f^cTS ^^1> Columbia ZLImbersttp mtbcCttpofMrtu^orlT (£olU gr of IJtjijflirianB anb S>argr una Srfmnr? ICItbrarg Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/painitsindicatioOOhill Pain and Its Indications AN ANALYTICAL OUTLINE OF DIAGNOSIS AND TREATMENT BY EDWARD C. HILL, M. S., M. D., MEDICAL ANALYST AND MICROSCOPIST; PROFESSOR OF CHEMISTRY IN THE MEDICAL AND DENTAL DEPART- MENTS OF THE UNIVERSITY OF DENVER; ATTEND- ING PHYSICIAN TO ST. ANTHONY'S HOSPITAL, DENVER; AUTHOR OF "A TEXT BOOK OF MEDICAL CHEMISTRY." CHICAGO : G. P. ENGELHARD & COMPANY, 1904. COPYRIGHT, 1904, BY G. P. ENGELHARD & CO. H 55 It gives me much pleasure to dedi- cate this book on PAI N to my constant friend Thomas Hayden Hawkins, A.M., M. D. 90 or CONTENTS. INTRODUCTION n I. HEADACHE 14 Organic, 14 — Arteriosclerotic, 19 — Active Hy- peremic, 20 — Passive Hyperemic, 24 — Anemic, 25 — Hysterical or Imitative, 27 — Neurasthenic, 28 — Migrainous or Nervous, 30 — Toxemic, 33 — Febrile, 40 — Neuritic, 43 — Syphilitic, 44 — Osteoalgetic, 45 — Ocular, 45 — Nasopharyngeal, 48 — Miscellaneous Reflex, 50 — Traumatic, 53 — Adolescent, 53 — Cephalic Neuralgia, 54. II. PAIN IN THE EAR AND NOSE 66 Otalgia, 66 — Nasal Pain, 69 III. PAIN IN THE MOUTH AND THROAT. . 71 Toothache, 71 — Sore Mouth and Throat, 72 — Laryngeal Pain, 97 — Pain in Neck, 99. IV. CHEST PAIN 103 Extraprecordiai, 103 — Precordial, 113 — Sub- sternal, 121. V. BACKACHE 124 Spinal, 124 — Neuromuscular, 133 — Renal, 136 — Referred, 142. VI. ABDOMINAL PAIN i 4 6 Colicky, 146— Neuralgic, 159— Dyspeptic, 166— Inflammatory, 174— Pressure and Traction, 183. VII. PELVIC PAIN r88 Uterine, 188— Tubo-Ovarian, 199— Peritoneal and Cellular, 207 — Vulvovaginal, 213 — Dys- menorrhea, 218— Instrumental Pain, 222. 8 PAIN AND ITS INDICATIONS VIII. GENITO-URINARY PAIN 224 Duffused Suprapubic, 225 — Perineal, 230 — Ure- thral, 235 — Genital Sores, 242 — Infracostal Pain, 246 — Pain at the Seat of Disease, 253 — Referred Pain 253. IX. PROCTALGIA 255 X. LIMB AND JOINT PAINS 264 Organic Arthralgia and Ostalgia, 264 — Neural- gic Arthralgia, 288 — Sciatica, 292 — Divers Neu- ralgias, 29(3 — Muscular Pains, 300 — Vascular Pains, 304 — Periungual Pains, 306 — Reflex Pains, 307 — Growing Pains, 311. XL DERMATALGIA 313 FOREWORD. To the patient, pain is the most important of symptoms. It is indeed that which most often leads him to seek medical advice. The great va- riety of causes of regional pains and the conse- quent difficulty of differentiation and of rational causal treatment, are appreciated by physicians and surgeons. In this reference outline are to be found all sorts of pains, systematically ar- ranged for comparison in a few types and regions, and fully indexed. I trust that my labors in this connection will prove of practical service to my fellow practitioners. With the paragraphs on treatment due credit is given to the authors whose therapeutic ideas I have gleaned. For diagnostic points I am specially indebted to the following authorities : American Text-Book of Surgery, Anders, Bishop, Bosworth, Byford, Church and Peterson, Da Costa, De Schweinitz, Ewald, Garrigues, Gould and Pyle's Cyclopedia, Hare, Head, Hirst, Kyle, Musser, Osier, Per- shing, Ranney, Roberts, Sajous, Skene, Tyson, Vierordt, White and Martin. Denver, February i, 1904. INTRODUCTION. Local inflammatory pain. — Generally severe, constant, throbbing, sticking, cutting, gnawing, radiating along peripheral nerves and increased by firm deep pressure and by movement of part; with heat, redness, swelling and rigidity and dif- fuse soreness of muscles over affected part, or disturbance of function. Constant aching in mus- cular pain; dull pain in connective tissues (aching) and mucous membranes (soreness or burning) ; sharp and stabbing in serous tissues (increased by deep breathing in pleural and peri- toneal) ; tingling and shooting along nerve in neuritis (with herpes and tenderness all along course) and neuralgia (tender points and often local flushing; sometimes due to pressure by growths or scars) ; burning and itching in local skin lesions ; constant, deep, boring in diseases of bones and periosteum — often worse at night; modified by weather in neuralgic, neuritic lithe- mic or rheumatic pain; paroxysmal, colicky in obstruction of channels. General pain, soreness and fatigue in toxemia; general aching, sometimes with chill, at onset of acute infections. Pain increased by movement in diseases of bones, joints, muscles and nerves; pain diminished or absent in shock or gangrene. 12 INTRODUCTION Local non-inflammatory pain. — Generally re- mittent or intermittent and relieved or not in- creased by firm, deep pressure; very limited pain, usually functional; rhythmical recurrence in con- tractile pain (labor pains, distended tubes or bladder.) Referred or reflex pains. — Due to lesions at other points having the same or related nerve supplies; not affected by pressure, but with cuta- neous tenderness in same area — constant if de- pendent on chronic disease elsewhere; pain cuts across ribs in segments of the spinal areas as fol- lows: Heart=l — 3 dorsal; hmgs=l — 5 dorsal, and cervical plexus; stomach=6 — 9 dorsal (pyloric, 9) ; liver and gall-bladder=7 — 10 dorsal and cervical plexus; intestines above rectum=9 — 12 dorsal; rectum=2 — 4 sacral; kidneys and ureters=10 — 12 dorsal and 1 lum- bar; bladder=ll — 12 dorsal and 1 lumbar (over- distention) and 2 — 4 sacral (neck of bladder; incontinence) ; prostate=10 — 11 dorsal, 5 lum- bar, 1 — 3 sacral; epididymis=ll — 12 dorsal and 1 lumbar; testis=10 dorsal; ovary=10 dorsal; uterus=l lumbar (contraction) and 2 — 4 sacral (os uteri) ; Fallopian tubes=ll — 12 dorsal. Algo-genesia (persistent or reviving pain on di- recting attention to it) is common in traumatic neurosis. Neuralgic pain. — Shifting, intermittent, re- INTRODUCTION 13 ferred to nerve trunks or to deeper distribution; firm pressure usually relieves; movement may aggravate or not; no characteristic disturbance of function. Intercostal neuralgia is distinguished from organic disease by freezing tender spinous processes with ethyl chlorid spray, when, if neu- ralgic, the pain, tenderness and muscular con- traction all disappear. Hysterical pain. — Usually burning, subject to suggestion, not influenced by rest; zones of pain (often geometric) independent of course of nerves. Traumatic pain. — Specific in character; very in- tense at first, soon diminishing. Pressure pain. — Constant, uneasy, at seat of causative organic lesion; often radiates along course of affected nerve trunk. Nerve supply of head and neck. — Forehead and vertex^supraorbital ; temple and lower jaw— auriculotemporal; over malar bone=malar; mid- dle of cheek^buccal ; upper lip=rinfraorbital ; chin=mental; upper occiput=great occipital; lower occiput and upper neck=small occipital; front of neck^superficial cervical; mastoid and post-maxillary region=great auricular; side of neck and post-auricular region=small occipital; lower part of neck= descending cervical. HEADACHE 15 CHAPTER I. HEADACHE. [Two or more forms often combined.] Organic. — Severe (may prevent sleep) and generally persistent, but variable, not ceasing with stupor or delirium; often circumscribed, with fulness and throbbing; increased by mental or physical effort, coughing, jarring or stooping, or by percussing over area of lesion if cortical ; often apparently causeless vomiting, slow breathing and pulse, vertigo, drowsiness, irritability, spasms, paralysis, optic neuritis. General treatment. — Try potassium iodid in large doses for some time; morphin with coca wine and dr.i tinct. hyoscyamus or gr.x chloral. — Corning. Meningitis. — Usually constant and boring (often paroxysmal in tubercular) diffuse frontal, occipital, vertical or parietal; in excess of fever; explosive vomiting, photophobia, stiffness of neck ; rapid onset in acute ; passes into stupor and coma ; patient shrieks out during sleep; no gestures as a rule. Treatment. — Ice bag or ice-cold compresses to head; leeches to mastoid apophyses; wet cups to neck; morphin. — Debove and Douvin. Brain Tumors. — Slow course, paroxysmal and varying — boring, gnawing, splitting, benumbing, local or diffuse; often worse at night; cerebellar 16 PAIN AND ITS INDICATIONS and cortical forms most severe — glioma least; may be local tenderness; often choked disc. Treatment. — Phenacetin and antipyrin in com- bination sometimes give great relief. — Mills. Potassium iodid in full doses sometimes gives marked relief; ice cap; Paquelin cautery for occipital; morphin last resort. — Osier. Cerebral Abscess. — Usually localized, very severe and persistent in acute, worse in early night; patient bores head into pillow; fever and chills, vertigo, mental dullness; history of injury to head or focus of infection, particularly middle ear dis- ease. Treatment. — Trephine and evacuate. Cranial Trauma. — Concussion, pressure or laceration, or depressed fracture, causing menin- gitis; pain circumscribed at site of injury or on opposite side of head; history, scalp tenderness and other signs. Treatment. — Eest, stimulants, warmth to ex- tremities; surgical intervention if indicated. Cerebral Syphilis. — Constant, rushing, frontal or temporal, with somnolence; worse at night; quasiperiodical. Treatment. — Potassium or sodium iodid gr. xx t. i. d. increasing a grain each day until improve- ment or iodism ; fresh air, appropriate diet, bath- ing, exercise and rest. — Anders. Thrombosis of Cerebral Sinuses. — Earache and marked edema back of ear if lateral sinus affected HEADACHE 17 (chronic otorrhea) ; edema of eyelids and face on affected side in cavernous; epistaxis in superior longitudinal. Treatment. — Open and cleanse mastoid and lat- eral sinus; stop bleeding by plugging with strips of iodoform gauze; ligate internal jugular vein, wash out and make aseptic. General treatment of pyemia for other forms. — Am. Text-Book of Sur- gery. Cerebral Thrombosis and Softening. — Dull, continuous, frontal; vertigo, tingling in fingers, aphasia, loss of memory, gradual paralysis and loss of consciousness. Treatment. — Stimulants and small doses of digitalis if heart's action weak and irregular ; keep bowels open without active purgation; potassium iodid freely, with mercury if case is recent, in syphilitic form. — Osier. Hydrocephalus. — Severe headache in acute, moderate or absent in chronic; vertigo, vomiting, convulsions, paralysis; enlarged, rounded skull. Treatment. — Systematic support to exterior of skull as long as possible ; from time to time apply mercurial ointment or oleate of mercury (5 per cent) ; internally iodid of iron and cod-liver oil. — Goodhart. Intracranial Aneurism. — Constant or paroxys- mal; occipital if basal artery; may be distinct rushing feelings; rarely objective murmur; ver- tigo, epistaxis and tinnitus aurium in miliary. IB PAIN AND ITS INDICATIONS Treatment. — Ergot for miliary form — Bar- tholow. Potassium iodid, nitroglycerin and morphin for ordinary form. Disseminated Sclerosis. — Dull headache from early emotional stage; intention tremor, nystag- mus, slow scanning speech. Treatment. — Coal tar analgesics; warm baths. Hereditary Cerebellar Ataxia. — Reeling gait as if inebriated; intentional choreiform movements; speech hesitating, abrupt, defective. Diffuse Encephalitis and Chronic Insanity. — Headache often localized. Treatment. — Cold wet pack, using enough blankets to get good reaction and wetting head also. Acute Delirium. — (Bell's Mania.) : Rapid, violent outbreaks and wild hallucinations with fever. Treatment. — Calomel in early stage; cold baths and ice bag to