only vegetables and fats, two or three eggs may be introduced into the dietary. Thus we may give for such a " vegetable day " (Liithje) : 8 a.m. — Asparagus with 50 grams of butter. 10 a.m. — Spinach with 50 grams of butter. 1 p.m. — Red cabbage (rotkraut) with 50 grams of butter. 4 p.m. — Cabbage with 50 grams of butter. 7 p.m. — Cauliflower with 50 grams of butter. These vegetables may be salted to suit the taste. Even sour wine may be added to the regularly permitted beverages (coffee, tea, mineral water). Opium (tincture) in small doses overcomes any tendency to diarrhea in using such a diet. 358 DISORDERS OF METABOLISM Another interruption to the monotony of the strict diet may be obtained by introducing in between the vegetable days, days on which oatmeal is practically the only food. Thus von Noorden gives 250 grams of oatmeal, distributed through the day at two-hour intervals, in the form of soup or porridge. The " soup " is made by having 50 grams of oatmeal boiled with 1 liter of water (or lightly salted bouillon) for forty minutes, then rubbed through a sieve. Salt and beef broth may be added to suit the taste. The porridge is made by adding 50 grams of oatmeal to sufficient cold water, gently boiling for thirty to forty minutes, adding 30 to 50 grams of butter, and salting to suit the taste. The porridge is eaten with cream or cranberry sauce. The beverages are as on other days. Three or four such oatmeal days may be given in succession. As an illustration of this procedure we quote the following tabulation from the case history of a fifteen-year-old girl (who had been sick for three months when she came into treatment) from Liithje (" Handbuch d. Therapie," Vol. II, pages 76-77) : Absolute Ace- tone. o ^s Date. Quantity of urine. quantity of sugar Diet. ■c o Remarks. in urine. g- £ December 250 ccm. milk 1908 900 50 g. ham 12-13 incomplete 1,500 30.6 33.5 0.47 50 g. white bread Strict diet 250 13-14 22.5 35.3 1.85 2,187 35.8 3X5.0 g. Sod. bicarb. 14-15 1,000 l 17.5 24.2 1.81 (< 1,971 .... ii 15-16 1,500 28.5 32.7 1.65 «< 2,584 35.8 a 16-17 1,800 30.6 42.3 2.52 " 3,038.... 2X15 Gtt. Tct. opii+do. 2X10 Gtt. Tct. 17-18 700 3.5 7.7 0.68 Vegetable day 1,095 36.5 | opii+do. 18-19 1,800 22.5 30.4 2.17 Strict diet 2,675 36.9 " 19-20 1,900 30.4 44.1 3.04 " 3,067.... tt 20-21 900 0.4 7.8 1.58 Vegetable day 1,512 .... 5X10 Gtt. Tct. opii+do. 21-22 1,000 1.0 1.03 a 2,008 36.1 " 22-23 1,500 1.2 0.79 a 2,352 37.0 3X5.0 g. Sod. bicarb. 23-24 1,500 0.96 CI 2,747 37.6 n 24-25 1,700 1.02 Strict diet 2,873 37.6 " 25-26 2,000 18.0 25.0 2.10| 2,354 37.8 a 26-27 18,00 27.0 34.2 1.32 n 2,250 37.2 a 1 Some urine lost. DIABETES MELLITUS 359 Date. Quantity of urine. Absolute quantity of sugar Ace- tone. Diet. "S jo XI Remarks. in urine. g- O £ December 1908 27-28 1,300 12.3 17.9 1.17 Oatmeal day 3,814 36.5 3X5.0 g. Sod. bicarb. 28-29 1,400 24.5 26.6 0.29 tt 3,778 36.9 tt 29-30 1,400 39.9 ? 0.16 tt 4,012 37.5 tt 30-31 1,900 7.6 8.0 0.11 Strict diet 1,568 38.3 tt 31 to 1909 Jan. 1 1,800 29.7 33.4 0.64 tt 1,496 38.0 " 1-2 1,200 7.8 13.5 0.96 " 1,736 38.0 n 2-3 1,600 8.0 13.1 0.86 ft 1,540 37.3 n 3-4 1,700 2.5 ? 0.37 tt 1,540 37.2 " 4-5 1,800 6.3 8.4 0.50 tt 1,580 37.4 a 5-6 1,700 24.6 28.2 0.85 tt 1,434 37.7 tt 6-7 1,800 14.4 19.0 0.82 tt 1,450 38.0 it 7-8 1,900 7.6 12.6 0.07 tt 1,500 37.8 tt 8-9 1,550 8.5 13.4 0.55 tt 1,513 38.5 " 9-10 2,100 28.3 31.3 0.79 tt 1,913 37.8 tt 10-11 1,600 17.6 24.6 0.52 " 2,180 38.2 it 11-12 1,600 14.4 17.2 1.36 tt 2,019 38.4 tt 12-13 1,200 3.0 0.64 Vegetable day 1,888 39.2 " 13-14 1,800 1.8 1.09 u 2,112 39.2 " 14-15 2,100 0.86 u 2,019 38.4 it 15-16 1,800 0.46 Strict diet 1,824 39.1 it 16-17 1,700 1.60 2,275 39.2 3X15 Gtt. Tct. opii 17-18 9 a.m. 253 10 A.M. 150 from 10-8 o'clock 4.0 2.8 2,000 34.8 32.0 0.44 Oatmeal day 3,488 39.8 tt 18-19 2,100 42.0 45.2 0.27 " 3,587 40.6 tt 19-20 2,800 8-10 o'clock 28.0 30.4 0.11 tt 3,619 40.6 tt 20-21 600 2.4 2.3 1,600 1.00 Vegetable day 2,073 39.6 tt 21-22 1,200 0.13 " 2,167 39.7 ft 22-23 1,700 10.2 14.4 0.69 Strict diet 1,946 40.0 tt 23-24 1,800 14.4 33.3 1.27 tt 2,138 39.5 " 24-25 1,300 0.10 a 2,175 40.0 ft 25-26 1,300 1.19 " 1,570 39.8 ft 26-27 1,400 1.06 it 1,570 39.5 3X15 Gtt. Tct opii 15 g. Sod. bicarb. 27-28 1,400 1.19 tt 1,570 39.8 tt 28-29 1,500 ? Vegetable day 2,250 40.1 tt 29-30 1,600 0.3 " 2,100 40.3 tt 30-31 1,700 0.56 ' Oatmeal day 3,580 41.0 tt 31 to Feb. 1 2,100 14.7 26.0 0.12 tt 3,400 41.7 tt 1-2 1,900 0.07 3,450 42.2 ft 2-3 2,600 1 Vegetable day 2,100 41.4 tt 360 DISORDERS OF METABOLISM Date. Quantity of urine. Absolute quantity of sugar in urine. Ace- tone g. Diet. m 'u o "3 O XI . Remarks. February 1909 3-4 1,700 0.22 Vegetable day- 2,160 40.7 3 X 15Gtt. Tct. opii 15 g. Sod. bicarb. 4-5 2,200 spur Strict diet 1,465 40.5 << 5-6 1,900 0.4 " 1,510 40.7 « 10 g. white bread 6-7 1,900 0.66 Strict diet 20 g white bread 1,535 40.5 «« 8-9 1,800 0.9 Strict diet 1,535 40.4 20 g. white bread 8-9 1,600 0.9 Strict diet 1,535 4] 20 g. white bread Transient glycosuria in young people should receive respectful attention and the diet carefully regulated for a year or two. If possible, its causation should be worked out and the patient's life arranged accordingly. The psychic or nervous form of glycosuria should be carefully differentiated. The cure is usually along psychotherapeutic lines, which, of course, include a regulation of the patient's activities and food to bring them within hygienic limits. These cases fur- nish the mass of the testimonials of quacks. When there is pancreatic insufficiency (steatorrhea, azotor- rhea), pancreatin should be given with calcium carbonate. The drugs should be given in larger doses than are usually found in the ready-made tablets of the pharmaceutical houses. For in- stance, forty-five grains each of pancreatin and calcium carbonate may be given three times a day, best in salol-covered capsules, two to three hours after food. Rarely the kidneys seem to be at fault and give a glycosuria when there is little or no sugar in the blood (hypoglycemia). These cases must be put on a very restricted diet, and special at- tention paid to the presence in the food of creatinin, phosphoric acid, and other renal irritants. RICKETS 361 The complication of diabetes with tuberculosis is almost hope- less. In such cases the diet should be regulated to give the great- est nourishment with the least hyperglycemia. The egg and meat and fat (oils, butter) diet, with the interpolation of vegetable and oatmeal days, afford the best prospect of comfort to the patient. In cases of gout and obesity, both the glycosuria and the other troubles will be benefited by ordering as much open-air exercises as possible. For glycosuria is usually distinctly benefited by con- siderable muscular activity. RICKETS Rickets is a disease of metabolism or nutrition in which the growing bones show the greatest changes, hence measures to secure a greater absorption of the bone constituents are to be taken at the outset. The first of these seems to be the ingestion of larger quantities of sodium chlorid, the next seems to be the supplying of phosphorus; then follows the stimulant action of cool or cold sea-water baths, accompanied by careful rubbing and good hy- gienic living. The salt is, of course, supplied with the food by simply in- creasing its quantity therein. The phosphorus is supplied in a drug mixture of which the fol- lowing is an illustration : Phosphori 0.01 gr. T V ; Olei olivas 5.0 T!X 1 ; Pulv. acaciae Sacch. albi aa 10.0 gr. c ; Aquge 75.0 gjss. One half to one teaspoonful t. i. d. (Kassowitz). Or cod-liver oil may be combined with the phosphorus, e. g. : Phosphori 0.01 gms. Olei jecoris aselli 100.0 c.c. One half to one teaspoonful t. i. d. The salt baths may be made as strong as one half per cent of rock salt for older children. For the nurslings they must, of course, be much weaker. 362 DISORDERS OF METABOLISM The patient should not remain long in the bath, but should be put into the tub with the water just cool enough to be stimulating. The water should be thoroughly splashed over and against the body and the child taken out and dried with gentle friction. Deformities are to be prevented by keeping the patient from using his body vigorously; hence he should be kept on a cot (in the open air most of the time) until the bones show firmness. Laryngospasm must be watched for and the child prevented from making its condition worse by excitement or struggle. The use of the bromids in nervous children, is therefore justified. At any rate, the attendants must be schooled to avoid doing anything to excite or frighten the child. CHAPTER IX INFECTIOUS DISEASES GENERAL CONSIDERATIONS The self-limited infectious diseases demand in some respects similar treatment without regard to the specific causal organism; for in a few we have some more or less causal therapy, but in the majority the treatment is largely expectant and symptomatic ; but in all these diseases isolation and precautions against spreading the disease are to be considered of primary importance. We shall here mention a few of the more important regulations applicable to the whole group. The sick room needs to be well lighted and ventilated. Its tem- perature needs to be maintained equably at 65° to 70° F. Ordinary ventilation is usually inadequate and the windows must be used to increase the interchange of air. The clothing and utensils and dishes used about the patient must be sterilized before they are put with the family supplies. Clothing may be soaked in hot crude carbolic-acid solution (four fluid ounces to the gallon), or, better, in a five-per-cent liq. cresolis comp., for thirty minutes before being put into the family wash (provided that the whole wash is thoroughly boiled; otherwise they must be boiled separately). Nonwashable clothing should be fumigated with formaldehyd in a closed room for twenty-four hours. Dishes and similar apparatus should be thrown into boil- ing water before being handled by the servants or members of the family. Even the attendant's clothing should be considered in- fectious and kept separate until disinfected. In all these diseases the care of the skin forms an important part of the treatment. When there are eruptions inunction with an antiseptic oil after the daily soap- and tepid-water bath is called for. When there are no eruptions cool rubs in addition 363 364 INFECTIOUS DISEASES to the cleansing baths are used to stimulate the skin and the vasomotor system. The intestinal canal must be kept free from fermenting putre- fying masses. In cases where the intestinal tract is the seat of the lesions only the very gentlest cathartics may be used, and the main dependence for emptying the bowel must be placed on ene- mata. In diseases other than those affecting the intestine it is rather immaterial which cathartic is used. In such cases the pa- tient's whims may be followed. The gentlest cathartic for infec- tious diseases is usually calomel, given in doses of one tenth to one fourth grain at hourly intervals until a grain or two has been given. For the initial catharsis Epsom salts (magnesium sulphate) in one-half- to one-ounce doses seems satisfactory. The more con- centrated the solution of these salts the more vigorous is the cathartic action. For convalescents the familiar Hinkle 's tablet * has proven very satisfactory. These may be given once, twice, or three times a day, as needed. Phenolphthalein does not seem to be satisfactory for this sort of work. Headache and backache are usually treated by giving the coal- tar analgesics, though in many fevers the diaphoretic Dover's powder, in five- to ten-grain doses, is preferred. Diarrhea in these disorders is treated usually with opium (ten to fifteen drops of the tincture), but where the intestine is con- gested the tannin albuminates (fifteen-grain doses) are preferable. In all these infectious diseases the care of the teeth and mouth should be looked after by the physician. He should see to it that the nurse brushes the teeth and cleanses the mouth with hydrogen peroxid or the alkaline antiseptic fluid (of the National Formu- lary) two or three times a day. In general the food should be liquid. Milk is the best base. Broths, bouillons, unfermented grape juice, eggnogs, etc., are all useful in keeping the peristalsis active and the mucosa of the in- testine free from debris. On the other hand, they are not liable 1 ]$ Cascarin £ gr. Aloin \ Ext. belladonna leaves £ Oleoresin ginger tV Strychnin sulphate /o Podophyllum resin £ BACILLARY DYSENTERY 365 to injure inflamed surfaces or set up indigestion. The first solid food for the convalescent may be scraped steak. If this goes well, oven-dried toast may be added; then it will be proper to give a mealy baked potato. Following this, cooked fruits and other solids may be added according to the appetite of the patient and the doctor's wishes. Because in fever there is already increased tissue consumption, patients should be kept quiet even if they do not appreciate the need of the bed rest. The recovery after the periods of full rest are more rapid and complete than when the patient has been al- lowed to move about. In the following paragraphs we name practically only those diseases for which there is some peculiar line of treatment to be given. The rest of the infectious disorders may be treated symp- tomatically according to the principles laid down in our discussion of symptomatic therapeutics. ACTINOMYCOSIS Actinomycosis requires, besides the regular symptomatic treat- ment, surgical treatment whenever possible. When it is not pos- sible to reach the growths, the iodid of potash should be given in solution in doses of fifteen to twenty grains three times a day. An illustrative prescription follows: I£ Potassii iodidi 22 grams ; Elixir, gentianag glycerinati (N. F.) . . . . 180 c.c. Sig. One dessertspoonful t. i. d. with or after food. ANTHRAX The treatment differs from that of other infective diseases in that wherever possible the malignant pustules should be burned out with the cautery or injected with carbolic acid or bichlorid of mercury. The rest of the treatment is purely symptomatic. BACILLARY DYSENTERY The first duty of the physician is to free the intestine of as much of the putrefying and fermenting masses as possible. This 366 INFECTIOUS DISEASES is best accomplished by giving magnesium sulphate in ounce doses until the stools become less offensive. The next step is to use some drug that will inhibit the bac- teria still remaining in the colon. For this ipecac seems the most successful. Forty to sixty grains of this drug in pills covered with salol are administered daily on an empty stomach (see Amebic Dysentery). If necessary, laudanum or morphin is given before- hand. The dose is gradually decreased on the succeeding days. Where it may be well done, high colonic injections of quinin bisulphate (1:500 to 1:1,000) should be used daily. If the anus and rectum be tender a preliminary anesthetizing of the rectum should be done with quinin or cocain or belladonna. The tube should be inserted with the water flowing and slowly pushed up until it is past the sigmoid flexure. Nitrate of silver may also be used for the irrigating solution in the strength of one or two grains to the ounce. The diet must be nonirritating and of the kind to be absorbed in the upper intestine, thus milk and eggs should be its chief con- stituents. If curds appear the food should be peptonized. Shiga's serum may be used, but its results show that it is not at all specific, hence we must for the time being depend upon the above line of treatment. CHICKEN POX Chicken pox requires no special treatment. The principles governing the treatment of infectious diseases are sufficient to guide the student here. The mouth and the itching need looking after according to the principles used in all infections, that is, the former should be thoroughly cleansed twice or thrice daily with an alkaline antiseptic or with hydrogen peroxid, and the skin kept comfortable with a mentholated oil. CHOLERA For this disease we have both a serum (Gaffky, Kitasato) and a vaccine (Haffkine's). We immunize with the latter, we combat the established disease with the former. The success of both pro- cedures has been called into question, but doubtless continued CHOLERA 367 experimentation will perfect both products until we can see as good results here as with diphtheria. In the present state of affairs, we should in case of need use the vaccine or serum if it be available, but place our reliance on the symptomatic pro- cedures. The disease is hardly more infective than typhoid, hence under careful supervision it ought not to spread rapidly. The precau- tions to be observed to prevent the spread of the disease are enu- merated thus by Tyson: (1) The vomited matter and the discharges from the bowels are to be gathered in carbolic solution (1 to 20) or chlorinated lime (1 to 10), some of which should be in the vessels before it is used; after use, more should be added. The matter thus collected should be gently stirred and allowed to remain twenty minutes before being poured into the water-closet hopper. When the ex- creta can be thrown into a pit, or even, as may be done in the country, on a manure pile, milk of lime, or what is the same thing, ordinary whitewash, is a very efficient and cheap medium with which to disinfect them. (2) After vomiting, the mouth of the patient should be rinsed with a solution of hydronaphthol (1 to 5,000), care being taken that none is swallowed. After each evacuation from the bowels, the buttocks, thighs, and anus should be washed with soap and water. (3) All body and bed linen soiled with the discharges should be immediately moistened with carbolic solution (1 to 60) and removed in a covered vessel from the apartment, placed in a wash- boiler, and boiled for half an hour in a one-per-cent solution of washing soda. (4) Napkins, towels, and table linen should be placed in a similar vessel or canvas bag for removal and similarly boiled. (5) All dishes, knives, forks, spoons, etc., used by the patient should be boiled after each meal in a one-per-cent solution of soda. (6) The remains of meals should be thrown into a vessel con- taining milk of lime or whitewash, and removed at the end of the day. (7) Door knobs are liable to be soiled by the hands of one car- rying out excreta, and should be carefully washed and cleansed and 25 368 INFECTIOUS DISEASES sterilized lest they, in turn, communicate the infectious material to another person handling them. (8) In case of death, the body, without being washed, should be wrapped in sheets wet in a solution of bichlorid of mercury (1 to 1,000) and allowed to remain until removed for prompt burial. Special Directions to Nurses. — (1) Nurses of cholera patients should not hold any direct communication with others during at- tendance on such cases. (2) They should under no circumstances take their meals in the same apartment with the patient, and before leaving the room the hands should be cleansed with soap and bichlorid solution and such portion of the dress as is liable to be soiled should be changed. The hands should be again rinsed in bichlorid solution (1 to 100) after leaving the patient's room. A very convenient plan is to wear a slip or " overall " with a hood to cover the hair, which can be easily thrown aside before leaving the room. A canvas slipper or overshoe, readily removed, should always be worn in the sick room. (3) The food of the nurse should be wholesome and plain, freshly cooked, and served hot. No uncooked vegetables should be eaten. Milk should be boiled and, if desired, cooled before using. Cold drinks should be taken moderately, if at all. Coffee and tea may be taken hot. (4) The teeth should be cleansed after each meal, as the mouth affords peculiarly favorable nidus for decomposing matters and for the multiplication of pathogenic fungi. A daily bath in warm water with the use of soap should be taken by each nurse. (5) Care should be observed to keep the body from being chilled by draughts or other cool exposures, and to this end woolen underclothing should be worn. (6) Courage and cheerfulness are amply justified, because it is really almost impossible to take cholera if the above precau- tions are carried out. The pains and beginning diarrhea are treated by subcutaneous injections or morphin in full doses. The collapse is treated by giving hot drinks and applying ex- ternal heat. A patient may be put into a tub of hot water (110° to 120° F.) and left fifteen minutes to overcome the severe lowering YELLOW FEVER 369 of the body temperature. If this does not succeed, subcutaneous and intravenous injections of sterile salt solution at 107° F. should be resorted to. The vomiting should be treated by gastric lavage with hot water, by the giving of cocain (one fourth grain) or other gastric sedative. The colitis requires colonic irrigation; one to two quarts of a one-per-cent solution of tannic acid will precipitate the vibrios as well as constrict the mucous membrane. YELLOW FEVER We are not yet in a position to give more than simple symp- tomatic treatment for this disease. Our first duty is to remove the patient to an uninfected, isolated room. Then both the bed and the room should be thoroughly screened, for to prevent the spread of the disease we have chiefly to guard against the presence and bites of the stegomyia mos- quito, hence we cannot be too careful with our fumigation and screening. We must rely chiefly upon good nursing to bring the patient through the attack. This will be shown chiefly in the giving of baths, and rubs to promote sweating and the elimination through the skin of the toxins of the disease. The pains and backache are helped by acetphenetidin and quinin bisulphate, each in five-grain doses, repeated as needed (e. g., every three or four hours). The vomiting may be helped by swallowing small pieces of ice, by acidulated drinks, by belladonna, or by cocain. The hemorrhages are treated by ergotoxin or adrenalin subcu- taneously. The heart is kept even by camphor, caffein, or digitalis, accord- ing to whether it is a vasomotor or myocardial weakness. Nourishment may be given by the rectum, and should always be so given when there is gastric irritation. In short, we follow the principles laid down for symptomatic treatment throughout. The patient should be allowed to drink freely. In a comatose stage one should resort to hot baths, hot packs, 370 INFECTIOUS DISEASES mustard baths, etc., to rouse the skin circulation. At the same time hot drinks should be given and the administration of normal salt solution by hypodermoclysis pushed to the limit. If the patient recovers he should be carefully watched to pre- vent dietetic errors. He should be given bitter tonics and light cathartics to stimulate the digestive tract. Massage and salt baths will also assist him to regain his strength. ERYSIPELAS Erysipelas is usually self-limited, but the resistance of some patients is so low that there is little or no systemic immunity de- veloped, and the disease continues for weeks, spreading from one part of the body to another, hence the expectant plan of treatment cannot be adopted in all cases. The aggressive treatment is by means of the antistreptococcic serum. The more polyvalent the serum the greater the likelihood of success. This should be introduced in doses of 20 to 30 c.c. at eight- to twelve-hour intervals until the spread of the disease is checked. When possible, the injections should be made into the inflamed area. The symptomatic treatment consists in relieving the local dis- comfort and in stimulating the vital functions. The first is ac- complished by applying a thick paste over the inflamed surface. Unna's jelly is excellent, but good results may be obtained by using vaselin and ichthyol in equal parts. The second is obtained by keeping the bowels active and the bodily functions well stimu- lated. The following prescription may serve to illustrate the treatment : •^ Tct. nucis vomica? 5.0 c.c. Hexamethylenaminee 4.0 grams. Fl. ext. cascarse sag 1.0 c.c. Elixiris aromatici 40.0 ' ' One teaspoonful t. i. d. Collapse must be watched for and guarded against. In laryn- geal involvement one must be ready to intubate or perform tracheotomy. HYDROPHOBIA 371 Erysipelas is extremely infectious and must be thoroughly iso- lated. It is particularly dangerous for a doctor to. treat erysipelas and at the same time try to do obstetric service. Likewise the nurse must thoroughly disinfect herself and her clothing before she goes to another case. GLANDERS Whenever possible, the cleaning out of the local infection should be practised; otherwise the treatment is symptomatic. HYDROPHOBIA Rabies is an acute, specific, rapidly fatal malady communicated to man from some lower animal. It is always an inoculation disease, that is, communicated directly through a wound, usually made by the teeth, the infective matter being the saliva, which contains the virus. The dog is, by far, the most frequent source of rabies not only for man, but for all other animals. The bites of other rabid animals, includ- ing cats, wolves, foxes, horses, cattle, etc., are, however, quite as dan- gerous as that of the dog. Rabies may also be transmitted by deposits of saliva, containing the virus, on abraded surfaces, as by licking; or through wounds received in making autopsies on persons or animals who have succumbed to the disease. The saliva of the dog has been shown to be virulent twenty-four to forty-eight hours before the animal exhibits any symptoms of illness. Therefore, if a person is bitten by an animal which develops rabies later, it is advisable to take the treatment as a protective measure. The bite of any suspicious animal should receive prompt attention. The invariable rule must be to cauterize as soon as possible, and in the meantime do everything possible to get the virus out of the wound and prevent absorption. Open the wound freely and bathe abundantly with tepid water, if convenient. If the wound is on the limb, a ligature may be applied above the site. Fuming nitric acid is the best cauterizing agent for this purpose. If nitric acid is not available, the actual cautery, carbolic acid, or lunar caustic may be used, though the two latter will coagulate the albumen of the tissues and therefore will not deeply pene- trate. The importance of early and thorough cauterization cannot be overstated. This should never be neglected, since it retards the develop- ment of the disease, and thus renders the Pasteur treatment more cer- tain of effect. It must be borne in mind that the Pasteur treatment is a 372 INFECTIOUS DISEASES preventive, or immunizing, treatment, and that there is no known cure for rabies. Therefore it is very important that the treatment be begun as. soon as possible after the infliction of the bite or wound. When a person is bitten by an animal suspected of having rabies, the animal should not be killed, but be kept securely confined. If the ani- mal has rabies, it will die within a few days showing symptoms of the disease. On the other hand, if the animal has already been killed, the head, with the neck attached, should be sent to some laboratory for ex- amination. Most state and municipal laboratories have facilities for this work. Antirabic virus or vaccine, as used in the Pasteur treatment for the prevention of rabies or hydrophobia in exposed persons, consists of the spinal-cord material of rabbits which have died from rabies (or have been killed just before its termination), which has been induced by the subdural inoculation of the fixed virus of the disease. This fixed virus is obtained by the serial passage of the rabies as met in nature (as, for instance, in mad dogs), through many successive rabbits. By this procedure it acquires finally a virulence which for any given strain of virus is fixed, and the incubation period of the disease caused by it in animals is uniform. At the same time its pathogenic properties have been modified so that it is less capable of causing rabies if inoculated subcutaneously. In Pasteur's method of treatment the spinal cord of the rabbit is dried for a time over caustic potash, at a temperature of 23° C, the result of this treatment being that the cord gradually loses its viru- lence, this so-called attenuation being probably a numerical decrease of infective units rather than a qualitative change. In inoculating persons who have been bitten by rabid animals those cords are admin- istered first which have been dried so long that their infectious proper- ties have become lost, and then on successive days cord is administered which has been dried for a shorter and shorter time, and which is con- sequently of increasing potency. The virus or vaccine consists then of the spinal-cord material of the rabbit, plus the microorganism of rabies and its products, artificially modified as to its pathogenic properties. It is administered subcutaneously, after being emulsified by rub- bing up in a mortar with a bland fluid, such as physiologic salt solution or bouillon. The anterior abdominal wall is the most suitable site for inoculations. The treatment lasts from two to three weeks, according to the formula adopted by the institution providing the treatment, and is usually modified according to the severity and site of the injury. Injections are given daily. — Stimson (Journal of the American Medical Association, January 22, 1910). INFLUENZA 373 It should be remembered that this is a vaccination in which the patient develops his own antibodies, hence it is useless after the hydrophobia has developed. The treatment in such cases is purely symptomatic. INFLUENZA Influenza has no specific treatment. Its course is ordinarily so short that our treatment needs to be directed more toward sus- taining the patient's strength than toward aborting the disease. This line of treatment demands that our patients take time to be sick. Even if they feel that they can drag themselves around, they should not be allowed to do so, because influenza, though of short duration, is a powerful depressant and renders its victim sus- ceptible to prostration from work, worry, and disease, which ordi- narily would have little or no effect upon him. Patients suffering from influenza should therefore be put to bed for two days at least, and as long as the temperature remains above normal. The chief symptom is the pain — the backache, headache, leg- ache — and this seems best relieved by central depressants. Of these the coal-tar analgesics are most effective. We may there- fore give antipyrin, acetphenetidin, or acetanilid in five-grain doses every two to four hours, according to the patient's reaction. With the active drug should be combined sodium bicarbonate to render it less toxic. Yeo recommends that quinin be added to this analgesic treatment. When this is done, probably the most ef- fective method of administration is to combine the antipyrin and quinin in an effervescent mixture, thus: IJ Antipyrin 10 grams. Quinin bisulph 15 " Sacch. sod. bicarb. (N. F.) 235 " Sacch. tartaric acid (N. F.) 115 Sacch. citric acid (N. F.) 115 " M. f . mist, effervescens. Sig. : One heaping teaspoonful in a glass of water every three hours. Hot baths and massage also assist in rendering the patient more comfortable. The gastrointestinal symptoms demand cathartics and anti- 374 INFECTIOUS DISEASES septics to prevent or overcome the stagnation and putrefaction in that tract. Thus a capsule or powder made up of the following would give great relief: I£ Acetphenetidini 0.3 grams. Hydrargyri chloridi mitis 0.05 " Phenyl salicylatis 0.3 One of these might be given an adult every four hours, with plenty of water. The respiratory form is the most dangerous; therefore, while we relieve the ordinary symptoms of discomfort, we should watch closely the heart and general vitality. We treat the bronchitis with vaporized medication, we apply packs for the pneumonia, we use the depressant drugs — quinin, acetanilid, etc. — more cau- tiously than in the other forms of influenza, and do not hesitate to use digitalis and strychnin at the first sign of cardiac or respir- atory weakness. It is important to diagnose the localized forms of influenza early and try to eliminate the toxins from the system. The use of sterile salt solution subcutaneously and by rectum, the use of hot packs, and, finally, the use of alcoholic stimulants should here be considered as in septicemia. The alcoholic beverages would be justified here, if anywhere, because the course of disease is so short that their stimulant effect would not have yielded to the depress- ant ones before the disease has run its course. Since the presence of the bacillus influenza? causes the rapid development of a mixed infection, especially in the upper air pas- sages, it is wise from the very onset of the disease to prescribe in- halations of steam charged with oil of eucalyptus in an effort to cleanse the passages as thoroughly as possible. Such inhalations should be given for ten minutes three or four times a day, either with a regular vaporizer or with a bowl of boiling water (e. g., chafing dish) containing a film of the oil. A towel or sheet over the head will enable the patient to secure a greater amount of the vapor. In the cerebrospinal type cold must be applied to the