head; hyoscin; stimulate freely later; forced feeding with milk, eggs and broths. — Anders. Epilepsy. — Vertical or occipital ; severe, sudden, before and after fits (may take place of fit) ; noc- turnal tongue-biting, vertigo, lassitude, mental confusion. Treatment. — Pre-convulsive : Diffusible stimu- lants, especially nitrites and large doses of bro- HEADACHE i9 mids. Postconvulsive: Strong, hot, black cof- fee. — Jos. Collins. Hydrophobia. — Throat spasms on attempting to swallow. Chloroform inhalations for spasm; morphin hypodermically ; cocain to throat. — Osier. Arteriosclerotic. — Severe, dull, throbbing, waking patient in early morning ; part or whole of head; increased by exertion or excitement; tin- nitus, vertigo, slight syncopal attacks; slight mental deterioration; sensation of head being drawn backward; general lowered vitality; hard pulse; elderly subjects. Brain Syphilis. — Persistent, usually diffuse; history and scars. Treatment. — R. Potassii iodidi gr. x; liq. hydrarg. bichlor. m. xxx-lx; tinct. gent. comp. dr. i; aq. cinuam. q. s. : An ounce in water t. i. d. after food. — Day. Degenerative Nephritis. — Frontal or occipital; gastrointestinal crises and other uremic symp- toms; albuminuria and casts. Treatment. — Dilute nitric acid m. xx in water ; also pilocarpin injections. — Ealfe. Citrate of caffein 1 or 2 gr. in pill; or nitro- glycerin 1 or 2 m. 1 per cent sol. in a little water. — Saundby. Milk and vegetable diet; no alcohol; water freely; woolen underclothing; Turkish bath once 20 PAIN AND ITS INDICATIONS a week; easy, quiet, regular life; avoid exposure to damp cold. — Edwin F. Wilson. See uremia under toxic. Chronic Alcoholism. — Persistent with tremors. Treatment. — Withdraw poison ; bromids, tri- onal, chloralamid, sulphoual in the dose of not less than 15 gr. to produce sleep; lryoscin hydro- bromate, 1/96 gr. to quiet excitement; some means of restraint usually indispensable; abun- dance of nutritious food; tea and coffee freely; strychnin 1/30 gr. 3 or 4 times a day or quinin. — Tyson. Chronic Lead Poisoning. — Colic with constipa- tion; tremors; wrist-drop. Treatment. — Iodids in full doses in plenty of water; magnesium sulphate as a hydragogue. Senility. — May be premature; depends on state of arteries. Treatment. — R. Spt. Chloroformi m. v; liq. ergotse ext. m. xx-xxx; aq. purae ad oz. i: Take t. i. d. — Day. Active Hyperemic. — Pulsating, throbbing, tensive frontal or diffuse; induced by exertion or excitement; increased by lowering head; vertigo, wakefulness; tinnitus, spots before eyes, feeling of fulness and tightness, irritability and depres- sion; subjective throbbing of temporal and caro- tid arteries; flushed face, injected eyes, heated vertex. HEADACHE l associated with tenderness on pressure in cervical region and with "weak back/' Treatment. — Saturated solution of camphor in eau de Cologne rubbed on head. — Kinger. Menstruation. — Pain severe, often through eye- balls. Treatment. — Cimicifuga in nervous and hys- terical women ; pulsatilla also useful when patient chilly. Menstrual Hemicrania. — Tinct. gelsemium, 2- 3 drops every 2-4 hours. — Dujardin-Beaumetz. Tinct. belladonna 3 m. every 3 hours for pain over brow and in eyeballs, due to uterine or gas- tric disturbances in young women. — Einger. Ovarian. — Occipital or vertical, with pain or tenderness in ovarian region. Treatment. — E. : Ammonii brom., gr. xv ; ext. hydrastis, fl. m. x. ; tinct. gent, co., m. xxx ; aquae, q. s. : A dessertspoonful t. i. d. — Sinkler. Menopause. — Treatment. — Cannabis indica given with uniformly good results. — Potter. E. : Sodii arsenat., gr. 1/15; ext. cannabis ind., gr. 1/6; ext. belladon., gr. 1/4: One pill twice daily. — Collins. A tablet containing 10 gr. potas. brom. and 1/48 gr. sodium arsenate every 4 hours till re- lieved. — Thornton. Vesical. — Vertical or occipital, with bladder symptoms. «"W PAIN AND ITS INDICATIONS Treatment. — Vesical sedatives and antiseptics. Caries of Teeth. — Frontal or temporal, on af- fected side — persistent with exacerbations. Middle Ear Disease. — Mastoid, or temporal and occipital; usually old-standing suppuration in at- tic; sometimes cholesteatoma. Gastro-Intcstinal Irritation. — Frontal or dif- fuse, with abdominal symptoms. Treatment. — Eegulation of diet and long con- tinued use of sodium phosphate for bilious sick headache. — Bartholow. With Flatulence and Acidity. — R. : Sodii bi- carb., bismuthi subcarb., pulv. acaciae, aa. gr. viii ; spt. amnion, arom., m. xv; syr. zingib., m. xx; aquae., q. s. : One oz. t. i. d. ^ hour before eating. —Day. With Atonic Dyspepsia. — E. : Ferri sulph., quia, sulph., aa. gr. lj-; sodii arsenitis, gr. 1/24; pulv. rhei., pulv. zing., aa. gr. 5/6 : One pill t. i. d. after meals. — Collins. Dinner Pill. — R. : Pulv. myrrhae et zing., aa. gr. 3/4 ; pil. aloes, gr. ss. ; ext. anthem., gr. iss. ; olei caryoph., m. 1/4 : One or two before midday meal. —Day. Genital Disorders. — Irregular, variable. Angioneurotic Edema. — Sometimes excruciat- ing. Treatment. — Phenacetin, antipyrin, antikam- nia, acetanilid. HEADACHE 53 Traumatic. — Usually intractable. Treatment. — Bromids and iodids. Adolescent. — Eapid growth (usually frontal with pain in joints, periostoses and hypertrophy of heart) ; intellectual activity; digestive troubles (1 to 3 hours after eating too much or too fast) ; nervous habit (premonitory of future neuropath- ies, epilepsy or hysteria) ; anemia ; gouty or rheu- matic diathesis (hereditary; neuralgia or arthral- gia; myalgia; phosphaturia, oxaluria, lithuria, may simulate meningitis). Treatment. — Muscular repose, tonics, liberal diet, phosphate of lime for too rapid growth ; mod- erate or cease intellectual activity and use luke- warm baths; for digestive type regulate hygiene and diet; give bitter tonics before and warm drinks after eating; nervous cases require baths, walking, massage and for epilepsy valerian, bel- ladonna and bromids; for arthritic children mod- erate diet, open-air exercise, vapor baths with friction, laxatives, alkalies, sodium salicylate (dose 4 or 5 gr.) and tinct. colchicum (10-15 drops daily). — Simon. •54 PAIN AND ITS INDICATIONS CHAPTER II. CEPHALIC NEURALGIA. General Character. — Often limited to one spot of head or face; sharp and paroxysmal; darting from spot to spot. Symptoms. — Paroxysmal, variable, sharp, shoot- ing, shifting, persistent pain, following linear course of nerves and branches; nearly always uni- lateral; usually relieved by firm, steady pressure or hot applications; tender pressure points at exit foramina; often local sweating, blushing or muscular twitchings; suffused eye and edema of lid in ophthalmic. General Treatment. — Antikamnia, phenacetim acetanilid (3 to 8 gr.), or antipyrin (8 to 12 gr.) with 2 gr. caffein citrate every 30 minutes. Ammonium chlorid 15 to 25 gr. t. i. d. — Taylor. Butyl chloral hydrate 5 gr. with 1-200 gr. gel- semin. — Murrell. Faradic brush — strong cutaneous faradization — often very satisfactory. — Hirt. Ext. belladonna 1-5 gr. every hour till dizzy, then lessen dose and continue for several days. — Trousseau. Hypodermic injection into seat of pain of 1-20 to 1-6 gr. morphin with 1-20 as much atropin, or of | to 1 gr. cocain, or 1-60 to 1-30 gr. gelsemin. — Gowers. CEPHALIC NEURALGIA 55 E. Aconitinae 1-160 to 1-60 gr. ; glycerini, alco- holis aa. m. iv ; aq. menth, pip. q. s. : A teaspoon- ful t. i. d. before meals carefully increased. — Seguin. Oil of peppermint painted over part. Oleate of morphin (1 or 2 gr. to dram) an ex- cellent application. — Ringer. Valerianate of zinc or ammonium in 20 gr. doses. R. Morphinas sulph. gr. xx; camphor-chloral dr. ii : For local application to painful spots. — Shoe- maker. R. Liq. sodii arseniat. m. iss. ; ext. hoang-nan fl. m. iss. ; elixir gent, ferrat. q. s. : A teaspoon- ful in water after meals. — Shoemaker. Phenacetin gr. v and lupulin gr. v in capsule every hour or two. — Shoemaker. R. Abstracti aconiti gr. 1-5; quin. bisulph. gr. iii ; piperini gr. \ : One pill every 2 hours till re- lieved, then every 4 hours as long as needed. — Shoemaker. Prolonged local medication of affected nerve branches by means of 5-per-cent cocain solution applied on positive sponge electrodes after punc- turing skin with Coming's needles — 3 to 6 cells of current for 10 to 20 minutes ; prolong local action of drug by means of elastic strap encircling head and holding in place a T-shaped block of wood pressing upon a piece of fine wire gauze; more 56 PAIN AND ITS INDICATIONS cocain, chloroform, aconite, etc. may be injected. Or cocain may be applied for a few hours en- dermically through metal nipple of India-rubber membrane covering area from which epidermis has been removed, with vesicating collodion and glued firmly around this area. — Corning. Morphin or atropin subcutaneously in region of nerve; gradually increased local massage; small quantity of ung. veratriae rubbed in over seat of pain; galvanization with plus pole over point of exit of nerve, minus pole over superior ganglia of cervical sympathetic — 10 cells for 5 to 8 minutes. — Bartholow. Codliver oil; change of air; excision of nerve; aquapuncture ; ether spray ; thermocautery or local heat in any form. Persistent Neuralgia. — Washed castor oil in 1 or 2-ounce doses every morning before breakfast until pain is relieved — take in a tumbler with 2 or 3 tablespoonfuls of foaming ale or with essence of anise. — Moyer. Gross Pill. — Quin. sulph. gr. ii; morph. sulph. gr. 1-20; strychnin gr. 1-30; arsenious acid gr. 1-120; ext. aconiti gr. ss. : One 3 or 4 times daily. Baltimore Liniment. — Chloroform and tinct. nconite aa. dr. ii; liniment of soap oz. iii: Apply to affected part. Occipital. — Energetic counter-irritation ; local CEPHALIC NEURALGIA 57 bleeding ; galvanism ; moist or dry heat ; antipyrin or phenacetin. — Hirt. Trigeminal. — Ether spray applied over affected part until thin, white layer forms on skin. — Hamm. Freeze parts with ether or rhigolene spray or apply solution of 10 gr. menthol to the ounce of alcohol. — Thornton. Neuralgia Persisting After Cause is Eemoved. — E. Phosphori gr. 1-32; alcohol q. s. ut ft. sol.; spt. menthae vir. m. i ; glycerin q. s. : A teaspoon- ful after eating, to be increased. — Allen McLane Hamilton. Obstinate Cases of Tic Douloreux. — Hypo- dermic injections of strychnin 1-30 grain rapidly increased to 1-6 or |- grain daily until slight toxic symptoms supervene; rest in bed, for weeks if need be, very important; diet liquid or semi- liquid — diluent fluids should be freely imbibed; massive doses of potassium iodid and iron as a tonic. — Dana. In cases resisting ordinary treatment, try nerve section, neurectomy, evulsion, nerve stretching or removal of Gasserian ganglion. — De Schweinitz. Exposure to Cold. — Usually trigeminal, rarely occipital. Treatment. — Nitroglycerin gives relief in many instances. — Bartholow. Disease of Middle Ear or External Auditory Canal. — Trigeminal and cervical. 