head, which may be shaved in order to secure greater effect. Hexa- methylenamin and cathartics should be given to prevent the greater development of the bacilli, thus: MEASLES 375 T$> Pulveris hexamethylenaminae effervescentis (N. F.) 100.0 Sig. : One heaped teaspoonful in water every four hours. As soon as the convalescence sets in, it is wise to prescribe tonics and carefully regulate the diet and exercise in order to avoid the long, dragging exhaustion usually following influenza. Thus, the tincture of nux vomica, with dilute hydrochloric acid, in a vehicle of essence of pepsin, given with the food will assist greatly in affording the needed stimulation. MALARIA The treatment of malaria is, fortunately, specific and causal. Its basis rests on the flooding of the blood with quinin at the time when the corpuscles rupture and the plasmodia swim freely in the blood current; hence when there are definite cycles we prescribe a half gram (7j grains) of quinin bisulphate eight hours before the expected outbreak of fever and the same quantity four hours later (i.e., four hours before the fever). In other cases we give smaller quantities of the quinin at short intervals throughout the day and thus keep the blood saturated with the quinin. For in- stance, three grains may be given every two hours very sat- isfactorily. Aside from the specific treatment we may treat the symptoms as they arise. In particular, we need to treat the constipation, for in nearly every case there is a sluggishness of the bowels that calls for frequent catharsis, hence calomel is frequently given with the initial doses of quinin. Since the quinin destroys only the free swimming forms of the Plasmodia, it is necessary to continue the exhibition of drug for some days even after the fever subsides in order to destroy iso- lated belated parasites as they break out from their corpuscles. The dosage for this purpose need not be as great as that for com- bating the fever. MEASLES Measles requires that particular attention be given to the re- spiratory tract. In the beginning of the disorder the infectious 376 INFECTIOUS DISEASES nasal discharge needs to be carefully secured and disinfected. The respiratory passages should be treated by the inhalation of steam containing the oil of eucalyptus. Should bronchitis develop it is treated as in the ordinary attacks of that disease. Should the eyes be unable to bear the bright light of the ordi- nary sick room, red curtains should be used, otherwise the prin- ciples governing the sick room in infectious diseases hold good. The conjunctivitis may even require a drop or two of adrenalin chlorid daily. This drug may also be needed for the rhinitis. (Apply by pushing a pledget of cotton saturated with it into the nostril and letting it remain five minutes.) The mouth must have its daily cleansing with hydrogen peroxid. The bowels must be kept loose with small doses of calomel, assisted by daily enemata. Vigorous catharsis should not be employed during the eruptive stage, lest the irritation of the mucosa, thereby set up, cause ulcers from the mucous eruptions. The skin is kept soft and smooth with oil rubs. The daily cleansing baths are given as in other diseases. One need not fear to " drive in " the disease. Com- plications and symptoms are treated as they arise. GERMAN MEASLES German measles requires only an initial clearing of the intes- tinal tract, and then a quiet, secluded life until all symptoms are past. The treatment is entirely symptomatic. THE PLAGUE For the plague we have both a vaccine (Haffkine) and a serum (Lustig and Yersin-Roux) that are much more effective than the corresponding products for cholera; hence in a time of epidemia, or on going into a plague district, physicians should provide them- selves with these two products. In case of the serum it is im- portant that it should be used at the earliest possible moment j hence as soon as a well-grounded suspicion is present that the patient has the plague we should inject 60 to 80 c.c. of the serum, half intravenously and half subcutaneously. Then we repeat the injections every twelve to twenty-four hours during the next five SCARLET FEVER 377 days. The above is the dose for the adult. Even 400 c.c. have been injected intravenously without harm. Otherwise we endeavor to make the patients as comfortable as we can. Alcoholic stimulants should be used. In other respects there is hardly any restriction on the symptomatic treatment. SCARLET FEVER Here also the treatment is expectant and symptomatic. The one precaution to be taken in all cases is the avoidance of every- thing that might excite a nephritis. This includes the avoidance of the chilling of the body, of the ingestion of renal irritants in either the food or the medicine, and of severe exercise or move- ment that might cause renal congestion or fatigue. The room needs to be light and airy and to be kept at an even temperature (65° to 70° P.). Antiseptic precautions need to be taken as in other infectious diseases. In particular, it is important that all objects, books, and playthings handled by the patient be either burned or disinfected under compressed steam. Even after the fever has subsided the patient should be kept in bed. Ordinarily, it is wise to prescribe bed rest for two or three weeks. The food should be bland and " chlorid poor " (see Nephritis), hence milk is the best diet. Buttermilk or lactic-acid " butter- milk " and fruit juices may be used when the patients cannot or will not take sweet milk. The skin should be kept moist with oil rubs. Thymol, methyl salicylate, or menthol should be added to olive oil or vaselin to render it the more soothing. Before the daily oil rub, a cleansing bath should be given with warm water and a mild soap (such as Castile or Ivory). The patient should be encouraged to drink water freely. Lemon juice, citric acid, or hydrochloric acid may be added to render the drinking easier. The mouth should be kept clean by daily cleansing with peroxid of hydrogen. In addition, the fauces should be sprayed (with an atomizer) with the liquor antisepticus alkalimus (N. P.) in twen- ty-five-per-cent dilution. Should the throat become sore and cov- 378 INFECTIOUS DISEASES ered with membrane or ulcerated, these spots should be carefully touched with the solution of the chlorid of iron. The bowels should be kept open with small doses of calomel; e. g., one tenth of a grain every hour until ten are taken each day. Inflamed lymph glands should be rubbed with guaiacol (fifty per cent in oil) or iodin (ten per cent in saponated petrolatum). Nephritis should be treated as described under that head. Car- diac weakness may call for the ice bag and cardiac stimulants. Otitis media requires usually the services of a specialist. If one is not available, then the following principles should be fol- lowed: The pain is best relieved by the application of heat, 1 al- though it may be necessary to give morphin at first. If the drum is tense and bulging it should be lanced. If a purulent discharge follows the paracentesis the ear should be washed out daily with a weak antiseptic solution, permitting a quart or two to flow through the external canal at each treatment. This is best done with a fountain syringe. After perforation, either spontaneously or by incision, the ear should be insufflated from the nose with a Politzer bag at least once a day, to drive the pus outward from the middle ear and also to stimulate the circulation. One may assist in the process of healing by using a large Bier's cup over the ear to induce hyperemia. A daily treatment of forty -five min- utes should be given. The cup should be large enough to fit over the ear. It fits better to the skin if its edges are covered with vaselin. SEPTICEMIA Septicemia may be treated along two lines: (1) Active attack on the infecting organism, as, for example, the infective organism may be isolated and the appropriate serum used, and (2) the body should be stimulated to withstand the depression due to the toxins. First of all, if collections of pus can be found they should be opened and drained. Only when such an opening would be cer- 1 Yeo advises the following procedure for relieving the pain : Heat a wineglass by pouring hot water into it, and then pour 10-20 drops of chloroform upon a small piece of cotton wool in the bottom of the glass and hold the glass close over the affected ear. SEPTICEMIA 379 tainly fatal should we abstain from giving the patient the benefit of the relief from the abscess. Serum Treatment. — The usual cause of septicemia is one or an- other strain of streptococcus, hence, even where we cannot isolate the organism causing the infection, but feel sure that it is a strep- tococcus, we may administer one of the standard polyvalent anti- streptococcic serums. These are made from the blood of horses rendered immune to several strains of human streptococci. Of the Parke, Davis & Co. serum, for example, we are told to inject for a light case 10 c.c. every eight to ten hours. In severer cases 20 to 40 c.c. every six to eight hours are injected. If the effect is what it should be the patient's temperature falls within twenty- four hours. The injection should be made where the skin is loose and there is abundant loose areolar tissue to take up the fluid; e. g., back, thighs, and abdomen. Antiseptics. — If we cannot use a serum we may try the effects of hexamethylenamin in doses of five grains every four hours, in es- sence of pepsin as a vehicle. We cannot expect great things from this drug, but it does render some of the body fluids less hospitable to the streptococci. Or again, we may follow Porchheimer and use the colloidal silver of Crede. This is used as an ointment (unguentum Crede) for inunction or as a fluid (collargolum) for intravenous injection. The former must be used in large doses; for instance, 4 grams twice a day for infants, or 15 grams morning and evening for chil- dren. In adults Forchheimer believes that he gets better results by injecting 0.3 to 0.5 gram suspended in sufficient water into the rectum from once to thrice daily. In using the ointment care should be taken not to wash it off the skin. Supportive Treatment. — Now, as for sustaining the patient's strength, we may try first to remove as much of the toxin from the system as possible by venesection and replacing the blood removed with sterile salt solution, or we may inject the salt directly into the vein without removing the blood. This, of course, increases the blood pressure and the diuresis, but may put too great a load on the heart; or we may inject 250 c.c. directly under the skin (hypodermoclysis) ; or, finally, we may inject slowly two or more liters into the rectum. All these methods seem to dilute the toxins and stimulate the heart. We may add to these elim- 380 INFECTIOUS DISEASES inative effects by using the hot-air bath or hot pack to promote diaphoresis. Systemic stimulants are required, and it is usual to give every- thing from whisky to strychnin. I believe it better, however, to use stimulants more selectively, reserving alcohol for emergencies and using nux vomica, caffein, and camphor, as the changing con- ditions indicate. Thus the nux vomica stimulates the gastroin- testinal tract and helps remove the coating from the tongue. Caf- fein is a rapid vasomotor tonic and stimulates the brain. The camphor is more sedative and also slower. After the fever falls the patient is utterly prostrate and must be kept quiet and under careful tonic treatment for weeks. In this treatment the great needs are bed rest ( alternated with out-of-door exercise), extra food (e.g., like that given in consumption), good air, and carefully selected tonic medication (e. g., mercury, ar- senic, and iron). SMALLPOX Ordinarily the diagnosis is not made during the initial stage preceding the eruption, and the symptoms, pointing as they do to influenza, usually are given that line of treatment. When, how- ever, the diagnosis is made, the treatment, although still symp- tomatic, should be less depressant. Thus, for instance, instead of giving acetphenetidin for the backache and malaise, Dover's pow- ders and hot baths (or packs) would be chosen. Of Dover's powders one gives 1 to 5 grains to a child, 10 to 12 grains to an adult. To assist in the diaphoresis the following alkaline draught (Yeo) might be ordered: 5 Ammonii carbonatis gr. v ; Potassii bicarbonatis gr. xv ; Liquoris ammonii acetatis 3i j ; Syrupi aurantii 3j ; Aquae ad §jss. Take with fifteen grains of citric acid (to render it effervescent) every four hours. Children one half this dose. The patient should be allowed to drink freely of acidulated fluids — lemonade, egg lemonade, phosphoric-acid lemonade, etc. SMALLPOX 381 The diet should be light — milk, buttermilk, broths, etc., at short intervals. Of course, as soon as the diagnosis is made the patient is iso- lated. For the sick room a large, well-lighted, well-heated, well- ventilated room on the second or third floor should be chosen. This should be freed of all unnecessary bric-a-brac and furniture. A sheet saturated with carbolic acid or formalin should be hung over the doorway and only the one (immune) attendant allowed within the room. The disagreeable odor from the patient may be combated by burning joss sticks or by saturating sponges or blotting paper with eucalyptus or other essential oil. The nurse must not go out- side the isolation limits or mingle with the family without chang- ing her clothing and taking an antiseptic bath. All excretions of the patient should be immediately burned or disinfected with for- malin. Thus the sputum cup should have a layer of formaldehyd solution, say one fourth inch thick, in the bottom. Flies and other insects must be screened out. Before the convalescent patient rejoins the family he must be thoroughly cleaned up with antiseptic washes. Even the hair must be washed with corrosive sublimate or carbolic-acid solution. In case of death the body must be wrapped in a sheet wrung out in formaldehyd solution. The room, at the termination of the disease, should be fumi- gated with formaldehyd. Thus for a room of 2,000 cubic feet one should take two pounds of potassium permanganate and two quarts of forty-per-cent formaldehyd solution. The permanganate is put in a three-gallon pail, and this set in a large dish pan containing water. After all is ready — the closet doors open, the bedcovers loosened up, and the windows and doors tightly shut — the solution is poured over the permanganate and the operator beats a hasty retreat and seals up the door. The room should be left closed for twenty-four hours at least. The fever may be lessened by bathing the patient in cool water, as we do for typhoid fever. The patient's reaction must, of course, be watched and the baths discontinued if they give too great a shock. When the eruption is fully out the fever is less and the greatest discomfort is from the itching. Antiseptic oils should then be used to keep the skin soft and comfortable. Such an oil might be made up as follows: 382 INFECTIOUS DISEASES ]J Thymol 5 grams. Guaiaeol 10 e.c. Olive oil 85 " Pitting is hard to prevent. The best results have been obtained by using red light (all the apertures in the room covered with red cloth or paint) or the ultra-violet ray. Both of these procedures are difficult to obtain outside of a hospital specially equipped for the purpose, hence in ordinary practice we must content ourselves with the application of antiseptic oils. The best results from such appliances have been obtained with ichthyol ointment (ichthyol, 10; lanolin, 40; benzoinated lard, 50). The pain of the eruptions is best relieved by hot fomentations. The diet must be liquid and bland, but as nutritious as can be devised. Thus milk, eggnogs, and meat soups must stand fore- most in the dietary. The bowels must be kept loose. Thus a general prescription might be made as follows: ^ Tct. nucis vomicae 10.0 c.c. PI. ext. cascarae sag 2.0 " Acidi hydrochlor. dil 20.0 " Glycerini Aquae aa 40.0 " One teaspoonful t. i. d. after food. The causal treatment is still applicable only in the incubation period — vaccination; hence after the onset of the disease we can use only the so-called expectant plan of treatment, and treat the symptoms and emergencies as they arise; but if an unvaccinated person be exposed, he may with profit be vaccinated even after two or three days. The technic of vaccination is somewhat as follows: We use for vaccination the skin over the deltoid muscle of the arm less used by the patient. We cleanse the area with soap and water, alcohol, and ether; then we make three crosses with a sharp knife, making the incision just deep enough for the blood to show, but not deep enough for it to flow; then we blow into each cross a little of the glycerinated virus from a capillary tube. We use a rubber bulb, SMALLPOX 383 not our lips, to blow with, and then rub this into the incision with our knife blade. The virus is allowed to dry in the air. When dry the incision is covered with sterile gauze or cotton held in place with adhesive strips. This dressing should not be disturbed for three days at least. It is usually better not to disturb it for Fig. 58. — The Two Methods of Vaccination. six days unless some emergency demand it, because each dressing affords a new opportunity for infection. Of course the operator should have his sleeves rolled to the elbows and his hands and fore- arms clean. Equally, of course, the instruments and towels should be sterile. Many prefer to use virus dried on an ivory point and scarify two or three places of the size of a dime, about one inch apart. The ivory point is sufficiently sharp to scarify with, thus obviat- ing the need of a knife. The virus is rubbed in and dried. A sterile bandage is applied and left in place from three to six days. It is important that the virus be fresh and active, and equally important that it be free from pathogenic organisms, hence we should be careful to secure only the best virus and that from the best manufacturers. Infants under six months should not be vaccinated. Skin dis- eases also act as a contraindication. Otherwise everyone should 26 384 INFECTIOUS DISEASES be vaccinated as a means of prophylaxis, and especially in the presence of an epidemic or after exposure. Bad results from vaccination are practically always due to care- lessness and contagion. Complications due to this should be treated according to the standard surgical or medical principles — abscesses opened, irrigated, and drained; erysipelas treated with serum, etc. Revaccination should be done every seven years. The im- munity may last for fifteen years, but that period is exception- ally long. SYPHILIS Syphilis requires, in its early stages, thorough treatment with mercury; in its later stages the iodids. The reason for this is probably that the mercury destroys the active spirochete and is useful only so long as they are active, while the iodids break down pathological tissues and are therefore indicated when the process has reached the gumma and ulcer-building stage. The most effective method of administering mercury is by in- unction. This is also the dirtiest and most unpleasant, hence a constant search is being made to secure another method equally efficient. To secure good results with inunction one should be very methodical. The body should be divided into six areas, as, e. g., right arm, right leg, right half of trunk, left arm, left leg, left half of trunk. A dram of the officinal mercurial ointment (fifty per cent) is rubbed into each of these regions successively for six nights. On the seventh a hot bath (with soap) is taken, and on the next the course is recommenced. If the mercury be rubbed up in lanolin, the skin is made less greasy than if lard and suet are used as the base of the ointment. The treatment should con- tinue five weeks and then be interrupted for one week and again continued for another five weeks. The person who does the rub- bing should be protected by rubber gloves. Each inunction should take at least fifteen minutes and the ointment should be .rubbed completely into the skin. Hairy parts of the body should be avoided, lest pustules be formed. Parke, Davis & Co. have re- cently devised a little briquette of mercurial ointment (called SYPHILIS 385 mercurette) which has the advantage of ease, cleanliness, and exactness of prescription and administration. A prescription for the divided paraffin papers follows: I? Unguenti hydrargyri 30 grams. Mitte in chartulis paraffinatis no. VI. Sig. Rub the contents of one packet into the skin every even- ing, as directed. The next most efficient method of administering mercury is intramuscularly. For this purpose oil emulsions of metallic mer- cury, solutions of mercuric chlorid, and suspensions of calomel are used in hypodermic syringes. Of the soluble preparations, mer- cury succinimid, which is put out in tablets of one fifth grain each, which are dissolved in sterile distilled hot water as needed, is the most used at present. The British army surgeons have used this method of treatment more than any other class of men and highly recommend it. In general, it has proven of special value with those patients who will not or cannot take daily treatment. Caille recommends that fifteen drops of the following emulsion be used for deep injection into the buttocks: If Hydrargyri salicylatis gr. xxij ; Olei olivaa Siijss. ; Lanolin 3ss. M. D. S. Inject every five, six, or seven days. Another prescription often used is the following : If Hydrargyri chlor. corros 1.0 grams. Sodii chloridi 6.0 " Aquae destillataa 100.0 c.c. Sig. Inject 1 c.c. into the gluteal muscles. The most common method of administering mercury is by the mouth. At present the yellow iodid of mercury is the favorite form and is given in one-fourth-grain tablets or pills three or four times a day. The ease of administration rather than its efficiency makes for its popularity. The pills or tablets are coated with sugar, gelatin, or chocolate, as the physician's fancy may suggest. For a simple pill the ordinary prescription might be: 386 INFECTIOUS DISEASES Jy Hydrargyri iodid flavi 0.8 grams. Fiat massa et in pilulas numero decern divide. Sig. One pill after each meal. The treatment with mercury in one form or another should be kept up for about three months. Then an interval of a few months should be allowed the patient, after which a second but milder course should be put through. A third course in the succeeding six months is always advisable. Insalivation is avoided by cleansing the teeth thoroughly after each meal with brush and tooth paste, and by gargling thoroughly with hydrogen peroxid at least once a day. The bowels should be kept free. Should, however, salivation develop, the adminis- tration of mercury should stop at once. In the later stages of the disease, potassium or sodium iodid should be given with or without mercury. The dose should be at least ten grains t. i. d. In obstinate cases as much as ninety grains every four hours may be given. With many patients it is sufficient to give the drug dissolved in an equal quantity of water, and in such case the dose is measured out in drops. In other cases it is necessary to use teaspoonful doses, wherefore an appropriate vehicle should be used. The compound tincture of gentian with water is often used, thus: I> Potassii iodidi 15 grams. Tct. gentian co 30 c.c. Aqua 60 " Sig. One teaspoonful t. i. d. Another illustrative prescription is: I? Potassii iodidi 30 grams. Elixiris gentianae glycerinati (N. F.) . . . . 200 c.c. Sig. One dessertspoonful after each meal. (The dosage here is for a severe case.) Sometimes it seems best to give both the iodid and the mer- cury. In such cases the best results seem to be obtained when the mercury is given intramuscularly or by inunction and the iodid by the mouth. SYPHILIS 387 As a minimum we must recommend that during each six months a course of treatment should be given until three years shall have elapsed. But, better still, whenever practicable the following scheme of treatment (Hay) should be adopted with all patients who would insure their freedom from the late effect of this ter- rible disease: Table of Course of Treatment for Five Years First Year: 2 months' inunctions or injections. 1 month's rest. 2 months' internal treatment. 1 month's rest. 2 months' inunctions or injections. 1 month's rest. 2 months' internal treatment. 1 month's rest. Giving eight months' treatment and 4 months' rest. Second Year: 6 weeks' inunctions or injections. 8 weeks' rest. 8 weeks' internal treatment. 4 weeks' rest. 6 weeks' inunctions or injections. 8 weeks' rest. 8 weeks' internal treatment. 4 weeks' rest. Giving total, second year, 7 months' treatment, 5 months' rest. Third Year: 1 month's inunctions or injections. 1 month's rest. 1 month's internal treatment. 1 month's rest, continuing so throughout the entire year, al- ternating from internal to injections or rubs. Thus giving the total during the third year of 6 months' treat- ment and 6 months' rest. 388 INFECTIOUS DISEASES Fourth Year: 6 weeks' inunctions or injections. Fifth Year: 4 to 6 weeks' inunctions or injections. Then one course of treatment of one month each for the next five years, thus carrying our patient up to or through the para- syphilitic stage. PAKT III NOTES ON REMEDIES CHAPTER I MISCELLANEOUS NOTES i BATHS IN COMMON USE 1. The Hot Bath.— Temperature from 98° F. (36.7° C.) to 106° F. (41.1° C), or even higher. The cold water should be placed in the bath first, and the hot water added until the thermometer registers the required temperature. 2. The Warm Bath.— Temperature 92° F. (33.3° C.) to 98° F. (36.7° C). 3. The Tepid Bath.— Temperature 85° F. (29.4° C.) to 92° F. (33.3° C). 4. The Cold Bath.— Temperature 33° F. (0.6° C.) to 65° F. (18.3° C). Accurately defined, a cold bath means a bath at the temperature incidental to the time and place without any hot water being added. It may be otherwise expressed as water at 65° F. (18.3° C), or reduced by gradual addition of ice to 40° F. (4.4° C.) or below. 5. The Alkaline Bath. — Add quarter of an ounce of sodium car- bonate to each gallon of water. 6. The Bran Bath. — Add two ounces of bran to each gallon of water. Mix the bran with a small quantity of boiling water, and add it to the water in the bath. 7. The Sulphur Bath. — Add a quarter of an ounce of potassa sulphurata to each gallon of water. 8. The Vapor Bath. — The temperature ranges from 96° F. (35.6° C.) to 180° F. (82.2° C). A vapor bath may be impro- vised by placing in the bed a few stone ginger-beer bottles, filled with nearly boiling water, tightly corked, wrapped around with 1 Adapted from the Therapeutic Notes of Parke, Davis & Co. 391 392 MISCELLANEOUS NOTES pieces of flannel wrung out of hot water and placed in the bed around the patient, who should be well wrapped. 9. Turkish Bath. — The temperature ranges from about 120° F. (48.9° C.) in the cooler rooms to 230° F. (110° C.) or even higher in the hottest room. The best method of taking a Turkish bath is to go at once into the hottest room and remain five minutes or less; then move into the second room for five minutes; and after- wards remain for twenty minutes in the coolest of the three hot rooms before being shampooed. By this method the hottest room is encountered before there is any heart fatigue. Its high tem- perature initiates perspiration, which commences freely in the second room, and is continued freely in the third. DOSES PROPORTIONATE TO AGE According to Young's rule the dose is obtained by dividing the age by 12 plus the age. Thus, for a child of three years 8 =Y5 or T' Cowling's rule is to divide the number of the next birthday by 24. Thus, for a child five years old yt— h ^ nar " cotics not more than one half of this proportion should be pre- scribed, while of cathartics this dose may be exceeded by two or three times. Here is Gaubin's dose table, based on 1 grain for the adult dose: Under one year T V grain Under two years £ Under three years ^ Under four years \ Under seven years J Under fourteen years ^ Under twenty years § From twenty-one to sixty years, the full dosage. SUBSTANCES EXCRETED IN MILK Many substances taken by the mother are excreted in the milk. Among these are ammonia and certain aromatic and volatile oils, such as the oils of anise, cumin, dill, wormwood, garlic, turpentine, and copaiba; the purgative principles of rhubarb, senna, castor ALCOHOL TABLE 393 oil, and seammony; opium, iodin, antimony, arsenic, bismuth, iron, lead, mercury, and zinc. The therapeutic actions of certain drugs administered to the mother may thus be observed in the child. Among these are opium, mercury, arsenic, potassium iodid, senna, castor oil, and some other purgatives. Substances which increase the flow of milk: Jaborandi, pilo- carpin, rich foods, stimulants, and probably thyroid-gland sub- stance. Substances which lessen the flow of milk: White agaric, bella- donna, atropin, ergot, potassium iodid, and sodium iodid. ALCOHOL TABLE Percentages of alcohol contained in the following liquids Rum 60 to 75 Whisky 50 to 60 Brandy (British) 50 to 60 Brandy (French) 50 to 55 Gin 48 to 60 Port 18 to 20 Marsala 15 to 21 Sherry 18 to 20 Madeira 14 to 17 Hungarian Wines 9 to 15 Claret 8 to 12 Sauterne 11 to 18 Burgundy 8 to 14 Moselle 8 to 12 Rhine Wines 7 to 16 Chablis 7 to 10 Champagne 6 to 13 Bitter Ale 6 to 9 Cider 2 to 9 Porter 4 to 7 Beer 2 to 4 Ginger Beer (brewed) 1 to 3 a, PQ (^ < H -V W *■» O »— i fl H £> r HH* (-1 o W c/) Ph W O o < U H rH fe n W s u rt hj w «! 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Exact. Liquids 1 minim 1 fl. dram 1 fl. ounce 1 pint 1 gallon 1 c.c 4 c.c 30 c.c 470 c.c 1000 c.c. (1 liter) 4 liters Solids. 1-509 grain 1-64 grain 1 grain 15 grains 1 ounce 1 pound 1 milligram 1 gram 1 decagram 1 hectogram 1 kilogram 0.06 c.c. 4 c.c. 30 c.c. 473 c.c. 4 liters. 16 minims. 1 fl. dram. 1 fl. ounce. 1 pint. 34 fl. ounces. 1 gallon. 0.00013 gm. 0.001 gm. 0.065 gm. 1 gm. 28 gm. 450 gm. 15^ grs. i oz. 3^ ozs. 2* lbs. 0.061 c.c. 3.696 c.c. 29.574 c.c. 473.197 c.c. 3 . 785 liters. 16.23 mins. 1.082 fl. drs. 1.014 fl. ozs. 15.892 fl. ozs. 33.81 fl. ozs. 1.056 gals. 0.000129 gm. 0.001013 gm. 0.064798 gm. 0.972 gm. 28.350 gm. 453.592 gm. 0.015 gr. 15.432 grs. 154.324 grs. 3 ozs. 230 . 7 grs. 2 lbs. 3 ozs. 120 grs. CHAPTER II MATERIA MEDICA Acidum Aceticum {Acetic Acid) is a liquid composed of thir- ty-six per cent of absolute Acetic Acid, HC 2 H 3 2 and sixty-four per cent of water. It is a clear, colorless liquid, of a distinctly vinegar odor, a purely acid taste, and a strongly acid reaction; miscible in all proportions with water or alcohol, and wholly vola- tilized by heat. It is prepared from wood by destructive distilla- tion and purification. Acetic Acid is also official in two other degrees of concentration, viz. : Acidum Aceticum Glaciale (Glacial Acetic Acid; HC 2 H 3 OJ is nearly or quite absolute Acetic Acid, solid below 59° F., above that temperature a colorless liquid. Is strongly escharotic and only used locally. Acidum Aceticum Dilutum (Diluted Acetic Acid) consists of Acetic Acid, 10, Distilled Water, 50 parts; contains six per cent of absolute Acetic Acid, and has a sp. gr. of 1.009. It is used in the preparation of the two official Aceta (Vinegars). Dose TTt xv-3ij [av. TTLxxx]. Acetum (Vinegar, unofficial) is an impure dilute Acetic Acid, formed by the action of a ferment on a dilute alcoholic liquid, the alcohol being oxidized thereby. Acetonum (Acetone, Dimethyl Ketone; C 3 H 6 0), a colorless, mobile, and volatile liquid, miscible with water, alcohol, etc. It is an excellent solvent for resins, gums, camphor, fats, and gun cotton, and is employed in the manufacture of some oleoresins and of sulphonmethane (sulphonal). (Potter.) Aconite (Monkshood, Wolfsbane, Friar's Cowl, Mousebane). — Dried tuber of aconitum napellus, L. Ranunculaceae. Found in the mountainous regions of Europe, Asia, and North America. Contains aconite, aconin, napellin (isoaconitin), pseudoaconitin, 396 MATERIA MEDICA 397 picroaconitin, aconitic acid, fats, and sugar. This is another com- plex drug, the chief action of which is the depression of various parts of the nervous system. Maximum dose of the fluid extract, 1 minim; of the tincture, 10 minims. Adrenalin (see Epinephrin). Aloe, Aloes, is the inspissated juice of the leaves of Aloe vera, Aloe Chinensis, Aloe Perryi, or other species of Aloe, a plant of the nat. ord. Liliaceie. It occurs in masses of yellowish-brown color, fragrant odor and bitter taste, soluble in alcohol and in boiling water. It contains a peculiar volatile oil, a resin, and soaloin, C 15 H 16 T , a variety of the principle Aloin, which is common to all varieties of aloes; also Aloetic and Chrysammic Acids. Dose, gr. j-vj [av. gr. jv]. (Potter.) Alumen, Alum {Potassium Alum, Aluminum, and Potassium Sulphate; A1 2 K 2 (S0 2 ) 4 -f 12 H 2 0) occurs in large, octahedral crystals, or cubes, of sweetish astringent taste and acid reaction, soluble in 9 parts of water and in 0.3 of boiling water, insoluble in alcohol. The Ammonia alum (Alumini et Ammonii Sulphas) was formerly official, and is still sold and dispensed as Alum. Dose, gr. v-x (av. gr. vijss.) ; as an emetic, 3j for a child. (Potter.) Ammonium Salts. — All Ammonium Salts stimulate and finally paralyze the spinal cord, motor nerves, and muscles in animals, but the order and intensity of the action vary with the salts employed, some having a predominating influence on the cord, others on the motor nerves. In general, they may be said to form a series, of which the members at one end stimulate the cord, and those at the other paralyze both the cord and the motor nerves. At the stimu- lant end are Ammonia and the Chlorid; at the paralyzant end the Iodid; the Bromid, Phosphate, and Sulphate lying between. (Brunton.) In medicinal doses they act on man as stimulating expectorants, in large quantity they injure the structure of the red blood corpuscles, and if long continued they produce rapid emaciation by impairing digestion and increasing tissue waste. (Potter.) Anisum, Anise is the ripe fruit of Pimpinella Anisum, a European plant of the nat. ord. Umbelliferas. It occurs in ovate bodies, ^ inch long, hairy, of grayish color, aromatic odor, and sweet, spicy taste, resembling conium fruit in appearance. Dose, gr. v-x [av. gr. vijss.]. 398 MATERIA MEDICA Oleum Anisi (Oil of Anise) is a volatile oil distilled from Anise, and represents the medicinal qualities of the plant. It con- tains Anethol, C 10 H 12 O, or Anise Camphor, congeals at 50° to 59° F., is soluble in an equal part of alcohol, and is an ingredient of Tinctura Opii Camphorata, Trochisci Glycyrrhizae et Opii, Aqua Anisi, and Spiritus Anisi. Dose, Til j-v [av. ir^iij]. (Potter.) Antipyrina, Antipyrin (Phenyl-dimethyl-pyrazolon; C 11 H 12 N 2 0, official in the B. P. under the name Phenazonum, Phenazone) , is a crystalline substance obtained from the phenyl-hydrazin, and pre- pared by a patented and complicated process. It is a synthetical base, forming salts which are analogous to those of Ammonium; and occurs as colorless and inodorous scaly crystals, with a bitter taste, freely soluble in water, alcohol, and chloroform, less soluble in ether. It gives a deep red color with ferric chlorid, a deep green with nitrous acid, and with nitric acid a yellow color which deepens to crimson on warming. Dose, gr. j-x [av. gr. iv]. (Potter.) Apomorphinae Hydrochloridum (Apomorphin Hydrochlorid; C 17 H 17 N0 2 HC1) is the hydrochlorid of the artificial alkaloid Apo- morphina, which is prepared from morphin or codein by the action of strong acids or zinc chlorid, the morphin losing in the process a molecule of water. The salt occurs in minute, colorless crystals, odorless, of bitter taste, and neutral or faintly acid reaction ; solu- ble in about 45 of water and in the same quantity of alcohol at 59° P., almost insoluble in ether or chloroform; decomposed by boiling water or boiling alcohol. Dose, as an expectorant, gr. ^V" inr [av. gr. -jVl ; as an emetic, gr. T V to J [av. gr. T V]. For young children gr. ^ should not be exceeded. Solutions should be fresh when used, and as they alter rapidly by keeping, should have a few drops of hydrochloric acid added to them to prevent decomposition. Argyrol (Silver Vitellin) contains thirty per cent of silver, and is very soluble in water. It is absolutely painless and nonirritant, even in concentrated solutions on the conjunctiva. Solutions of two- to ten- or twenty-per-cent strength are used as local astrin- gents of 1 to 1,000 for irrigating the vagina, bladder, and urethra. Arnica is the dried flower heads of Arnica montana, Leopard's Bane, a perennial of the nat. ord. Composite, indigenous to the mountains of northern Europe and Siberia, and said to have been found in the mountains about the headwaters of the Missouri and MATERIA MEDICA 399 Columbia rivers. It has large orange-yellow flowers and a small, curved rhizome with several rootlets. It contains two alkaloids, Arnicin and Cytisin, the latter being probably identical with the active principle of Cytisus laburnum, the Laburnum; also Tri- methylamin (CH 3 ) 3 N, an ammoniacal alkaloidal principle, which has been looked upon as the active ingredient. Arnica also con- tains Inulin, Capronic, and Caprylic Acids, tannin, mucilage, resins, and two essential oils, one in the flowers, the other in the root. Dose, gr. v-xx [av. gr. xv]. Tinctura Arnica (Tincture of Arnica), strength twenty per cent. Dose, Tl\ v-xxx [av. rr^xv]. Arsenic. — The primary action of arsenic seems to be that of kill- ing epithelial tissue. By epithelial tissue I mean derivatives of the embryonal ectoderm. Thus after the giving of arsenic one finds the mucous membrane of the intestine necrotic in the form of a fatty degeneration; one finds, when further doses are given, that the skin, the hair and the nails, the glandular structures, and finally the nervous tissues show the arsenic in either the form of arsenites or in albuminates. The necrosis is in the form of fatty degenera- tion, so that the tissue resembles that following phosphorus poison- ing, and appears to be on the way to becoming structureless, sof- tened, and more or less white in color. In the intestine this permits epithelial layers to slough off in the form of shreds, producing the well-known " rice-water " stools. Another action very closely allied to the above is that upon the capillaries of the splanchnic area. There seems to be the paralysis of the vasomotor system, so that the capillaries are dilated and flaccid, permitting a free exudation of the serum and gradually an edema of the tissues around about them. This action is periph- eral rather than central, and must be thought of, I believe, as one similar in kind to that upon the mucous membrane of the in- testine — essentially a destruction of the trophic power of the cells involved. The action of arsenic resides in the ion of arsenous acid, there- fore the arsenic is innocuous so long as it is not broken up into arsenous acid; and in the same way the albuminates of arsenic are not only innocuous, but also useless until they have been re- duced slowly to arsenous acid, thus liberating the active ion. Hence the most active of the medicinal preparations of arsenic 27 400 MATERIA MEDICA are the solutions of arsenous acid. I believe the next active is the arsenic iodid salt, and probably the slowest are the cacodylic-acid and the arsanilic-acid preparations. Thus we give thirty drops of a ten-per-cent solution of atoxyl hypodermically every third day with no toxic symptoms. This dose would in an active preparation of arsenic cause a great deal of trouble. It is simply a matter of storing up in the system a considerable supply of arsenic, which is brought into use by the body tissues by breaking it down and making it over into arsenous acid ; hence it would not be at all im- possible for some bodies under some conditions to produce toxic effects with atoxyl simply because they might break up the drug more rapidly than usual. From the above, it is easy to understand that arsenic is of con- siderable value in affecting the metabolic processes of the body, in particular those concerning the ectodermal tissues. On the old principle that those drugs which cause a necrosis or paralysis when administered in large doses, in minor doses stimulate, we may, by utilizing minor doses of arsenic, secure a stimulating effect on the cells of the ectodermal tissues as far as their nutrition is concerned. Thus, if we wish to make a horse's coat of hair look glossy, we give him arsenic to stimulate the ectodermal nutrition ; when a woman wishes to whiten her complexion, making the skin cells fuller, rounder, and glossier, she uses arsenic; when we wish to stimulate the nutrition of the intestinal mucosa, we give arsenic in doses just strong enough to stimulate the nutrition of the nerve fibers and cells ; hence the use of arsenic in anemia is not so much the replac- ing the hemoglobin or even the corpuscular elements of the blood as it is the stimulation of the nutritional forces governing the blood supplies. The drug is not useful in all skin diseases. Referring to the physiologic action outlined above, we can readily see why it is of use in only those conditions wherein the nutrition of the dermal structures is involved; therefore in acute inflammatory conditions it would be contraindicated, because there is already a hyperactiv- ity of the nutritional centers, and the only need is one of sedation rather than stimulation. If, however, we had a rough, dry skin before us, showing a lack of cell growth, of smoothness in the cell, of fullness of development, and we could not find the cause in some extraneous or external irritation, we would be justified in MATERIA MEDICA 401 prescribing arsenic in doses strong enough to stimulate dermal growth. The use of arsenic in inoperable cancer is theoretically justifi- able, because a cancer is an epithelial product and the cells of can- cer are of lesser resistance than the cells of the normal tissue. Therefore, if Ave should give arsenic in doses just strong enough to destroy the pathologic cells but not the normal ones, we would be following exactly the same principle of treatment that we em- ploy in using the X-ray. We cannot employ heavier doses because if we should give the arsenic locally hypodermically, it would spread throughout the body and give toxic effects, and if we em- ploy it in the form of paste we cannot regulate its strength well enough to make it destroy the pathologic and leave untouched the normal cells. Asafetida: Mistura Magnesias et Asafoetidae (DeWees' Carmina- tive). — Each fluid ounce contains 24 grains magnesium carbonate, 1 fluid dram tincture asafetida, and 5 minims tincture opium. Dose, \ to 1 fluid ounce (16 to 32 c.c). The magnesia in this mixture is valuable chiefly as an alkali, while the asafetida is a gastric stimulant. This latter drug has come down to us from ancient Hindu and Persian medicine. It is a gum resin from the root of the ferula fcetida (Umbelliferas) growing in Turkestan and Afghanistan. It contains three to nine per cent volatile oil, twenty to thirty per cent gum, forty-five to seventy per cent resin. The alcoholic preparations yield turbid mixtures with aqueous fluids. The tincture of asafetida is twenty per cent strength and may be used in 1-c.c. (15-drop) doses. The milk of asafetida (the officinal emulsion) is four per cent strength and should be used in tablespoonful (4-dram, 16-c.c.) doses. The officinal pill contains 3 grains and two are usually given at a dose. Some surgeons give a suppository containing 3 grains of asafetida after a laparotomy in order to prevent abdominal distention. Atropin (Atropina; C 17 H 23 N0 3 = 287.04), an alkaloid obtained from atropa belladonna and other plants of the same family (Fam. Solanacese). White, odorless, bitter, acid crystals. Soluble in 450 parts water, 1.46 alcohol, 16.6 ether, 1.56 chloroform, and 50 glycerin. Average dose, y^-g- gr. (0.0004 gm.). Applied locally as the oleate. Antidotes: morphin, pilocarpin, physostigmin, or aconitin. 402 MATERIA MEDICA There is a large group of drugs used in medicine which de- pend for their activity on an atropin-like substance, and it has been found that the bases of most of these are the same; that is, the tropins and oscins. The tropins and oscins themselves are practically inactive. Their derivatives, however, tropeins and osceins, are very active agents. Atropin is isomeric with hyos- cyamin, but it is optically inactive, while the latter turns the spec- troscope to the left. Atroscin is isomeric with scopolomin, but is also optically inactive. The two mixed, atroscin and scopolomin, produce hyoscin, hence hyoscin is a difficult drug to use because we are never sure just which action we may expect. The names of the principal plants from which these drugs are derived are the atropa belladonna, the datura stramonium (from which the stramonium for burning is derived), hyoscyamus niger or hen- bane, duboisia myroporoides, mandragora autumnalis (mandrake), scopola atropoides. The group action of atropin excites first and then paralyzes the cerebral centers. It paralyzes the end nerves of glands, pupils, the unstriped, and also the cardiac muscle. It slightly stimulates and then paralyzes the smooth and cardiac muscle directly. Fi- nally, it paralyzes the sensory nerve endings when locally applied. Thus atropin dilates the pupil by paralyzing the oculomotor nerve endings, while cocain dilates the pupil by stimulating the sym- pathetic. Atropin is rapidly excreted in the urine, and therefore in cases of poisoning the fate of the patient is known within a few hours. In fact, because of this rapid excretion, rarely does anyone die from atropin poisoning. The drug is used either as the tincture of belladonna (ten per cent, dose 5 to 15 drops), or as atropin in doses of t^o" to §V of a grain. Benzoinum, Benzoin, a balsamic resin obtained from Styrax Ben- zoin Dryander and another unidentified species of Styrax (Fam. Styraceas) . In pebble-like bodies or tears, mostly 0.5 to 5 cm. long and about one fourth as thick, slightly flattened, straight, or curved, yellowish to rusty brown externally, milky white on fresh frac- ture, separate or very slightly agglutinated (Siam Benzoin) or embedded in a dry resinous mass, which varies from reddish brown to reddish gray or grayish brown; opaque or slightly translucent MATERIA MEDICA 403 and more or less lustrous (Sumatra Benzoin) ; brittle, becoming soft on warming, and yielding benzoic acid on sublimation; odor agreeable, balsamic (vanilla-like in the Siam variety) ; taste slightly acid. Benzoin is almost wholly soluble in five parts of warm alcohol, the solution showing an acid reaction to blue litmus paper ; soluble in solutions of sodium or potassium hydroxid. Average dose, 1 gm. (15 grains). (U. S. P.) Adeps Benzoinatus (Benzoated Lard), Lard, 1,000 grams; Benzoin in coarse powder, 20 grams. (U. S. P.) Berberis (Barberry), the dried rhizome and roots of Berberis aquifolium and other species of berberis (Fam. Berberidaceag), North America. This is akin to the berberin found in golden seal. It is a bitter yellow drug and is generally given in the fluid ex- tract in a dose of 2 c.c. The bitter principle, berberin, is found in many of the drugs used in domestic medicine, hence the sus- picion is justified that they depend for their value on its presence. Thus xanthoxylum and hydrastis, both of reputation as tonics, contain berberin. (Sollmann.) Bismuth. — It should always be kept in mind in dealing with this drug that there are two classes of bismuth salts, the soluble and the insoluble. The soluble salts are rarely used in medi- cine. When introduced into the system they produce the arsenic phenomena with a depression of the central nervous system and also of the cardiac muscles. The insoluble salts, on the other hand, when free from contamination are practically innocuous and present only the local effects. These are the basic or oxy salts. They are used externally for dusting on wounds, where they pro- duce a dry scab under which the healing process may go on free from external irritation. Not only on this account are they valuable, but also because they dry up the secretions in and about the wounds, thus depriving any bacteria that might be present of nu- trient media. On account of this property, bismuth subnitrate has even been injected into the urethra to check the secretions and reduce inflammation in cases of acute urethritis. When given by the mouth, the basic salts have a tendency to neutralize the ex- cessive acidity of the stomach. They are also valuable in cases of vomiting and diarrhea and for intestinal putrefaction. In the latter case they are best given with salol. 404 MATERIA MEDICA In the intestinal canal bismuth subnitrate combines with the sulphids there present and produces a black color in the stools which has sometimes been confounded with that due to hem- orrhage. When combined with iodin (as in the proprietary preparation airol) they are perhaps still more antiseptic and therefore better dusting powders. A similar combination for use in the intestinal canal is that with the phenols ; for example, we have tribromphenol (xerofrom), a yellow powder containing sixty per cent bismuth, insoluble in water; and the combination with the betanaphthol (orphol), a grayish powder of unpleasant taste and odor of naphthol. The preparations most in demand are: Bismuth Subnitrate (Bismuthi Subnitras, Magistery of Bis- muth, Bismuth Oxynitrate; BiN0 3 H 2 0), white, odorless, heavy, almost tasteless, insoluble in usual solvents. Incompatible with gallic acid, salicylic acid, and tannin. When bismuth subnitrate is pure and free from arsenic, it may be given in almost unlimited doses, because it can have no toxic effects unless absorbed. The dose, therefore, varies greatly, the minimum being probably 3 to 5 grains (0.2 to 0.3). Bismuth Subcarbonate (Bismuthi Subcarbonas; (BiO) 2 C 7 - H 5 5 ), stomachic, intestinal astringent. This is a combination of bismuth subnitrate with sodium bicarbonate. The dose for internal use is J gram (7f grains). Acidum Boricum (Boric Acid, Boracic Acid; H 3 B0 8 ) is a weak acid occurring in transparent, colorless, six-sided plates, of unctu- ous touch, odorless, of a cooling and slightly bitter taste, soluble in 25 of water, in 15 of alcohol, and in 10 of glycerin. Its aqueous solubility is increased by the addition of hydrochloric acid or borax. It is produced from Borax by the action of sulphuric acid ; also by the purification of the native acid. Dose, gr. v-xv [av. gr. vijss.]. There are two official Borates, viz.: Sodii Boras (Sodium Borate, Borax; Na 2 B 4 7 + 10 H 2 0), col- orless, transparent prisms, of cooling and sweetish, afterwards alkaline, taste and alkaline reaction, soluble in 16 of water at 59° P., and in 0.5 of boiling water; insoluble in alcohol. Occurs native in ancient lake beds in Death Valley region, California, and various other parts of the world. Dose, gr. v-xxx [av. gr. vijss.]. MATERIA MEDICA 405 Glyceryl Borate (Boroglycerin), official in the following preparation : Glyceritum Boroglycerini (Glycerite of Boroglycerin), pre- pared by heating together Boric Acid, 310, and Glycerin, 460, until reduced to 500 grams, then adding an equal weight of Glycerin. Liquor Antisepticus (Antiseptic Solution), contains of Boric Acid, 2 ; Benzoic Acid, 0.1 ; Thymol, 0.1 ; Eucalyptol, 0.025 ; Oil of Peppermint, 0.05; Oil of Gaultheria, 0.025; Oil of Thyme, 0.01; Alcohol, 25; Purified Talc, 2; Water to 100. Dose, 3ss.-ij [av. 5j]. Unguentum Acidi Borici (Ointment of Boric Acid) has of Boric Acid, 10; Paraffin, 10; White Petrolatum, 80. Bromids. — Potassii Bromidum (Potassium Bromid; KBr), col- orless, cubical crystals, soluble in 1.6 of water and in 200 of alcohol. Dose, gr. ij-3j [av. gr. xv], well diluted. Sodii Bromidum (Sodium Bromid; NaBr), colorless, monoclinic crystals, soluble in 1.2 of water and in 13 of alcohol. Dose, gr. ij -3j [av. gr. xv], well diluted. Lithii Bromidum (Lithium Bromid; LiBr), a white, granular, deliquescent salt, very soluble in water and in alcohol. Dose, gr. ij-xl [av. gr. xv], well diluted. Ammonii Bromidum (Ammonium Bromid; NH 4 Br), colorless, prismatic crystals, soluble in 1.5 of water and in 30 of alcohol. Dose, gr. ij-x [av. gr. xv], well diluted. This Bromid is well borne by children in comparatively large doses if epileptic from reflex causes. A child one year old can tolerate gr. v every four hours. (Barton.) Calcii Bromidum ( Calcium Bromid; CaBr 2 ) , a white granular, deliquescent salt, very soluble in water and in alcohol. Dose, gr. ij— 3j [av. gr. xv], well diluted. Strontii Bromidum (Strontium Bromid; SrBr 2 (H 2 0) 6 , color- less, hexagonal crystals, very deliquescent, very soluble in water and in alcohol; insoluble in ether. Dose, gr. ij-xxx [av. gr. xv], well diluted. Zinci Bromidum (Zinc Bromid; ZnBr 2 ), a white, granular, deliquescent powder, very soluble in water and in alcohol. Dose, gr. £-iij [av. gr. ij], well diluted. Bromids are rapidly absorbed and slowly eliminated by the kidneys, skin, saliva, intestinal and bronchial mucous membranes, and the milk. They irritate the mucous membranes at the points 406 MATERIA MEDICA of elimination, and increase the quantity of the urine and the excretion of the chlorids and the nitrogenous constituents, but de- crease the elimination of the phosphates. Hydrobromic Acid is more irritant to the stomach than the bromids, but after absorption it has the same action as these agents on the nervous system and the circulation. Difference in Action Behveen the Bromids. — Potassium Bromid is the most toxic to the heart and the muscular system, and is the least hypnotic. It contains sixty-six per cent of bromin. Sodium Bromid is the least toxic, but the most hypnotic, and acts more energetically on the circulation. It contains seventy- eight per cent of bromin. Ammonium Bromid resembles the Potassium salt in action, ex- cept that it exerts less influence on the heart and on the muscular system, and is somewhat more stimulating. Lithium Bromid contains the most Bromin (ninety-two per cent) and resembles the sodium salt in action. It has proved better than the others in some cases of epilepsy, and is by several authori- ties considered the best hypnotic of the series. Calcium Bromid is an efficient hypnotic, but otherwise much less active than the other bromids. Strontium Bromid is said to be less apt than the other bromids to produce the bromic acne and the other results of bromism. Zinc Bromid, in large doses, is violently irritant. It is sup- posed to combine the tonic effects of zinc with the sedative action of the bromids. (Potter.) Bromural is a nerve sedative which is claimed to produce sleep without markedly affecting the circulation or respiration. All action by bromural is said to cease after from three to five hours. In many cases, however, the sleep caused by the preparation con- tinues beyond the limits of its action. Bromural does not produce the desired effects in cases of insomnia where pain, cough, angina pectoris, and excitement or delirium exist. It is given as a nerve sedative in doses of 0.3 gram (5 grains) three times daily, as a soporific at bedtime 0.6 gram (10 grains), which dose may be re- peated if needful during the night, after the action of the first dose has ceased. Bromural is supplied as a powder and also in tablets of 0.3 gram (5 grains) each. MATERIA MEDICA 407 Oleum Cadinum (Oil of Cade, Empyreumatic Oil of Juniper) is a product of the dry distillation of the wood of Juniperus oxy- cedrus. It is a tarlike substance of uncertain composition and pur- ity, insoluble in water, partially soluble in alcohol, completely so in ether, chloroform, or carbon disulphid. Used locally as a stimu- lant. (Potter.) Caffein (Caffeina, Coffeine, Thein, Guarananine, Trimethyl- xanthine; C 10 H 10 N 4 O 2 H 2 O = 210.64), alkaloid from dried leaves of thea senensis (Fam. Ternstroemiacese), or dried seeds of coffea arabica (Fam. Rubiaceae). White, silky, odorless, bitter needles. Soluble in 45.6 parts water, 53.2 alcohol, 375 ether, 8 chloroform. Aqueous solubility is increased by potassium bromid, sodium ben- zoate, sodium salicylate. Average dose: 1 grain (0.065 gram). This is one of the xanthin bodies. Its action in general is to increase the nervous irritability of the central nervous system from above downward, in contrast to strychnin, which acts from below upward. It increases muscular contraction (like alcohol) even to the point of rigor — that is, to the point of the loss of elas- ticity. It has a diuretic action through its local influence on the renal functions. Expressed differently, the effect of the drug is to produce a quicker flow of blood and a release from drowsiness. Its action on the respiration and circulation is similar to that of strychnin, but weaker. The spinal cord is affected only by heavy doses. Since its action affects not only the medulla, but also the vagus and vasomotor centers, the effect on the circulation will vary from patient to patient and from time to time. It is rapidly absorbed and easily broken up in the body. Of the xanthin group, caffein has the strongest action on the nervous system. Paraxanthin is the most diuretic, then theophyllin (theocin), then theobromin, and lastly caffein. The action of the members of the group on striped muscle is parallel to the diuresis. Of the crude drugs containing these bodies, coffee contains 1 to 3 per cent caffein — that is, an ordinary cup of coffee would con- tain 0.1 to 0.2 per cent of caffein. Tea shows 1J to 4 per cent caffein; cola, 2 per cent; guarana, 4 to 5 per cent (3-J per cent U. S. P.) ; mate, T \ to l T 6 o per cent. The preparations of this drug are not chemical compounds, but simple mixtures. Thus: 408 MATERIA MEDICA Caffein Citrated contains 50 per cent caffein and 50 per cent citric acid, and is soluble in 25 parts water. This mixture is made in order to make the practically insoluble caffein somewhat more soluble. The dose of caffeina citrata is 0.15 to 0.5 gram. Caffein Citrata Effervescens contains only two per cent caf- fein, and should be used in dosage of 4 to 15 grams. Caffein Sodio-benzoas and Caffein Sodio-salicylas contain 50 per cent caffein, the double salt being used to obtain greater solubility and permanence. Pulvis Acetanilidi Compositus contains 10 per cent caffein wherein the caffein is used to counteract the depressant effects of the acetanilid. Because of its limited solubility, caffein itself may not be used subcutaneously, and therefore probably is as effective in the form of hot coffee as in any other way. But where the hypodermic use of caffein is needed the sodio-benzoate (now called " caffein and sodium benzoate ") is preferred in doses of 2 to 3 grains. Caffein is, of course, not to be used in cases of high blood pressure. Calcium (Ca) is the metal characteristic of lime, chalk, and all calcareous substances, and although itself unofficial it is repre- sented by several official salts and preparations. Lime (calx) and chalk (creta) are respectively the oxid (CaO) and the carbonate (CaC0 3 ) of calcium, the carbonate occurring in the native forms called chalk, marble, limestone, oyster shells, etc., which are con- verted into lime by heating to full redness (calcination), thereby driving off carbonic acid and leaving the oxid behind. The lat- ter, in this form, is known as " burnt lime " or " quicklime," and by the addition of one half or three fourths its weight of water, combines with one molecule of H 2 to form calcium hy- droxid, Ca (HO) 2 , or " slaked lime," the process being termed " slaking " and being accompanied by the evolution of a high de- gree of heat. Liquor Calcis (Solution of Calcium Hydroxid, Lime Water) contains not less than 0.14 per cent of calcium hydroxid Ca(HO) 2 . A clear, colorless liquid of saline taste and alkaline re- action. Dose, o ss ~J [ av - 3iv], Creta Pr^eparata (Prepared Chalk; CaC0 3 ) is native calcium carbonate, freed from most of its impurities by elutriation ; a white, amorphous powder, odorless and tasteless, insoluble in water or MATERIA MEDICA 409 alcohol. Dose, gr. x-xxx [av. gr. xv]. It is a constituent of Hy- drargyrum cum Creta, and also of the following: Pulvis Cret.e Compositus (Compound Chalk Powder) has of prepared chalk, 30 parts; acacia, 20 parts; sugar, 50 parts. Dose, gr. v-3j [av. gr. xxx] . Mistura Cret^ (Chalk Mixture) has of the preceding 20 parts, cinnamon water 40, water to 100, rubbed together and made fresh as required. Dose, 3j-§j [av. 3iv]. (Potter.) Camphor. — This is one of the stereoptenes and is a solid de- posited from a volatile oil. To this group belong: Turpentine (C 10 H 16 ), Camphor (C 10 H 16 O), Camphoric acid (C 10 H 16 OJ, Bromate of camphor (C 10 H 18 O), Menthol (C 10 H 20 O), and others. The action of camphor in general is similar to that of carbolic acid, but more stimulant, especially to the medulla. It stimulates the vasomotor centers, the cardiac muscle, and produces an effect on the endings of the sensory nerves (sensation of cold in the case of menthol). Ordinarily there is a peripheral depression of the tonus of the blood vessels. It acts as a mild antiseptic. In contra- distinction to strychnin it acts more on the medulla and brain than on the cord. It is readily absorbed and broken up into the hydroxyls in the tissues. It is used hypodermically in nervous spasms and circulatory depression, and is given by the mouth for colds and similar conditions. It is sometimes used for local anes- thesia, and has been given for dyspeptic conditions both for its antiseptic as well as its stimulant effect. (Sollmann.) The best camphor comes from China and Japan. The dose of the crude drug is 0.05 to 0.3. Aqua Camphors is the saturated solution, and is used in doses of 8 c.c. The spirits of camphor form a ten-per-cent solution. Monobromated Camphor (C amphora Monobromata, Bromcam- phor), bromin substitution product of camphor, colorless needles or scales of mild camphoraceous odor and taste. Almost insoluble in water; freely soluble in alcohol, ether, chloroform, and oils. Sedative, antispasmodic, antineuralgic. Average dose, 2 grains. 410 MATERIA MEDICA Incompatible on trituration with butyl-chloral hydrate, chloral hydrate, phenol, menthol, beta-naphthol, resorcin, salol, salicylic acid, thymol, and urethane. It is used in cases of mild insomnia. Linimentum Camphors is a twenty-per-cent solution in cotton- seed oil. The officinal cerate is a ten-per-cent preparation. The compound tincture of camphor is the paregoric mentioned under opium. Camphor and chloral when rubbed together in equal parts form an oil combination which has a very sedative effect and may be used for dropping in the external ear to soothe the pain of otitis media. Oxy Camphor (camphor in which H is replaced by OH) is used in a fifty-per-cent solution (alcoholic) in dose of 1 c.c. as a respiratory cough sedative. Camphoric Acid is used in dosage of 0.6 to 2 for night sweats in phthisis. It does not seem to be very efficient, and ordinary agaracinum (from the Boletus Laricis) in doses of 0.005 to 0.3 is preferable. Menthol may be given in doses of 0.02 to 0.12 (av., 1 grain). Phenolated Camphor is a mixture of equal parts of phenol crystal and camphor gum. It is useful as an antiseptic and in dis- infecting wounds and abscesses, and is also useful in injecting hypodermically into inflamed hemorrhoids to produce a gradual sloughing. For this latter purpose the dose should be 1 to 5 drops. (Sollmann.) Carbo Animalis {Animal Charcoal), prepared from bone, occur- ring in dull black fragments or powder, odorless and nearly taste- less, insoluble in water or alcohol. Carbo Ligni {Charcoal), prepared from soft wood, and very finely powdered, is black, shining, brittle, inodorous, tasteless, and insoluble. Dose, gr. x-xx [av. gr. xv]. (Potter.) Cardamomum {Cardamom) is the dried fruit of Elettaria. re- pens, a plant of the nat. ord. Zingiberacea?, cultivated in Malabar. It contains about four and a half per cent of a volatile oil (C 10 H 1G ) isomeric with oil of turpentine, the oil being the active principle; also a fixed oil, coloring matter, etc. It is an ingredient of pulvis aromaticus and of fluidextractum aromaticum, as well of several compound preparations. Dose, gr. x-xx [av. gr. xv]. Tinctura Cardamomi {Tincture of Cardamom), twenty per cent. Dose, 3ss-jss [av. 5j]. MATERIA MEDICA 411 Tinctura Cardamomi Composita (Compound Tincture of Car- damom) has of cardamom 25, cinnamon 25, caraway 12, cochineal 5, glycerin 50, diluted alcohol to 1,000 parts. Dose, 3ss.