58 PAIN AND ITS INDICATIONS Enlarged Cervical Glands. — Great auricular or small occipital nerve. Treatment. — Excision of offending glands. Intracranial Growths. — Usually one branch of trigeminus. Chronic Malaria. — Periodic, supraorbital "brow ague;" sometimes preceded by slight chill or malaise. Treatment. — A dram of f . e. ergot every 2 hours with the same quantity of elixir of cinchona. — Thomson. Quinin aided by arsenic. Salicylic acid if quinin has failed. — Butler. Morbid Growths in Upper Jaw and Parotid Re- gion. — Neuralgia may be first symptom. Nervous Exhaustion. Treatment. — Phosphorus very useful in con- valescence from acute fevers. — Hare. Overwork. Treatment. — Equal parts of elixir of phos- phorus (N\ F.) and elixir of cinchona calisaya: One or 2 teaspoonfuls every 3 hours. — Shoemaker. Anemia. — First division or auriculotemporal. — Temporary improvement from stimulants and re- cumbency; worse during movement or menstrua- tion ; pallor and blood changes. Treatment. — Iron (m. 20 to 40 of tincture or 20 gr. of saccharated carbonate bis or ter die) CEPHALIC NEURALGIA 59 Treatment. — Blister beneath occiput or behind sar; treat ear disease. Dental Caries. — Trigeminal, radiating from decayed tooth; if lesion is internal, tooth appears dark ashy gray instead of bright pink by trans- mitted electric light; pointing finger tip passes up side of face to 1 inch below sagittal suture. Other causes of dental neuralgia are pulpitis, pyorrhea, recession of gums, substances under gums, malposition of teeth, dying of pulp, pulp- stones, exostosis, pericementitis, periosteal thick- ening, secondary dentine in pulp chamber, un- erupted or impacted teeth, uiseased antrum or catarrhal conditions. Treatment. — Hot alkaline fluids to wash mouth and volatile oils or carbolic acid in hollow tooth help to relieve pain; proper filling cures; extract if tooth is dead (septic outside inflammation; surrounding parts tender; local temperature raised) . Five to 10 drops of fluid exts. gelsemium and cannabis indica at 2-hour intervals. — S. H. Creighton. Gelsemium in non-inflammatory cases. — Einger. Injury to Cord. — Cervical neuralgia if high up. Treatment. — Absolute rest and opiates. Cervical Caries or Cancer. — Occipital neuralgia and other pressure symptoms. Treatment. — Fixation apparatus for caries; operation or opiates for cancer. 60 PAIN AND ITS INDICATIONS and strychnin — the latter may be used hypoderm ically. — Anstie. E. Ext. belladonna gr. £ ; quin. sulph. gr. iss. ; ferri sulph. exsic, gr. ss. ; strych. sulph. gr. 1-60 ; acidi arseniosi gr. 1-40; oleores. pip. m. ss. : A pill t. i d. — Shoemaker. Impaired Nutrition. Treatment. — Pilulae ph.osph.ori gr. 1-100 every 4 hours. — Butler. E. Zinci phosphidi gr. 1-10 ; ext. nucis vomicae gr. -J : One pill every 3 or 4 hours. — Shoemaker. Fresh air, rest, full nutritious diet; small quantities of alcohol at meals. Debilitated Children (8 to 12 years).— R. Ferri et potassii tart. gr. iv ; tinct. cinch, co. q. s. : A teaspoonful 4 times a day. — J. Lewis Smith. Tuberculosis. Treatment. — : Codliver oil. E. Guaiacol gr. 75; methyl salicylat. gr. 75; ext. belladonnae gr. 3; ext. opii gr. 3-f ; vaselin et lanolin aa. dr. 4: Apply small quantity without rubbing and cover with cotton. — Capitan. Lithemia. — Pain preceded by drowsiness; lithuria; patients perspire easily and are subject to catarrh. Treatment. — Turkish or vapor baths ; potassium iodid; salophen. Gout. — Family and personal history; irritable temper; rich food and red meat. CEPHALIC NEURALGIA <51 Treatment. — Cimicifuga, cannabis indica and gelsemium ; strictly vegetable diet ; salicylates and colehicum. Ammonium chlorid dr. ss. several times a day. — Ringer. Influenza. — Dull, aching, intractable, ophthal- mic or occipital. Treatment. — Aconitin gr. 1-200 to 1-100 in hot water on an empty stomach, repeated every 4 hours if needed. Blister over supraorbital nerve in severe cases. Severe Acute Indigestion. — Occipital and su- praorbital. Treatment. — Clear out stomach; antikamnia and salol. Chronic Nephritis. — Supraorbital, dental or oc- cipital, often with cramps in muscles of extremi- ties. Treatment. — Potassium bitartrate, sodium or magnesium sulphate, Eochelle salts; vapor sweat baths. Diabetes. — Symmetric; usually third division; worse with increase of sugar; neuralgia elsewhere in body. Treatment. — Cut off carbohydrates from diet. Senile Atheroma. — With hard, tense pulse. Treatment. — Full doses of nitroglycerin admin- istered simultaneously with full doses of strychnin or nux vomica. — Hare. t'i PAIN AND ITS INDICATIONS Syphilis. — Boring, worse at night, may be periodic; local tenderness the rule; supraorbital in orbital periostitis, with squint, diplopia and restriction of eyeball movements. Treatment. — Large doses of potassium iodid after meals in milk or water. Locomotor Ataxia. — Sudden, very severe crises at long intervals of shooting, stabbing pains not confined to one nerve-trunk ; loss of knee-jerk and defective pupillary reaction to light. Treatment. — Acetanilid, antikamnia, phenace- tin, antipyrin, warm baths. Chronic Plumbism and Hydrargyrism. — With tremors and paralysis.. Treatment. — Remove cause; full doses of potassium iodid in a glass of milk or water after meals. Chronic Alcoholism. — Often associated with peripheral neuritis. Treatment. — Rest, strychnin, antipyrin and phenacetin. — E. D. Fisher. Epileptiform Neuralgia. — Very sudden and severe attacks, usually lasting less than a minute ; recurrent, intractable ; may be spasm of face. Functional Irritability of Nervous System. — Wandering neuralgic pains and restlessness. Treatment. — Strychnin the remedy. — Bartho- low. Pelvic Disorders. CEPHALIC NEURALGIA f 65r Treatment. — K. Zinci valer. gr. i ; ext. gentianae gr. i; ext. nucis vomicae gr. £: One pill 3 or 4 times a day. — Bartholow. Pregnancy. Treatment. — Emulsion of codliver or olive oil; complete rest, systematic feeding and tonics — arsenic, quinin, iron (sulphate or double citrate or tartrate) combined with, bitter tonics; menthol or iodin locally. — E. P. Davis. Pericarditis and Diaphragmatic Pleurisy. — Phrenic nerve in neck. Wounds and Cicatrices Pressing on Nerve. — Pain usually does not begin for some weeks or months. Treatment. — Dissect out and remove scar. Reflex from Disease or Injury Elsewhere. — Neuralgia limited to 5th has been caused by trauma to ulnar or occipital nerve. Occupations. — Such as carrying heavy weights on head and neck. Ocular Neuralgia. — From ametropia, anemia or rheumatism. Treatment. — Ten per cent solution of muriate of quinin instilled every 15 minutes if need be. — Markoff. Correct any error of refraction under a mydri- atic. Acute Gout of Tenon's Capsule. — Pain severe, "4 PAIN AND ITS INDICATIONS often with edema of conjunctiva, photophobia and phosphenes; uricacidemia. Treatment. — Salicylates or salophen. Iritis. — Kadiating pains over distribution of two upper branches of 5th nerve. Treatment. — Keep pupil dilated with a tropin ; treat cause (rheumatism, syphilis, etc.). Glaucoma. — Violent ocular and supraorbital pain, with dimmed vision and increased intra- ocular tension. Treatment. — Broad iridectomy; instillation of eserin in chronic cases. Cephalic Myalgia. — Tender points at origin, in- sertion and in course of certain muscles (fronto- occipital, sternomastoid, temporal, upper mas- toid) ; sometimes produced by unnatural positions during sleep. Treatment. — Slight pressure and kneading, fol- lowed by more energetic massage. — Hirt. Suppurative Ethmoiditis. — Pain referred to root of nose and back of eye and temporal region ; discharge like that of antral suppuration ; may be bulging prominence between eye and root of nose, and eyeball may protrude abnormally. Treatment. — Cleanse nostril thoroughly and frequently by means of syringe and warm antisep- tic wash; correct nasal irregularities and re- move obstruction to free drainage; dry diseased surface with pledgets of cotton and apply 50-per- CEPHALIC NEURALGIA 65 cent ointment of ichthyol in lanolin by means of pledgets of cotton allowed to remain in contact from 1 to 3 hours at a time; injection of pyoktanin solution 1 :500 serviceable in cases of only moderate severity; intractable cases demand free opening of cavity and radical removal of dis- ease. — Kyle. 66 PAIN AND ITS INDICATIONS CHAPTER III. PAIN IN THE EAR AND NOSE. OTALGIA. For Immediate Relief. — Wash out canal and drop in 4 drops of warmed 1-per-cent sol. atropin. — Sexton. Decayed Teeth. — On affected side — generally a lower molar, which may be free of pain. Treatment. — Filling or pulling or local treat- ment of sensitive pulp. Obstruction of Eustacliian Tube. — Clicking t-ounds; fulness in ear, impaired hearing; may be due to mumps. Treatment. — Cleanse nose and throat and use Valsalvian method carefully, or close mouth and blow into nose. Acute Otitis Media. — From cold or extension of pharyngitis; very painful, tense, throbbing; ring- ing in ears; redness and bulging of tympanic membrane. Treatment. — Dry, hot applications (salt bag or hot-water bag) ; nasal alkaline spray; politzeriza- tion; mild sudorifics and aperients. — Burnett. To abort, fill canal with 12-per-cent solution of carbolic acid in glycerin. — A. H. Andrews. A few drops of warmed 4-per-cent solution of EAR AND NOSE 67 cocain dropped into ear every 2 or 3 hours in early stage; leeches to tragus; perforate membrane when pus has formed and drain with iodoform gauze. Inflammation of Meatus. — Local signs. Treatment. — Leeches to tragus or scarification of cartilaginous meatus (f- to 1 inch incisions) fol- lowed by hot-water douche. — Jennings. Furuncle of Meatus. — Circumscribed tender swelling. Treatment. — Free early incision; for severe pain instill a tablespoonful in a wineglassful of warm water of the following: liq. plumbi, liq. morphinae aa. oz. i, aquae oz. x ; to prevent return of boil apply twice a day on cartilaginous portion after acute symptoms subside, ointment of mercuric nitrate 1 part to 8 each of oil of almond and vaselin. — Jennings. Neuralgia. — Sharp, shooting, intermittent; no local signs. Treatment. — Hot-water bag to ear. Phenacetin 5 gr. every hour till severe pain ceases. — Thornton . Collection of Wax. — Shown by simple inspec- tion. Treatment. — Soften with warm glycerin or solu- tion of baking soda and douche freely with hot water to remove wax. 68 PAIN AND ITS INDICATIONS Nocturnal Recurrent Earache of Small Chil- dren. Treatment. — Atropin sulphate 1 gr. to the ounce of water — 5 drops warmed and dropped into ear (seldom needs repeating). — Mcllvane. Earache with Nervous Excitement. Treatment. — Tinct. anemon. praten. 1-10 to y 3 drop in water as necessary. — Sexton. Lingual Ulcer, Abscess or Cancer. — Sharp, lancinating pain in temporal region and extend- ing to ear. Mastoiditis. — Pain and tenderness in mastoid, becoming severe and persistent with tenderness on pressure; redness and edematous swelling; fluctu- ation if abscess forms; temp, normal to 103° — fluctuating with rapid, thread)' pulse if lateral sinus involved. Treatment. — Best in bed ; light diet ; free evacu- ation of bowels with calomel and saline; free in- cision of drum membrane if congestion and bulg- ing; irrigate ear with hot antiseptic solution several times a day; continuous application of cold by means of Leiter coil or Bishop ice-bag for 24 to 48 hours; if swelling and tenderness con- tinue, surgical measures should be instituted at once. — Wm. C. Bane. Inflammation of Epiglottis and Upper Larynx. — Laryngeal tuberculosis (severe pain radiating to or referred to ear, aggravated by swallowing or KAR AND NOSK pressure on larynx) ; laryngeal carcinoma with ulceration (lancinating aural pain). Minor Causes. — Ulcer of pharynx or upper esophagus; thoracic aneurysm; cold, anemia, neurasthenia, syphilis (sometimes violent non- inflammatory paroxysms in mastoid region), malaria, sexual disorders; irritation of Gasseriaa ganglion or 5th nerve; caries of bone; brain tumors; prolonged stimulation of auditory nerve (piano-players). Treatment of Xon-Inflammatory Otalgia. — Iron for anemia; quinin and amyl nitrite for periodic malarial otalgia and tic douloureux; full doses of potassium iodid for syphilis. Tinct. of belladonna in 5 m. doses, or atropin (5 drops of a 1-per-cent solution several times daily) has proved efficacious in chronic cases. Galvanism (anode on ear and cathode on back of neck) occasionally use- ful when other means have failed. A blister over mastoid sometimes gives relief. When pain affects entire aural region and is increased by pressure beneath tragus, massage may cure promptly. — Hovel! . NASAL PAIN". Smarting or burning at root of nose in acute rhinitis and post-nasal catarrh; diffuse and in- definite in dry catarrh and diphtheria; severe from foreign body (gradual increase if a vegeta- ble), glanders or primary syphilis; radiates to ear 70 PAIN AND ITS INDICATIONS if Eustachian tube is involved; cheek pain in antral disease; severe pain in side of nose often first symptom in iritis or irritation of ciliary nerves. Treatment. — Spray of adrenalin chlorid (1:10,- 000 or stronger) for nasal and sinus inflamma- tions. MOUTH AND THROAT 71 CHAPTER IV. PAIN IN THE MOUTH AND THROAT. TOOTHACHE OR ODONTALGIA. [Cold drinks make worse if pulp not decayed — pack or fill; hot drinks make wfrrse if pulp decayed — open up or pull.] Caries. — R. Creasoti m. vi ; tinct. iodi dr. i ; liq. plumbi subacet. dr. i; chloroformi, tinct. opii aa. dr. ss. : Apply gently on softest cotton wool to pulp and brush same on surrounding gum. — Gar- retson. Wash out with warm solution of baking soda and put in a bit of cotton wet with carbolic acid or oil of cloves or chloroform. Pyorrhea Alveolaris. — Suppuration around and at roots of teeth. Treatment. — Open abscess freely and irrigate with mild antiseptic; Lugol's solution or diluted tinct. iodin with tannic acid useful to reduce granulations. Catching Cold. Treatment. — Sodium salicylate 15 gr. with 15 m. tinct. belladonna every 4 hours if first dose fails to relieve. — Fred. Coles. After-Pains from Extraction. — Retention of pyogenic membrane; expansion of osseous walls; fracture of alveolus; sundering of maxillary pro- cess and alveolus, with laceration of tissues; re- IX PAIN AND ITS INDICATIONS lention of root and spiculae; necrosis of wall and septum of non-antagonized tooth ; perforation of alveolus from pus. Treatment. — Kemove foreign substances with curet or burr under local anesthesia ; local use of sedative antiseptics. — Charles B. Isaacson. SORE MOUTH AND THROAT. Catarrhal Stomatitis. — Erythema of mucous membrane of mouth limited to gums, or general ; mucous glands prominent, yielding on pressure a drop of mucus; acid and irritant buccal over- secretion. Treatment. — Mel boracis with alum, or alum alone in powder, or 6 per cent (saturated solu- tion) potassium chlorate, or equal parts of iron and glycerin. — Tyson. A dram of borax to a half ounce each of water and glycerin; apply locally p. r. n. — J. Lewis Smith. Prophylactic in Nursing Babes. — B. Sodii borat. dr. ii; f. e. pinus canad., glycerini aa. oz. ss. ; aquae rosae oz. iii. Wash mouth morning and evening. — Love. Aphthous Stomatitis. — (Thrush, Follicular or Vesicular Stomatitis.) — Small number of discrete, slightly raised, superficial, small, roundish, very tender "canker ulcers" (following herpetic vesicles), with yellowish- white depressed bases and bright red margins — simultaneous or in crops; MOUTH A Nil THROAT 7" mostly on inner side of lips and cheeks and edges of tongue; over-secretion of mucus and acid and irritating saliva. Treatment. — Glycerin and Monsel's solution, equal parts painted on ulcers, rinsing mouth after- wards. — Beale. Thrush. — Solution of 1 dr. borax in 2 dr. glycerin and 6 dr. water, applied thoroughly 4 or 5 times daily and continued for a week after dis- appearance of affection. — Thornton. Ulcerative Stomatitis ( Stomacace) . — Excessive blood-stained salivation; gums red, swollen and spongy, sloughing and bleeding readily ; deep and ragged ulcers mostly along gums, with bases cov- ered with closely adherent grayish-white mem- brane; breath horribly foul. Treatment. — Potassium chlorate 10 gr. t. i. d. to a child — twice as much for an adult — also lo- cally as a mouth wash; potassium permanganate mouth wash if much fetor, with silver nitrate to ulcers. — Osier. Infants. — Swab with water acidulated with a few drops of acetic acid, then paint with 1 part borax in 8 of glycerin. — Garrigues. Mycotic Stomatitis (Thrush or Sprue). — Nu- merous slightly raised pearly white painless spots, beginning on tongue and coalescing into gray- white membrane, spreading to other parts of mouth and throat — readily removed without causing 71 PAIN AXD ITS INDICATIONS bleeding or ulceration; microscope reveals sac- charomyces or oidium albicans. Treatment. — Bicarbonate or biborate of sodium ; glycerin, soda and water; potassium chlorate; listerine; calomel, gr. 1-12 for babies every 2 hours. — X. Wiest. Bednar's Aphthae. — Atrophic white spots on hard palate of nursing infants ; no significance. Mercurial Stomatitis. — Gums extremely tender; ptyalism; breath fetid; may be ulceration of mu- cosa, loosened teeth or even necrosis of jaw. Treatment. — Suspend administration of drug; simple mouth- wash for mild cases; potassium chlorate internally, and to rinse mouth in more severe cases; open bowels freely; hot bath every evening; plenty of alkaline mineral waters; atropin sometimes serviceable, 1-100 gr. twice a day; iodin also recommended. — Osier. Gangrenous Stomatitis. — Insidious formation from small hard nodule, then ichorous vesicle, of black-edged sloughing ulcer with brawny red in- duration of gums or cheek — spreads rapidly and may perforate cheek or invade bones of jaw; ichorous blood-stained oral discharge mixed with shreds of gangrenous tissue; breath intolerable; great prostration; septic diarrhea; lethargy or de- lirium; fever often high. Treatment. — Burn with lunar caustic and pack in bismuth and alum every 3 hours, using car- MOUTH AND THROAT 75 bolic acid or potassium permanganate as a mouth- wash. — J. Lewis Smith. Membranous Stomatitis. — From true diphtheria or excessive use of strong mouth-washes; false membrane (Klebs-Loeffler bacilli in true diph- theria) ; strongly fetid breath; salivation; may be severe hemorrhages. Foot and Mouth Disease. — Vesicles and ulcers on edges of tongue and inside of lips; affected milk yellowish-white, bitter and nauseous. Treatment. — Same as for aphthous stomatitis. Mucous Pfl£c7ies.--Circumscribed, slightly raised, whitish serpiginous very tender spots; ham-col- ored eruptions on skin. Treatment. — Ten per cent solution of chromic oxid locally; mercury internally. Acute Glossitis. — Tongue tender and painful and much swollen; coating of thick soft yellow- ish-white fur; may be cracked or ulcerated in infectious cases; speech impossible. Treatment. — Tinct. aconite m. i-iii every half hour or hour for fever; constant application of ice or persistent use of hot water for enlarge- ment; if these do not relieve promptly, scarify deeply; open abscesses and give quinin; tracheo- tomy if suffocation imminent. — Hughes. Chronic Superficial Glossitis. — Pricking sensa- tion or soreness; tongue enlarged with more or less reddened edges; often smooth, shiny, ovoid 76 PAIN AND ITS INDICATIONS patches separated by deep furrows; excoriations and superficial ulcers. Treatment. — Blandest diet and absolute ab- stention from causal irritants; Seller's tablets in solution ; chromic acid or silver nitrate, 5 or 10 gr. to ounce of glycerin or honey, applied once or twice daily bv gentle brushing; general tonics. — Anders. Glossitis Desiccans. — Gradual development of a number of deep fissures and indentations, giv- ing an uneven, ragged look; excoriations and ul- cers. Treatment. — Potassium iodid gr. ii increased to gr. v t. i. d. in a half pint of water after meals ; adding sometimes syrup of ginger and liquor cin- chonae. — Beale. Fissures of Tongue. — Local application of a mixture of 1 part carbolic acid, 3 tincture of iodin and 10 glycerin. Acute Inflammation of Lingual Tonsil. — Exces- sive secretion and constant tendency to clear throat; pain about hyoid and shooting to ear on swallowing in phlegmonous variety; throat-ache on use of voice; may be harassing cough; laryn- goscope shows elevation and secretion at base of tongue. Correct dyspepsia and dyscrasiae; gentle pur- gation; gargle after each meal with 8 gr. alum and 4 gr. tannic acid in 2 oz. water; apply every MOUTH AND THROAT 77 day with cotton on curved applicator zinc sulpho- carbolate (6-10 gr. to oz.) or 2 to 5 per cent zinc chlorid solution till symptoms are relieved; or apply equal parts of comp. tinct. benzoin and 50 per cent boroglycerid, or tincture of iodin twice daily; incise abscess at once; treat mycosis (yellowish mold-like projection under tonsil) with 6 per cent zinc chlorid solution or pure iodin or 2 per cent formalin solution or actual galvano- cautery. — Kyle. Ranula. — Soft semitranslucent swelling at one side of frenum — covered with dilated veins and contains clear, glairy, mucoid fluid ; from obstruc- tion and dilatation of gland ducts. Treatment. — Hypodermic injection of 1/6 gr. pilocarpin hydrochlorate. — S. Harnsberger. Edema of Uvula. — Painful distortion. Treatment. — Multiple puncture with small sharp-pointed bistoury or double-cutting aspira- ting needle; follow with spray of ice water; daily cleansing with alkaline solution and application of tannin 3 to 5 gr. to ounce of water. — Kyle. Scorbutus. — Swollen, bleeding gums; hem- orrhages elsewhere; mostly in artificially fed in- fants. Treatment. — Two or 3 lemons or oranges daily; liberal quantities of potatoes, water-cress, raw cabbage, lettuce, sauerkraut, meat juice, egg- white, milk; potassium chlorate for ulcers; 2 per 78 PAIN AND ITS INDICATIONS cent tannin on cotton swab for swollen gums. — Anders. Infantile. — Proper feeding from wet nurse or with unboiled cow's milk. Angina Ludovici. — Marked pain and difficulty in speaking, chewing and swallowing; may be dan- gerous laryngeal dyspnea from edema; usually fever — often typhoid or septic; acute circum- scribed woodeny swelling in region of submaxil- lary glands and cellular tissue of floor of mouth — (most marked below one jaw) and front of neck, and hard swelling of tongue; streptococcus infection. Treatment. — Sustain strength; prompt surgical interference at beginning of suppuration or gang- rene; tracheotomy if asphyxia threatens life. — Anders. Actinomycosis. — Toothache, dysphagia and diffi- culty in opening jaw; swelling at angle of jaw quickly passing into suppuration; opens and dis- charges little yellow masses (ray fungus under microscope) ; may extend downward or upward. Treatment. — Eemoval of parts involved and disinfection with acid-sublimate solution. — An- ders. Hypertrophy of Faucial Tonsils. — Lymphatic diathesis; disturbed sleep and nightmare; mouth- breathing, especially at night with snoring; va- cant expression; "mushy" voice; enlargement of MOUTH AND THROAT 79 gland easily recognized; abnormal adhesions, cheesy particles, impacted mucus, concretions, my- cosis and crypts easily discerned with aid of probe and tenaculum. Treatment. — Tonsillotomy a radical cure. Introduce forefinger, protected by rubber cot, as far as possible behind tonsil and rub 15 or 20 times around it and then up and down. — Kantoro- wicz. Foreign Body in Tonsil. — Ineffectual swallow- ing; may be hidden behind projecting portion. Tonsillar Calculi. — Feeling of rough body; fol- low frequent attacks of quinsy. Depress tongue and remove with curet; destroy secreting surface of tonsillar crypts with 50 per cent solution of trichloracetic acid on cotton car- rier. — H. W. Whitaker. Hydatid of Tonsil. — Clear cysts containing characteristic echinococcus hooklets. Cancer of Tonsil. — Pain very severe, but no general symptoms. Treatment. — Complete eradication through mouth by thermocautery or galvanocautery or with scalpel and dry dissector — or by incision through neck. — Kyle. Diphtheria. — Slight pain; tough, dirty dusky- gray pseudomembrane spreading continuously and uniformly from tonsils over half arches — very adherent — can be torn off only in strips, leav- 80 PAIN AND ITS INDICATIONS ing bleeding erosion and reforming in 12 to 24 hours unless prevented by antitoxin; fibrinous exudate contains Klebs-Loeffler bacilli; moderate fever or may be subnormal temperature; prostra- tion. Treatment. — Isolate in well ventilated room with little furniture at 65° F. ; impregnate air of room with steam containing eucalyptol, car- bolic acid or lime water; keep patient quiet in bed and feed with spoon or feeding cup; for first few days beef -tea, milk, (may be frozen) yolk of raw eggs or broths every 2 or 3 hours with or- angeade or lemonade — as soon as membrane has cleared add fish, fresh vegetables and rice pud- ding; apply LoefHer's solution (toluol 36, abso- lute alcohol 60, liquor ferri sesquichlor. 