-jss. [av. 3j]. Cascara Sagrada, Rhamnus Purshiana (Chittem Bark, Sacred Bark) is the bark of rhamnus purshiana, the California buck- thorn, a small tree of the nat. ord. Rhamnaceae, growing on the Pacific coast of the United States. It contains a volatile oil, a neutral crystalline substance, several resins, with tannic, malic, and oxalic acids. It has been found very serviceable in the treatment of chronic gout and chronic constipation, given in gradually dimin- ished doses. It produces large, soft, and painless evacuations, and the bowels are said to act naturally and regularly after its disuse. Dose, gr. x-xxx [av. gr. xv]. Another species of the same order, rhamnus frangula, is official under the title frangula. Extractum Rhamni PuRSHiANiE (Extract of Cascara Sa- grada). Dose, gr. j-vj [av. gr. iv], Fluidextractum Rhamni Purshiana (Fluidextract of Cas- cara Sagrada). Dose, TTt x-xxx [av. Tr\, xv]. Fluidextractum Rhamni Purshiana Aromaticum (Aromatic Fluidextract of Cascara Sagrada). Dose, Tl^ x-xxx [av. n\xv]. (Potter.) Castor Oil, Ricini Oleum, is a fixed oil expressed from the seeds of Ricinus communis, a tree of the nat. ord. Euphorbiaceae, indige- nous to India, but extensively cultivated in the United States. The oil is an almost colorless, transparent, viscid liquid, of faint odor, bland or slightly acrid taste, neutral reaction, soluble in an equal weight of alcohol. It consists mainly of ricinolein, the glycerid of ricinoleic acid, also palmitin, stearin, and myristin in small quantities, and an acrid principle. The seeds contain a highly toxic ferment or phytalbumose named ricin, and an alka- loid (ricinine) which seems to be inert. Dose, 3ij-§j [av. 3iv]. The nauseous smell is best concealed by the essential oil of bit- ter almonds. Emulsions are not a success. Capsules containing the requisite dose are easily obtained. In the absence of these the best way to administer a dose of oil is to smear the sides of a clean wineglass with very thick cream, then pour in the oil, covering it with a little more cream. A teaspoonful of cream being then taken into the patient's mouth, he is directed to bolt the dose at 412 MATERIA MEDICA one gulp. Some prefer it floated on orange juice, strong coffee, gruel, or wine. One of the best vehicles for it is foaming beer. Glycerin increases its purgative power when given conjointly. If the mouth be chilled by broken ice immediately before taking the oil, the taste of the latter will be imperceptible. (Potter.) A pleasant preparation is sold under the trade name of laxol. Chloral Hydrate is a trichloraldehyd : CH3COH CCI3COH CCl 3 COH.H 2 — Ethyl aldehyd. = Chloral. = Chloral hydrate. This substance was discovered by Liebig in 1831 and introduced as a hypnotic by Liebreich in 1868. He assumed that it was decom- posed in the organism, as it is by the action of alkalies in the test tube : CCI3OH + KOH = CHC1 3 + KC0 2 H Chloral. Chloroform. Pot. formate. This is not the case, the chloral being excreted for the most part as trichlorethyl-glycuronic acid. This latter reduces Fehling's so- lution, which gave rise to the erroneous assertion that chloral causes glycosuria. A small portion of the chloral is excreted unchanged, while a fraction is decomposed, being excreted as chlorids. Chloral is soluble in water, alcohol, ether, and glycerin. Its melting point is 58° C, and it boils at 97° C. Heavy doses depress the medulla and slow the respiration and lower the blood pressure. It may, like chloroform, paralyze the heart, but fatal effects are more apt to be due to the depression of the medullary respiratory center. Chloral causes a more rapid destruction of proteid. Lo- cally it is a rubefacient. A mixture of chloral and bromid is sometimes used as follows : ty Chloral hydrate (0.8) 200 grams. Potassium bromid (0.8) 200 " Ext. cannabis indica (0.008) 2 " Ext. hyoscyamus (0.008) 20 " Pumice 2 " Water q. s. ad (4.0) 1000 c.c. (Mistura chlorali et potassii bromidi composita of the National Formulary.) One teaspoonful is the usual dose. MATERIA MEDICA 413 Chloretone (Acetone Chloroform) is a trichlor- tertiary butyl- alcohol, obtained by the action of caustic potash on equal weights of acetone and chloroform. It occurs as a white crystalline powder of camphoraceous odor, sparingly soluble in water, very soluble in alcohol, in ether, and in chloroform. Dose, gr. v-xxx. Chloroformum (Chloroform, Trichloro-methane; CHC1 3 ). — Ab- solute chloroform is formed by the substitution of three atoms of chlorin for three of hydrogen in marsh gas, methyl hydrid (CHJ, and is obtained by the action of chlorinated lime on ethylic or methylic alcohol, or by that of an alkaline hydrate on chloral. If prepared from methylic alcohol (wood spirit) it is called methylic chloroform, and is purified with great difficulty. The object of its purification is the removal of the chlorinated pyrogenous oil. The official form is: Chloroformum (chloroform) is a liquid consisting of 99 to 99.4 per cent by weight of absolute chloroform, and 0.6 to 1 per cent of alcohol. A heavy, clear, colorless, mobile, and diffusible liquid, of characteristic, ethereal odor, a burning, sweet taste, neutral reaction; volatile, not inflammable; soluble in 200 volumes of water, freely so in alcohol and in ether, also in oils, benzol, and benzine. Sp. gr. not below 1.490 at 59° F., or 1.476 at 77° F. Dose, internally, TTL ij-x [av. n\ v] ; for inhalation, 5ss-j, repeated until the desired effect is produced. (Potter.) Acidum Citricum (Citric Acid; H 3 C 6 H 5 7 + H 2 0) is obtained from the juice of the lemon or the lime by adding chalk to form cal- cium citrate, which is then decomposed by dilute sulphuric acid. It occurs in colorless, rhombic crystals which are very soluble in water. A solution of gr. xvij in §ss of water corresponds to §ss of fresh lemon juice, and this quantity of either will neutralize of potas- sium bicarbonate gr. xxv, of sodium bicarbonate gr. xx, and of ammonium carbonate gr. xivss. Dose, gr. v-xv [av. gr. vijss]. Citrates of bismuth, bismuth and ammonium, iron, iron and ammonium, iron and quinin, iron and strychnin, lithium, magne- sium, potassium, and sodium, ten in all, are officinal. Coal-tar Derivatives. — Their origin is to be traced back to a desire to obtain a cheap substitute for quinin, resulting first in Kolbe's pro- ducing synthetic salicylic acid from phenol, and Knorr's discovery of antipyrin. After this, a new group of drugs owed its origin to the dis- covery, by Cohn and Hepp, that anilin (C 6 H 5 NH 2 ) had very great 414 MATERIA MEDICA antiseptic properties and could be used in the less dangerous form of acetanilid (found by Gerhard in 1852), which was quickly patented in Germany under the name of " antif ebrin " and exploited. But still its effects were too marked (collapse and methemoglobinuria) and too dan- gerous, so that phenacetin (acetphenetidin, Hinsberg), also patented and exploited, was soon introduced by Kast and Baumler. All the vari- ous medicinal antipyretics and so-called specifics are the result of these three bodies — salicylic acid, antipyrin, and phenacetin, and therefore acetanilid — by the changes produced in the molecules of one of them, either by combination of salicylic-acid molecules or with some other organic molecule. It would be impossible, in this connection, to give all the various combinations that have been produced; a few of the more common ones may be mentioned: From salicylic acid, salol, salo- phen, aspirin; from antipyrin, salipyrin, pyramidon; from phenacetin, salophen, lactophenin, citrophen, exalgin, malakin, kyrofin, and pheno- coll. As for the effects of these drugs, they are the resultant of the parent drug or drugs, and depend upon the rapidity with which they are changed to these primary drugs in the system and the number of molecules of the parent drugs in the combination. In so far as the former is accomplished good has been done, especially in the acetanilid, the antipyrin, and phenacetin combinations. But the dose must be in- creased so that, with the increasing avidity of the manufacturers in introducing new compounds, the parent molecule will be finally repre- sented in such small quantity that it will have no effects; only such effects will be noticed as are produced by the substituting molecule, or the change will go on so slowly that no general effects can be noticed, unless the medicine is given in enormous doses — a desideratum much sought by the manufacturers. Every physician is flooded with an- nouncements of these new combinations, frequently, unfortunately, signed by men of eminence in the profession. How can he best perform his duty to his patients and to himself? To his patients, in neglecting the use of a drug which might do good; to himself, in not having done this and in being looked upon as a nonprogressive man for failing to use a new drug which his neighbor has used with such eminent success ? The matter is perfectly simple ; learn to use that drug which is followed by the best results — i. e., by prompt action and the minimum amount of damage — and use this drug until satisfied that something better has been offered. In adhering to one drug, the administration and effects of which are thoroughly understood by the physician, both he and his patients will fare better than by taking up new, unknown drugs, whose number promises to be without end. In influenza many of these pro- duce good effects for the nervous, the gastrointestinal, and the febrile symptoms; not any of them is a specific, notwithstanding statements to MATERIA MEDICA 415 the contrary. It must be remembered that phenacetin derivatives pro- duce collapse and blood changes; that acetanilid should never be used at the present day; that synthetic salicylic acid produces most un- pleasant and sometimes fatal heart complications; and that antipyrin, especially in fever, may produce collapse. It is wrong, therefore, to use any of them in continued fevers in large doses, because of their bad effects, because the cause of the lesion is not removed — indeed, there is a retention of it in the blood — and because the recovery of the patient is postponed. When the temperature produces dangerous symptoms not to be removed by other means, they should be used. In hyperthermia in diseases in which the febrile course is very short, they may be used; unfortunately, without affecting the final result. (Forchheimer.) Colchicum (Meadow Saffron) is the corm and seed of the Col- chicum autumnale, a European plant of the nat. ord. Liliaceag. It contains an intensely bitter, poisonous alkaloid (colchicine, C 22 H 25 - N0 6 ) which by the action of acetic and mineral acids is converted into colchiceme and a resin; also tannic and gallic acids, resin, starch, sugar, etc. It is official in two forms, namely : Colchici Cormus (Colchicum Corm), the dried corm, about an inch long, white internally, grooved on one side, inodorous, taste sweetish, bitter and acrid. Is less active than the seed. Dose, gr. ij-viij [av. gr. iv]. Colchici Semen (Colchicum Seed), about T V i ncn thick, sub- globular, resembling black mustard seed but larger, very hard and tough, inodorous, of bitter and acrid taste. Dose, gr. j-v [av. gr. iij]. Colchicina ( Colchicine ) , a white or yellowish, amorphous pow- der, of saffronlike odor and bitter taste, soluble in water and in alcohol. Dose, gr. -j-J^ to -fa [av. gr. tJ*]. Is suitable for hypo- dermic injection. (Potter.) Collodium, Collodion, made by dissolving Pyroxylin, 4; in Ether, 75, and Alcohol, 25. Collodium Flexile (Flexible Collodion), Collodion, 92; Can- ada Turpentine, 5 ; Castor Oil, 3, mixed thoroughly. Collodium Stypticum (Styptic Collodion), Ether, 25; Alcohol, 5 ; Tannic Acid, 20 ; Collodion to 100. Collodium Cantharidatum (Cantharidal Collodion, Blistering Collodion), Cantharides, 60; Flexible Collodion, 85; Chloroform, q. s. to 100. (Potter.) 28 416 MATERIA MEDICA Colocynthis, Colocynth, is the dried fruit of Citrullus Colo- cynthis, deprived of its rind. The plant is a native of Spain and Asiatic Turkey, and belongs to the nat. ord. Cucurbitaceae. The fruit is of the size of a small orange, white, light, spongy, inodor- ous, very bitter, containing many flat, brown seeds, which should be rejected before the pulp is used. Its active principle is Colo- cynthin, C 56 H 84 23 , an amorphous but crystallizable bitter gluco- side, readily soluble in water. It also contains Colocynthein, a resin, and Colocynthitin, a tasteless, crystalline powder, soluble in ether but not in water, and devoid of purgative action. Dose, gr. ss.-jss. [av. gr. j]. Extractum Colocynthidis {Extract of Colocynth), Dose, gr. J-j [av. gr. ss.]. Extractum Colocynthidis Compositum (Compound Extract of Colocynth) contains of the preceding 16 parts; Aloes, 50; Car- damom, 6; Resin of Scammony, 14; Soap, 14; Alcohol, 10. Dose, gr. v-xx [av. gr. vijss.]. Pilul^e Cathartics Composite (Compound Cathartic Pills) have of the preceding, 8 ; Calomel, 6 ; Resin of Jalap, 2 ; Gamboge, 1J; water to make 100 pills. Dose, j-iij [av. ij pills]. (Potter.) Condurango. — This is the bark of Marsdenia condurango (gono- lobus condurango), one of the asclepiadge from Peru and Ecuador. It is an astringent bitter and therefore a stimulant tonic. There are two preparations, the fluid extract, dosage 1 to 2.5 c.c. (15 to 40 n\ ) ; the tincture, a ten-per-cent solution, dosage 1 to 4 c.c. (15 to 60 HI). Condurangin Glucoside, si. solution in water. Dose, 0.006 to 0.015 ( T V to J gr.) t. i. d. in sweetened mixture. Creosotum (Creosote) is a mixture of phenols and phenol de- rivatives, chiefly Guaiacol and Creosol, obtained during the distil- lation of wood tar, preferably that derived from the beech. It occurs as an almost colorless, or pinkish, inflammable, oily liquid, of smoky odor, caustic taste, and neutral reaction ; soluble in about 150 of water and in all proportions in absolute alcohol, ether, chloroform, carbon disulphid, acetic acid, and fixed and volatile oils. It does not coagulate albumin or collodion, though phenol does. It was named from its remarkable preservative power over meat. Much of the commercial Creosote is an impure phenol or a heavy oil distilled from coal tar and containing phenol and cres- MATERIA MEDICA 417 ylic acid. Dose, nx j-v [av. nx iij], well diluted in wine or whisky. Morson's beechwood creosote is the best for internal use. (Potter.) Liquor Cresolis Compositus. (U. S. P.) Compound Solution of Cresol Cresol 500.0 grams. Linseed Oil 350.0 " Potassium Hydroxid 80.0 ' ' Water to make .1,000.0 grams. Cupri Sulphas (Copper Sulphate) (CuS0 4 + 5 H 2 0), blue, trans- lucent crystals, efflorescent, of nauseous, metallic taste and acid reaction, very soluble in water, soluble in 400 of alcohol. Its solu- tion is blue by transmitted light, green by reflected light. Dose, as an emetic, gr. ij-v [av. gr. iv] every ten or fifteen minutes ; as an astringent, gr. ^ to J [av. gr. J]. (Potter.) Digitalis (Fox-glove, Digitalis purpurea; Fam. Scrophulari- ace^e), heart tonic and diuretic. Average dose, 1 grain (0.065 gram). The root and the leaves of the fox-glove are all used in making this drug. It was for some time only grown in the Black Forest of Germany, but it is now grown in both Europe and America. The caution, however, should be observed to use only assayed specimens, because many varieties of digitalis are prac- tically inert. Thus Dr. Janeway, of New York, claims that Allen's English leaves are the only ones that have proven successful in his practice. Of these leaves, the new ones of the second half year are four times as strong as the old ones of the first half year. The derivatives of digitalis are : Digitalin, practically insoluble in water, soluble in water and alcohol, almost insoluble in ether or chloroform. Digitoxin (C 28 H 46 O 10 ), only slightly soluble in water, spar- ingly soluble in ether, and readily in alcohol and chloroform. Digitonin, freely soluble in water; depressant (saponin) in its action. Digitalein, freely soluble in water. Digitin, inactive. Digitophyllin and Digitoflavon in the leaves. The solutions of the crude drug vary according to their con- 418 MATERIA MEDICA tent of the several active principles. In general, alcoholic prepa- rations have a tendency to contain more of the digitoxin, while the aqueous solutions have more of the digitalin and the digitonin. The action of the drug may be summarized as follows (Soll- mann) : 1. It increases the irritability of the cardiac muscle. 2. It stimulates the vagus. 3. It constricts the vessel walls, especially the arterial. 4. It increases diuresis in cases of cardiac diseases. 5. It stimulates and then depresses the medullary centers (pic- rotoxin action). 6. It is a local irritant ; and finally, 7. It has a veratrin action on skeletal and smooth muscle. Digitalis is very slowly absorbed and one cannot expect its action to appear in less than from twelve to twenty hours. Digi- toxin, however, acts much more rapidly and may show its action in from four to eight hours. Combined with this slow absorption of the crude preparations, there is a tendency to accumulative action. That is, the drug remains stored up in the system and shows no effect until many doses have been given ; then all the drug contained in the body gives action at once, which is some- times so strong as to become dangerous. *d While the digitalin increases the blood pressure in the splanch- nic area, digitoxin affects the blood pressure more nearly uni- formly throughout the body. The preparations of digitalis are : The Infusion. — One and one half per cent; dosage, 15 to 30 drops (4 to 15 c.c). Fat-free Tincture. — Ten per cent; dosage, 20 to 30 drops (0.3 to 1.5). Digitalin, German. — Merck, powdered; dosage, to to ^ grain. Digitalin, French. — Merck ; dosage, -^ to -jV grain. Digitoxin. — Merck ; 1 milligram of the digitoxin equals 1 gram of the herb ; dosage, -gV of a grain. A daily dose of T V of a grain should not be exceeded. The ordinary dose varies from ^J-j- to T V of a grain. This preparation is soluble in 147 parts of water, and is supplied in tablets of -jJq- of a grain, but it should be remem- bered that it is rather expensive. The following note from the report of the Council on Phar- MATERIA MEDICA 419 macy of the American Medical Association summarizes the present status of the chemistry of digitalis: The chemistry of digitalis is very imperfectly understood, but sev- eral principles have been isolated in a greater or less degree of purity. These include digitalin, digitalein, digitoxin, digitonin, and digitin. The term digitalin, unfortunately, is applied in a loose way to all of these principles, and in a more restricted sense to indicate digitalinum verum, or true digitalin, which is probably a definite substance. Digitalinum purum, or German digitalin, is a mixture of several glucosids, consisting of fifty to sixty per cent of digitonin and only six per cent of true digitalin. German digitalin is the preparation usu- ally found on the market and is ordinarily dispensed when digitalin is prescribed. French digitalin, or Homolle's digitalin, is also a mixture of several glucosids, but consists mainly of true digitalin. Merck's crystallized digitalin is neither digitalin nor digitoxin, but digitonin or digitin, Merck using the three terms — crystallized digitalin, digitonin, and digitin — as synonomous. Digitaline crystallisee of Nativelle is not digitalin, but is nearly identical with digitoxin. It must be remembered, therefore, that Merck's " crystallized " digi- talin, Merck's " pure " digitalin, and the " true " digitalin of Boehringer & Sons, which naturally might be supposed to be identical, are different in their action. (Journal A. M. A., May 8, 1909.) When digitalis cannot be given by the mouth it can be intro- duced by way of the rectum by using a tablespoonful of the in- fusion in four ounces of water twice daily. When the infusion is given by the mouth, a dose of one table- spoonful every two hours is not too great. That the dosage of digitalin has been too small is shown by such statements as the following: The growing tendency to employ digitalin in larger doses than was thought feasible a few years ago has prompted us to add to our list a \ -grain hypodermic tablet of this drug. Our assortment of hypodermic tablets of Digitalin, Pure (German), now includes the following grain- ages : ^fo, tm) -gV> iV» tV 4? and \. According to recent information the dose of this drug ranges from -^ to | grain. (Parke, Davis & Co.) Dormiol (Amylene-chloral) is the trade name of a mixture of equal molecules of Chloral and Amylene Hydrate, forming a col- 420 MATERIA MEDICA orless, oily fluid. Dose, 3ss.-j of the ten-per-eent aqueous solution, in which form it is marketed. Dover's Powder (Pulvis Ipecacuanhce et Opii, Powder of Ipecac and Opium) has of Ipecac, 10; Powdered Opium, 10; Sugar of Milk, 80, triturated together to a fine powder. Dose, gr. iij-xv [av. gr. vijss.]. Elixirs (Elixiria), sweetened, alcoholic, agreeably flavored liquids, which may be simply aromatic or adjuvant, to serve as vehicles to disguise the taste of bitter or nauseous drugs; or they may contain medicinal agents. Elixir of any drug may be pre- pared extemporaneously from the fluid extract, e. g., Elixir Calumbae : ^ Flext. calumbae gj 25.0 c.c. Elixir adjuvantis oiij 75.0 ' ' M. Sig. : Dose, one teaspoonf ul. The elixirs represent one of the most agreeable and promptly acting forms of medication, which, containing about twenty-five per cent alcohol by volume (with a few exceptions, viz., Elixir Terpini Hydratis, etc.), should, however, be employed with dis- crimination. Elixir Adjuvans (Adjuvant Elixir, Aromatic Elixir), con- taining twelve per cent glycerrhiza. Especially valuable to mask the taste of quinin. Since the active principle of the Licorice (Glycerrhizin) is precipitated by acids, the quinin should not be dissolved by the aid of dilute acid, but simply be suspended in the elixir as a " shake-well " mixture. Elixir Apii Graveolentis Compositum (N. F.), nerve stimu- lant and tonic. Dose, 4 c.c, or 1 fluid dram, containing 0.3 gram (5 grains) each of celery seed, coca, kola, and viburnum pruni- folium. Similar in composition to a well-known trade article. To avoid confusion with " Opii," the title Apii Graveolentis should be written out in full. Elixir Aromaticum (Simple Elixir), a cordial flavored with orange, lemon, and coriander. Elixir Calcii Hypophosphitis (N. F.), alterative, reconstruc- tive. Dose, 8 c.c. (2 fluid drams), representing 0.2 gram (4 grains) calcium hypophosphite. MATERIA MEDICA 421 Elixir Cooe et Guaran^e (N. F.), stimulant, analgesic. Dose, 4 c.c., or 1 fluid dram, representing 0.5 gram (7J grains) each of coca and guarana. Elixir Gentians Glycerinatum (N. F.), bitter tonic, stom- achic. Dose, 8 c.c, or 2 fluid drams, representing gentian, taraxa- cum, phosphoric acid, in glycerin and white wine, flavored with sweet orange peel, compound tincture cardamom, and acetic ether. Similar in composition to a trade article, becoming known to the public asa " glycerin tonic." Epicarin (Oxynaphthyl - Ortho - Oxytoluic Acid; C 6 H 3 (OH) (COOH) (Ch 2 C 10 H 6 OH) 2: 3: 1 = C 18 H 14 OJ. Epicarin is /?- naphthol-hydroxy-toluic acid. It forms colorless or yellowish needles, melting at 190° to 195° C. (380° to 389° F.), diffi- cultly soluble in water, but easily soluble in alcohol, ether, acetone, and in soaps. It dissolves in oils on addition of a little ether. It has the character of a strong acid, forming well crystallized salts, which, however, are sparingly soluble in water, particularly the sodium salt. On exposure to air it ac- quires a reddish color, due to oxidation; if it is then recrystal- lized from glacial acetic acid, colorless crystals are again obtained, which melt at 166° C. (338° P.). These, however, retain a little acetic acid, but lose this by heating at 120° C. (248° F.). Being a strong acid, it is incompatible with alkaline hydroxids or carbonate, especially those of sodium, with which it forms an almost insoluble salt. It should not be exposed to The air, which colors it red. Epicarin is a nonpoisonous antiseptic and parasiticide. Ad- ministered internally, it is excreted mostly undecomposed. It is said to be useful in the treatment of skin diseases, particularly scabies, tinea tonsurans, prurigo, and certain forms of eczema. Dose : It is used only externally in the form of a five- to twenty- per-cent ointment, with petrolatum or wool fat (lanolin) as base, or in the form of oily or alcoholic solutions (ten per cent). (N. N. R.) Epinephrin, a principle isolated by Abel, is found only in the medulla of the suprarenal gland, and in very small quantity, but it is very active, the t^stt of a grain per kilo of body weight pro- ducing a distinct effect on the blood pressure. Takamine has iso- lated another principle, named 422 MATERIA MEDICA Adrenalin, which is said to manifest all the properties of the gland substance in greater concentration, being the most powerful hemostatic and astringent known, and a cardiac stimulant of great energy. It is claimed to be 600 to 1,000 times more powerful than the extract, the rowoir °^ a gram ( 1 3 j, 00 of a grain), administered intravenously, producing a distinct effect upon the adult man ; and the fraction of a drop of a solution of 1 in 10,000 blanching the normal conjunctiva within thirty to sixty seconds. Its intravenous administration acts powerfully on the muscular system, especially the muscle of the heart and blood vessels, causing an enormous rise of blood pressure. It is nonirritant, nontoxic, noncumulative, devoid of injurious properties, and has little or no effect upon the cerebrum. It has no anesthetic power in itself, but when used in connection with cocain, holocain, etc., it prolongs the duration of the anesthesia produced by them. (Potter.) Ergot. Our experiments would lead us thus to advise the use of ergot in certain emergencies, namely, in shock and in postpartum hemorrhage. In both these cases we should use the drug intravenously, but in both cases the effect should be carefully watched and care taken not to re- peat the dose too frequently. Summary. — That most galenical preparations of ergot contain con- siderable amounts of the active principles but do not show any great or marked action when given per os. Their usually recommended doses are much too small. That ergotin is a highly active alkaloid and has the properties of ergot most desirable to medicine. That ergotin brings about a long-enduring contraction of the walls of arterioles, and increases the movements of the uterus. That this action is feeble when ergotin is given per os, but more marked in subcutaneous injections and much more marked when given intravenously. That in cases where a rapid and certain action is wished, either in shock or in postpartum hemorrhage, we would recommend intravenous administration. We would recommend further, if the effect proved too evanescent to achieve the results desired, that suprarenal be adminis- tered subsequently in repeated small doses. (Cronyn and Henderson.) Ether {2Ether [U. S. P.], Sulphuric Ether, Ethyl Oxid) con- tains ninety-six per cent by weight of (C 2 H 5 ) 2 ; made by acting on MATERIA MEDICA 423 alcohol with strong sulphuric acid, distilling and purifying the product. End reaction = 2C 2 H 5 OH + H 2 S0 4 + (C 2 H 5 ) 2 + H 2 + H 2 S0 4 . Sp. Gr. 0.716 to 0.717; boils at 35.5° C. Inflam- mable. Soluble in 10 volumes of water, all proportions of alcohol, etc. Dose, 1 c.c. = 15 TT\,, U. S. P. This is the ^Ether Purificatus (B. P.). JEther (B. P.) is a less pure and more watery ether. The preparations of Ether are : Spiritus iETHERis (J Ether, § Alcohol, U. S. P. ; ^ Ether, T 9 ¥ Alcohol, B. P.). Dose, 1 to 4 c.c. (J to 1 dram) (4 c.c. = 1 dram, U. S. P.). Spiritus ^Etheris Compositus (U. S. P., B. P.). " Hoffman's anodyne/' Above with 2.5 per cent of " Ethereal oil." Dose, same. JEther Aceticus (U. S. P., B. P.; C 2 H 5 .C 2 H 3 2 ). Boiling point, 72° C. Soluble in 7 parts water, freely in alcohol, etc. Dose, 1 c.c. = 15 TTl, U. S. P. JEthylis Chloridum (U. S. P.; Ethyl Chlorid; C 2 H 5 C1). Pre- pared by the action of HC1 on absolute alcohol. Colorless, ex- tremely volatile liquid, of sharp, sweet taste and peculiar odor. Inflammable. Sp. Gr. 0.918 at 8° C. Boiling point, 12.5° to 13° C. Sparingly soluble in water, readily in alcohol or ether. Dispensed in special glass or metal tubes. Used for freezing and for general anesthesia. Eucain (Beta-Eucain Hydrochlorid, Beta-Eucaince Hydro- chloridum, Eucain Hydrochlorid- ft) . — Beta-eucain hydrochlorid, C 5 H 7 N(CH 3 ) 3 (C 6 H 5 COO).HCL, is the hydrochlorid of 2, 6, 6- trimethyl-4-benzoyl-hydroxypiperidin. It is prepared by treating diacetonamin with paraldehyd, re- ducing the product with metallic sodium, benzoylating the vinyl- diacetonalkamin (melting at 138° C.) so produced by treatment with benzoylchlorid, neutralizing the resulting benzoylvinyldiace- tonalkamin with hydrochloric acid and crystallizing. It forms a white crystalline powder, soluble in 20 to 30 parts of water at the ordinary temperature, but more soluble in warm water, soluble in 25 to 30 parts of alcohol, producing neutral solu- tions which can be sterilized by boiling without change. The aque- ous solutions yield either soluble precipitates of the free base on addition of alkali hydroxids or carbonates. 424 MATERIA MEDICA Beta-eucain hydrochlorid is a local anesthetic like cocain, but weaker and devoid of the stimulating properties of the latter. It does not dilate the pupil, nor does it contract the blood vessels as does cocain. It has the advantage of stability even on prolonged boiling. It may be used in all cases in which cocain is indicated as a local anesthetic, especially in ophthalmology. Dose : It may be applied in a two- to three-per-cent solution to the eye, five to ten per cent for the nose, and five to ten per cent for ointment for hemorrhoids. (" New and Nonofncial Remedies of the A.M. A.") Eucalyptus (U. S. P.). — The leaves of Eucalyptus globulus, Myrtaceas. Australia; cultivated. Contains a resin, volatile oil, etc. The preparations are : Fluidextractum Eucalypti (U. S. P.). — Three fourths alco- hol. Dose, 2 c.c. = 30 Tl\. Becomes turbid with water. Elixir Eucalypti (N. F.). — 1:8. Dose, 8 to 15 c.c. (2 to 4 drams). The above Eucalyptus preparations are used mainly when the local (carminative) effect on the intestine is desired. Oleum Eucalypti (U. S. P., B. P.). — The volatile oil. Dose, 0.3 to 20 c.c. (5 to 30 ITt) (0.5 c.c. = 8 m., U. S. P.) ; or for in- halation. Eucalyptol (U. S. P.) (Cineol; C 10 H 18 O) constitutes fifty per cent of the oil. Colorless liquid. Dose, 0.3 c.c. = 5 nt. Eucalyptus oil is an active disinfectant as well as a local irritant. Fibrolysin. — Fibrolysin is a sterilized solution of a double salt of thiosinamin and sodium salicylate (NHCS.NHCHCH: CH) CH(OH) (COONa), containing fifteen per cent of the double salt. It is prepared by mixing the two compounds in solution. It is an aqueous, odorless solution. It does not keep well in the air, but is marketed in sealed, brown glass vials, each contain- ing 2.3 c.c, 37 TTL of the solution equivalent to 0.2 gram (3 grains) of thiosinamin. The tests are those of thiosinamin and sodium salicylate. Those of thiosinamin, with the advantage of quicker absorp- tion and freedom from pain or irritation, on account of its solu- bility and aqueous vehicle. MATERIA MEDICA 425 Dose: The contents of one vial (2.3 c.c. = 0.2 gram thiosina- min) by subcutaneous, intramuscular, or intravenous injection, one injection being administered daily or every second or third day. (N.N. R.) Formaldehyd (HCHO) is a colorless, irritant gas, discovered by von Hoffman in 1868, and prepared by the oxidation of methyl alcohol. It is freely soluble in water, and is found on the market in the form of a forty-per-cent solution (Formalin). The solu- tions tend to become inactive by the formation of the insoluble, polymeric paraform. This conversion is now prevented by chemic means. Formaldehyd in solution inhibits the growth of bacteria when it is present in the proportion of 1 : 5,000 to 1 : 20,000, according to the species. It checks the growth in 1 : 30,000 ; stronger solution (one half to two and one half per cent, according to the species and to the time of exposure) kill all bacteria and spores. The gas is similarly antiseptic, especially when it is moist. Formal- dehyd surpasses most other disinfectants in penetrating power, and does not injure metals or fabrics. It is employed for disin- fections of rooms, etc., as the gas prepared by spraying the solu- tion, by suspending sheets saturated in the solution, or best by the volatilization of paraform; for instruments and other articles, it is used as one-half- to one and one-half -per-cent solution ; feces are deodorized immediately by a one-per-cent solution, and rendered germ-free in ten minutes. The propriety of its internal use may be doubted on account of its irritant qualities, but it has been em- ployed for the disinfection of hands (one per cent), as a mouth wash and gargle (one half per cent), in skin diseases and hyperi- drosis (2.5 per cent), for painting the throat in diphtheria or tonsillitis (two and one half to five per cent), and as a preservative for milk and other foods and beverages (1:20,000 to 1:30,000). The evaporation of a small amount of the solution in the room has also been recommended in tuberculosis. Gelsemmm (U. S. P.) (Gelsemii Radix, B. P.; Yellow Jasmine). — Rhizome and roots of Gelsemium sempervirens, Loganiascege. Southern United States. Fluidextractum Gelsemii (U. S. P.). — Alcohol. Dose, 0.05 c.c. = 1 TTi. 426 MATERIA MEDICA Tinctura GrELSEMU (U. S. P., B. P.).