4 parts) every 2 hours to membrane and surrounding tis- sues (20 gr. menthol to ounce may be added for pain) ; spray throat (or nose) with equal parts hydrogen peroxid, aqueous ext. hamamelis and cinnamon water ; ice bags or Leiter s coil to neck ; calomel internally 1/12 to 1/6 gr. with 1 or 2 sr. sodium bicarbonate every hour till bowels move freely ; tincture of chloride of iron in 4 or 5 drop doses hourly to a child of 3 ; early injection of con- centrated standardized antitoxic serum under skin of intrascapular region or lateral abdominal wall (cover spot with absorbent cotton) — 500 units as a protective, 1,000 to 1,500 units in suspected MOUTH AND THROAT 81 eases, 2,000 units in well marked cases; repeat in G hours if case no better — give 3,000 units if worse — if much better wait 12 hours and repeat 3,000, or if worse give 3,000 or 4,000 — then again repeat every 6 or 12 hours; brandy or whisky when strength begins to fail; ytrychnia nitrate, digitalis or aromatic spirit ammonia if cardiac or respitatory failure threatens. — Kyle. Spray throat with 50 per cent solution hydrogen peroxid ; apply with mop a mixture of 4 dr. potas- sium chlorate, 2-4 gr. carbolic acid, 1 oz. tinct. myrrh and 2 oz. infusion of cinchona. — Hughes. Pseudodiplitheria . — Exudation of scarlatina and other debilitating infectious diseases; high fever and intensely red pharynx in scarlatina. Treatment. — Guaiacol diluted one-half with glycerin and applied with cotton on holder in early stage; spray hydrozone into throat every few hours ; 3 per cent camphor-menthol spray after cleansing. — Bishop. Scarlatinal Angina. — Tinct. ferri chloridi 1 part in 8 parts of glycerin and 7 parts of water: } to 1 teaspoonful undiluted every 2 hours ac- cording to age; also externally ice or cold or hot compresses ; dissolve small pellets of ice in mouth ; spray of Dobell's solution. — Daniel E. Hughes. Mycoses of Tonsil. — More or less pain and dis- comfort; fungi stain bluish-red with iodopotassic iodid solution; healthy persons. 82 PAIN AND ITS [NDICATIONS Treatment. — Curct, spray with hydro-zone or 1:10,000 mercuric chloric! solution and cauterize half a dozen points at each sitting with galvano- cautery under cocain. — Bishop. Acute Catarrhal Tonsillitis. — Acute pain ra- diating to ear and angle of jaw; tonsil and soft palate red and swollen — dry and glazed at first but soon coated with thin layer of mucopus readily removed by brushing, gargling or hawking; fetid breath and nasal twang. Treatment. — Aconite when temperature high, 1/2 to 1 drop every 1/4 hour for ? hours, then every hour. — Einger. H. Tinct. calendulae dr.i; sod. bibor. dr.ii; ext. hamamel fl.dr.iii; glycerin dr.iv; aquam ro- sae ad oz. iii : spray sensitive parts every hour or two. — Love. Follicular Tonsillitis. — Chill at onset; high fever and rapid pulse for a few days; moderately sore throat and painful deglutition; severe and wide-spread muscular pains, especially in small of hack; tonsils slightly swollen; small, yellowish- gray, soft pultaceous points exuding from mouths of crypts, sometimes coalcscent but limited to ton- sil and easily removed without bleeding, leaving a smooth surface; breath of a sweet, sickening odor; tonsils enlarged and irregular in chronic form, and contain fetid, yellowish pellets in crypts. MOUTH AND THROAT m Treatment. — Early and thorough application ol a mixture of guaiacol 10, menthol 1 and olive oil 10 parts. Tinct. ferri chlor. m.viii with 22 m. glycerin every hour for an adult. — Bosworth. Salophen or sodium salicylate in full doses. Rheumatic or Gouty Tonsillitis. — Eepeated at- tacks of catarrhal, cryptic or parenchymatous in- flammation; family history or rheumatic or gouty diathesis; lithuria. Treatment. — Exercise to point of fatigue; anti- lithemic diet; for constipation granular efferves- cent phosphate of sodium, a tablespoonful in a glass of cold water 1 to 3 times a day — preferably first thing in morning and on retiring; podophy- llum 1/8 gr. before each meal for sluggish in- testines of sedentary habits; dilute hydrochloric acid 6 to 10 drops in water through a glass tube after each meal to stimulate digestion; during acute attack give every 4 hours a capsule con- taining 2 1/2 gr. saloL 3 gr. each of phenacetin and sodium benzoate and 1/40 gr. strychnin ni- trate; in chronic cases push alkaline treatment (5 or 10 gr. sodium benzoate or lithium bicar- bonate every three hours) or alternate every 10 days with dilute hydrochloric acid; warm baths or Turkish baths twice a week unless heart com- plications contraindicate. — Kyle. 4^ PAIN AND ITS INDICATIONS Influenzal 'Tonsillitis. — Moderate sore throat with great depression. Treatment. — Hydrogen peroxid frequently to ulcers; guaiacol diluted with as much glycerin (most useful when temperature is high) as a local application; 4 per cent solution of potassium bro- mid grateful as gargle or spray; coarse spray of 3 per cent solution camphor-menthol. — Bishop. Herpetic Tonsillitis. — Repeated crops of minute vesicles, often coalescing into blebs and rupturing in 24 to 48 hours, leaving minute whitish ulcers; pharynx and tonsils very red and painful; high fever, chills, rheumatic pains and general malaise. Treatment. — Local application 2 or 3 times daily of equal parts comp. tinct. benzoin and 50 per cent boroglycerid, or a warm gargle of 10 gr. chloral hydrate with 1 dr. glycerin to an ounce of water; calomel 1/10 gr. and sodium bicarbonate 1 gr. every hour for 8 or 10 doses, followed by Rochelle salts to free purgation; for fever and headache a capsule every 3 hours of quinin bro- mid 3 gr., phenacetin 3 gr. and salol 2 1/2 gr. — Kyle. Caseous Tonsillitis. — Pockets in lower part of tonsil where secretions and food particles accu- mulate; repeated attacks of sore throat, pricking sensation in tonsil and occcasional discharge of MOUTH AND THROAT H5 caseous foul-smelling "peas"; may form a pecu- liar grayish-white gelatinous nodule or a calculus of lime salts. Treatment. — Slit pockets from top to bottom with hook blade and mop out carefully with car- bolic acid solution, or curet thoroughly — opening may need to be repeated. — Kyle. Cysts of Tonsil. — From inflammation or use of caustics; sensation of foreign body, lump in throat, irritation and desire to cough; gray or slightly yellow blister-like projection. Treatment. — Cocainize and open freely with knife ; if contents thick and cheesy, force out with blade of tongue depressor; scarify entire inner surface of cyst with galvanocautery. — Coakley. Peritonsillar Abscess (Quinsy). — Ushered in by chill, continuous fever, rapid pulse, pain in bones, severe headache; constant gnawing or bor- ing pain, usually on one side (referred to fauces and radiates to ear) and much aggravated by swallowing — becomes sharp and lancinating and later deep and throbbing; marked dyspnea; sali- vation and ineffectual hawking of thick, viscid mucus; great prostration; unilateral as a rule; tonsil smooth, firm, dusky-red or edematous; asymmetric swelling of distorted fauces, contain- ing pus about 4th or 5th day; half open mouth (patient cannot open it wide) ; fetid breath and 86 PAIN AND ITS INDICATIONS coated tongue; voice thick and muffled; rheumatic patients. Treatment. — R. Sodii salic. gr.xx; syr. acaciae m.xx ; aq. cinnam. q.s. : A dessertspoonful every 3 hours. — Easby. A teaspoonful of ammoniated tincture guaiac in a half glass of milk 3 or 4 times daily in early stage. — Sajous. R. Tinct. aconiti rad. m.i; tinct. ferri chlor. m.iv; sodii chloratis gr.iv; glycerini m. xxiv; aquam q.s. : A teaspoonful every hour, to be swallowed slowly and left as long as possible in contact with fauces. — A. H. Smith. Ice bag over tonsil to prevent abscess ; when pus forms incise where abscess points (usually near arch of anterior faucial pillar) with cutting edge of knife toward median line. — Bishop. Faucial Tuberculosis. — Sharp, lancinating pain aggravated by swallowing; chilly sensations, high hectic fever; discrete or grayish- white spots about size of mustard seed, breaking down in a few days into slowly spreading, pale gray, irregular shallow ulcers, flush with surface and covered with scanty, ropy mucus; mucous membrane pallid gray and somewhat muddy (marked hyperemia in lupus with almost total absence of secretion and sombre, dusky ulcer) ; voice thick and articulation im- paired. Treatment. — Creasote, iodid of iron and cod- MOUTH AND THROAT 87 liver oil; general hygienic and dietetic measures; local applications of potassium chlorate, carbolic acid inhalations or other disinfectants after cau- terization with galvanocautery ; dusting with iodo- form and touching with silver nitrate also recom- mended. — J. Ewing Mears. Faucial Syphilis. — Usually a secondary syn- drome; therapeutic test. Chancre. — Constant lancinating pain; enlarge- ment of tonsil; lesion wider than genital; grayish granular surface covered with thick mucus; in- duration of submaxillary and cervical glands of affected side. Treatment. — Systematic ' cleansing with alka- line sprays; apply on cotton a solution of potas- sium permanganate, silver nitrate, lead acetate or zinc chlorid — or dust on iodoform, iodol or aristol. — Price — Brown. Erythema. — Dark red or faint purple colora- tion, confined to soft palate and fauces and sharply demarcated at junction of hard and soft palate. Treatment. — Mercurous iodid, gray powder or corrosive sublimate pushed to physiologic limit. Mucous Patches. — -Hound or serpiginous, glazed, whitish, acutely sensitive superficial ulcers. Treatment. — Local application of 25 per cent solution chromic acid. — Shoemaker. Cleanse with coarse spray of Seller's or Dobell's 88 PAIN AND ITS INDICATIONS solution, then touch lesions with tincture of iodin on cotton carrier; cleanse and dry ulcers with ab- sorbent cotton and powder with aristol or noso- phen ; mixed treatment in secondary and tertiary stage. — Bishop. Gumma. — Usually unilateral, non-inflamma- tory, rounded or irregular, hard, dense, slightly tender swelling; mucous membrane paler than normal; swelling tends quickly to form deep, painful ulcer, with sharp-cut, excavated edges and well marked areola — overlying thick, ropy pus and necrotic tissue. Treatment. — Potassium iodid gr. xx or xxx after meals in a glass* of milk or water. Acute Catarrhal Pharyngitis. — "Scratchy feel- ing'' in throat, which is sensitive, and pain on swallowing; diffuse bright red hyperemia of all parts of lower throat, or lateral streaks of redness ; uvula swollen and edematous; slight serous or seromucous secretion after 2-i hours. Treatment. — Atropin 1/400 gr. and morphin •£ gr. in early stage — 3 to G times in first 2 days; \ dr. or more of sodium phosphate; steam inhala- tions from tea-pot containing 1 pint hot water and 10 drops camphor-menthol (wrap napkin around nozzle) ; lozenges containing each'l gr. ammonium ehlorid, 5 m. each of paregoric, comp. syrup of squills and syrup of tolu, and 3 gr. extract of lico- rice. — Bishop. MOUTH AND THROAT 89 R. Potassii chlorat. gr. x ; acidi hyclrochlor. dil. m. ix; tinct. aconiti m. ii; tinct. belladonnae m. iii; infusum rhois glab. q. s. : Tablespoonful every 3 hours. — Shoemaker. Troches of ext. eucalypti gr. 1 ; sodii borat. gr. 1/3; pulv. pimentae gr. £; ext. glycyrrhizae gr. v. — Bosworth. Simple Chronic Pharyngitis. — Constant sense of dry discomfort, scratching or rawness in pha- rynx, which is sensitive and irritable; mucous se- cretion "hawked up" in morning, often with nausea or vomiting; relaxed mucous membrane and marked diffuse venous, congestion (deep red, beefy, angry, raw-looking) ; tongue often heavily furred; breath foul and sour; often from chronic gastritis, particularly the alcoholic form; mucous membrane coated with mucus when disorder due to nasopharyngitis — dry and glazed when due to hypertrophic rhinitis. Treatment. — Glycerol tannin locally with brush ; etiologic treatment. Silver nitrate solution 40 gr. to ounce applied daily with cotton on holder, taking care to let none drip into larynx. — Sajous. Acute Follicular Pharyngitis. — (Cryptic, Lacu- nar.) — Dry, pricking sensation or severe pain and swelling; enlarged follicles. Treatment. — After thorough cleansing reduce 2 or 3 follicles at each sitting with galvanocautery, 90 PAIN AMI IIS INDICATIONS using -i per cent solution eucalyptol in lavolin twice a day as spray. — Bishop. Chronic Follicular Pharyngitis. — Dull, aching, semineuralgic pain and tenderness diffused over back of throat and aggravated by movements of same; constant desire to hawk and spit; vocal weakness; dry cough; symptoms vary greatly with nervous tone and with weather; mucous membrane generally healthy looking, but sprinkled with bright red masses, like bird-shot in size and shape, discrete or grouped within plaques and ridges; tough mucus in small areas; may be superficial ulceration and enlargement of superficial veins; lympathic diathesis. Treatment. — Same as acute. Sec above. Traumatic or Occupation Pharyngitis. — Wounds, foreign bodies, dust, vapors or caustic substances. Treatment. — Removal of exciting cause; fre- quent multiple punctures under antiseptic precau- tions for threatened edema; to relieve pain from scalds and burns smear freely with carbolized vaselin, to which is added -i gr. menthol to the ounce (improved by combining with equal parts 50 per cent boroglycerid and comp. tinct. ben- zoin) ; cold externally; morphin internally and by insufflation with stearate of zinc 2 or 3 times daily; after acute symptoms pass, cleanse thor- MOUTH AND THROAT 91 oughly with bland alkaline antiseptic washes.— Kyle. Atrophic Pharyngitis. — (Pharyngitis Sicca.) Final stage of other forms; constant dryness, burning and tickling in throat; smooth, shining, glazed atrophic appearance; dysphagia; hacking, rasping cough; dry, rough secretion covering highly inflamed or pale thin areas. Treatment. — Pilocarpin hydrochlorate -| gr. in a half dram each of glycerin and water t. i. d. — Sajous. R. Ergotinae gr. xx; tinct. iodi dr. i; glycerin ad oz. i: To be applied to pharynx twice a day with camel-hair brush. — Win. Aitken. R. Acidi carbol. gr. x; tinct. iodi, tinct. aloes, tinct. opii aa. gtt. x; glycerin q. s. ad oz. i: Use as spray several times a day. In young persons of scrofulous diathesis arsenic iodid in 1-200 to 1-100 gr. dose one of the best remedies, especially if anemia is present. — Kent 0. Folz. Chronic Lithemic or Rheumatic Pharyngitis — Constant sensitiveness with continual hacking and clearing of throat on account of accumulated secretion; patient easily affected by atmospheric changes; altered voice; subjective symptoms often greatly in excess of local signs; marked redness of mucous membrane and extreme pain and stiff- ness in surrounding tissues; often gives place to torticollis, lumbago, etc. M'2 PAIN AND ITS INDICATIONS Treatment. — Turkish baths; drink large quan- tities of water; lithium citrate 3 to 6 gr. every 2 hours, or 5 gr. 1 to 3 times a day — Kyle. lodin a satisfactory treatment. — Monmarson. Acute Cases. — Pi. Acidi salicyl gr. vi; sodii bicarb, gr. iv; elixir gaultb. m. viii; glycerini m. vi; aquam q.s. : A teaspoonful in water every 2 to 4 hours. — Bishop. Neuralgia of Pharynx. — Characteristic paroxys- mal pains. Treatment. — Local sedative applications and etiologic treatment ; for temporary relief use anti- kamnia, antipyrin or acetanilid. Neurotic Hyperesthesia of Pharynx. — Extreme sensitiveness of throat; no physical signs; neu- rotic subjects; sometimes apparently causeless feeling of pin or foreign body. Treatment. — Local application of 10 per cent solution carbolic acid in glycerin; also home treat- ment with spray of 3 per cent camphor-menthol in lavolin. — Bishop. Potassium bromid internally and inhalations of same drug 20 gr. to ounce; cocain or eucain 4-10 per cent; sucking of ice for 15 minutes; troches of slippery elm for hypersensitiveness of acute inflammation. — Kyle. Tabetic Pharyngeal Crises. — Sudden pain, con- gested face, profuse sweating, dysphagia. MOUTH AND THROAT '■>'■'> Treatment. — Antipyrin, acetanilid, antikamnia, phenacetin or morphin. Gastrointestinal Disorders. — May be great te- nesmus in throat, and rarely serious laryngeal spasms. Pharyngeal Tuberculosis. — Distressing pain, especially on speaking and swallowing; pale granular or ragged, superficial ill-defined ulcers covered with scanty mucous secretion; constitu- tional symptoms and pulmonary signs. Treatment. — Galvanocautery of greatest service both for cure and palliation; curet, lactic acid, iodoform, menthol inhalations sometimes satis- factory; cocain spray and iodoform and morphin insufflations valuable for home treatment; anti- syphilitic medication (especially mercury) in mixed cases; general treatment should not be neglected, and much attention should be paid to catarrhal affections of upper air tract and to proper hygiene and disinfection of mouth. — Levy. Phthisical Sore Throat. — R. Potassii chlorat. gr. i; glycerlni m. viii; morph. hydrochlor. gr. 1/20; syr. aurantii q. s. : A teaspoonful occa- sionally. — Shoemaker. Phthisical Congestion of Pharynx. — Fluid ex- tract of ergot, 20 m. t. i. d. — J. Howe Adams. Painful Throat of Tuberculosis Without Ul- ceration. — Lozenges of antipyrin 3 gr., cocain \ gr. — Levy. 94 PAIN AND ITS INDICATIONS Tubercle of Pharynx. — Spray oi ; morphin sul- phate gr. iv; acidi tannici. acidi carbol. aa. gr. xxx ; glycerini, aqua? dest. aa. oz. ss. — Ingals. Hemorrhagic Pharyngitis. — Very small, dull red, slightly edematous hemorrhagic areas; occa- sional blood-stained expectoration ; usually fol- lows eruptive fevers. Treatment. — Correct constipation and consti- tutional diathesis; repeated gargle of hot water; local application of 3 to 6 per cent alumnol solu- tion or sulphocarbolate of zinc 5 or 10 gr. to ounce of water. — Kyle. Gangrenous Pharyngitis (Putrid Sore Throat.) — Localized superficial necrosis following infec- tious catarrhal inflammation; frightfully fetid breath; early fever, marked prostration and men- tal depression. Treatment. — Stimulate secretion and aid elim- ination; cleanse affected areas repeatedly and thoroughly with disinfectant and antiseptic solu- tions (3 to 5 drops of carbolic acid to ounce) ; for stench spray with potassium permanganate solution, followed by hydrogen peroxid. — Kyle. Infective. Pharyngitis (Suppurative or Ulcera- tive Sore Throat). — Very small ulcers, often coated with shaggy membrane; throat extremely sensitive, especially on swallowing; slight fever; breath very offensive; frequent in physicians, nurses and hospital attendants. MOUTH AND THROAT 9fi Treatment. — Free purgation followed by con tinned use of small doses of calomel and sodium bicarbonate; tinct. ferri chloridi internally 10 to 30 drops every 2 hours; frequent cleansing with warm alkaline gargle; touch ulcerated areas with 3 per cent zinc chlorid solution or with nitric acid 20 drops to ounce of water; Mackenzie's carbolic acid throat tablets, one dissolved in mouth every hour or two, or local application of benzoinol con- taining to each ounce 4 gr. menthol, 4 gtt. san- dalwood oil and 2 drops oil of eucalyptus; early application of ice- water cloth (covered with dry cloth) around neck, followed by hot applications later ; tonics. — Kyle. Croupous Pharyngitis ("Erysipelas of Throat"). — False membrane; no ulcer on strip- ping; streptococcus p} f ogenes; common in labora- tory workers and persons exposed to infections. Treatment.— Thoroughly cleanse mucous mem- brane with alkaline solution, followed by equal parts 15 volume solution hydrogen peroxid, aqueous extract hamamelis and cinnamon water; dry membrane and apply with cotton applicator (removing any excess of fluid) Loefflers solution (toluol 36, absolute alcohol 60, liquor ferri chloridi 4 parts) or pure guaiacol; then paint throat with equal parts of comp. tinct. benzoin and 50 per cent boroglycerid, or if pain severe with camphor (gr. i) and menthol (gr. iv) in 90 PAIN AND US INDICATIONS Liquid albolene (oz. i) : spray or gargle of hot water to relieve congestion and stimulate circu- lation ; if membrane tends to reform repeat ap- plication of Locffler's solution or guaiacol; thor- ough cleansing of intestinal tract. — Kyle. Herpes of Pharynx. — Sudden, severe smarting pain in throat radiating toward ears; dysphagia; discrete round or oval patches, mostly vesicular, hut soon excoriations covered with thin, yellow- white, readily removed fibrinous false membrane; spontaneous disappearance and sudden recurrence. Treatment. — Free purgation with magnesium sulphate or magnesium citrate, and continued use of sodium succinate 10 gr. after meals; promote elimination; locally a gargle of 10 gr. chloral hydrate, 1 dr. glycerin and 2 oz. water; tablets of slippery elm slowly dissolved in mouth for dry- ness. — Kyle. Retropharyngeal Abscess. — Fluctuating prom- inence of posterior wall; dysphagia, dyspnea, pro- found septic infection; sequel of glandular or vertebral disease, usually in children. Treatment. — Ice to prevent pus formation; if pus forms make small but sufficient opening under cocain with trocar or guarded bistoury. Cancer of Pharynx. — Very painful after ulcera- tion; microscopic diagnosis of tumor particles. Treatment. — Injections into growth by means of Windier or Pravaz syringe of 30 to 50 per cent MOUTH AND THROAT 97 alcohol — 5 drops at first, increased gradually to 30 or 40 minims. Pharyngomycosis. — Little if any pain; small, white or yellow projecting and adherent growths composed of leptothrix buccalis, on npper pharyn- geal space and tonsils. Treatment. — Eemove fungi, and spray with un- diluted hydrozone or mercuric chlorid 1-10,000; cocainize each spot and cauterize a half dozen at one sitting. — Bishop. Pyoktanin in 25 per cent solution rubbed into masses twice or thrice weekly. — Year Book of Nose, Throat and Ear. LARYNGEAL PAIN. (Increased by pressure, swallowing or speaking; hoarseness and cough.) Acute