— Ten per cent; f alcohol. Dose, 0.5 c.c. = 8 nx. Gelseminin, the active alkaloid of gelsemium, produces effects in general almost identical with those of coniin. Its depressing action on the central nervous system is more marked than that of the latter, so that the central paralysis precedes the peripheral even in frogs. It has a very decided mydriatic effect upon the pupil, especially on local application. This is believed by some to be due to paraly- sis of the oculomotor endings after the manner of atropin, but the question cannot be considered as definitely settled. The mydriasis lasts from twelve to seventeen hours. Gelseminin, C 22 H 26 N 2 3 . Dose, 0.0005 to 0.002. (Sollmann.) Tincture Gentian Compound (Tinctura Gentianm Composita), 10 grams Gentian with bitter orange peel and cardamon, in 100 c.c. of the mixture. Bitter tonic, stomachic. Average dose, 1 fluid dram (4 c.c). Of the gentian lutea the root is used. The plant is a native of Switzerland. It has preserved for decades a reputation as a stomachic bitter. Guaiacol (C 7 H 8 2 ) is one of the chief constituents of creosote, and is prepared synthetically from catechol. It occurs as a color- less solid or liquid, of agreeable and aromatic odor, soluble in al- cohol, ether, acetic acid, and glycerin. Dose, TT\ v-xv [av. TTtviij] in capsule, pill, or whisky. Guaiacolis Carbonas (Guaiacol Carbonate, Duotal) occurs as an almost tasteless and odorless, white, crystalline powder, insoluble in water. Dose, gr. v-xx or more [av. gr. xv], gradually increased to a maximum of 3jss. per diem. Hexamethylenamin. — Hexamethylenamin liberates formaldehyd in the kidneys. It is obtained by the action of ammonia on formal- dehyd. It is soluble in 1J parts of water and 10 parts of alcohol. It dissolves uric-acid crystals and urates. Its urate-dissolving power is inferior to that of piperazin. Its dosage varies from 0.2 to 1 gram (3 to 15 grains) in water. (See Journal of the Amer- ican Medical Association, vol. li, No. 10; September 5, 1908, p. 818.) Hydrastis (Golden Seal, Yellow Puccoon, Yellow Root, Orange Root), dried rhizome and roots of hydrastis canadensis (Fam. MATERIA MEDICA 427 Ranunculacese). Average dose, 30 grains (2 grams). (See the Journal of the American Medical Association for July 4, 1908.) The active principles are said to be hydrastin, two and one half per cent; berberin, three and one fourth per cent; canadin, in traces. Canadin has a morphin-like action, but, inasmuch as it is so small in quantity, it does not cause any material effects in the use of the crude drug. Berberin is a bitter tonic. Large doses give a falling blood pressure from a vasomotor paralysis. It is a yellow drug and will stain the clothing if brought in contact with it. Hydrastin has a narcotin-like action. (See Opium.) The for- mer yields hydrastinin by oxidation, the latter cotarnin. Moderate doses of hydrastin have a strychnin effect on the cord. It has a weak local anesthetic action. Small doses cause a rise in the blood pressure, varying according to the condition of the drug. Hydras- tin is insoluble in water, but soluble in 135 parts of alcohol. The dose varies from 0.01 to 0.03 (J to -J grain). Hydrastintn (Hydrastince Hydrochloridum) . — It is usually produced by oxidizing the hydrastin with nitric acid. Light yel- lowish needles of microcrystalline powder, odorless and very bit- ter. Very soluble in water or alcohol, in 286 parts chloroform, 1,300 ether. Hydrastinin has no spinal action or paralysis of the muscle as hydrastin does. On the other hand, it stimulates the cardiac and arterial muscle. (This stimulation, as in the case of other drugs, if pressed too far, leads to a final paralysis.) It increases the blood pressure. It is usually given in the form of the hydrochlorid in the dose of 3 centigrams (0.03). Hydrogen Peroxid, a slightly acid, aqueous solution of Hydrogen Dioxid (H 2 2 = 33.76), which should contain, when freshly pre- pared, about three per cent, by weight, of absolute Hydrogen Dioxid, corresponding to about 10 volumes of available oxygen. It should be kept in a cool place. Upon removing the stopper from the bottle not more than a slight pressure should be observed. A colorless liquid, without odor, slightly acidulous to the taste, and producing a peculiar sensation and soapy froth in the mouth ; liable to deteriorate upon keeping or protracted agitation. If the stopper in the bottle be replaced by a pledget of cotton, deteriora- tion is retarded. 428 MATERIA MEDICA When exposed to the air at the ordinary temperature, or when heated on a water bath at a temperature not exceeding 60° C. (140° F.), the solution loses chiefly water. When rapidly heated, it frequently decomposes suddenly. Hyoscin Hydrobromid (C 17 H 21 N0 4 .HBr + 3H 2 = 434.92; Hy- oscinse Hydrobromas, Pharm., 1890). — The hydrobromid (HBr.- C 17 H 21 N0 4 -f 3H 2 0) of an alkaloid, chemically identical with scopo- lamin, obtained from hyoscyamus and other plants of the Solanaceae. It should be kept in well-stoppered, amber-colored vials. (U. S. P.) Hyoscyamus. — The preparations are: Tinctura Hyoscyami — Dose, 0.5 to 1.5 c.c. (8 to 25 ™j. Fluidextractum Hyoscyami — 0.15 to 0.3 c.c. (2J to 5 trt). Extractum Hyoscyami — 0.05 to 0.1 gram (f to 1^ grains). Ichthyol (Ammonii Ichthyosalphonas, Ammonium Sulpho-Ich- thyolate, Ammonium Ichthyol Sulphonate, Ammonium-Ichthyol) . — Ichthyol consists largely of the ammonium salts of sulphonic acids derived from the tar of a bituminous shale which is found in the Tyrol and which contains the remains of many fossil fishes. The exact composition and nature of ichthyol is still doubtful. It is incompatible with acid and saline solutions, fixed alkalies, their carbonates and iodids, alkaloidal salts, mercuric chlorid, etc. Iodids. — It should be remembered that the iodids have a posi- tive ionic action separate from that of the crude drug. This action may be analyzed as follows: (1) It increases the catabolism and thereby the absorption of pathological formations. (2) It has a specific action analogous to the above in tertiary syphilis and its sequela?. (3) This increase of catabolism makes the drug extremely useful in such conditions as chronic rheumatism and asthma, where there is an accumulation of pathological deposits. In short, the real effect of the iodids may be summarized under the term " increase of catabolism," because pathological material is more easily broken down than normal; hence in using such a drug as the iodids, this material is broken down and absorbed before the normal tissues are touched. Its effect is directly on the cells and not on the circulation. The excretion is by way of the kidneys and begins in ten to fifteen minutes after absorption. It reaches its maximum in two hours. The giving of the chlorids and nitrites hastens excretion. MATERIA MEDICA 429 Iodism is possibly due to the irritative effect of the ion while being excreted through the skin and elsewhere. It is usually pre- vented by giving plenty of alkalies. The drug is used in tertiary syphilis, in chronic rheumatism, in asthma for the absorption of hyperplastic tissue, in combination with expectorants in order to increase the secretion in the mucous membrane of the bronchial tubes. Since the potassium ion has a similar effect to the iodid ion, the use of potassium iodid gives a maximum effect in the way of catabolism. The drug is usually counted incompatible with quinin and strychnin. A very efficient form of the drug is the nascent iodid given in the form of the dilute hydriodic acid (ten per cent), the dose of which is 0.5 c.c. (6 to 8 drops). The syrup of hydriodic acid, a one-per-cent solu- tion, is especially agreeable in dealing with children. It should be given one half hour before meals in doses of one teaspoonful. Iodoform possesses not only the iodid action, but also an action of its own. This latter action produces delirium and mania when the drug is given in too great doses. The temperature rises, the pulse rate is increased ; hence, in using iodoform as a dusting pow- der or for vaginal or rectal packs, one should guard against suf- ficient absorption to produce this intoxication. Some of the iodoform is broken up into iodids; some is excreted unchanged. The presence of the drug on exposed tissue causes granulation on account of its irritation. Iodoform as such has little antiseptic action ; it is antiseptic only as it is broken up by the action of ferments of other reagents into nascent iodin. This occurs so slowly that the effects are mild, but quite sufficient to be markedly antiseptic to bacteria and stimulant to the cells. Iodoform is therefore very valuable in treating open wounds, since it promotes healing by stimulating granulation and lessening or preventing in- fection. It is the most universally used dusting powder ; it is also injected into tubercular joints, usually as an emulsion with glycerin. Iodoform has, however, a number of disadvantages. The most objectionable feature is the persistent odor, which cannot be dis- guised by any perfume. Iodoform is also apt to develop irritant phenomena in susceptible individuals, producing particularly ec- zemas, even in minute amounts. Ipecacuanha (U. S. P., B. P.). — The root of Cephselis Ipeca- cuanha Rubiaceae. Brazil and Colombia; cultivated in India. 430 MATERIA MEDICA Two varieties are found on the market, called Rio and Car- thagena Ipecac. The B. P. recognizes only the former, the U. S. P. both. Recent researches have shown that the Carthagena variety contains more of both alkaloids, but particularly of cephalin, and is therefore the more valuable. Besides the active ingredients enumerated, there are starch, volatile oil, etc. The total alkaloids amount to 2.7 per cent to 2.9 per cent (at least 2 per cent U. S. P.). The ratio of emetin to cephalin varies from 3 emetin: 1 cephalin in Rio to |: 1 in Carthagena. Pulvis Ipecacuanha. — Dose, as emetic, 1 to 2 grams (-J to J teaspoonful) in lukewarm water (U. S. P.: Expectorant, 0.065 gram = 1 grain; emetic, 1 gram = 15 grains). The simple preparations are : Fluidextractum Ipecacuanha (U. S. P.). — | alcohol 1.75 per cent alkaloids. Dose, Expectorant, 0.05 to 0.3 c.c. (1 to 5 n\); emetic, 2 c.c. (30 TTl). (U. S. P.: 0.05 c.c. = 1 1U ; 1 c.c. = 15 ttl.) Extr. Ipecac Liq. (B. P.). — Alcohol; 2.25 per cent alkali. Dose, as the preceding. Syrupus Ipec. (U. S. P.). — Seven per cent of fldext. ; contains acetic acid. Dose, as expectorant, 1 c.c. = 15 Til ; as emetic, 15 c.c. = 4 ounces (U. S. P.). Vinum Ipec. (U. S. P.). — Ten per cent of fldext. Dose, as ex- pectorant, 0.5 to 2 c.c. (10 to 30 TTt, U. S. P.) ; as emetic, 15 c.c. (4 ounces). Vinum Ipec. (B. P.). — Five per cent; 0.1 per cent alkaloids. Dose, twice the preceding. Acetum Ipecacuanha (B. P.). — As the wine. The compound preparations are: Pulvis Ipecacuanha et Opii (U. S. P.; Pulvis Ipec. Compos., B. P.). — Dover's powder: ten per cent of each active ingredient. Dose, 0.05 to 1 gram (1 to 15 grains). (0.5 gram = 1\ grains, U. S. P.) Trochisci Morphina et Ipecacuanha (B. P.). — Each contains ¥ V grain (0.0016 gram) of morphin hydrochlorate and T V grain (0.005 gram) ipecac. Tinctura Ipecacuanha et Opii (U. S. P.) contains ten per cent of each. Dose, 0.2 to 1.2 c.c. (3 to 20 ra). (0.5 c.c. = 8 ra, U. S. P.) MATERIA MEDICA 431 Iron. — It should be remembered that iron is a natural part of the human body, therefore the giving of it in cases of deficiency is merely feeding the body needed food. This remark is par- ticularly applicable in the case of young women from puberty through adolescence, because at this time there seems to be a need of additional iron to the female organism. The metal is locally astringent, producing this effect by the precipitation of the proteids. This astringent action renders the metal antiseptic also. It should be remembered that iron may produce fatal corrosive poisoning from the intestinal tract. The iron action produces gastrointestinal irritation, diarrhea, and finally paralysis of the central nervous system. The salts of iron are absorbed chiefly in the duodenum and jejunum, the inorganic salt being absorbed just as well as the organic, but is changed in the mucosa to an organic salt. Most of the iron salts are excreted by the colon. Blaud's Mass (Pilula Ferri Carbonatis). — The formula is: Ferrous sulphate 16 Potassium carbonate 8 Sugar 4 Tragacanth 1 Althaea 1 Glycerin and water in sufficient quantity to make 100 parts. Saccharated Ferrous Carbonate (Ferri Carbonas Saccha- rahis; FeC0 3 ). — Greenish-brown powder, odorless or sweetish, then slightly ferruginous taste. Partially soluble in water. Cha- lybeate tonic. Average dose, 4 grains. It should be kept well stoppered, as it gradually becomes oxidized in contact with air. It may be used instead of Blaud's mass and will probably be just as efficient. This may be given in a gelatin capsule, and is used in the same dosage as Blaud's mass. Ovoferrin (Ferri Vitellinam Syntheticum) . — Ovoferrin is a solution containing five per cent of an artificial proteid product in which iron is present in the so-called " organic " or " masked ,: form (a form which does not give the iron test directly). The solution also contains ten per cent of alcohol and some aromatics. Ovoferrin is prepared by modifying serum-albumin by elec- trolysis, producing a proteid which is classed by the manufacturers 29 432 MATERIA MEDICA as a vitellin, and introducing ferric hydrate into this proteid by heating under pressure. The ' ' vitellin ' ' constituent of this prepa- ration should not be confounded with the well-known vitellin of the yolk of eggs. The solution has a reddish-brown color, little odor, and a flat, slightly aromatic and alcoholic taste. The solution does not give a blue color on the addition of potas- sium f errocyanid solution ; a blue tint develops slowly if an equal volume of five-per-cent hydrochloric acid is added to the mixture ; a deep-blue color develops at once if this mixture is boiled (dif- ferent from egg yolk). The solution is not precipitated by boiling, but gives precipi- tates with the alkalies, with which it is incompatible. It is also precipitated by acids. Ovoferrin is not appreciably affected by the gastric juice, as 0.5-per-cent solution of hydrochloric acid liberating its iron very slowly and incompletely. The product ranks with the other forms of artificially masked iron, which are devoid of the local action of the soluble inorganic iron salts, and, according to some authorities, are more readily absorbed and utilized. Dose: 8 to 16 c.c. (2 to 4 fluid drams) corresponding to 0.03 to 0.06 gram (J to 1 grain) three times a day. (N. N. R.) Kaolinum (Kaolin) is a native aluminum silicate, powdered and freed from gritty particles by elutriation. It is a fine white clay, derived from the decomposition of the feldspar of granitic rocks. It is used as an excipient for the easily reduced metallic salts, and as an ingredient of Cataplasma Kaolini (Cataplasm of Kaolin) contains Kaolin, Glycerin, Boric Acid, Thymol, Methyl Salicylate, Oil of Pepper- mint. It is identical with the trade preparation known as Anti- phlogistic (U. S. P.) Acidum Lacticum (Lactic Acid), a liquid organic acid, composed of not less than seventy-five per cent, by weight, of absolute lactic acid (CH3CHOH.COOH = 89.37) and about twenty-five per cent of water. Specific gravity, about 1.206 at 25° C. (77° F.). Freely miscible with water, alcohol, or ether; insoluble in chloroform, petroleum benzine, or carbon disulphid. (U. S. P.) MATERIA MEDICA 433 Lysol. — Lysol is a preparation made by dissolving in fat and saponifying with alcohol that part of tar oil which boils between 190° and 200° C, and is a brownish, clear, oily fluid, smelling somewhat like creosote. It is used for the same antiseptic purposes as creolin, but possesses the advantage of forming a clear, soapy fluid when mixed with water, in which instruments can be seen. Mercury. — Hydrargyrum cum Creta (Mercury with Chalk, Gray Powder) has of Mercury, 38; Honey, 10; Prepared Chalk, 57 ; Water, q. s., shaken, triturated together, dried to 100, and then reduced to a uniform gray powder. Dose, gr. ss.-x [av. gr. iv]. Massa Hydrargyri (Mass of Mercury, Blue Mass, Blue Pill) has of Mercury, 33 ; Licorice, 10 ; Althsea, 15 ; Glycerin, 9 ; Honey of Rose, 33. Each grain contains gr. J of Mercury. Dose, gr. ss. -x [av. gr. iv]. Unguentum Hydrargyri (Mercurial Ointment). — Mercury, 50 ; Lard, 25 ; Suet, 23 ; Oleate of Mercury, 2, triturated together, until globules of Mercury cease to be visible under a lens having a magnifying power of ten diameters. Unguentum Hydrargyri Dilutum (Blue Ointment) has of the preceding, 67, with Petrolatum, 33, thoroughly mixed. Hydrargyri Chloridum Corrosivum (Corrosive Mercuric Chlorid, Bichlorid of Mercury, Corrosive Sublimate; HgCl 2 ), heavy, colorless crystals, of acrid, metallic taste and .acid reaction ; soluble in 16 of water and in 3 of alcohol, in 2 of boiling water, 1.2 of boiling alcohol, 4 of ether, and in about 14 of glycerin. Dose, gr. ^Vro [av. gr. *V] • Hydrargyri Chloridum Mite (Mild Mercurous Chlorid, Sub- chlorid of Mercury, Calomel; HgCl), a heavy, white, impalpable powder, odorless and tasteless; insoluble in water, alcohol, or ether; is an ingredient of Pil. Catharticas Co. Dose, gr. -gV-gr. v. The dose depends on the effect desired. [Av. laxative, gr. i j ; al- terative, gr. j.] Hydrargyrum Ammoniatum (Ammoniated Mercury, White Precipitate, Mercuric Ammonium Chlorid; HgNH 2 Cl) is a white, insoluble powder, odorless and tasteless. Used only externally. Unguentum Hydrargyri Ammoniati. — Ointment of Ammoni- ated Mercury (White Precipitate Ointment) : Ammoniated Mer- cury, 10; White Petrolatum, 50; Hydrous Wool Fat, 40. 434 MATERIA MEDICA Hydrargyri Oxidum Flavum (Yellow Mercuric Oxid; HgO), an orange-yellow, heavy, impalpable powder, odorless and tasteless, insoluble in water or alcohol, but wholly soluble in nitric or hydro- chloric acid. Used to prepare : Unguentum Hydrargyri Oxidi Plavi (Ointment of Yellow Mercuric Oxid), strength, 1 to 9. Hydrargyri Oxidum Rubrum (Red Mercuric Oxid, Bed Pre- cipitate; HgO), a heavy, orange-red, crystalline powder, having the same properties as the yellow oxid, from which it differs only in being crystalline and in a less minute state of subdivision. Dose, gr. tWV Lotio Hydrargyri Nigra (Black Wash, Unofficial), prepared by adding Calomel, gr. xxx, to Lime Water, §x, producing the black oxid. Hydrargyri Iodidum Flavum (Yellow Mercurous Iodid, Pro- tiodid of Mercury; Hgl), a dull green or greenish-yellow powder, insoluble in alcohol or ether and almost so in water. Dose, gr, T V -J [av. gr. i]. Unguentum Hydrargyri Nitratis (Ointment of Mercuric Ni- trate, Citrin Ointment). — Mercury, 7, dissolved in Nitric Acid, 17J, adding Lard, 76. Methylioninae Hydrochloridum (U. S. P., Methylene Blue — medic- inal — not to be confused with methyl blue, C 16 H 18 N 3 SC1), readily soluble in water or alcohol. Dose, 0.02 to 0.25 gram (-§ to 4 grains). (0.25 gram = 4 grains, U. S. P. Externally, in 0.5-per-cent solu- tion for mucous membranes ; in two per cent for skin. The drug has been used considerably as analgesic and antipy- retic in neuralgia, neuritis, and sciatica; as an antipyretic in cystitis, urethritis, conjunctivitis, and in skin diseases; as an anti- zymotic in malaria. It paralyzes the malarial plasmodia even more powerfully than does quinin, but in practice it has not proven a very useful substitute for the alkaloid. It sometimes produces gastrointestinal irritation, vesical spasm, and excessive diuresis. It is sometimes used as a diuretic. Beta-Naphthol (U. S. P.; Naphthol, B. P.). — A monatomic phenol occurring in coal tar, but usually prepared from naphtha- lene. It should be kept in dark, amber-colored, well-stoppered bot- tles. It occurs as a colorless or pale, buff-colored, shining crys- MATERIA MEDICA 435 talline laminae or as a white or yellowish-white crystalline powder, having a faint phenol-like odor and a sharp and pungent but not persistent taste. It is permanent in the air. It is soluble in about 950 parts of water and in 0.61 parts of alcohol at 25° C. (77° F.) ; in about 75 parts of boiling water, and very soluble in boiling al- cohol; easily soluble in ether, chloroform, or a solution of alkali hydroxids. Dose, 2 to 5 grains. (See Epicarin.) Nitrites. 1 — The group action of the nitrites is the dilation of the superficial blood vessels, with a blushing of the face and neck ; later, a dilation of the internal blood vessels and a fall of the blood pressure. Large doses paralyze the central nervous system in the same order as does ether (narcotic effect). There is a final depres- sion of the heart muscle and the formation of methemoglobin. (Tyrode.) Sollmann analyzes the action of this group as follows: 1. Paralysis of the vaso-constrictor mechanism, mainly pe- ripheral. 2. Paralysis of the vagus center. 3. Slow paralysis of muscles, of all kinds with which it comes in contact. 4. Methemoglobin formation. In using the nitrites, it should be remembered that the dilation of the blood vessels is especially pronounced in those of the meninges, and that therefore there is a tendency to headache and even syncope. The elapse of time before the various nitrites show their effect is as follows: 1. Nitroglycerin, 1 minute. 2. Sodium and potassium nitrites, 5 minutes. 3. Erythrolnitrate, about 5J minutes. 4. Manitol nitrate, about 12 minutes. The amount of fall pressure in millimeters of mercury was found to be (by Matthew) : 1. Nitroglycerin, 28 millimeters. 2. Sodium and potassium nitrites, 32 millimeters. 1 A valuable article on the use of the vaso-dilators in high blood pressure is to be found in the Quarterly Journal of Medicine for April, 1909, by Edwin Matthew, from which many of the following statements have been obtained. 436 MATERIA MEDICA 3. Erythrolnitrate, 35 millimeters. 4. Manitol nitrate, 35 millimeters. This is the average fall. The difference between the greatest and the least does not exceed six millimeters. The time in which the maximum fall was reached was as follows : 1. Nitroglycerin, 4| minutes. 2. Sodium and potassium nitrites, 14 minutes. 3. Erythrol tetranitrate, 22 minutes. 4. Manitol hexanitrate, about 100 minutes. These nitrites begin to act in 1, 5, 5J, and 10 minutes respec- tively. The maximum, therefore, is produced in 3J, 9, 16J, and 90 minutes after the vaso-dilator action begins. The amount of fall produced by each is about the same, and therefore with the spirit of glyceryl trinitrate there is a very sudden and prompt action. The action is not so sudden in the case of sodium and potassium nitrites, more prolonged with erythrol nitrate, and, lastly, a very gradual and slow action with manitol nitrate. The rise in pressure after the fall: 1. With the spirit of glyceryl trinitrate, the pressure begins to rise almost immediately after the maximum fall has been reached. The rise is slower than the fall, but in all cases the effect of the drugs has completely passed off in thirty minutes. 2. Sodium and potassium nitrite maintain their action from forty to fifty minutes. The rise is then slow and the effect does not pass off until two hours have passed since the administration. 3. Erythrol and manitol behave alike as regards length of ac- tion. The maximum effect is maintained for between one and two hours. The rise is very gradual, and the original level is reached only after five or six hours from the time of administration. Matthew found that in the case of Bright 's disease a stage is reached when the nitrites produce little or no response, although they seem to be effective in the earlier stages. When marked edema is present in the case of heart or kidney disease, the nitrites do not act well until after the edema has disappeared, then the usual vaso- dilator action may reappear. For therapeutic purposes, a fall of 30 millimeters of mercury is sufficient for all practical purposes. The dose of the liquor tri- nitrini (equivalent to the spirit of glyceryl trinitrate) is 2 milli- MATERIA MEDICA 437 grams (-^ grain), the dose to be repeated within a half hour if necessary. With sodium and potassium nitrites, it is necessary to give 2 grains (0.13). The dose may be repeated after two hours. Erythrolnitrate produces an effect with J to 1 grain which lasts for six hours. Inasmuch as this drug sometimes produces unpleasant sensations, a smaller dose should be used whenever possible. Of the manitol nitrate 1 grain seems to be sufficient. Nitroglycerin, equivalent to Spirit of Glyceryl Trinitrate. Glonon, a one-per-cent, by weight, alcoholic solution of nitro- glycerin. Dose, 1 to 2 TTt- This is slowly broken up in the body into nitrites and glycerin. It may produce severe headaches and dizziness on account of the meningeal irritation. Amyl Nitrite (Amylis Nitris; CgH^NO., = 116.24), miscible in all proportions with alcohol or ether; almost insoluble in water. Used as an antispasmodic in angina pectoris, dyspnea, asthma, fainting, cocain poisoning either by mouth or by inhalation. Av- erage dose, 3 drops (0.2 c.c.) in sweetened water. Antidotes: atropin, ergot, or strychnin used hypodermically. Inflammable. This drug takes effect in ten to fifteen seconds and lasts only a few minutes. The drug is usually prepared in a breakable sealed glass, to be broken in a handkerchief and held under the nostrils of the patient. Amyl nitrite produces dilation of the peripheral vessels with pronounced anemia of the pulmonary tissue; hence its value in hemoptysis. Sweet Spirits of Niter (Spiritus JEtheris Nitrosi), volatile, in- flammable, clear liquid of pungent odor and sharp, burning taste. Sp. gr. about 0.823. Diuretic, diaphoretic, antispasmodic. Aver- age dose, 30 TTt (2 c.c). Incompatible with antipyrin, acetan- ilid, or phenacetin, fluid extract buchu, morphin salts, and iodids (when it is acid). Must be kept in dark amber bottles, in a cool place, remote from light and fire. This is a four-per-cent alcoholic solution and used to be given regularly to produce diuresis, and is still used by the laity for that purpose. It seems to be quite ineffective for this purpose, but it does quite often produce some perspiration. The dosage varies from 1 to 4 c.c. Sodium Nitrite (Sodii Nitris; NaN0 2 = 68.57). — White, opaque masses, or pencils, or colorless, transparent crystals. Odor- 438 MATERIA MEDICA less, of mild saline taste. Soluble in 1.4 parts water, slightly in alcohol. Antispasmodic, vaso-dilator, diuretic, also reagent. Av- erage dose, 1 grain (0.065 gram). Antidotes: sodium sulphanilate, naphthionic acid, emetics. Incompatible in solution with acetan ilid, antipyrin, hypophosphites, iodids, vegetable infusions, de- coctions, or tinctures, or mercury salts. Keep well stoppered, as on exposure it deliquesces and is oxidized to the nitrate. Nitrous Oxid. — Anesthesia by Undiluted Gas. — For very short operations (as in dentistry) the gas is inhaled through a tightly fitting mask, with the exclusion of air until the face becomes cy- anotic, the breathing stertorous, the pupils enlarged, and the patient unconscious. This occurs in sixty-three to eighty seconds. The gas is then removed and the operation performed at once, the anesthesia lasting only twenty-two to thirty seconds. The time from beginning the inhalation to complete recovery is only one hundred to one hundred and twenty seconds. There is very little nausea and no other after effect. The anesthesia is due to the com- bined action of the gas and of asphyxia, but mainly to the latter. It cannot, therefore, be prolonged. For short operations, it is the least dangerous of anesthetics. Only seventeen deaths have been reported, making a fatality of about 1 : 5,250,000. In case of accident, artificial respiration or, preferably, oxygen, should be applied. Anesthesia by Nitrous Oxid Diluted with Oxygen. — The anesthesia may be prolonged indefinitely by mixing the nitrous oxid with twenty per cent of oxygen and using it under an excess pressure of one fourth atmosphere. Even lesser proportions of oxygen permit a more or less lasting anesthesia. This principle has been utilized in practice. A special apparatus is required, al- lowing the mixture of two gases in any proportion. This is con- nected with a close-fitting mask. It is advisable to warm the gas mixture before it is inhaled. To hasten the anesthesia, the administration is begun with a mixture containing two per cent of oxygen. This is gradually in- creased to ten per cent. The induction of anesthesia is very rapid, perhaps twelve to fifteen minutes. The patients recover consciousness at once. The nausea is very slight, and with this method of administration there is no marked asphyxia — at most a slight cyanosis. The anesthesia MATERIA MEDICA 439 is most readily induced in children or old people, is much more difficult in hysterics and alcoholics, sometimes failing entirely. The gas has, however, some disadvantages. Its administration re- quires skill and constant watching, since either recovery or as- phyxia occur very rapidly. The muscular relaxation is not nearly so complete as with ether. This method of anesthesia has proved especially valuable as a preliminary to other anesthesia. Its principal drawback is the expense and inconvenience of the apparatus and the expense of the gases. (By great skill and care in regulating the distance of the mask from the face, a prolonged anesthesia may be kept up with nitrous oxid, without oxygen.) (Sollmann.) Opium (Gum Opium), concrete milky exudation obtained by incising the unripe capsules of Papaver somniferum (Fam. Papa- veraceae). Asia Minor and India. Irregular, rounded masses of cakes, grayish brown externally, dark brown internally, plastic when fresh, of strong, narcotic odor and bitter taste. Antidotes: potassium permanganate (2 grains in solution) ; emetics: atropin or strychnin hypodermically ; hot strong coffee; exercise. The active principles are morphin, 10 per cent; codein, which is really methyl morphin, 0.5 per cent; narcotin, 0.6 per cent; papaverin, 1 per cent; thebain, which has a strychnin action, 0.3 per cent. There are also three artificial alkaloids, all derived by chemical changes from morphin, thus: heroin is diacetylmorphin, dionin is ethylmorphin, peronin is benzylmorphin. The general action of opium may be said to be (1) the simul- taneous stimulation and depression of different parts of the central nervous system. Thus it depresses the perceptive powers of the hemispheres so that the attention of the patient is weakened and small impulses are not recognized. Memory also suffers. An in- crease in the size of the dose gradually cuts off the perceptive powers from the other parts of the nervous system. Opium has (2) a local action, when taken by the mouth, on the peristaltic mechanism of the intestine. This action is also mani- fested by morphin when given hypodermically, since the morphin is excreted from the circulation into the stomach. (3) Large doses paralyze the heart muscle. 