Laryngitis. — Cutting, tickling, burning; mucous membrane symmetrically swollen, bright red and sometimes streaked with mucus. Treatment. — Calomel and saline purge at out- set; in very early stage give a capsule containing 2^ gr. phenacetin, 5 gr. salol and 1/24 gr. apomor- phin every 4 hours; locally a spray of aqueous solution of suprarenal extract (5 gr. to 2 dr., allow to stand 12 hours, then filter) . Later mildly stimulant expectorants; locally tincture of ferric chlorid 20 m. per oz. of water. As disease pro- gresses it may be necessary to make local applica- y<» PAIN AND ITS INDICATIONS tions of silver nitrate 10 to 20 gr. per oz., by means of cotton applicator. Limit use of voice as much as possible. — Levy. Simple Chronic Laryngitis. — Slight soreness and tickling aggravated by use of voice ; symmetric swelling and slight redness of mucous membrane. Treatment. — Remove cause, whether nasal, dia- thetic or digestive. Locally, after thorough cleans- ing with Dobell's solution, apply silver nitrate solution, beginning first 10 gr. to the ounce, and in- creasing to 40 or 50 grains where considerable thickening. Attention to local and general hy- giene. — Levy. Laryngeal Tuberculosis. — Often early paresthe- sia, later severe pain, most marked on swallowing ; pale, broad, shallow, ragged, ill-defined ulcers; usually accompanying pulmonary phthisis. Treatment. — Hourly inhalations of a 4 per cent solution of menthol in albolene. — Knight. Orthoform (^ gr.) lozenges (marshmallow or fruit jelly) far back on tongue 5 minutes before each meal. — Solis-Cohen. Insufflations of a mixture of 20 gr. cocain, 2 dr. iodoform and 1 dr. of stearate of zinc. — Coakley. Local application of guaiacol, full strength or diluted with an equal part of glycerin. — Coghill. Cocain lozenges ^ gr. each dissolved slowly in mouth 10 minutes before meals; also 3 to 5 per cent cocain spray; to cure rub with lactic acid, MOUTH AND THROAT 99 sometimes curetting first, and supplement with insufflations of iodoform. — Levy. Cancer of Larynx. — Severe pain extending to ears if much ulceration; irregular nodular infil- trating mass or deep, ragged, bleeding ulcer. Treatment. — Curative: Early radical extirpa- tion. Palliative : Dust parts with cocainized iodol (1 per cent cocain) or with morphin powder, or spray frequently with 5-10 per cent cocain solu- tion; inject minute quantites of formaldehyd (1 :1000-1 :500) around border of tumor. — Kyle. Tabetic Laryngeal Crises. — Sudden attacks of dry cough, pain and dyspnea; loss of knee-jerk and ataxia. Treatment. — Nitrite of amyl or nitroglycerin; local application of cocain. — Gowers. PAIN IN" THE NECK. Parotitis. — Swelling of parotid and dull pain at angle of jaw, much increased by mastication; specific infection or putrefaction in mouth. Treatment. — Equal parts of tincture belladonna, tinct. aconite and tinct. opium applied several times daily over swelling with finger tips or camel-hair pencil; strict oral cleanliness. — Trouchet. Epidemic (Mumps): Rest in bed; laxatives; light liquid diet ; cold compresses or pad of cotton wadding covered with oiled silk; leeches if red and tender. — Osier. 100 PAIN AND ITS INDICATIONS Cervical Adenitis. — Swollen, tender lymphatic glands; infection through throat or mouth. Treatment. — Eub in equal parts of laudanum, fluid extract arnica and soap liniment. — Shoe- maker. Mercuric chlorid 1/60 gr. every 2 hours in acute inflammation of submaxillary and sublingual glands. — Bartholow. Calcium sulphid 1/10 gr. every hour or two for hard, swollen glands behind angle of jaw with deep-seated suppuration. — Kinger. Syrup of iodid of iron 5 to 40 m. well diluted after meals. — Bartholow. Oleate of mercury and morphin (gr. i ad dr. i) in obstinate cases. — Einger. Spasmodic Torticollis. — Wry-neck and painful, tender sternomastoid, especially on movement. Treatment. — Iron with a hot flat-iron through flannel. — Anders. Strong infusion of capsicum applied on lint, covered with gutta-percha. — Einger. Cervical Caries of Spine. — Local tenderness and deformity; pain increased by turning or pressing on head. Treatment. — Eecumbent posture in bed, with head and neck fixed by a sand-bag on each side; extension from chin and occiput or lower limbs or both, in bad cases; cod-liver oil, phosphates, iodid of iron. — Am. Text-Book of Surgery. MOUTH AND THROAT 101 Onset of Acute Infections. — With headache, backache, malaise, chill, fever. Obscure Rheumatic Symptoms. — Neurasthenia, anemia, debility, slight fever, disturbances of ab- dominal, organs, lymphangitis; tenderness from mastoid process down neck or over upper scapular region. Treatment. — Spray tonsils with zinc sulpho- carbolate 4 gr. to ounce of water; or insufflate 3 to 5 gr. each of salol and sodium bicarbonate. — Wade. Pericarditis. — Neuralgic pain in phrenic nerve; friction sound or increased area of dullness. Treatment. — Tincture of aconite -J to 1 drop every \ hour for 2 hours, then every hour or two. — Einger. Diaphragmatic Pleurisy. — Sharp pain around lower edge of ribs and neuralgic pain in phrenic nerve. Treatment. — Leeches; hypodermic of morphin; Paquelin cautery lightly but freely applied; blis- ters; rest in bed. — Osier. Displacement or Hernia of Muscle. — Follows sudden twisting ; may be soft localized swelling. Treatment. — Replace by massage and manipu- lation. False or True Angina Pectoris and Aortic Le- sions. — Usually with precordial distress and pain running down inner side of left arm. 102 PAIN AND ITS INDICATIONS Treatment. — Equal parts of spt. etheris coinp., elixir lupnlin and ammoniated tinct. valerian. Two teaspoonfuls in water ever}' 15 or 20 minutes. — Shoemaker. Hepatic Disease. — Dull pain over right shoulder and lower part of neck. Treatment. — Sodium phosphate. Tracheitis and Tracheal Ulcers. — Constant lo- calized pain and soreness. Treatment. — Frequent steam inhalations im- pregnated with carbolic acid or creosote or tur- pentine or pine oil and paregoric. — N. S. Davis, Jr. Neuralgia, Herpes Zoster, Rheumatoid Arthritis of Cervical Vertebrae. CHEST PAIN 103 CHAPTER V.; CHEST PAIN. EXTBAPEECORDIAL CHIEFLY. Pleurodynia. — Severe burning and tingling "stitch in side/' aggravated by cough or deep in- spiration; afebrile, bilateral or unilateral; sensi- tive muscles on palpation; deep breathing does not excite cough ; hand pressed firmly against side. Treatment. — Hot poultices and fomentations; belladonna and aconite applications; massage; vapor or Turkish bath; galvanism or faradism; potassium citrate, acetate or tartrate in full doses with potassium iodid in dose of 5 to 7 grains; salicylic acid in 15 or 20 gr. dose. — Fredk. Taylor. Myalgia. — Diffuse soreness, relieved by uniform pressure, markedly aggravated on bringing affected muscles into action ; due to coughing, strain, rheu- matism or debility. Treatment. — Equal parts of camphor-menthol and chloral hydrate, painted on with camel-hair pencil once a day. — Solis- Cohen. Salophen, salicylates or potassium iodid for rheumatic form. Ammonium bromid gr. x-xx 3 or 4 times a day. — Eshner. Flannel band tied around chest lessens painful concussions of violent coughing spells. — Knopf. Aponeurotic Rheumatism. — Diffused, shifting 104 PAIN AND ITS INDICATIONS and irregular, with muscular soreness; usually from exposure to cold, particularly in gouty or rheumatic subjects. Treatment. — Often cured at once by application of -well-made mustard plaster for 20 minutes. Intercostal Neuralgia. — Sharp, darting, stinging or burning, intermittent pain along intercostal nerves on either side; superficial tender point near spine, at outer edge of scapula, and near costo- chondral junction; no fever; sometimes herpes zoster. Treatment. — Liquid air spray to spinal end of nerve. Touch very painful spots along intercostal nerves with a 1/30 solution of morphin sulphate in tinct. iodin. — Cheron. Inject along side of affected nerve 15-60 m. of parts guaiacol in 10 of chloroform. Strapping of chest. Quinin and occasional mercurial purge. Iron, quinin, arsenic; fresh air, generous diet; belladonna plaster, or chloroform liniment 3 parts with belladonna liniment 1 part sprinkled on lint or flannel backed by oiled silk. — Powell. Strychnin for wandering neuralgic pains from functional nervous irritability. — Bartholow. Phthisical: Hot water compresses frequently repeated, or mustard plasters, small blisters, dry cupping or ignipuncture ; morphin hypoderms as a last resort. — Knopf. Inframammary Neuralgia. — Sharp, shooting, CHEST PAIN 106 paroxysmal pain beneath one nipple, often extend- ing to axilla and running down arm — marked su- perficial tenderness; common in anemic young women; may accompany overwork, leucorrhea, pregnancy, superlactation, ovaritis, cervical lacera- tion, chronic endometritis, lithemia or thoracic aneurism. Treatment. — Tinct. gelsemium m. iii in syrup and water 3 to 5 times daily a half hour before eating or 3 hours after. Dyspepsia. — Diffusible, radiating pains. Treatment. — Treat cause; tonics; good hygiene; change of air; soothing applications; ordinary antineuralgics. Mastodynia ("Irritable Breast"). — A form of intercostal neuralgia due to injury, cracked or shrunken nipples or tumors pressing on nerves. Treatment. — Remove cause. Phrenic Neuralgia. — Pain chiefly at lower part of thorax on a line with insertion of diaphragm, and here may be painful points on deep pressure; full inspiration painful; great sensitiveness on coughing or other sudden depression of diaphragm. Treatment. — Aconitin (Duquesnel's) gr. 1/160 in 4 m. each of glycerin and alcohol and 52 m. peppermint water 3 or 4 times a day. — Seguin. Pleuritis. — Sharp, stabbing pain (indicated by finger tips), usually basal, shooting along inter- costal spaces; increased by cough or deep breath- 100 PAIN AND ITS INDICATIONS ing — may be referred to abdomen; entire side sometimes tender, but no cutaneous tenderness; slight cough and fever and respiratory friction sounds. Treatment. — Rest in bed; fluid diet; leeches, hot poultices or blister to affected side; Dover's powder or morphin hypodermically. — Powell. Strap affected side with overlapping strips of adhesive plaster. Rub affected side with a solu- tion of half a dram each of iodin and potassium iodid in 2 oz. of water. — Memeyer. Local applications of guaiacol or of this and oil of gaultheria made in an ointment (10 m. of each with 5 gr. menthol and 2 m. mustard oil to the dram, in equal parts cerate and wool- fat.) — Solis- Cohen. Early administrtion of £ gr. morphin hypoder- mically, keeping patient under influence of suffi- cient doses during acute stages ; coal tar antipyret- ics (phenacetin,kryofin, antipyrin, acetanilid) may be given also, 5 to 10 gr. every 2 or 3 hours; quinin if malaria complicates; for the fever | m. tinct. aconite and 8 m. spt. eth. nitrosi in 2 dr. liq. potassii cit. and syrup of tolu. — Butler. Diaphragmatic Pleurisy. — Sharp, costo-xiphoi- dal pain, much increased by deep breathing ; respi- ratory friction sounds; tender points over end of tenth rib and diaphragm and in posterior triangle of neck. CHEST PAIN 107 Treatment. — Morphin sulphate gr. £ and quinin sulphate gr. xv-xx in one dose to abort incipient pleurisy. — Bartholow. Gouty or Diabetic Neuritis. — Burning pain along affected nerves, which are tender throughout course. Treatment. — Morphin or hot applications of lead water and laudanum often required; salicy- lates" and antipyrin if fever. — Osier. Locomotor Ataxia. — Neuralgic axillary pain. Treatment. — Acetanilid, antipyrin, phenacetin, antikamnia. Fluid extract ergot, a dram 3 or 4 times a day with bromids