440 MATERIA MEDICA (4) The respiratory center is depressed. The result is that the volume of air respired is diminished. The amount of carbonic acid in the blood is increased, and we frequently have the phe- nomena of the Cheyne-Stokes respiration. Morphin is rapidly absorbed in the intestinal canal, and when absorbed lessens the metabolism of the body. The sweat is in- creased through the dilation of the cutaneous vessels. The num- ber of leukocytes is decreased. The excretion takes place through saliva and gastric juices to the extent of sixty-six per cent, but enough goes through the urine to cause sometimes a reduction of copper on account of the presence of morphin — glycuronic acid. It should be noted in this connection that some morphin is ex- creted in the milk, which makes the drug inadvisable to use for nursing mothers. A single dose disappears entirely from the body in two days. Small doses of morphin dilate the cutaneous vessels. Large doses, however, make the skin appear blue because the dilation of the vessels of the splanchnic area has taken so much blood that there is none left to fill the skin in spite of the local dilation. Un- der such circumstances the skin may become cyanotic. The pupils are contracted through the paralysis of the medul- lary pupillo-dilator center. There is no local action of the drug and it is very slightly ab- sorbed through the skin, therefore to paint it on the skin for the sake of lessening pain in the deeper structures is not as wise as it would be to select some other drug such as atropin or aconite, either of which is readily absorbed. It should be remembered that morphin follows the general law, and while large doses depress the cardiac muscle, small doses stim- ulate it. Acute poisoning from morphin should be treated by gastric lav- age. The best solution is potassium permanganate, because this has the power to oxidize the morphin and thus render it innocuous. Inasmuch as the morphin is excreted into the stomach, the gastric lavage must be repeated until there is practically no more of the drug in the body to be excreted into the stomach. As stimulant, coffee is the best. The fatal dose varies from 3 to 6 grains. The fatal dose of opium is 3 grams. Heroin depresses the respiratory and cough reflex centers be- MATERIA MEDICA 441 sides increasing the venosity of the blood. It is interesting to note that while the rate of respiration is decreased fifty per cent, the volume of each respiration through the action of heroin is in- creased by forty per cent. There is hardly any action on the ali- mentary canal. The action of Codein is midway between morphin and he- roin. Dionin has a specific action on the conjunctiva, causing a local hyperemia and irritation followed by anesthesia. The general indication for opium and morphin is pain. It should be used for insomnia only when that insomnia is due to pain. In this connection it is wise to note that the phenomena of pain may be checked by depressing the perceptive center (as by morphin), by blocking the transmitting nerve fiber (as by cocain), and finally by paralyzing the end organ of the sensory nerve (as by atropin). Whenever it is possible, it is best to use the latter type of analgesia because it interferes less with the general organism. Opium is better than morphin for checking peristalsis in diar- rhea and peritonitis, and for this purpose is usually given in the form of the tincture in doses from three to twenty drops. It may be given by the rectum when it is unwise to pass it through the stomach. In this case, a larger dose by one fourth should be given than when given by the mouth. Before severe operations a hypodermic dose of morphin will be found very useful in quieting the patient and making him ready for the anesthetic. In fact, when combined with hyoscin (tJtt)* the patient may be put to sleep so completely that ordinary operations may be performed without awaking him. The celebrated " Dover's powders " are an apparent contra- diction, because the opium would seem to be used to depress the reflexes from the intestinal canal, while the ipecac would exalt them. However, the value of the opium in this combination is that it dilates the capillaries of the skin and thus produces hyperemia and perspiration. It is indicated, if at all, therefore, in such con- ditions as beginning colds. In using heroin for cough, care should be taken to avoid the vertigo which sometimes accompanies the use of this drug. This is best accomplished by keeping the patient flat on his back. 442 MATERIA MEDICA The nauseating effect of morphin is usually counteracted by atropin (tVo-^to grain), especially when given hypodermically. The preparations of opium are : Powdered opium, dose J to 2 grains. This ordinarily contains from twelve to twelve and one half per cent morphin. Dover's powders, which contain ten per cent each of powdered ipecac and opium; dose, 5 to 15 grains. Laudanum, which is a tincture made up half alcohol and half water, containing ten per cent of the powdered opium, that is, one and one fourth per cent morphin ; dose, 3 to 20 drops. Deodorized tincture of opium is one fifth alcohol; dosage, the same as lauda- num. Camphorated tincture of opium (paregoric) should be used in teaspoonful doses, which would make the content of opium in such a dose (4 c.c.) 4 grain. For a baby two days old, 2 drops should be the dose; for a child two years old, 12 drops should be the dose. The alkaloids, morphin: Of the salts of morphin, the acetate is the most soluble, then the hydrochlorid. The dose varies from -J to J grain. Codein is usually used in the phosphate; dos- age, | to 2 grains. Narcotin, dose, 3 grains. Heroin, dose, T V to £ grain. Dionin is used in a ten-per-cent ointment for trachoma. Orthoform is the methyl ester of metamidoparaoxybenzoic acid, C 6 H 3 OH.NH 3 COOCH 3 , white, bulky, inodorless, tasteless powder. Soluble readily in alcohol, ether, or collodion; sparingly in water. Local anesthetic and analgesic. Dose, 7J to 15 grains. Orthoform is very slowly absorbed, but rapidly excreted. It should, therefore, never be given hypodermically and is of no value when rubbed into the skin. It may be used as a dusting powder with bismuth for its antiseptic effect (benzoic-acid effect), or it may be used on the skin in the form of an ointment in the strength of ten to twenty per cent in the case of parasites, or even for abrasions. When used internally, a dose of five grains in a one- per-cent solution on an empty stomach seems sometimes to be ef- fective in relieving the pain of gastric ulcer and erosion. Ox Gall. Fel Bovis, the fresh bile of bos taurus Linne. A brownish-green, somewhat viscid liquid, having a peculiar, un- pleasant odor and a disagreeable, bitter taste. Specific gravity, 1.015 to 1.025 at 25° C. (77° F.). It is neutral or has a faintly alkaline reaction upon litmus paper. MATERIA MEDICA 443 Purified Ox Gall. — Ox gall, 300 c.c. ; Alcohol, 100 c.c. A yel- lowish-green, soft solid, having a peculiar odor and a partly sweet and partly bitter taste. Very soluble in water and in alcohol. An aqueous solution of purified ox gall should be clear, and should remain transparent upon the addition of an equal volume of alcohol (evidence of proper purification). Dose: 0.500 gram = 500 milligrams (7J grains). (U. S. P.) Pancreatin (Pancreatinum) . — It should be remembered that the pancreatic ferments act only in an alkaline medium. In order to be given effectively, they must, therefore, not be destroyed in the stomach. A combination of pancreatic ferments should digest twenty-five times its weight in starch. An excellent comparison of the di- gestive ferments in the market is found in the Journal of the Amer- ican Medical Association for July 11, 1908. According to this comparison, holadin is the most efficient starch digestant. Pancreatin is a mixture of enzymes naturally existing in pan- creas of warm-blooded animals, and obtained from pancreas of the hog. (Sus scrofa.) Cream-colored, amorphous powder, of faint, not unpleasant, odor and somewhat meatlike taste. Slowly soluble in water (more than ninety per cent) ; insoluble in alcohol. In- compatible with pepsin, mineral acids in greater concentration than 0.5 per cent, concentrated alkalies, alcohol. Average dose, 7J grains. Pancreatin should be given on an empty stomach, or when the chyme is rapidly passing into the duodenum. It should be given with soda or ox gall, or both; or else should be given in a salol capsule. Holadin presents all the constituents of the pancreas gland, both of the digestive and of the internal secretion. Holadin, while possessing great tryptic activity, is of special potency in respect to the amylolytic and lipolytic enzymes ; it is rich in the important cell constituents, lecithin, and nuclein, which peculiarly abound in the pancreas. Holadin is offered in gelatin capsules, each containing about 0.185 gram, approximately 3 grains. The usual dose is one cap- sule about three hours after meals and one at bedtime. In cases 444 MATERIA MEDICA of constitutional disease, or in serious disorders of digestion at- tributed to faulty pancreatic functioning, the dose may be gradu- ally increased to two or three capsules at a time. Holadin may be obtained combined with the bile salts in the proportion of 2\ grains holadin to J grain bile salts, put up in capsules. The dose is one capsule two to three hours after eating. Diazyme Essence is a liquid stated to contain the amylolytic enzyme of the pancreas, devoid of trypsin and lipase in a men- struum containing 18.5 per cent of alcohol by volume. Diazyme essence is an amber fluid of aromatic taste and odor and slightly acid reaction. One c.c. will convert at 40° C. 200 grams of pure starch mucilage, containing 8 grams of dry starch, so that the solution will cease to give a color reaction with iodin at the end of ten minutes. Dose: 4 to 8 c.c. (1 to 2 fluid drams). Diazyme Glycerole is a liquid stated to contain the amylo- lytic enzyme of the pancreas, devoid of trypsin and lipase, in a menstruum containing about sixty per cent of glycerin by volume. It is a dense amber fluid of agreeable taste and odor and of slightly acid reaction. One c.c. will convert at 40° C. 200 grams of pure starch mucilage, containing 8 grams of dry starch, so that the solution will cease to give a color reaction with iodin in ten minutes. This should also be given two to three hours after food. Papain. — Papain, papayotin, and papoid are names given to a digestive ferment derived from the juice of Carica papaya. This ferment possesses the power of changing proteids into peptones in the presence of an acid or an alkali, or even in a neutral mix- ture, thereby differing from pepsin and pancreatin. This power would be of great value, since the drug would then be useful in all forms of dyspepsia, were it not that careful experimentation renders it doubtful whether papain, papayotin, or papoid can really supplant either of the animal ferments named above. The dose of all these products is from 1 to 8 grains (0.06 to 0.50) given in solution or, better, in capsule. Peppermint (Mentha Piperita, U. S. P.) is official in the form of dried leaves and tops of Mentha piperita. It has an aromatic odor and taste and contains oil. Locally applied, the oil acts as MATERIA MEDICA 445 an irritant and local anesthetic. From this oil is obtained men- thol, a camphoraceous substance of a hot, burning taste, possessing marked power as a local anesthetic. Peppermint is used in the form of the oil (Oleum Menthae Piperita?, U. S. P. and B. P.), dose, 1 to 4 Hi (0.06 to 0.25) ; the spirit (Spiritus Menthae Piperita?, U. S. P. and B. P.), dose, 10 to 30 Hi (0.60 to 2) ; the water (Aqua Mentha? Piperita?, U. S. P. and B. P.), dose, 1 to 2 drams (4 to 8) ; and, finally, as the troches (Trochisci Menthae Piperitae), to be held in the mouth in indefinite number. Pepsin (Pepsinum, U. S. P. and B. P.) is the digestive ferment of the gastric juice. That sold in the shops is generally derived from the pig, and is prepared by manufacturers in many ways. Much of the pepsin of the market contains more peptone than pepsin, and much mucus and albumin. Used with hydrochloric acid in weak solution, pepsin carries out the digestive action of the stomach. Pepsin containing peptone has the peculiar musty smell of peptone, and if the peptone is in excess will absorb moisture and become sticky on exposure to the air. Permanganate of Potassium (Potassii Permanganas, U. S. P. and B. P.) is a salt of a dark purplish-red color, appearing in small crystals and readily soluble in water. In the presence of moisture it rapidly gives up the oxygen which it contains and becomes the dioxid of manganese. By reason of its oxidizing power the permanganate of potas- sium is useful as an antiseptic and deodorant. It should not be employed as a disinfectant for filth, because its action is too fleet- ing, but in saturated solution, followed by oxalic-acid solution, it proves itself one of the best disinfectants for the hands in sur- gical practice. For irrigating the vagina and bladder it is used in 1 : 4,000 solution. In gastric lavage following morphin poisoning it may be used as strong as 1 : 1,000. Petrolatum (Petrolatum Molle, Petrolatum, Spissum, Pharm., 1890), a mixture of hydrocarbons, chiefly of the methane series, obtained by distilling off the lighter and more volatile portions from petroleum and purifying the residue. Petrolatum is insoluble in water; scarcely soluble in cold or hot alcohol, or in cold, absolute alcohol, but soluble in boiling ab- 446 MATERIA MEDICA solute alcohol, and readily soluble in ether, chloroform, carbon disulphid, oil of turpentine, petroleum benzine, benzene, and fixed or volatile oils. The melting point of petrolatum ranges between 45° and 48° C. (113° and 118.4° F.). (U. S. P.) Phenol (Acidum Carlolicum, Pharm., 1890; C 6 H 5 OH = 93.34), Hydroxylbenzene, obtained either from coal tar by fractional dis- tillation and subsequent purification, or made synthetically. It should contain, when assayed, not less than ninety-six per cent of absolute phenol. It should be kept in dark amber-colored, well- stoppered bottles. Soluble in 19.6 parts of water at 25° C. (77° P.), the solubility varying according to the degree of hydration of the phenol; very soluble in alcohol, ether, chloroform, benzene, carbon disulphid, glycerin, fixed and volatile oils; almost insoluble in petroleum benzine. When gently heated, phenol melts, forming a highly refractive fluid. It is also liquefied by the addition of about eight per cent of water. If the phenol be liquefied by a gentle heat, and then slowly cooled under constant stirring until it is partly recrystal- lized, the semiliquid mass should have a temperature (remaining stationary for a short time) not lower than 40° C. (104° P.). Phenolphthalein (C 20 H 14 OJ is a product of the interaction of phenol and phthalic anhydrid. It may be prepared by heating together 10 parts of phenol, 5 parts of phthalic anhydrid, and 4 parts of concentrated sul- phuric acid for ten to twelve hours, at 115° to 120° C. (239° to 248° F.). The product of the reaction is boiled with water and the residue dissolved in soda lye. From this solution the phenol- phthalein is precipitated by the addition of acetic acid. The pre- cipitate, after washing, is dissolved in six times its weight of abso- lute alcohol and the solution decolorized by animal charcoal. A part of the alcohol is then distilled, the mixture filtered, and the phenolphthalein separated from the filtrate by the addition of water. Phenolphthalein occurs as a crystalline or amorphous powder, white or grayish white, melting at 250° to 253° C. (482° to 487.4° F.). It is soluble in 600 parts water and in 10 alcohol. Its solu- tions in acid liquids are colorless, but turn red when the liquid is MATERIA MEDICA 447 alkaline. The red color of the solution disappears if it is boiled with zinc dust, phenolphthalein, C 20 H 16 O 4 , being formed. Dose: For adults the average dose is 0.1 to 0.2 gram (1.5 to 3 grains), given as powder in cachets, capsules, or pills. It may be given with safety in doses of 0.5 gram (8 grains), and these doses seem to be necessary to secure its effects in bedridden patients or in obstinate cases. Phosphorus (P = 30.77). — It should contain not less than 99.5 per cent of pure phosphorus, and be carefully kept under water, in strong, well-closed vessels, protected from light. A translucent, nearly colorless solid, of a waxy luster, having, at ordinary temperatures, about the consistence of beeswax. By long keeping, the surface becomes white or red, and occasionally black. It has a distinctive and disagreeable odor and taste (but should not be tasted, except in very dilute solution). When exposed to the air it emits white fumes, which are luminous in the dark, and have an odor somewhat resembling that of garlic; on longer exposure to air it often takes fire spontaneously. Specific gravity: 1.830 at 10° C. (50° F.) and 1.820 at 25° C. (77° F.). Melting point: 44° C. (111.2° F.). Phosphorus is insoluble, or nearly so, in water, to which, how- ever, it imparts its characteristic, disagreeable odor and taste; soluble in 350 parts of absolute alcohol at 15° C. (59° F.), in 240 parts of boiling absolute alcohol, in 80 parts of absolute ether, in about 50 parts of any fatty oil, and in about 25 parts of chloro- form; it is very soluble in carbon disulphid, the latter yielding a solution which must be handled with the greatest care to prevent evaporation, which would be followed by instant ignition. (U.S.P.) Piperazin. — Mucus is decomposed by the action of the alkalies, but it has been found that the urates and mucus collected in in- flammation of the urinary tract are better decomposed by the organic bases. These, however, accomplish little in the presence of sodium salts. Therefore, for vesical calculi, at least, irrigation is the best method of treatment, and piperazin in from one- to five- per-cent solution forms the best solution. The tartrate of dimethyl piperazin is called lycetol, and is used in the dose of 1 gram (15 grains) three times a day. The dose for piperazin is the same. Lysidin, the hydrochlorate of ethylin-diamin, is more solvent 30 448 MATERIA MEDICA than piperazin. Ethylin-diamin has been used for dissolving false membranes. Pollantin (Fall, Dunbar's Serum), an antitoxic serum from horses treated with pollen toxin derived from ragweed. Horses are injected with gradually increased doses of pollen toxin (derived from ragweed), which results in the formation of an antitoxin after two or three months of treatment. The horses are then bled and the strength of the serum is estimated by de- termining the proportion which will prevent the action of a solu- tion of pollen toxin, of which one drop is barely sufficient to produce a reaction when instilled into the conjunctival sac of a hay-fever patient. The serum is preserved by the addition of 0.25 per cent of phenol. It is a clear, slightly yellowish liquid, having the odor and taste of a dilute solution of phenol. On standing, the liquid deposits a slight precipitate. The liquid is alkaline in reaction and not irri- tating to the normal conjunctiva. It should neutralize the effects of a solution of pollen toxin when mixed with it and dropped into the eye or when a drop is applied immediately after a drop of the toxin solution. The liquid does not keep well if exposed to the air. When it becomes cloudy or a bad odor develops, decomposition has occurred and the preparations should no longer be used. Dose: One drop should be instilled by means of a pipette into the outer angle of each eye and one or two drops into one nostril, the other being kept closed, every morning before rising. If the first application causes sneezing or reddening of the mucous mem- brane of the eye, it is recommended to repeat the application, even for the fourth time, if necessary. (N. N. R.) Potassium Compounds. — Potassium Acetate (KC 2 H 3 2 = 97.44). It should contain, when thoroughly dried, not less than ninety-eight per cent of pure Potassium Acetate (CH 3 .COOK), and should be kept in well-stoppered bottles. A white powder, or in crystalline masses of a satinlike luster, odorless, and having a warming, saline taste. Very deliquescent on exposure to the air. Soluble in 0.4 part of water and in 2 parts of alcohol at 25° C. (77° F.) ; with increasing temperature it becomes much more solu- ble in both liquids. MATERIA MEDICA 449 Potassium Bromid (KBr = 118.22). — It should contain not less than ninety-seven per cent of pure Potassium Bromid, and should be kept in well-stoppered bottles. Colorless, or white, cubical crystals, or a granular powder; odorless, and having a strongly saline taste. Permanent in the air. Soluble in about 1.5 parts of water and in about 180 parts of alcohol at 25° C. (77° F.) ; in less than 1 part of boiling water, and in 16 parts of boiling alcohol; also soluble in glycerin. Potassium Chlorate (KC10 3 == 121.68). — It should contain not less than ninety-nine per cent of pure Potassium Chlorate (ClOoOK), and should be kept in well-stoppered bottles. Great caution should be observed in handling it, as dangerous explosions are liable to occur when it is heated or subjected to concussion or trituration with organic substances (cork, tannic acid, sugar, etc.) or with sulphur, antimony sulphid, phosphorus, or other easily oxidizable substances. Colorless, lustrous, monoclinic prisms or plates, or a white, granular powder; odorless, and having a cooling, characteristic taste. Permanent in the air. Soluble in 16 parts of water at 25° C. (77° F.), and in 1.7 parts of boiling water; insoluble in absolute alcohol, and but slightly soluble in diluted alcohol. The drug is irritant to the kid- neys and should be used with great caution. Effervescent Potassium Citrate. — Potassium Citrate, 200 grams ; Sodium Bicarbonate, dried and powdered, 477 grams ; Tar- taric Acid, dried and powdered, 252 grams; Citric Acid, unef- floresced crystals, 162 grams. To make about 1,000 grams. Potassium Iodid (KI = 164.76). — It should not contain less than ninety-nine per cent of pure Potassium Iodid, and should be kept in well-stoppered bottles. Colorless, transparent, translucent, or opaque white, cubical crystals, or a white granular powder having a peculiar, faint, iodinlike odor, and a pungent, saline, afterwards bitter taste. Permanent in dry air, and but slightly deliquescent in moist air. Soluble in 0.7 part of water, and in about 12 parts of alcohol at 25° C. (77° F.) ; in 0.5 part of boiling water, and in 6 parts of boiling alcohol; also soluble in 2.5 parts of glycerin. (U.S. P.) 450 MATERIA MEDICA Quinin (Quinina; C 20 H 24 N 2 O 2 HC 2 H 3 O 2 = 375.46), white, odor- less, bitter, slightly efflorescent powder. Soluble in 1,750 parts water, 0.6 alcohol, 4.5 ether, 1.9 chloroform, 158 glycerin. Average dose, 4 grains (0.25 gram). This is derived from the cinchona bark. Its actions may be summarized as follows : ( 1 ) It has a toxic action on all protoplasm, and inhibits ferment action. (2) It seems to have specific toxicity for the malarial organism. (3) It diminishes the production of heat and fever by a direct depression of the centers controlling heat production. (4) It depresses the central nervous system after a slight preliminary stimulation. The heart is weakened by doses of one gram and upward. This is accompanied by a vaso-dilation, which makes a collapse more probable. Locally, it causes irritation which may even reach the point of abscess formation. Striped muscle is irritated and weakened, while smooth muscle ordinarily shows no reaction, in spite of the popular belief that quinin stimulates the contraction of uterine fibers. It is interesting to note that the hemoglobinuria in malaria is often due to quinin rather than to malarial organisms. Since quinin inhibits ferment action, it is well adapted for use as a bitter tonic in stomachic combinations. The signs of intoxication are ringing in the ears, photophobia, etc., and are probably due to the local effect on specialized organs. In malaria the drug should be given in such a way that there is present in the blood stream 1 gram of the quinin at the time of the division of the plasmodia, that is, at the time of the outbreak of the fever. To accomplish this, we ordinarily give J gram eight hours before the time of the expected chill, and J gram four hours later. Quinin decreases the size of the spleen, especially in cases of enlarged spleen (Splenomegaly). Quinin is useful in neuralgias in connection with the bromids. Thus you would give a dose of 1 gram of bromid and ^ gram of quinin in sufficient flavored water to make a pleasant solu- tion. It should be remembered that the bisulphate is soluble in 8J parts of water, while the sulphate is only soluble in some hundreds (740) of parts of water. The hydrochlorid is soluble in 18 parts. MATERIA MEDICA 451 For this reason the bisulphate should ordinarily be chosen as the salt for use, especially for colonic irrigation. Quinin is excreted through the urine, and the excretion begins one hour after absorption. Resorcin (Resorcinol; C 6 H 6 2 = 109.22), a diatomic phenol (metadihydroxybenzene, C 6 H 4 (OH 2 ) 1:3), obtained usually by the reaction of fused sodium hydroxid upon sodium metabenzene- disulphonate. Resorcinol should be kept in dark amber-colored vials. Colorless, needle-shaped crystals, having a faint, peculiar odor and a sweetish, followed by a bitter, taste. It acquires a pinkish tint on exposure to light and air. Soluble in 0.5 part of water at 25° C. (77° F.), slightly soluble in boiling water or in boiling alcohol ; also readily soluble in ether and glycerin; very slightly soluble in chloroform, carbon di- sulphid, and benzene. (U. S. P.) Rhubarb (Rheum, U. S. P.; Rhei Radix, B. P.) is the root of several species of Rheum, a plant of Thibet, but which is cultivated in America and elsewhere. It is also derived from China, and this variety is known as Chinese rhubarb. Several alkaloids are con- tained in it, all of which are unimportant and never used alone, except chrysophanic acid. Owing to the astringent properties possessed by rhubarb, it does not purge excessively, and improves the appetite, digestion, and intestinal tone. Its constant use produces chronic consti- pation. Rhubarb, because of its chrysophan, may stain alkaline urine carmin, or acid urine yellow. Rochelle Salts (Potassium and Sodium, Tartrate; KNaC 4 H 4 6 + 4H 2 = 280.18). — It should not contain less than ninety-nine per cent of pure Potassium and Sodium Tartrate (C 2 H 2 (OH) 2 - (COOK)(COONa) +4H,0), and should be kept in" well-stop- pered bottles. Colorless, transparent, rhombic prisms, or a white powder, odor- less, and having a cooling, saline taste. The crystals slightly ef- floresce in dry air. Soluble in about 1.2 parts of water at 25° C. (77° F.), and in less than 1 part of boiling water; almost insoluble in alcohol. (U. S. P.) 452 MATERIA MEDICA Sabromin was originated by von Mering, of Halle, and Fischer, of Berlin, and is a calcium salt of dibrombehenic acid. It contains about 29 per cent bromin and 3.8 per cent calcium, and appears as a white, odorless, and tasteless powder of neutral reaction, in- soluble in water and alcohol. If protected against light, it remains unchanged. Pharmacological experiments have shown that sabromin is practically nonpoisonous, since it was well tolerated by medium- sized dogs in 10-gram doses, without causing any toxic phe- nomena. The excretion of sabromin by way of the urine takes place very slowly and extends over several days. As sabromin is insoluble in water and ordinary solvents, it can be administered in powder form, wafers, or, best of all, in tablets. It has been introduced in the form of tablets of 8 grains each. Salicylates are white powders or crystals, turning pink on ex- posure; disagreeable, sweetish taste. The solutions soon acquire a brown color. Dose, 0.3 to 2 grams (5 to 30 grains). One part is soluble in Water Alcohol Sodii salicylas (U. S. P., B. P.), NaC 7 H 5 3 . 0.8 5.5 Ammonii salicylas (U. S. P.), NH 4 C 7 H 5 3 . 0.9 2.3 Lithii salicylas (U. S. P.), Li.C 7 H 5 3 Very soluble Strontii salicylas (U. S. P.), Sr(C 7 H 5 3 ) 2 . . 18.0 66.0 Salicylates are incompatible with acids. Salicylic Esters (Methyl Salicylate; CH 3 C 7 H 5 3 ) exists in three forms: As a synthetic product — Methyl salicylas (U. S. P.). As the volatile oil of Betula lenta — Oleum betulae volatile (U. S. P.), Oil of Sweet Birch. As the volatile oil of Gaultheria procumbens — Oleum Gaul- theria? (U. S. P.), Oil of Wintergreen. The dose of these is 0.05 to 1 c.c. (1 to 15 lit). (1 c.c. = 15 lit, U. S. P.) Soluble in all proportions of alcohol; very sparingly in water. They are less irritant and disagreeable, but also much less active, than the solium salicylate. Aspirin (Acetyl-salicylic Acid), white needles, acidulous taste. Soluble in 100 water. Incompatible with alkalies. Dose, 1 gram (15 grains), in powders. MATERIA MEDICA 453 Mesotan (Methyloxy methyl- salicylic Acid), clear, yellow, faintly aromatic fluid, almost insoluble in water ; soluble in alcohol and in oils. Readily absorbed by the skin from its oily solution. It is used by rubbing a teaspoonful of a mixture of equal parts of mesotan and olive oil into the skin at the site of the rheumatic pain. (Dreser, 1903.) Salophen (Aceto-para-amido-salol) , colorless crystals, insolu- ble in water, soluble in alcohol. Dose, 1 to 2 grams (15 to 30 grains) . Salicinum (U. S. P., B. P.; C 13 H 18 7 ), a glucosid derived from several species of willow and poplar. Soluble in 21 parts of water or 71 of alcohol. Dose, 0.3 to 2 grams (5 to 30 grains). Saline Solution. — Various formulae exist for the preparation of the so-called normal saline solution. Some persons are satisfied to employ the ordinary solution of common salt in the strength of 0.7 per cent (1£ drams to a quart) in distilled and sterilized water, but this is a dan- gerous plan, for the reason given below. Very slight variations in the percentage of normal saline solution render it harmful. While 0.7 to 0.9 may be considered permissible, a solution lower than 0.6 should not be used, because of the deleterious effects on the red blood cells, and also because it will abstract salts from the tissues. If the solution is too strong it will cause the cells to shrivel. It is evident, therefore, that an absolutely correct percentage is essential if salt solutions are to be employed. Many years ago Dr. Syd- ney Ringer, in London, found by accident, and proved by careful ex- periment, that a small quantity of calcium was essential to the satis- factory use of a sodium chlorid solution. Later than this Loeb, Howell, Locke, and others have shown, with Ringer, that calcium and potas- sium are both essential, and Howell has concluded that the sodium maintains the proper osmotic relations between the cells and the fluid, that the calcium is a stimulating agent to the heart and muscle, and that potassium is essential to its rhythmical contraction and relaxation. Surgeons and physicians should not be content to employ salt solu- tions prepared by haphazard methods. It is vitally important that these solutions shall be most accurately prepared, not only because they will fail to be of benefit if they are carelessly used, but also because the physician may do actual damage and impair his patient's chances of recovery if such care is not followed. In addition to the effects which may be exercised upon the blood and its serum, it is interesting to note that Brown has shown that the 454 MATERIA MEDICA use of pure sodium chlorid solutions is not infrequently followed by glycosuria, whereas if calcium is added to the solution such a leakage of sugar does not take place. The old rule, therefore, that the normal salt solution may be made by adding a teaspoonful of common salt to a pint of water ought never to be followed if it can be avoided. Mathews also believes, and I heartily agree with him, that when large quantities of fluid are used in the peritoneal cavity, calcium and potassium should be present in addition to sodium chlorid in normal quantities. The best solution, because it at once supplants the blood which has been lost or is impure, and because it supports the heart, is : Calcium chlorid 0.25 gram. Potassium chlorid 0.1 Sodium chlorid 9.0 " Sterilized water 1,000 c.c. At the author's suggestion, there is now placed upon the market a " concentrated saline solution," in which the salts just named are dis- solved in 1 ounce of sterile water and placed in a sealed sterile bottle. The contents of one of these vials added to 1 quart (1,000 c.c.) of pure sterile water make a normal saline fluid ready for instant use. The dry salts, carefully sterilized, are also marketed. The method of injection is as follows: The thoroughly sterilized saline solution, after being warmed to the temperature of 101° F., is placed in a warm glass irrigation flask. The patient's skin over the elbow is bared and sterilized; the skin over one of the veins, which is made prominent by a bandage about the upper arm, is incised by a scalpel, and the sheath of the vein raised by means of a pair of dissect- ing forceps. This sheath is thoroughly dissected off the vein until this vessel lies free from any attachments for the space of half an inch. A small and gentle bulldog clip is applied on the vein at the proximal end of the incision, so as to keep the lower part of the vein full of blood. A ligature is now passed around the vein at the distal end of the in- cision and tied. Another ligature is then passed under the vein and left untied. The distended area of the vein, between the ligature which has been tied and the clip, is now snipped by means of a pair of fine scissors, and a glass canula, previously dipped in the saline solution to prevent the few drops of blood from coagulating on its tip, is inserted into the opening in the vein. The loose ligature is now tied around it and the vein to hold the canula in place. This canula should have a shoulder at its tip to prevent the ligature from slipping off, and its other end should be attached to a piece of sterile rubber tubing not more than four inches long. By means of a sterilized glass pipette some of MATERIA MEDICA 455 the saline is now run into the rubber and glass canula until all air is displaced and they are filled to the utmost. The saline is then allowed to flow out of the tubing attached to the irrigator, which is armed by a glass tip, until all the air is displaced, when one tube is slipped inside the other. By this means all danger of air embolism is excluded. The irrigator is now held about two feet above the arm and the fluid al- lowed slowly to enter the vein, a half hour being spent in injecting about a quart. As the injection is given the pulse begins to improve, the respirations are deeper and less hurried, and if fever is present the temperature usually falls. The patient is evidently better, but soon enters the critical stage, which may come on in from two to thirty minutes. There are sometimes a violent chill, a strong, rapid pulse, and in the course of three quarters of an hour a flushing of the skin, followed by a profuse sweat. The respiration may be labored. The urinary flow is also increased, and sometimes water escapes from the bowel. Several hours later the real benefit appears in convalescence or in marked improvement. (Quoted from Hare's Therapeutics.) Salol (Phenylis Salicylas, Phenyl Salicylate; C 13 H 10 O 3 ), sali- cylic ester of phenyl. White, crystalline powder of slightly aromatic odor and taste. Very sparingly soluble in water, readily in 5 parts alcohol, very freely in hot alcohol, ether, chloroform, and oils. (U.S.P.) This is broken up in the presence of an alkaline medium. It is rarely decomposed in the stomach, but it is slowly but com- pletely decomposed in the intestine. The salicylic acid is valuable as a disinfectant in the bile ducts and kidneys; the phenol action is valuable in the intestines. Because of its insolubility salol is used as a coating for enteric pills. It is also used as an intestinal antiseptic in typhoid fever and similar disorders. It is used as urinary and biliary antiseptic also. The ordinary dose is one half gram. The indications of systemic intoxication are either satura- tion of the urine with phenol or ringing in the ears. The urine is only weakly antiseptic in salol. (Sollmann, Journal American Medical Association, September 5, 1908.) Sandalwood Oil (Oleum Santali, U. S. P, and B. P.) is derived from the wood of Santalum album, a tree of India, and has a hot, burning taste. The odor is very pleasant and the oil has been used as a perfume. In overdose the oil is capable of producing great irritation of the genito-urinary passages. 456 MATERIA MEDICA • In all cases it should be given in capsule in the dose of 5 to 20 TTl (0.30 to 1.3), 5 711 (0.30) being usually sufficient, although the druggists generally keep it in 10-TTt (0.60) capsules. Oil of sandalwood may irritate the stomach, but it is not so apt to do so as in cubebs or copaiba. Santonin (Santoninum, U. S. P. and B. P. J is a neutral prin- ciple derived from Levant worm-seed or Santonica, TJ. S., which is the unexpanded flower-heads of Artemisia pauciflora (Maritima, B. P.), a plant of Asia Minor and Turkestan. Santonin is soluble in alcohol and chloroform, but slightly so in water. Santoninic acid is formed by warming santonin with alkalies, and Hesse has found that santonin is an anhydrid of santoninic acid. Santoninic acid is more soluble than santonin. Poisoning. — Santonin causes, when taken in overdose, muscular tremors, convulsive movements, unconsciousness, and sometimes epileptiform convulsions. One of the most common symptoms of the poisoning is chroma- topsia or xanthopsia, during the existence of which all objects look yellow. This is due to the staining of the humors of the eye by the drug. This may go on to total blindness or pass away in a few days. If the vision is not yellow it may be green. The urine is also stained — first yellow, then saffron, and finally purple red, or is bloody looking. This is not due to the presence of blood, but to the drug. Poisonous doses of the drug do not cause gastro- enteritis. (Sollmann.) Senna (U. S. P.). — The leaflets of Cassia acutifolia (Senna Alexandrina, B. P.) (Alexandria Senna) or Cassia Angustifolia (Sinna Indica, B. P.) (India or Tinnevelly Senna) Leguminosae. Easter and Central Africa and India; cultivated. Dose, 5 to 15 grams (1 to 41 drams). (4 grams = 1 dram, U. S. P.) The leaf- lets of the Indian senna are much longer than those of the Alex- andria variety. Senna produces considerable griping. This may be almost abolished without greatly reducing the strength of its action by first exhausting it with strong alcohol. Fluidextr. Senn,e (U. S. P.) is made in this manner. Dose, 2 c.c. = 30 til. The stools occur about five to twelve hours after its adminis- tration. MATERIA MEDICA 457 The best preparation is an extemporaneous infusion. This must not be boiled very long, else the activity suffers. The following are officinal: Infusum (Mistura, B. P.) Senn^e Compositum (U. S. P., B. P.) (Black Draught) .—Dose, 120 c.c. = 4 oz., U. S. P. An ex- cellent preparation. Contains per cent : Senna, 6 ; Manna, 12 ; Magnesium Sulphate, 12 ; Fennel, 2. Pulvis GtLYCYrrhiz^ Compositus (U. S. P., B. P. ; Compound Licorice Powder). — Dose, 2 to 8 grams (J to 2 drams), stirred in water (4 grams = 1 oz., U. S. P). Contains per cent: Senna, 18; Sulphur, 8; and Glycyrrhiza, Oil of Fennel, and Sugar. Confectio Senn^ (U. S. P., B. P.). — Contains per cent: Senna, 10 ; Cassia Fistula, 16 ; Tamarind, Prune, and Coriander. Dose, 4 to 8 grams (1 to 2 drams). (4 grams = 60 grains, U. S. P.) Silver. — Silver is one of the most toxic metals for bacteria and protozoa, but is comparatively innocuous for the mammalian or- ganism. The salts have a great affinity for proteids, and are therefore astringent, irritant, or caustic, according to the strength in which they are used. This combination of astringent, caustic, and antiseptic actions, and the ease with which the effect may be graduated, make the silver salts, particularly the nitrate, very valuable. The lactate has recently been introduced under the name of ' ' actol, ' 7 but seems to possess no advantage. The citrate (also known as " itrol ") may be used sparingly as a dusting powder, since it is so little soluble (requiring 4,000 parts of water) that it cannot become caustic. The ordinary silver salts do not penetrate very deeply, since they are precipitated by proteids and chlorids. The addition of diethylendiamin to silver phosphate prevents this precipitation. This compound (Argentamin) is therefore more penetrating. It is marketed as a fluid containing as much Ag as a ten-per-cent silver-nitrate solution, and is used in corresponding strengths. The precipitation can also be avoided by combining the silver with proteids. The resulting products usually dissolve slowly in cold water. The solutions decompose on exposure to light. A number of these products are on the market, such as Argyrol (with 458 MATERIA MEDICA vitellin, 20 to 25 per cent Ag.) ; Argonin (with casein, 4 per cent Ag.) ; Protargol (with albumose, 8 per cent Ag.) ; Largin (with protalbin, 11 per cent Ag.). The compounds retain the bac- tericidal properties of silver, but are practically nonastringent and nonirritant. The absence of these qualities may be desirable in some cases, while it is a serious drawback in others. They are used in gonorrhea ( T V to 2 per cent), conjunctivitis (0.5 to 5 per cent), nose and throat infections (2 to 10 per cent), etc. Colloidal Silver (" Collar golum ") is also permanently solu- ble in albuminous fluids, but is rendered insoluble by excessive quantities of salts. It is claimed to possess a peculiar value, since it is itself inert and harmless, and remains so in contact with normal tissues, while bacteria transform it into the active ionic form. It should therefore act automatically. It has been used locally like the ordinary silver salts; subcutaneously, in 0.5-per- cent solution for tuberculous joints; and systematically, for septi- cemia. For the latter purpose it may be given by mouth (pills of 0.01 gram) ; by inunction, 3 grams of Unguentum Crede (15 per cent per day) ; or intravenously (10 c.c. of 0.5 per cent). (Sollmann.) Sodium (Natrum, Na). — The alkali metal sodium forms the greatest number of official compounds of any element. The series of compounds or salts are analogous to those of the other alkali metals, potassium, lithium, and ammonium. Like these, sodium compounds are all very soluble in water, the borate (borax) being the least soluble, requiring 20 parts water for solution, though none are deliquescent. They are, as a rule, insoluble in alcohol and other liquids, except that the bromid, iodid, and salicylate are fairly soluble in alcohol. The alkalies are represented by the hy- droxid, carbonate, and bicarbonate, their relative strength being in the order named. Soda cum Calce (N. F.; London Paste), a paste of equal parts of Sodium Hydroxid and Lime. Sodii Bicarbonas (Acid Sodium Carbonate, Baking Soda; NaHC0 3 ), white powder, soluble in 12 parts water, decomposed in boiling water. Uses: Antacid, alterative, antipruritic. The most convenient alkali base to form extemporaneously salts with the organic acids as illustrated in the following: 100 parts sodium bicarbonate re- MATERIA MEDICA 459 quire for saturation or neutralization, in 25 fluid drams (100 c.c.) water, the stated number of parts of these respective acids and produce the parts named of the respective salts: Acid Benzoic, 144 parts = Sodium Benzoate, 170 parts. Acid Citric, 83 parts = Sodium Citrate, 140 parts. Acid Salicylic, 162.5 parts = Sodium Salicylate, 188.5 parts. Acid Tartaric 88.8 parts = Sodium Tartrate, 135.5 parts. Sodii Bisulphis. — Acid Sodium Sulphite; NaHS0 3 . Sodii Boras (Borax), transparent prisms, or white powder, soluble in 20 parts water, in 1 part glycerin; the solution in glyc- erin reacts and forms boroglycerid, with evolution of gas. Dose: 0.5 gram (7-§ grains). An antiseptic astringent powder for vaginal injection is pre- pared as follows: T$ Sodii boratis §ij 60 grams. Aluminis exsiccati ox 40 Thymolis Phenolis Eucalyptolis Olei gaultheriae aa gr. vii j 5 ' ' M. Sig. : A heaping teaspoonful to be dissolved in 1 liter (1 quart) of hot water, to be used as a douche. When it is desired to use sodium borate with boric acid, the fol- lowing will be found satisfactory: ^ Acidi borici gr. xv 1 grams. Sodii boratis gr. xxx 2 ' ' Aquse dest. Aquae camphoraa aa Jiss 50 c.c. M. et ft. sol. Sig. : For instillation in the eye. Sodii Bromidum (Sodium Bromid; NaBr), cubical crystals, or white granular powder, soluble in 1.7 parts water, in 12.5 parts alcohol. Dose: 1 gram (15 grains). Sodii Carbonas Monohydratus. — Sodium carbonate contain- ing only one molecule water of crystallization, and therefore nearly twice as strong as the ordinary carbonate. 460 MATERIA MEDICA Sodii Chloridum (Salt; NaCl). — Soluble in 2.8 parts water, in 25 parts boiling water. Uses : For preparing physiologic salt solution : 9 grams to 1,000 c.c. sterile water ; not to be confused with the chemical normal solu- tion of NaCl. Dose: As emetic, 16 grams (240 grains). Sodii Citras (Sodium citrate), white, granular powder, soluble in 1.1 parts water, in 0.4 part boiling water; slightly soluble in alcohol. Dose: 1 gram (15 grains). Sodii Hypophosphis (Sodium Hypophosphite) , small plates, or white, granular powder ; very deliquescent ; soluble in 1 part water. Dose: 1 gram (15 grains). Syrupus Hypophosphitum, U. S. P. — Dose, 8 c.c. (2 fluid drams) . Syrapus Hypophosphitum Compositus, U. S. P. — Dose, 8 c.c. (2 fluid drams). Sodii Phosphas (Di-sodium-ortho-phosphate) , colorless prisms, or granular crystalline salt; soluble in 5.5 parts water; insoluble in alcohol. Dose: 0.25 gram (4 grains). Starch. — Amylum (Cornstarch), the starch grains obtained from the fruit of zea mays Linne (fam. Graminacea 3 ). In fine powder of irregular, angular white masses, consisting of somewhat spherical, but usually polygonal, grains, about 0.010 to 0.025 mm. in diameter, with a lenticular, circular, or triangular central fissure; inodorous and tasteless; insoluble in cold water or alcohol; forming a whitish jelly when boiled with water, which, when cool, gives a deep blue color with iodin T. S. ; triturated with cold water, showing neither acid nor alkaline reaction with litmus paper; when completely incinerated, leaving not more that one per cent of ash. When freed from water by careful drying in a current of warm air, starch should show not less than ninety-five per cent of hy- drolyzable carbohydrate. (U. S. P.) Stramonium. — Leaves of Datura Stramonium. Dose: 0.065 gram, or 1 grain. Fluidextractum Stramonii, U. S. P. — Dose, 0.05 c.c. (1 TTl). Extractum Stramonii, U. S. P. — Dose, 0.01 gram (| grain). MATERIA MEDICA 461 Tinctura Stramonii, U. S. P. — Dose, 1 c.c. (15 1TL). Unguentum Stramonii, U. S. P. — (Ten per cent extract.) Strychnin (Strychnina; C 21 H 22 N 2 2 = 331.73), alkaloid from nux vomica. Colorless, transparent, odorless, intensely bitter crys- tals, or white powder. Soluble in 6,400 parts water, 110 alcohol, 5,500 ether, 6 chloroform. Excito-motor, nervine, stomachic, car- diac stimulant. Average dose: -^ grain (0.001 gram) in pills or tablets. Antidote: tannin; emetics: chloral hydrate, chloroform, or nicotin. The drug increases the irritability of the reflex arcs, beginning in the spinal cord and working upward; therefore a dose strong enough to affect the brain would begin to give almost a convulsive effect in the spinal centers. The drug has a local effect as a bitter tonic when taken by the mouth. This makes it particularly useful in wasting diseases, but it is questionable whether strychnin (the active principle) is as useful as the crude drug in such a condition. Strychnin is rapidly absorbed and is excreted by the sweat, saliva, bile, and especially urine. This excretion begins very soon after absorption, but lasts from two to eight days. The drug is unchanged in the body. In general, strychnin may be said to intensify the ordinary im- pulses, and it therefore is not a cardiac stimulant, strictly speak- ing, but rather a drug that brings about a general stimulation not only of the respiration and circulation, but also of all other bodily movements. In cases of poisoning from strychnin where a stage of tetanus or opisthotonos has been reached, chloroform is perhaps the best antidote. Preparations. — Tincture of nux vomica, ten-per-cent solution, used in 0.3- to 1.2-c.c. doses. Strychnin sulphate, used in 1-milli- gram (0.001 to 0.005 doses) dose, to be repeated in four hours if necessary. Brucin has more effect on the intestinal canal and a weaker effect on the spinal cord. It is therefore a very good stimulant for indigestion and for use in children. The dose varies from 0.005 to 0.03. Toxicity of Brucin and Strychnin. — Drs. W. E. Dixon and W. H. Harvey (Br. Phar. Conf., through Bull. Phar.) find by ex- periments that brucin is about one eighth as toxic as strychnin, but that the two alkaloids have a very different action. Strychnin 462 MATERIA MEDICA acts on the sensory cells of the spinal cord and causes death by asphyxia, the muscles of the chest being locked in convulsions. Brucin causes slight convulsions at first, but this effect passes quickly, and the alkaloid then acts as a narcotic, paralyzing all the motor nerves. Stypticin. — Cotarnin (from opium) has been put on the market under the name of stypticin. It is cotarnin hydrochlorid ; C 12 H 13 - N0 3 H 2 0.HC1. Yellow, very bitter, hygroscopic powder. Soluble in water or alcohol. Dose : in habitual menorrhagia, f to 1J grains four or five times daily; in violent hemorrhage, 1J to 4 grains hypodermically. Another salt is called styptol, which is a neutral phthalate of cotarnin. This has a narcotic action, but no strychnin effect. It lowers the blood pressure by depressing the vasomotors. Its use is therefore indicated in capillary hemorrhage. Sulphonal, Trional, and Tetronal.— (CH 3 ) 2 C(S0 2 C 2 H 5 ) 2 = Sul- phonal (Sidphonmethanum) . CH 3 C 2 H 5 C(S0 2 C 2 H 5 ) 2 = Trional (Sulphonethylmethanum). (C 2 H 5 ) 2 C. (SO~C 2 H 5 ) 2 = Tetronal. These three resemble each other very closely in their action. Since trional is the more soluble, more quickly absorbed, and more active, it is now preferred. They are less dangerous than chloral, but do not act as strongly on pain, and if used for the latter must be supplemented by mor- phin. (Kast, 1888.) Their excretion seems to be slower than their absorption, so that there is a tendency to a cumulative action. This leads to gastritis, renal disease, and ill-understood changes in the blood, re- sulting in hematoporphyrinuria. The latter has so far been pro- duced only in man and rabbits. These phenomena can be avoided by intermitting the administration at times. The factor urea — nitrogen is lessened. The fate of sulphonal in the organism is not known. Sulphonal habit has been reported. Quite a number of fatal cases of acute sulphonal poisoning are on record. The prominent symptoms were: Various forms of paralysis, often of wide extent, rarely spasms; various cutaneous eruptions; gastrointestinal disturbance and extreme constipation; cardia and respiratory weakness, with a peculiar dyspnea; som- MATERIA MEDICA 463 nolence or insomnia, frequently with mental disorder. Hemato- porphyrinuria is not always seen in acute eases. The autopsy is generally negative. (Taylor and Sailer, 1900.) Sulphonmethanum (U. S. P.; Sulphonal, B. P.), colorless crystals, odorless and tasteless. Soluble in 360 water, 47 alcohol, 15 boiling water. Dose, to 2 grams (30 grains). (1 gram = 15 grains, U. S. P.) Best as powders. Sulphonethylmethanum (U. S. P.; Trional) , colorless, odor- less crystals, bitter taste. Soluble in 195 water, more readily in boiling water, readily in alcohol. Dose, as preceding. Tetronal. — Properties and dose resembling the preceding. Sulphur. — Calx Sulphurata (Sulphurated Lime, improperly called " calcium sulphid "), mixture of sixty per cent Calcium Sulphid with Calcium Sulphate and Carbon. Grayish-white powder, decomposing by liberation of hydrogen sulphid when exposed to moist air; slightly soluble in cold water, readily in boiling water, which decomposes it. Dose: 0.065 gram (1 grain), in powder or capsule; should not be massed or formed in pills. Sulphur Lotum (Washed Sulphur.) — Uses: Alterative, laxa- tive, antiparasitic. Dose, 4 grams (60 grains). Pulveris GlyrrhizyE Compositus, U. S. P. — Dose, 4 grams (60 grains) . Unguentum Sulphuris, U. S. P. — (Fifteen per cent.) Acidum Sulphuricum Dilutum (Diluted Sulphuric Acid). — Ten per cent ; H 2 S04. Uses : Tonic, astringent, and refrigerant ; to dissolve quinin and other alkaloids. Dose: 2 c.c. (30 TT\,), diluted. Syrup of Orange (Syrupus Aurantii, Syrup Aurantii Corticis). — Prepared from the tincture of fresh orange peel; this is a most exquisite flavored vehicle. Uses: As addition to liquid mixtures of various salts, that is, bromids, iodids, etc., about 25 c.c. (6 fluid drams) to a 100-c.c. (25 fluid drams) mixture. Talc (Talcum Purificatum) . Talc, in fine powder 500 grams. Hydrochloric Acid 75 c.c. Water, a sufficient quantity. 31 464 MATERIA MEDICA Mix the powdered talc with about 2,500 c.c. of boiling water, gradually add 50 c.c. of the hydrochloric acid, and boil the mix- ture during fifteen minutes; then allow it to stand for fifteen minutes. Decant, and reject the supernatant liquid containing the finer particles of talc in suspension, and again boil the residue with 2,500 c.c. of water, mixed with the remainder of hydrochloric acid, and allow it to stand for fifteen minutes. Again decant, and re- ject the finer suspended particles, and wash the coarser residue with water by repeated decantation, until a portion of the wash- water, after filtering and acidifying with nitric acid, fails to be- come opalescent upon the addition of silver-nitrate test solution, then transfer the magma to a close linen or muslin strainer, allow it to drain, and dry it at 110° C. (230° P.). Tannin (Acidum Tannicum, Gallotannic Acid; HC 14 H 9 9 ). — Very soluble in alcohol and water, cold or hot; in glycerin; almost insoluble in ether, chloroform, benzine, or petroleum benzine. It is prone to darken on exposure. Astringent and styptic. Used locally in hemorrhages, pure; in one- to ten-per-cent solutions as mouth washes, injections, lotions, collodion, etc. Average dose, 1\ grains (0.5 gram). Incompatible with salts of antimony, copper, iron, lead, mercury, and silver; with alkaloids, albumin, gelatin, iodin, iodoform; with permanganates, chlorates, and other ox- idizers; spirit nitrous ether. Tannin precipitates proteids, connective tissues, etc., by local contact. In this contact, albuminates are formed and an irritant acid quite similar to that formed by the mineral caustics is liberated. Tannin is very slowly absorbed from the intestinal canal. A small part of that which is absorbed is excreted by the urine. The major part of the tannin introduced into the intestinal canal is broken up into gallic acid, which is not astringent. Because of its astringent effect, small doses of tannic acid have some tonic action upon the bowel. Large doses, however, lead to gastroenteritis. It perhaps is the best drug for the treatment of diarrhea, it being valuable even in cases of cholera. To be most effective, tan- nin should, however « not act until it reaches the intestine, there- fore it should be given, if possible, in some form which passes through the acid contents of the stomach without decomposition. Such preparations may be obtained from natural drugs in the form MATERIA MEDICA 465 of the tincture of gambir, or the tincture of kino, or krameria, any one of which is to be used in dosage of one half to one teaspoonful. Similar effects have been produced by artificial combinations; for instance, Tannalbin (Tannin Albuminate Exsiccated). Tannalbin contains fifty per cent of tannic acid, insoluble in ordinary solvents. Intestinal astringent. It is not acted upon at all in the stomach, but readily decomposed in the intestine, where it produces its local astringent action. Tannopin (Hexamethylenetetraminetannin; (CH 2 ) 6 N 4 , (C 14 - H 10 O 9 ) 3 = 1,098.16), a fawn-colored, odorless, tasteless powder. Eighty-seven per cent tannic acid and thirteen per cent urotropin (Hexamethylenamin). Insoluble in usual solvents decomposed by alkalies. Intestinal astringent and disinfectant. Dose, 10 to 15 grains (0.65 to 1 gram) four times daily. This is insoluble, but liberates the tannin and the formaldehyd in the intestine. It is therefore recommended for septic diarrhea, but is of no value as an intestinal or urinary antiseptic. (Soll- mann, Journal of the American Medical Association, September 5, 1908.) It is used also as a dusting powder. Tannoform (Tannin- formaldehyd; C 29 H 20 O 18 = 651.23), a condensation product of tannic acid and formaldehyd. Whitish- red, odorless powder. Soluble in alcohol, ammonia, alkalies; in- soluble in water. Drying antiseptic and deodorant, intestinal as- tringent and disinfectant. Dose, 4 to 15 grains (0.25 to 1 gram). This is a similar preparation to tannopin, but, since it is irri- tant, it can be used only for external application. Tannigen (Acetyltannin, Tannic Acid Acetic Ester), a light gray, nearly odorless and tasteless, slightly hygroscopic powder. Soluble in alcohol ; insoluble in water. Intestinal astringent. Dose, 7 \ to 15 grains (0.5 to 1 gram), three to five times daily. This compound has proven quite satisfactory in the East. The dosage for a child should vary from 0.3 to 0.5. Collodion Stypticum is a combination containing twenty per cent tannin and eighty per cent collodion. Unguentum Acidi Tannici. — This is a twenty-per-cent oint- ment of tannic acid in benzoinated lard. GtLyceritum Acidi Tannici contains twenty per cent tannic acid. This is used externally as an astringent paint ; rarely internally. 466 MATERIA MEDICA For rectal irrigation, etc., the ten-per-cent solution of tannin may be used, but for repeated colonic irrigations, as in bacillary dysentery, a two-per-cent solution seems sufficient. Tars. — Pix Liquida (U. S. P., B. P.; Pix Carbonis Preparata, B. P. ; Pine Tar) , an aromatic oleoresin obtained by the destructive distillation of pine woods, particularly that of Pinus palustris, conifera?, United States. Dose, 0.5 gram = 7J grains (U. S. P.). Soluble in alcohol or oils; only partly in water. Tar consists of a mixture of resinous and volatile principles. When it is sub- jected to redistillation, it can be separated into a fixed portion — pitch — consisting mainly of rosin; and a volatile portion, which separates into Oil of Tar (Oleum Picis Liquids, U. S. P.) and pyroligneous (crude acetic) acid. The oil of tar consists of various coal-tar derivatives, mainly Cresols, Guaiacol, Phenol, Xylol, Tol- uol, and Pyrocatechin. It also contains methyl alcohol and ace- tone. Dose, 0.2 c.c. = 3 ni (U. S. P.). Tar is used externally as antiseptic, parasiticide, and counter- irritant, in the form of: TJnguentum Picis Liquidce (U. S. P., B. P.). — Fifty per cent, in yellow wax and lard. Internally, it is used in bronchitis, like creosote; and as an ex- pectorant, most usefully as : Syrupus Picis Liquidce (U. S. P.). — Dose, 4 to 15 c.c. (1 to 4 drams) . Theobromine Preparations : Diuretin. — We have already spoken of this drug under the head of caffein. It is chemically theobromin sodio-salicylate and con- tains fifty per cent theobromin. The dose is one gram in solution three times a day. It is well used in the form of a prescription written by Professor Eichhorst: ^ Fol. Digitalis, Pulv 0.1 grams. Diuretini 1.0 " Sacch. Lactis 0.3 M. f. chart, no. I. Da tales doses no. decern. S. : Take one powder in water three times a day. The difficulty with this prescription is that unless diuretin be used immediately it decomposes. Therefore only a small number MATERIA MEDICA 467 of powders should be ordered. It would be preferable if the drug could be used iu solution, but its solubility seems to vary according to the condition in which the druggist has kept his stock. In other words, diuretin decomposes so readily that only fresh prod- ucts should be used. With the fresh drug solutions in peppermint water might be used, e. g. : ^ Diuretini 10.0 grams. Aquae menthae piperita? 100.0 c.c. M. D. S. : One dessertspoonful t. i. d. Agurin. — Theobromine sodio-acetas. C 7 H 7 NaN 4 2 . NaC 2 - H 3 2 = 282.19. AVhite, hygroscopic, alkaline powder. Soluble freely in water; decomposed by acids. Diuretic, without effect on heart. Dose, 5 to 15 grains (0.3 to 1 gram). Agurin contains 63.6 per cent of theobromin. In my hands it has been less effective than diuretin. Theocin. — Theophyllin; dimethylxanthin, C 7 H s N 4 2 . White, odorless, bitter powder. Soluble in 180 parts water; forms salts with alkalies. Diuretic. Dose, 3 to 5 grains (0.2 to 0.3 gram). This costs more than diuretin and agurin, and is practically in- soluble. On the other hand, the doses are smaller. Thiosinamin (Thiosinamina, Allyl Sulphocarbamid, Allyl Thi- ourea, Rlwdallin; (NH 2 ) . CS . NHCH 2 CH : 2 CH = C 4 H 8 N 2 S) is a condensation product of allyl thiocyanate and ammonia. It is prepared by warming together volatile oil of mustard (chiefly allyl thiocyanate) and alcoholic solution of ammonia, col- lecting the crystalline product of condensation, and recrystallizing from alcohol. It forms colorless crystals, having a slight alliaceous odor and bitter taste and melting at 74° C. (165.2° F.). It is moderately soluble in water, but is decomposed by this solvent. It is soluble in about 3 parts of alcohol and readily soluble in ether. It is incompatible with water, which decomposes it, but this change is, to a limited extent, prevented by the presence of glycerin. Thiosinamin appears to cause or quicken the absorption of exu- dates, lymphatic swellings, scar tissue, etc., the action being unex- plained. The opinions as to its value are contradictory. 468 MATERIA MEDICA It is used by hypodermic injection in lupus, chronic glandular tumors, cicatrices, etc. By the mouth in stricture, corneal opacity, chronic deafness. Dose : 0.3 to 0.1 gram (J to 1-J grains) , in capsules or tablet triturates; in subcutaneous injections, 0.05 to 0.2 gram (1 to 5 grains), in fifteen-per-cent alcoholic or ten-per-cent glycerinated water solution. (N. N. R.) Thymol (U. S. P., B. P.; C 6 H 3 (CH 3 ) (OH) (C 3 H 7 ) 1:3:4:), a phenol (stereoptene) occurring in the volatile oil of Thymus vul- garis, Carum Ajowan, and some others. Large, colorless crystals of peculiar odor. Liquefies when triturated with camphor, menthol, or chloral. Soluble in 1,100 water, freely in alcohol. Dose, 0.05 to 1 gram (1 to 15 grains). Liquor Antisepticus (U. S. P.), a mild antiseptic, containing in 1,000: 20, Boric acid; 1, Benzoic acid; 1, Thymol; 0.25, Eu- calyptol; 0.5, Oil Peppermint; 0.25, Oil Gaultheria; 0.1, Oil Thyme; 250, Alcohol. A number of proprietary mixtures, e. g., ' ' listerine, ' ' have a similar composition. Thyroid Extract {Glandulce Thyroidece Siccce, Desiccated Thy- roid Glands) , the thyroid glands of the sheep (Ovis aries Linne), freed from fat, and cleaned, dried, and powdered. A yellowish, amorphous powder, having a slight, peculiar odor, and containing the active ingredient of the thyroid tissue ; partially soluble in water. One part of Desiccated Thyroid Glands represents approxi- mately 5 parts of the fresh glands. (U. S. P.) Tohi. — Balsamum Tolutanum (U. S. P., B. P.). — Its prepara- tions are very popular as vehicles in cough mixtures, etc. It is a solid balsam, derived from Toluifera Balsamum, Leguminosae; Venezuela. It is used as: Syrupus Tolutanus (U. S. P., B. P.). — Dose, ad libitum. Tinctura Tolutana (U. S. P., B. P.). — Twenty per cent. Dose, 2 to 4 c.c. (-| to 1 dram). Acidum Trichloracetum (Trichloracetic Acid), white, deliques- cent crystals, very soluble in alcohol or ether. Uses: Chiefly as a chemical reagent; astringent, escharotic, hemostatic; to remove warts and other skin blemishes, in ten-per- cent water solution ; astringent or hemostatic, one- to three-per-cent solution ; must be used with care. MATERIA MEDICA 469 Oil of Turpentine (Oleum Terebinthince Rectificatum) . — For medicinal use. Anthelmintic, diuretic, antiseptic. Used in dysen- tery, whooping cough, retention of urine, tapeworm, phosphorus poisoning, etc. Average dose, 15 TT\, (1 c.c.) ; in tapeworm, 1 to 2 fluid drams (4 to 8 c.c). The oil of turpentine is insoluble in water, but soluble in 3 parts of alcohol. It is used as a liniment, which, if covered by an impermeable bandage, produces a blister. It is excellent for use in bronchitis, either as an oil spray or in a vapor with steam. In this connection it should be noted that it has a tendency to stimu- late the bronchial mucous membrane to throw off the accumula- tion of exudates. In this way it may cause a paroxysm of cough- ing, and in weak patients, on this account, it may have to be avoided. In chronic cases, if used in the form of the turpentine pipe, it will prove very effective. It has a considerable reputation as an anthelmintic, and for such purpose should be given in the morning before breakfast in doses of five drops each at fifteen-minute intervals, to be followed by an active purge. The drug should, of course, not be adminis- tered to patients with diseased kidneys. Its general action is that of phenol or camphor. Applied to the skin, it penetrates deeply and irritates. This irritation is followed Ijy a paralysis of the sensory nerves. Because of this paralysis, it may appear to give relief in boils and bruises and similar irritative conditions, as soon as the preliminary burning is over. The maxi- mum dosage of the rectified spirits (or oil) is 1 c.c. Linimentum Terebinthin^ consists of 1 part turpentine to 2 parts rosin cerate. Urea, CO(NH 2 ) 2 = CH 4 ON 2 , is the diamid of carbonic acid. Urea occurs as colorless, transparent prismatic crystals, almost odorless, having a cooling, saline taste. It is somewhat hygroscopic. It is soluble in water (1-1), more readily in hot water. Soluble in alcohol (1-7) and (1-1) in boiling alcohol. It is insoluble in ether and chloroform. Urea is an active diuretic; it is rapidly eliminated and is not poisonous. It has been claimed, without convincing proof, to have the power of dissolving urinary calculi. It has been recommended in the treatment of tuberculosis, but this use of it is generally aban- 470 MATERIA MEDICA cloned. It may be employed where diuresis is indicated, though it appears irrational in primary renal disease. Dose, 0.5 to 4 grams (10 to 60 grains). Urea is given in solu- tion, or it may be inclosed in cachets. (N. N. R.) Valerian. — The name valerian is said to come from that of Valerius, the man who first introduced it into medicine. The rhi- zome and roots of the plant are used, and they contain one to two per cent of volatile oil with valerianic and other acids, tannin, and resin. The oil develops the medicinal properties while the plant is dried or drying, only to lose this property if kept too long. The fluid extract is three fourths alcohol. Dose, 2 c.c. (30 TT^). The tincture is twenty per cent. Dose, 5 c.c. The Ammoniated Tincture is also thirty per cent, the rest being the aromatic spirits of ammonia. Dose, same ; well diluted. Valyl (Diethylamid of Valerianic Acid), a colorless liquid of peculiar odor and burning taste, is marketed in capsules which do not dissolve in the stomach (to avoid causing the patient to belch), and which contain 0.125 gram (2 grains). The dose is two to three of these " pearls " three times a day. This preparation is there- fore intended more for the hysteria and general nervousness than for the local condition. Veratrum Viride (American Hellebore, Green Hellebore, Amer- ican Yeratrum, Indian Vote), the dried rhizome and roots of vera- trum viride, liliacse. North America. Contains jervin, pseudo- jervin, veratrin (cevadin), rubijervin, veratralbin, veratroiodin, resin, and starch. Because of having such a complex constitution its physiological action is very complex and variable. It retards the heart's action and softens the pulse. The dose of the fluid ex- tract is one to three drops. Veronal (Diethyl-malonyl-urea) has been highly recommended. It is a white, crystalline powder of faintly bitter taste. Soluble in 150 water. Dose, 0.3 to 1 gram (5 to 15 grains), in capsule or in hot milk. Habit has been reported. (Krep, 1905.) Waters (Mineral Waters). — In order that the reader may be able to utilize the more available American waters where our text- books have directed the use of European waters, we give below some general analyses, both of the European and American waters. MATERIA MEDICA 471 Thus the artificial Kissingen water is made up as follows (N. F.) : Potassium Chlorid 17 Sodium Chlorid 337 Magnesium Sulphate 59 Sodium Bicarbonate 107 (24 grains of this to 6 ounces of water is the usual proportion.) We secure a similar water when we prescribe the White Rock and other light American table waters. Kissingen is regarded as a plain saline water, but of the plain salines ocean water is, of course, the type. Of this 1,000 parts contain : NaCl 27.0 KC1 0.75 MgCl 2 3.7 MgBr 0.027 MgS0 4 2.3 CaS0 4 1.4 CaC0 3 0.02 Iodids, etc Traces. Artificial sea baths may be made by dissolving four per cent of sea or rock salt in water. Vichy, according to the National Formulary, contains: Sodium Bicarbonate 846.0 Potassium Carbonate 38.5 Magnesium Sulphate 38.5 Sodium Chlorid 77.0 (14 grains to 6 ounces of water — ^ teaspoonful to the tumbler — is the usual proportion.) This is an alkaline saline water. Carlsbad is a carbonated saline water. The artificial salt is made as follows: K 2 S0 4 0.12 Na 2 S0 4 2.64 NaHCO s 2.16 NaCl 1.08 This equals a teaspoonful of the combined salts, and should be added to the liter of water. 472 MATERIA MEDICA Hunyadi Janos contains in 1,000 grams: MgS0 4 22.3 Na 2 S0 4 22.5 NaCl 1.3 This water makes a strongly cathartic alkaline water, suitable for bad cases of constipation, especially if complicated with hyperacid- ity of the stomach. Seidlitz in 1,000 grams contains : MgS0 4 13.5 CaS0 4 1.4 MgCl 2 0.4 Friedrichshall belongs to the same group. The following are representative American waters, and the analyses here given will enable the student to classify them with the European waters just named. Allouez Magnesia Water, Green Bay, Wis. : (Calcic bicarb onated alkaline) Parts per Formula and Name. million. NH 4 C1 (Ammonium Chlorid) 0.03 LiCl (Lithium Chlorid) Trace KC1 (Potassium Chlorid) 3.2 NaCl (Sodium Chlorid) 27.7 MgCl 2 (Magnesium Chlorid) 17.1 MgS0 4 (Magnesium Sulphate) 73.7 Ca 3 (P0 4 ) 2 (Calcium Phosphate) ... . Trace NaN0 3 (Sodium Nitrate) 36.43 Mg(HC0 3 ) 2 (Magnesium Bicarbo- nate) 145.1 Ca(HC0 3 ) 2 (Calcium Bicarbonate). 317.8 23 I (Ferric Oxid and Albumina) . 1.2 CaSi0 3 (Calcium Silicate) 25.9 Si0 2 (Silica) 7.7 Total 655.86 Per cent of total inorganic material in solution. 0.49 4.22 2.61 11.24 5.55 22.13 48.46 0.18 3.95 1.17 100.00 MATERIA MEDICA 473 Buffalo Lithia Water, Buffalo Lithia Springs, Va. : (Calcic Sulphated Saline) Formula and Name. Parts per million. NH 4 C1 (Ammonium Chlorid) 0.114 LiCl (Lithium Chlorid) Trace KC1 (Potassium Chlorid) 7.6 NaCl (Sodium Chlorid) 12.0 NaS0 4 (Sodium Sulphate) 77.7 MgS0 4 (Magnesium Sulphate) 31.7 CaS0 4 (Calcium Sulphate) 463.8 Ca 3 (P0 4 ) 2 (Calcium Phosphate) Heavy trace NaN0 2 (Sodium Nitrite) Trace NaN0 3 (Sodium Nitrate) 3.03 Ca(HC0 3 ), (Calcium Bicarbonate). 112.6 Fe O ) aiVi 3 \ ( Ferric Oxid an d Alumina) . 0.7 A1 2 (J 3 ) CaSi0 3 (Calcium Silicate) 6.4 Si0 2 (Silica) 31.6 Total 747.244 Per cent of total inorganic material in solution. 0.02 1.02 1.61 10.40 4.24 62.05 0.41 15.07 0.09 0.86 4.23 100.00 The value of this water lies evidently not in its lithium content, but rather in the calcium and sulphates. 474 MATERIA MEDICA Congress Water, Saratoga, N. Y. : (Sodic muriated alkaline-saline, carbondioxated) Formula and Name. Parts per million. NH 4 C1 (Ammonium Chlorid) 30.64 LiCl (Lithium Chlorid) 32.7 KC1 (Potassium Chlorid) 340.5 NaCl (Sodium Chlorid) 5,141.6 KBr (Potassium Bromid) 40.0 KI (Potassium Iodid) 1.0 Na 2 S0 4 (Sodium Sulphate) 12.9 NaB0 2 (Sodium Metaborate) . Small amount NaN0 2 (Sodium Nitrite) Trace Na(HCO s ) (Sodium Bicarbonate). 627.8 Mg(HC0 3 ) 2 (Magnesium Bicarbon- ate 1,674.9 Ca(HC0 3 ) 2 (Calcium Bicarbonate) 2,276.5 Ba(HC0 3 ) 2 (Barium Bicarbonate) 13.4 Sr(HC0 3 ) 2 (Strontium Bicarbon- ate) Trace Fe Oo ) 23 v (Ferric Oxid and Alumina) 21.0 •AI 2 3 ) Si6 2 (Silica) 19.8 Total 10,232.74 Per cent of total inorganic material in solution. 0.30 0.32 3.33 50.24 0.39 0.01 0.12 6.14 16.38 22.25 0.13 0.20 0.19 100.00 MATERIA MEDICA 475 Hathorn Water, Saratoga, N. Y. : (Sodic muriated alkaline-saline, carbondioxated) Formula and Name. NH 4 C1 (Ammonium Chlorid) LiCl (Lithium Chlorid) KC1 (Potassium Chlorid) NaCl (Sodium Chlorid) KBr (Potassium Bromid) KI (Potassium Iodid) Na 2 S0 4 (Sodium Sulphate) NaB0 2 (Sodium Metaborate) . Small amount NaN0 2 (Sodium Nitrite) Trace Na(HC0 3 ) (Sodium Bicarbonate). 220.9 Mg(HC0 3 ) 2 (Magnesium Bicarbon- ate 1,974.7 Ca(HC0 3 ) 2 (Calcium Bicarbonate) 3,098.3 Ba(HC0 3 ) 2 (Barium Bicarbonate) 14.2 Sr(HC0 3 ) 2 (Strontium Bicarbon- ate) Trace aiV* 3 [ (ferric Oxid and Alumina) 9.6 A1 2 (J 3 ) Si0 2 (Silica) 16.5 Total .*... 13,170.39 Parts per million. Per cent of total inorganic material in solution. 37.80 0.29 44.9 0.34 332.5 2.52 ,343.7 55.76 70.0 0.53 2.2 0.02 5.0 0.04 1.68 14.99 23.52 0.11 0.07 0.13 100.00 476 MATERIA MEDICA Manitou Table Water, Manitou, Col.: (Sodic and calcic bicarb onated alkaline carbondioxated) m at Parts per Formula and Name. .«. million. NH 4 C1 (Ammonium Chlorid) 0.15 LiCl (Lithium Chlorid) 1.38 KC1 (Potassium Chlorid) 136.10 NaCl (Sodium Chlorid) 303,20 KBr (Potassium Bromid) Faint trace Na 2 S0 4 (Sodium Sulphate) 324.20 NaB0 2 (Sodium Metaborate) . Small amount Na(HCO s ) 2 (Sodium Bicarbonate). 1,193.20 Mg(HC0 3 ) 2 (Magnesium Bicarbon- ate) 476.80 Ca(HC0 3 ) 2 (Calcium Bicarbonate). 1,854.50 Fe(HC0 3 ) 2 (Ferrous Bicarbonate) . 5.70 Mn 3 4 (Mangano-manganic Oxid) . . 2.40 Si0 2 (Silica) 47.2 Total 4,344.83 Per cent of total material. 0.03 3.13 6.98 7.46 27.46 10.97 42.69 .13 .06 1.09 100.00 MATERIA MEDICA 477 Mount Clemens Water, Mount Clemens, Mich.: Formula and Name. Parts per million. NHC1 (Ammonium Chlorid) 0.157 LiCl (Lithium Chlorid) Trace KC1 (Potassium Chlorid) 6.5 NaCl (Sodium Chlorid) 37.6 KBr (Potassium Bromid) Trace KI (Potassium Iodid) Trace Na 2 S0 4 (Sodium Sulphate) 459.6 MgS0 4 (Magnesium Sulphate) 291.5 CaS0 4 (Calcium Sulphate) 1,618.7 NaB0 2 (Sodium Metaborate) Small amount NaN0 3 (Sodium Nitrate) Trace NaN0 2 (Sodium Nitrite) .014 Ca(HCO) (Calcium Bicarbonate) 197.0 Fe(HC0 3 ) 2 (Ferrous Bicarbonate) ... 4.5 Mn 3 4 (Mangano-manganic Oxid) .... Trace SiO (Silica) 27.6 Total 2,643.171 Per cent of total inorganic material in solution. 0.25 1.42 17.39 11.03 61.25 7.45 .17 1.04 100.00 In Japan the waters of such springs as the above — particularly when hot — are used freely by syphilitics. The government classifi- cation makes this a sodic muriated saline sulphureted water. 478 MATERIA MEDICA Pagosa Spring, Colorado: Great Carlsbad (Sprudel Spring. Spring). Sodium Chlorid 13.380 15.450 Sodium Carbonate 18.025 20.415 Sodium Sulphate 32.730 35.580 Calcium Carbonate 9.040 4.455 Magnesium Carbonate 1.440 1.860 Lithium Carbonate 0.710 Potassium Carbonate 0.607 Strontium Carbonate 0.012 Iron Protoxid 0.036 0.030 Manganese Protoxid 0.042 0.009 Calcium Fluorid 0.066 0.045 Calcium Phosphid 0.007 0.003 Silica 0.155 0.108 " Pagosa Springs, by quantitative analyses, is the nearest to the famous Carlsbad Sprudel Spring of anything found in the United States ; and it is owing to the similarity to these waters that Pagosa Springs can rightfully be called ' The Carlsbad of America.' " (Circular from the owners.) MATERIA MEDICA 479 Pluto Concentrated Water, French Lick, Ind. (Sodic sulphated saline) _ AT Parts per Formula and Name. .,,- LiCl (Lithium Chlorid) Heavy trace KC1 (Potassium Chlorid) 539.9 NaCl (Sodium Chlorid) 1,960.9 KI (Potassium Iodid) Trace MgS0 4 (Magnesium Sulphate) 30,195.8 Na 2 S0 4 (Sodium Sulphate) 64,425.2 CaS0 4 (Calcium Sulphate) . 1,095.8 NaN0 2 (Sodium Nitrate) Trace Ca(HC0 3 ) 2 (Calcium Bicarbonate) .... 288.8 FeO ) . 3 > (Ferric Oxid and Alumina).. . . 5.0 A1 2 (J 3 ) Si0 2 (Silica) 29.2 Total 98,540.6 Per cent of total material. 0.55 1.99 30.65 65.38 1.11 .29 .03 100.00 Red Raven Aperient Water, Formula and Name. NaCl (Sodium Chlorid) Na 2 S0 4 (Sodium Sulphate) Na 2 HP0 4 (Di-sodium Phosphate) Na(HCOg) (Sodium Bicarbonate) . . Si0 2 (Silica) Total armarville, Pa.: Parts per Per cent of million. total material, 166.1 0.60 986.9 3.55 26,329.8 94.40 341.5 1.22 63.6 .23 100.00 This water is supersaturated with carbon dioxid. 480 MATERIA MEDICA Regent Spring Water, Excelsior Springs, Mo.: Grains per Name - U. S. Gallon. Alumina 0.1224 Silica 0.6998 Potassium Sulphate 0.2834 Potassium Chlorid 0.1633 Sodium Chlorid 1.0264 Sodium Bicarbonate 0.5452 Iron Bicarbonate 4.1934 Manganese Bicarbonate 0.8445 Magnesium Bicarbonate 5.5445 Calcium Bicarbonate 34.2406 47.6635 Siloam Springs Water, Excelsior Springs, Mo.: Grains per Name - U. S. Gallon. Silica 1.6777 Potassium Sulphate 0.1929 Calcium Sulphate 1.3028 Calcium Bicarbonate 21.5233 Magnesium Bicarbonate 0.2524 Manganese Bicarbonate 0.2524 Iron Bicarbonate 2.7688 Sodium Chlorid 0.9949 Magnesium Chlorid 0.7540 Alumina 0.3890 32.2863 MATERIA MEDICA 481 Sulphosaline Water, Excelsior Springs, Mo.: Grains per Name ' U. S. Gallon. Silica 0.5899 Alumina 2.2780 Ferrous Carbonate 0.0921 Calcium Bicarbonate 17.9658 Calcium Sulphate 32.1800 Magnesium Sulphate 29.7400 Potassium Chlorid 4.7300 Sodium Chlorid 363.6535 479.7793 Veronica Formula and Name. Parts per million. NH 4 C1 (Ammonium Chlorid) 0.24 KC1 (Potassium Chlorid) 169.5 NaCl (Sodium Chlorid) 3,170.0 KI (Potassium Iodid) Heavy trace Na 2 S0 4 (Sodium Sulphate) 802.7 MgS0 4 (Magnesium Sulphate) 15,151.4 CaS0 4 (Calcium Sulphate) 744.3 Ca 3 (P0 4 ) 2 (Calcium Phosphate) Trace NaN0 3 (Sodium Nitrate) 2,384.9 Ca(HC0 3 ) 2 (Calcium Bicarbonate) 1,397.8 Fe O ) . 2 3 [ (Ferric Oxid and Alumina) 3.7 Si0 2 (Silica) 18.1 Total 22,842.64 Per cent of total inorganic material in solution. 0.74 13.88 3.51 61.95 3.26 10.44 6.12 .02 .08 100.00 This water is found at Santa Barbara, Cal., and is bottled without additions. It is a magnesic sulphated saline. 482 MATERIA MEDICA Vichy Water, Saratoga, N. Y. : (Sodic muriated alkaline-saline, carbondioxated) Formula and Name. NH 4 C1 (Ammonium Chlorid) LiCl (Lithium Chlorid) KC1 (Potassium Chlorid) NaCl (Sodium Chlorid) KBr (Potassium Bromid) KI (Potassium Iodid) Na 2 S0 4 (Sodium Sulphate) NaB0 2 (Sodium Metaborate) Small Na(HC0 3 ) (Sodium Bicarbonate) Mg(HC0 3 ) 2 (Magnesium Bicarbonate) . . Ca(HC0 3 S) 2 (Calcium Bicarbonate).... (Ferric Oxid and Alumina) ai 2 o 3 CaSI0 3 (Calcium Silicate) Si0 2 (Silica) Parts per million. 2.64 .6 7.4 1,499.1 Trace Trace 29.9 amount 837.1 60.8 158.8 3.2 27.6 1.9 Per cent of total inorganic material in solution. 0.10 .02 .28 57.02 1.14 31.85 2.31 6.04 .12 1.05 .07 Total 2,629.04 100.00 MATERIA MBDICA 483 White Rock Lithia Water, Waukesha, Wis.: Per cent of Parts per total inorganic Formula and Name. million. material in solution. NH 4 C1 (Ammonium Chlorid) 0.125 0.01 LiCl (Lithium Chlorid) 76.4 6.35 KC1 (Potassium Chlorid) 5.7 .47 NaCl (Sodium Chlorid) 573.6 47.65 MgCl 2 (Magnesium Chlorid) 26.2 2.18 MgS0 4 (Magnesium Sulphate) 49.6 4.12 NaN0 2 (Sodium Nitrite) .024 NaN0 3 (Sodium Nitrate) 6.07 .50 Mg(HC0 3 ) 2 (Magnesium Bicarbonate) . . 125.2 10.41 Ca(HC0 3 ) 2 (Calcium Bicarbonate) 327.7 27.23 FeO ) 3 [■ (Ferric Oxid and Alumina) .57 .05 Si0 2 (Silica) 12.4 1.03 Total 1,203.589 100.00 This is a sodic and calcic muriated alkaline-saline carbondiox- ated water. 484 MATERIA MEDICA Witter Springs Water Name. Grains per U. S. Gallon. Lithium Chlorid .018 Potassium Chlorid 9.615 Sodium Chlorid 55.216 Sodium Sulphate .144 Strontium Bicarbonate (with Spectroscope).. .Strong test Sodium Metaborate .058 Magnesium Sulphate .501 Calcium Phosphate .032 Sodium Nitrate Trace Sodium Bicarbonate 579.258 Barium Bicarbonate (with Spectroscope) Strong test Calcium Bicarbonate 34.928 Magnesium Bicarbonate 333.030 Ferrous Bicarbonate .778 Manganese Bicarbonate .289 Silica 488 Carbonic Acid, Free 67.999 Total 1,082.354 The water is obtained from the Witter Medical Springs in Lake County, Cal., and is bottled directly from the springs without charging. MATERIA MEDICA 485 Wool Fat: Adeps Lan,e (Wool Fat). — The purified fat of the wool of sheep (Ovis Linne) freed from water. A light yellowish, tenacious, unctuous mass, having a slight, peculiar odor. Insoluble in, but miscible with, large quantities of water, spar- ingly soluble in cold alcohol, more soluble in hot alcohol, readily soluble in ether and chloroform. Wool fat melts at about 40° C. (104° P.), and at a higher temperature vaporizes, the vapor igniting and burning with a luminous, sooty flame. Adeps Lan^e Hydrosus (Hydrous Wool Fat). — The purified fat of the wool of sheep (Ovis aries Linne), mixed with not more than thirty per cent of water. A yellowish-white, or nearly white, ointment-like mass, having a slight, peculiar odor. Insoluble in water, but miscible with twice its weight of the latter, without losing its ointment-like character. With ether or chloroform it yields turbid solutions which are neutral to mois- tened litmus paper. Hydrous wool fat melts at about 40° C. (104° F.), and sepa- rates into an upper oily and a lower aqueous layer. (U. S. P.) Yohimbin (C 22 H 28 N 2 3 HC1), an alkaloid isolated by Spiegel (1896) from the bark of the Yohimbehe tree (family of Apocy- naceas), growing in German West Africa. The local application one- to two-per-cent solution) produces the same anesthetic effect as cocain, and is less toxic. The effect begins in ten to fifteen minutes and lasts one half to one and three quarter hours. The vessels are rather dilated, even when adrenalin is added. In the eye, the anesthesia occurs more promptly (one half to one minute, lasting ten to fifteen minutes) . It should not be used in this organ, since it causes considerable irritation, lasting four to six hours. The pupils are dilated, the mydriasis lasting some twenty-four hours. Accommodation is but little affected. When it is given by the mouth or hypodermically in moderate doses it produces a general vaso-dilation in the skin, mucous mem- branes, and particularly in the sexual organs. In consequence of the latter, and perhaps by a direct action on the spinal centers, 486 MATERIA MEDICA it produces erection. It does not seem to stimulate the production of spermatozoa or sexual desire. In consequence of this action on animals, the alkaloid has been used as an aphrodisiac in neuropathic impotence, apparently with fair success. The reports must be accepted with caution, consider- ing the possibility of psychic suggestion. The effect in animals occurs immediately ; that in man only after some four to six weeks. This makes it difficult to explain the clinical observations by the animal experiments. The continued administration of the alkaloid is said to lead to no bad effects; however, the resemblance of its action to that of cocain would suggest that it may perhaps create a habit. Ordi- nary doses produce a psychic excitement similar to that of cocain. (This has been referred to dilation of the cerebral vessels.) There is also some distention of the cerebral vessels and vertigo. Gastric disturbance has been noticed. The effects of larger doses also agree with those of cocain. Toxic doses cause general stimulation and subsequent paralysis of the nervous centers, particularly in the medulla. The free alkaloid and the solutions of the hypochlorid being unstable, the dry salt is marketed in the form of tablets, contain- ing 5 mg. ( T V gr.) ; three tablets per day are the ordinary dose. (Sollmann.) Zinc Compounds. — All the zinc compounds^ except the carbonate and oxid, are very soluble in water and are regarded as poi- sonous. Poison. — Antidotes: Alkaline carbonates, tannin, emetics, stimulants. Zinci Chloridum (Zinc Chlorid; ZnCl 2 ), white granular pow- der, or fused mass, so very deliquescent that the official solution should preferably be used by taking twice the weight required of the salt. Liquor Zinci Chloridi, U. S. P. — (Fifty per cent.) Caution. — Solutions for injection should not exceed 0.2 per cent in strength. Zinc Oxidum. — Zinc Oxid. — ZnO. White, fine amorphous powder, insoluble in water or alcohol. Unguentum Zinci Oxidi, U. S. P. — (Twenty per cent.) INDEX INDEX Aborting a cold, 113. Abrasions, 95. Abscess of liver, 228. Acetanilid, 22. Acetic acid, 396. Acetic ether, 423. Acetone chloroform, 413. Acetonum, 396. Acetphenetidin, 22. Acidosis, 356. Acidum aceticum, 396. boricum, 404. carbolicum, 446. citricum, 413. lacticum, 432. tannicum, 464. trichloracetum, 468. Aconite, 120, 396. in fever, 32. Actinomycosis, 365. Actol, 457. Adenitis, 339. Adiposa dolorosa, 63. Adolescence, heart in, 267. Adrenal bodies, 342. Adrenalin, 422. in shock, 58, 92. Adrenalin inhalant, 122. Age and dose, 392. Agurin, 467. Alcohol, as solvent, 14. for sciatica, 17. Alcoholic content of beverages, 393. Alcoholic solutions for itching, 37. Alkalies in arthritis, 348. Alkaline sprays, 115. Allouez water, 472. Aloe, 397. Alternating douche, 63. Alum, 397. Ameba coli, 242. Ammonium carbonate, 136, 380. Ammonium salts, 397. Ammonium sulpho-ichthyolate, 428. Amyl nitrite, 437. Amyloid kidney, 292. Amylum, 460. Anacidity, 201. Anal fissures, 251. Analgesic balm, 119. Anaphylaxis, 88. Anemia, lymphatic, 339. primary, 277. secondary, 280. Anesthesia, by water, 18. general, 25. local, 15. Angina pectoris, 255. Anise, 397. Anterior poliomyelitis, 317. Anthrax, 365. Antidiphtheritic serum, 125. Antipyretics, 31. Antipyrin, 22, 398. Antiseptics, 83. Antitoxin, diphtheritic, 125. Anuria, 283. Aphthae, 191. Apomorphin, 53, 136, 398. for convulsions, 72. Apoplexy, 270. Apothecaries' weights, 395. 489 490 INDEX Argentamin, 457. Argonin, 458. Argyrol, 398, 457. Arnica, 398. Arsenic, 399. in dystrophia, 108. in skin diseases, 98. Arsenic pastes, 98. Arteriosclerosis, 269. pains of, 23. Arthritis, 346. Asafetida, 401. Ascites, 227. Aspiration of pericardium, 258. pleural, 156. Aspirators, 159, 160. Aspirin, 452. Asthma, 57, 136. Atropin, 401. for children, 126. in asthma, 57. in vomiting, 54. Auto-sero-therapie, 228. Auto-vaocination in cirrhosis, 228. Avicenna, 26. Azotorrhea, 360. Bacilli of dysentery, 365. Bacterial colitis, 240. Barberry, 403. Barber's itch, 35. Bartholinitis, 309. Baths, coM, 61. in common use, 391. in heart disease, 262. in phthisis, 167. permanent, 90, 91. Beck's paste, 109. Belladonna ointment, 14. Benzoin, 402. Berberis, 403. Be'ri-beri, 338. Beta-eucain, 16. Beta-naphthol, 434. Betula lenta, oleum, 452. Binswanger's dietary, 59. Birch, oil of, 452. Bismuth, 403. Bismuth subnitrate, 13, 54, 55, 103. Bladder, size of, 296. Bladder irrigation, 293. Blood, diseases of, 277. Blood letting, 151. Blood vessels, diseases of, 269. Blue ointment, 36. Bones, inflammations of, 108. Borax, 404. Boric acid, 404. Boroglycerin, 405. Bradycardia, 257. Brand bath, 29. Bromidia, 412. Bromids, 405. for croup, 124. in insomnia, 44. Bromural, 44, 406. Bronchial asthma, 143. Bronchitis, 134. Bronchitis tent, 135. Broncho-pneumonia, 137. Brucin, 461. Bruises, 95. of muscles, 105. Buboes, 339. Buffalo lithia water, 473. Burns, 90. Cade, oil of, 407. Caffein, 407. Calcium, 408. in hemoptysis, 184. Calcium sulphid in fever, 33. Calculus, renal, 292. Calories needed, 64. Calx sulphurata, 463. Camphor, 136, 409. Camphoric acid, 410. Cancer of stomach, 23, 204. Capillary hemorrhage, 274. Carbo animalis, 412. Carbo ligni, 412. Carbohydrates needed, 64. Carbolic acid, 446. Carbonic-acid baths, 262. INDEX 491 Carcinoma of esophagus, 195. Cardamomum, 410. Cardia, spasm of, 197. Cardiac neuroses, 255. Carlsbad water, 49, 471. Cascara, 50, 410. Castor oil, 50, 411. Cataplasma kaolini, 7, 121, 432. Catheterization, 294. Caustics, 89. Cerebro-spinal fluid, 316. Chalk, 408. Charcoal, 412. Chicken-pox, 366. Chloral hydrate, 43, 412. Chloretone, 44, 413. Chloretone inhalant, 56, 177. Chlorine -poor diets, 289. Chloroform, 413. Chlorosis, 277. Cholangitis, 221. Cholecystitis, 221. chronic, 224. Cholelithiasis, 225. Cholera, 366. Chorea, 323. Chronic bronchitis, 140. Chronic urethritis, 302. Cigarettes for asthma, 143. Circulation, influencing, 76. Cirrhosis of liver, 226. Citric acid, 413. Clay poultice, 78, 121. Climate for phthisis, 169. Coagulability of blood, 237. Coal-tar derivatives, 22, 413. Cocain, 15, 16. Codein, 441. Cohnheim's apparatus for dilating cardia, 198. Colchicum, 415. Cold baths, 28, 61. Cold sponging, 29. Cold-water coils, 30. Colic of infants, 230. Colica flatulenta, 229. Colica mucosa, 229, 237. Colica rheumatica, 229. Colica verminosa, 229. Colitis, 237. from metals, 239. Collargol, 261, 379, 458. Collodion, 415. Collodion stypticum, 465. Colloidal silver, 458. Colocynth, 416. Complementary space, 161. Condurango, 205, 416. Condylomata, 38. Congress water, 474. Constipation, 45. Convulsions, 71. Copper sulphate, 416. Cornstarch, 460. Coryza, 113. Cough, 55. of phthisis, 182. Counterirritation, 81. Creatinin excretion, 285. Creosote, 416. Cretinism, 344. Croup, 123. Cupri sulphas, 416. Cuts, 93. Cystitis, 293. De Bove's diet, 70. Demulcents, 81. De Wees's carminative, 401. Diabetes mellitus, 349. Diaphoresis, 31. Diarrhea of phthisis, 186. Diazyme, 444. Diet for emaciation, 59. in esophageal stricture, 196. in fever, 33. in hepatitis, 221. in infectious diseases, 364. in phthisis, 165. in typhoid, 234. Digitalin in pneumonia, 147. Digitalis, 417. for children, 126. Dilatation, gastric, 208. 492 INDEX Dionin, 441. Diphtheria, 124. Diphtheria serum, 86. Disinfectants for stools, 237. Disinfection of sick room, 363. Diuretin, 466. Dobell's solution, 101. Donovan's solution for emaciation, 61. Dormiol, 44, 419. Dosage and age, 392. Douglass's solution, 102. Dover's powders, 380, 420, 441. Drip sheet, 62. Dunbar's serum, 448. Duotal, 426. Dysentery, bacillary, 365. Dysmenorrhea, 24. Dystrophia muscularis, 107. Eclampsia, 73. Edema glottidis, 124. Edema of the lungs, 144. Effervescent potass, citrate, 449. Electric light, 8. Electro-massage, 11. Elimination, 82. Elixirs, 420. Emaciation, 58. Embolism, 311. Emesis gravidarum, 53. Emollients, 81. Emphysema, 144. Encephalitis, 311. Endocarditis, 264. Endometritis, 308. Enemata, 51. nutrient, 203. Enteralgia, 229. Enteritis, 231. Enteroptosis, 244. Enuresis, 299. Epicarin, 421. Epididymitis, 306. Epilepsy, 324. Epileptic seizures, 73. Epinephrin, 421. Epistaxis, 116. Ergot, 422. in anuria, 284. in shock, 91. Ergotoxin in shock, 58. Erysipelas, 370. Esophageal stricture, 216. Esophagus, inflammations of, 193. length of, 212. Ether, 422. Ethyl chlorid, 423. Ethyl oxid, 422. Eucain, 423. Eucalyptol, 104, 424. Eucalyptus, 424. Evening rub, 62. Excelsior Springs waters, 480, 481. Exercises for phthisis, 168. Exophthalmic goiter, 344. Expectorant mixture, 136, 139. Eye wash, 459. Fats needed, 64. Feces, disinfection of, 237. Ferrous carbonate, 431. Fever, 26. of phthisis, 181. Fibrolysin, 89, 424. in pericarditis, 258. Fissure in ano, 251. Fistula in ano, 251. Flatulence, 233. Fletcher, Horace, 64. Fomentations, hot and cold, 7. to chest, 149. Food values, 68, 69, 350. Formaldehyd, 425. Fox-glove, 417. Friar's cowl, 396. Friction, 9. Friedrichshall water, 472. Frostbite, 93. Gallotannic acid, 464. Gall-stones, 225. Gangrenous stomatitis, 192. Gant, 18. INDEX 493 Gastralgia, 200. Gastrectasis, 209. Gastric ulcer, 203. Gelatin for hemorrhage, 275. Gelsemium, 425. in fever, 32. Gentian, 426. Geographical tongue, 192. German measles, 376. Glanders, 371. Glands, 339. enlarged, 197. Glonoin, 437. Glyceritum acidi tannici, 465. Glycosuria, 355. Golden seal, 426. Gonorrhea, 301. Gouget diet, 288. Gout, 345. Guaiacol, 426. as antipyretic, 32. for obesity pains, 71. in pleurisy, 155. Guarananine, 407. Gummata, hepatic, 226. Hathorn water, 475. Hay fever, 117. Headache in infectious diseases, 364. Heart, diseases of, 255. in constitutional diseases, 266. Heat centers, 31. Heat for pain, 6. Hebra's itch ointment, 36. Hebra's ointment, 97. Heitzman's hemorrhoidectomy, 250. Hellebore, 470. Hematoporphyrinuria, 286. Hematuria, 286. Hemoglobinuria, 286. Hemophilia, 276. Hemoptysis, 183. Hemorrhage, capillary, 274. in typhoid, 236. intracranial, 311. Hemorrhagic pleurisy, 162. Hemorrhoids, 250. Henock's pack, 138. Hepatitis, 220. Heroin, 56, 137, 440. Herpetic stomatitis, 191. Hexamethylenamin, 426. Hiccough, 54. Hinkle's cascarin compound, 364. Hodgkin's disease, 339. Hoffman's anodyne, 423. Holadin, 443. Hookworm, 243. Hot air, 11. Hot-air baths for icterus, 218. Hot-air cabinet for obesity, 70. Houghton's soup, 235. Hunyadi Janos water, 472. Hydatid cyst, 228. Hydrargyrum, 433. Hydrastinin, 427. Hydrastis, 426. Hydrocephalus, 312. Hydrochloric acid in anacidity, 201. Hydrogen peroxid, 427. Hydronephrosis, 292. Hydrophobia, 371. Hydrotherapy in hysteria, 331. in neurasthenia, 333. Hyoscin, 44. Hyoscin hydrobromid, 428. Hyoscyamus, 428. Hyperacidity, 202. Hyperemia, 7, 8, 80, 94, 149. Hyperthyroidism, 344. Hypnotism, 328. Hypodermic medication, 19. Hypodermoclysis, 283. Hypoglycemia, 360. Hypothyroidism, 344. Hysteria, 73, 230, 325. Ice bags, 30. Ichthyol, 428. Icterus, 217. Ileocolitis, 232. Ileus, 230. Impotence, 306. Infantile cerebral palsy, 312. 494 INDEX Infectious diseases, 363. Inflammations, acute, 75. chronic, 83. of biliary passages, 221. of kidney, 285. Influenza, 373. Inhalations for phthisis, 176. Injections, intramuscular, 92. intravenous, 92. Insomnia, 41. of pericarditis, 260. Insufficiency of heart, 267. of kidney, 287. Intestines, diseases of, 229. Intoxications, 82. Intracranial disorders, 310. Intramuscular injection, 21, 92. Intravenous injection, 21, 92. Intubation, 127. Intussusception, 230. Invagination, 230. Iodids, 386, 428. in pleurisy, 155. Iodin inhalant, 123, 177. Iodized lime, 122. Iodoform, 429. Iodoform inhalant, 176. Ipecac in colitis, 242. Ipecacuanha, 429. Iron, 431. Iron preparations, 278. Irrigation, of bladder, 293. principles of, 100. Itching, 34. Itrol, 457. Ivy poisoning, 38. Kaolin, 432. Karel cur, 261, 265. Kidneys, diseases of, 282. Kissingen water, 471. Kneading, 9. Lactic acid, 432. Lactic-acid therapy, 232. Lanolin, 485. Laryngeal tuberculosis, 186. Laryngismus stridulus, 123. Laryngitis, 122. Laryngospasm, 362. Larynx, tuberculosis of, 23. Lavage, gastric, 210. of esophagus, 196. Lead colic, 230. Leiter coils, 30. Leukemia, 280. Leukoplakia oris, 193. Lime, iodized, 122. Lime water, 408. Linimentum camphorse, 410. Liquor cresolis compos., 417. Liver, diseases of, 216. Local anesthesia, 15. Localized inflammations, 75. Loeffler's solution, 126. London paste, 99, 458. Lugol's solution, 117. Lumbar puncture, 313. Lupus, 99. Luxus consumption, 64. Lycetol, 292, 447. Lymphadenitis, 339. Lysidin, 447. Lysol, 433. Magnesium sulphate in tetanus, 320. Malaria, 375. Male fern, 241. Mania, 321. Manitou water, 476. Massage, 9. of colon, 48. of prostate, 305. Meadow saffron, 415. Measles, 375. Meningeal convulsions, 73. Meningitis, 312. Mentha piperita, 444. Menthol, 13, 410. Menthol tablets, 118. Mercurial ointment, 35. Mercurial stomatitis, 191. Mercury, 384, 433. ammoniated, 96. INDEX 495 Mercury succinimid, 178. Mesotan, 453. Methyl salicylate, 452. Methylene blue, 434. Methylioninse hydrochlor., 434. Metric equivalence, 395. Milk, in nephritis, 288. substances excreted in, 392. Mineral waters, 231, 470. Monkshood, 396. Monobromated camphor, 409. Morbilli, 375. Morphin, 18, 440. in pleurisy, 155. Mount Clemens water, 477. Mousebane, 396. Mucous membrane, inflammations of, 100. Muscles, inflammations of, 105. injections into, 92. Mustard poultice, 78. Myalgia, 106. Myelitis, 317. Myocarditis, 260. Myxedema, 344. Naphthol, 36, 96, 434. Natrum, 458. Nauheim treatment, 262. Needles, 20. Neoplasms, intracranial, 312. Nephritin, 283. Nephritis, 23. acute, 285. chronic, 286. heart in, 266. Neuralgia, 336. Neurasthenia, 333. Neuritis, 337. Neuroses, 320. gastric, 207. of heart, 255. Nitrites, 435. in asthma, 57. Nitroglycerin for children, 126. Nitrous oxid, 438. Noma, 192. 33 Normal solutions, 453. Nursing precautions in cholera, 367. Nutrient enemata, 203. Nutritive ratios, 68. Obesity, 63. Obstruction of bowels, 230. Ocean water, 471. Oertel's diet, 70. Oil of sandalwood, 455. of sweet birch, 452. of turpentine, 469. of wintergreen, 452. Ointments, 14, 35. for pain, 119. Oleata, 223. Oleum cadinum, 407. santali, 455. Oophoritis, 308. Opium, 439. Orange, syrup of, 463. Orange root, 426. Orchitis, 306. Organic iron, 278. Orthoform, 103, 442. Osteomyelitis, 108. Otitis media, 378. Ovoferrin, 431. Oxaluria, 284. Ox gall, 222, 442. Oxycamphor, 410. Pachymeningitis, 317. Pack, hot, 31. Pagosa water, 478. Pain, 5. local treatment of, 6. Palpitation, cardiac, 255. Pancreatin, 443. Pancreatitis, 245. Papain, 444. Paracentesis abdominis, 227. pericardii, 258. Paralysis, diphtheritic, 134. Parasites, in itching, 35. intestinal, 241. 496 INDEX Paresis, 311. Peppermint, 444, Pepsin, 445. Percussion, 11. Pericarditis, 257. Pericardium, aspiration of, 258. Periostitis, 108. Peritonitis, 246. Permanganate of potash, 445. Pernicious anemia, 279. Pest, 376. Petrolatum, 445. Pharyngitis, 117. Phenacetin, 22. Phenol, 446. Phenolated camphor, 410. Phenolphthalein, 446. Phenylis salicylas, 455. Phlebotomy, 151. Phosphaturia, 285. Phosphoric acid, 150. Phosphoric-acid excretion, 285. Phosphorus, 447. Photophore, 8. Phthisis, 164. Pinworms, 243. Piperazin, 292, 447. Pituitary body, 342. Pix liquida, 466. Plague, 376. Pleuresie bloqu6e, 163. Pleurisy, 154. of phthisis, 187. Plummer's dilator for cardia, 199. Pluto water, 479. Pneumonia, 145. Pneumonia jacket, 145. Pneumothorax, 187. Pollantin, 117, 448. Portal congestion, 206. Potassii permanganas, 445. Potassium compounds, 448. Poultices, 77 et seq. Powders for itching, 37. Priessnitz bandage, 7, 121. Probilin, 224. Proctolysis, 247. Prostatitis, 304. Protargol, 458. Protein needed, 64. Pruritus, 39. ani, 253. of icterus, 218. Pseudoleukemia, 339. Ptomain poisoning, • 73. Pulvis acetanilidi comp., 408. Pulvis antisepticus, N. F., 13. Pulvis antisepticus solubile, 39. Purpura, 275. Pyloric stenosis, 205. Pyorrhea alveolaris, 192. Quetelet's tables, 65. Quinin, 450. in pneumonia, 148. Quinin hydrobromate, 344. Rabies, 371. Ratio, nutritive, 68. Rectum, diseases of, 250. Red Raven water, 479. Reeducation, 326, 329. Regent water, 480. Relaxed vessels, 272. Renal calculus, 292. Resorcin, 103, 451. compound, ointment, 97. Resorcin ointment, 37. Resorcinol for tonsillitis, 119. Respirator, 140. Rest, 79, 81. Rhamnus purshiana, 410. Rheum, 451. Rheumatism, 346. Rhinitis, 113. Rhubarb, 451. Rickets, 361. Ringer's solution, 453. Ringworm, 35. Rochelle salts, 451. Round worms, 244. Rubella, 376. Rubeola, 376. INDEX 497 Sabromin, 452. Salicin, 453. Salicylates, 452. in myalgia, 106. Saline solution, 453. Salol, 455. Salophen, 453. Salpingitis, 308. Salt free diets, 289. Salt glow, 62. Salts, cathartic, 49. Sanatoria for phthisis, 170. Sandalwood oil, 455. Sand bag, 7. Santonin, 456. Saratoga Congress water, 474. Saratoga Hathorn water, 475. Saratoga Vichy water, 482. Scabies, 35. Scarlet fever, 377. Schleich's solutions, 16, 17. Schott movements, 267. Schott treatment, 262. Sciatica, 17. Scorbutic stomatitis, 192. Scurvy, 276. Sea water, 471. Seasickness, 53. Seat worms, 243. Seidlitz water, 472. Senna, 456. Septicemia, 378. Serous membranes, inflammations of, 104. Serum therapy, 86. Shaeffer and Coleman, 235. Shock, 57, 91. Siloam water, 480. Silver, 457. nitrate, 103. vitellin, 398. Simaruba, 232. Skin, inflammations of, 89. bacterial, 95. Sleeping sickness, 281. Smallpox, 380. Sodium, 458. Sodium acetate, 6. nitrite, 437. oleate, 223. succinate, 223. Soluble antiseptic powder, 39. Solutions by percentage, 394. Soup, vegetable, 235. Spasm of cardia, 197. Spasmodic laryngitis, 123. Spermatorrhea, 306. Spinal analgesia, 317. Spinal fluid, 315, 316. Splanchnic neurasthenia, 273. Spleen, 341. Splenomegaly, 341. Spongia combusta, 122. Sprays, alkaline, 115. Starch, 460. Steam for cough, 56. Steatorrhea, 360. Stenosis, pyloric, 205. Stomach, dilatation of, 208. lavage of, 210. Stomach solutions, 102. Stomach tubes, 211. Stomatitis, 188. Stools, disinfection of, 237. Strains, 106. Stramonium, 460. Stricture of esophagus, 194. spasmodic, 197. Stroking, 9. Strychnin, 461. for children, 126. in shock, 92. Strychnin poisoning, 73. Stypticin, 462. Styptol, 462. Succinates, 223. Sulphonal, 462. Sulphonmethanum, 462. Sulpho-saline water, 481. Sulphur, 463. compound, ointment, 97. Sulphur ointment, 35, 96. Sunstroke, 312. Suppositories, 252. 498 INDEX Suppurative peritonsillitis, 117. Suprarenal glands, 342. Sweats of phthisis, 182. Sweet spirits of niter, 437. Syncope, 162. Syphilis, 384. Syphilitic buboes, 339. Syringes, 19. Syrup of orange, 463. of Tolu, 468. Tabes cerebralis, 311. dorsalis, 318. Tables of weight, 65, 66, 67. Tachycardia, 257. Taenia, 241. Talc, 463. Talcum powder, 38. Tannalbin, 465. Tannigen, 465. Tannin, 464. Tannoform, 465. Tannopin, 465. Tapping the abdomen, 227. Tar, 104, 466. Tartrate of potash and soda, 451. Tendons, inflammations of, 105. Tetanus, 319. Tetronal, 462. Thein, 407. Theobromin, 466. Theocin, 467. Thiosinamin, 467. Thoracocentesis, 156. Throat lozenges, 118. Thrombosis, 311. Thrush, 190. Thymol, 103, 243, 344, 468. Thymol inhalant, 142. Thyroid extract, 468. Thyroid gland, 343. Tolu, 468. Tonsillitis, 118. Tooth powder, 188. Toxic colitis, 239. Toxic neuritis, 338. Tracheotomy, 131. Trichloracetic acid, 99, 468. Trimethyl xanthin, 407. Trional, 44, 462. Trousseau's bougies, 198. Trypan red, 281. Trypanosomes, 281. Tubage of esophagus, 194. Tuberculin, 180. Tuberculosis of bones, 109. of glands, 340. of peritoneum, 249. Turpentine, 469. for cough, 56. Turpentine pipe, 141. Typhoid fever, 234. heart in, 266. Ulcerative stomatitis, 191. Ulcers, intestinal, 90. of stomach, 203. pain of, 12. varicose, 272. Uncinaria, 243. Unguentum Crede, 379. hydrargyri ammoniati, 36. hydrargyri dilutum, 36. resorcini co., 37. sulphuris compositum, 36. Urea, 469. Uremia, 73, 282. Urethritis, 300. Urinary solids, 287. Vaccination, 85. for smallpox, 382. for urethritis, 302. Vaccines, 88. Vaginal douches, 102, 459. Valerian, 470. Valyl, 470. Vapor for cough, 56. Vapor massage, 10. Varicella, 366. Varicose ulcers, 272. Varicose veins, 271. Variola, 380. Vegetable days, 357. INDEX 499 Vein, injection into, 92. Venereal buboes, 339. Venesection, 151. Veratrum viride, 185, 470. Veronal, 44, 470. Veronica water, 49, 481. Vibration, 10. Vichy water, 471. Vichy water (Saratoga), 482. Vienna paste, 99. Vinegar, 396. Voit's calories, 63. Vomiting, 52. of phthisis, 183. Warts, paste for, 100. Water for constipation, 50. Waters, 470. Wechsel douche, 273. Weight equivalents, 395. Weight tables, 65, 66, 67. Weir-Mitchell dietary, 59. White precipitate ointment, White Rock water, 483. Wilkinson's ointment, 97. Wilkinson's salve, 36. Wintergreen, oil of, 452. Witter Springs water, 484. Wolf's bane, 396. Wool fat, 485. Wright, Sir A. E., 237. Yellow fever, 369. Yellow jasmine, 425. Yellow puccoon, 426. Yellow root, 426. Yohimbin, 486. Zinc compounds, 486. 36. (1) THE END AUG 3.0 I9EG One copy del. to Cat. Div. AOQ ?& mm