in early stage; ^ to 2 gr. doses co- dein. — Hammond. Herpes Zoster. — Severe neuralgic pain; charac- teristic vesicular eruption over shoulder and upper chest. Treatment. — Coal tar anodynes alone or vith bromids; morphin if pain severe; weak galvanic current once or twice a day over affected areas; collodion or antiseptic dusting powder in mild cases — may contain a few grains of opium — and area should be covered with absorbent cotton and a bandage. — Schamberg. Cocain salve containing 1 per cent of drug. — Bleuler. Pulmonary Tuberculosis. — Constantly recurring unilateral pleuritic pain or persistent dull sore- 108 PAIN AND ITS INDICATIONS ness, particularly near apex; cough, emaciation, localized signs. Treatment. — Kub on a mixture of 10 in. croton oil, 1 oz. soap liniment and ■£ oz. laudanum. — Cooper. Pleuritic : Compound iodin ointment or strap- ping of side. Neuralgic: Guaiacol 1 part in 10 of olive oil, locally or hypodermically. — Moissy. Paint affected area with equal parts of guaiacol and glycerin. — Yonge. Dorsal Caries. — Bilateral neuralgia correspond- ing with segment of cord involved ; spinal tender- ness and careful, rigid attitude. Treatment. — Recumbent posture in bed until consolidation takes place; extension from above or from below, or both in bad cases; cod-liver oil, phosphates and iodid of iron. — Am. Text-Book of Surgery. Acute Myelitis. — Girdle pain at upper level of lesion ; paraplegia. Treatment. — Actual cautery at white heat to skin at each side of spine (ether spray as anes- thetic) ; large doses of ergot. — Hammond. Bronchitis. — Often substernal soreness and ten- derness; also myalgia around lower edge of ribs from coughing. Treatment. — Turpentine stupe or camphorated oil applied 2 or 3 times a day. Hot fomentations CHEST PAIN 109 of capsicum, a half teaspoonf ul to a quart, in bron- chopneumonia of children. — Dickey. Pneumonia. — Dull pain, usually near one nip- ple; high fever, rapid respiration, crepitant rales or bronchial breathing. Treatment. — Ice-bag or hot poultices or leeches or blister to side; morphin hypodermically if re- quired. Enlarged Bronchial Glands. — Enlarged cervical glands ; anemia ; asthmatic attacks without bron- chial symptoms; may be localized dullness. Treatment. — Most favorable hygienic condi- tions ; best of food ; cod-liver oil and iodid of iron. — Tyson. Periostitis. — Steady, deep, boring pain; costo- chondral articulations swollen and very tender; from tuberculosis, aneurism, cancer, typhoid or syphilis (nodes on clavicles, sternum or ribs). Treatment. — Compound tincture of iodin; if fluctuation or sinus, open up and remove dead bone. Tubercular with Nodes: Syrup iodid of iron, 15 drops in water or milk after meals. — Thornton. Pointing Empyema. — Localized inflammatory pain, soon followed by local swelling, heat, redness and edema. Treatment. — Simple incision, resection of rib or siphonage. 110 PAIN AND ITS INDICATIONS Abscess of Chest Wall. — Local swelling, heat, redness, fluctuation. Treatment. — Open and secure free drainage. Fracture of Ribs. — Pain evoked by pressure lo- cally or on sternum; crepitus. Treatment. — Immobilize chest with broad band of adhesive plaster. Abscess of Lung. — Pain in side; profuse puru- lent expectoration. Treatment. — Open and drain if superficial. Cancer of Lung. — Steady pain in side ; currant jelly clots and cachexia. Treatment. — Opiates usually required. Pulmonary Apoplexy. — Sudden, severe pain with dyspnea, florid expectoration and circum- scribed dullness. Treatment. — Eest, anodynes and treatment of primary cause. Acute Miliary Tuberculosis. — Hyperpnea, cyan- osis, repeated chills, fever and diffuse chest signs. Treatment. — Three to 5 gr. phenacetin; also anodynes; supporting food and stimulants. — Tyson. Pleural Neoplasms. — Constant severe pain; physical signs of growth. Treatment. — Operation or opiates. Pneumothorax. — Sudden, intense, with dyspnea, amphoric resonance and diminished breath sounds CHEST PAIN 111 on one side; usually from running, jumping, rapid mounting, loud singing or blow on chest. Treatment. — Cold water compresses or ice-bags ; rest in bed, liquid diet and stimulants. — Knopf. Morphin subcutaneously ; hot poultices or fo- mentations frequently applied; paracentesis if dis- tention extreme. — Taylor. Sore Nipples. — Use nipple shield ; boric acid lo- tion before and after nursing; white of egg; al- cohol ; cacao butter ; lunar caustic to cracks. Acute Mastitis. — Pain in breast, shooting into axilla; local redness, heat and swelling; fluctua- tion if pus forms. Treatment. — Fomentations of ammonium car- bonate 20 gr. to pint of boiling water for threat- ened mammary abscess. — Einger. Radial incision, irrigation with hydrogen per- oxid and free drainage as soon as pus forms. Pregnancy or Lactation. — Firm strapping with many-tailed bandage ; lead and opium or lead and belladonna lotion; saline aperients; iron, quinin and mineral acids, especially if toward end of suck- ling; wean. — Bryant. Women Not Pregnant or Nursing. — Application of cold by ice-bag or Leiter's coil. — Bryant. Puberty. — Warm lead lotion with or without opium (5 gr. of extract to ounce of lotion), fol- 112 PAIN AND ITS INDICATIONS lowed by local application of ext. belladonna di- luted with glycerin. — Bryant. Infants. — Apply a pad of absorbent cotton dipped in warm lead lotion, protecting breast after- ward with cotton-wool. — Bryant. Chronic Interstitial Mastitis. — Most common about menopause; pain often neuralgic and made worse by handling and at menstrual period; in- durated, but not stony nodules. Treatment. — Small doses of potassium iodid with liquor potassse well diluted ; correct menstrual irregularities; tonics, particularly iron; protect breast from all irritation and cover it with a well- shaped belladonna plaster. — Gould and Pyle's Cy- clopedia. Cancer of Breast. — Pain often late — radiates into axilla, where glands are enlarged; adherent tumor. Treatment. — Eemove tumor thoroughly, and also axillary glands if tumor is cancerous. Ointment of 1 dr. ale. ext. conium, 5 gr. menthol, 10 gr. ale. ext. belladonna and -J oz. each of lanolin and zinc oxid ointment. — Shoemaker. Suprarenal extract, 10 per cent solution applied locally 2 or 3 times daily in advanced stages. — E. A. Peters. Pain of Cancer. — Irradiation often gives al- most instant relief. CHEST PAIN 113 Vesical Stone. — Eeferred pain at apex. Treatment. — E. Potassii brom. gr. xx; tinct. hyos. m. xxx; tinct. lupuli dr. i; mist, cam- phorae oz. i. Draught at bedtime. — Fothergill. PKECOEDIAL CHIEFLY. Pain of organic cardiac disease commonly after exertion; functional when patient quiet. Flatulent Dyspepsia. — Indistinct aching and soreness after meals, with belching and feeling of fullness. Treatment. — Charcoal and bismuth tablets. E. Pulv. capsici gr. ii; ext. nucis vomicae gr. 1/7 ; ext .pancreatis gr. iii. A capsule after meals. — Shoemaker. Neuritis and Neuralgia. — Sharp, shooting, in- termittent pain; anemia or heart fatigue, gout, atheroma, syphilis, alcohol, malaria or rheumatism. Treatment. — See above under extraprecordial pain. E. Zinci phosphidi gr. 1/10; ext. nucis vomicae gr. \. One pill every 3 or 4 hours. — Shoemaker. Anemias. — Often severe pain after exertion, with pallor and palpitation. Treatment. — Iron with belladonna for wander- ing pains. — Waugh. Young Girls at Puberty. — Pil. ferri carb. (Val- let), one after meals. — Eobinson. Gastralgia (Cardialgia). — Sudden, severe, ap- 114 PAIN AND ITS INDICATIONS parently causeless pain radiating from epigas- trium. Treatment. — See under abdominal pain. E. Liq. chlorof. aq. sat. dr. ss; aq. aurant. flor. m. xxvi; tinct. anisi stell. m. iv. A teaspoonful every £ hour. — Dujardin-Beaumetz. Nervous Debility. — Often attended by a dull, more or less constant pain about heart. Neurovascular Spasm (False Angina Pectoris). — Vasomotor angina pectoris of central origin; painful sensation of cardiac distention, often ra- diating down left arm — spontaneous, insidious, often nocturnal; may follow exposure to cold: common in neurasthenic women. Treatment. — Correct digestive disturbances and regulate diet. Amyl nitrite by inhalation ; antipyrin or potas- sium bromid ; ether or ethyl chlorid vapor to peri- cardium; 1 dr. each of comp. spt. of ether and tinctures of valerian, digitalis and belladonna — a teaspoonful at beginning of attack. — Norbury. Lithemia. — Often dull pain about heart, or pseudo-angina pectoris; lithuria, vertigo, bilious attacks. Treatment. — Blue pill followed by saline to move bowels freely ; avoid alcoholics and excess of proteid foods and fats and sweets; salophen cr salicylates for a few days to relieve. True Angina Pectoris. — Abrupt onset, usually CHEST PAIN 11 5 after exertion, or vise-like cardiac anguish, lasting but a minute or so, and radiating to back, axilla, occiput and down left arm; feeling of impending death ; usually in men above 40 ; disease of coro- nary artery or heart muscle. Treatment. — Amyl nitrite m. iii-v in perles or by mouth, combined with tinct. capsicum in pep- permint water; if pain not quickly relieved, inject £ gr. morphin and repeat in ^ or f hour if need be; if paroxysm very severe, inhale chloroform from handkerchief or sponge in bottle. Give po- tassium iodid for 2 to 4 years, 10-15 gr. t. i. d., stopping occasionally for a week; fresh nitro- glycerin 1/100 gr. t. i. d., gradually increasing to 4 or 5 times this amount; arsenic sometimes very valuable, alone or in combination with iron and strychnin. — Osier. Coronary Angina of Arteriosclerosis. — Saturated solution potassium iodid 5 drops in milk after meals until symptoms yield or iodism occurs. — Vierordt. Fatty Heart. — Occasional anginal and pseudo- apoplectiform attacks; pulse often very slow; short breath on exertion; may be Cheyne-Stokes breathing. Treatment. — Strychnin arsenite 1/100-1/30 gr. every 4 hours; comp. spt. ether | or 1 dram in water for acute attacks. 1115 TAIN AND ITS INDICATIONS Fibroid Heart. — Chest pains, breathlessnesa, vertigo; arteriosclerotic signs elsewhere. Treatment. — R. Lithii brom. gr. xx; spt. glonoini m. i ; liq. potassii cit. q. s. A tablespoon- ful 4 times daily, diluted. — Hughes. Myocardial Degeneration. — Tinct. digitalis m. x, with ammonium carbonate gr. iiss. 3 or 4 times a day ; can be continued for a long period. — A. V. Meigs. Aortic Valvular Disease. — Sharp pain, usually located at base of heart, radiating into neck and down left arm ; aggravated by exertion. Treatment. — Potassium iodid 5 to 10 gr. t. i. d. or nitroglycerin ; small blisters. — Osier. Regurgitation. — Amyl nitrite or erythrol tetra- nitrate, 1/100-1/30 gr. every 4 hours. Equal parts of tinctures of strophanthus, digi- talis and nux vomica: 20-30 drops of mixture t. i. d. — Thornton. Cardiac Dilation. — Cardiac asthma; dropsy of the feet; enlarged heart; usually valvular de- fect — mitral most common. Treatment. — Fresh air, moderate exercise, mas- sage, iron, nitroglycerin ; begin with 1 dr. infusion digitalis 4 times a day for 2 or 3 days, then change permanently to •§ gr. of powder t. i. d. ; avoid milk and restrict other fluids. — Thomson. Dangerous Stages. — Strychnin 1/30 gr. hypo- dermically every 3 or 4 hours or oftener for a short CHEST PAIN 117 time, or digitalis 1/60 gr. in same manner. — Tyson- Acute Cardiac Dilation. — "Stitch in side" after sudden prolonged efforts or cold baths. Treatment. — Caffein, camphor, aromatic spirit of ammonia, digitalis, strychnin. Rheumatic Cardiac Hypertrophy. — Indistinct pain about heart, which is enlarged and overacting. Treatment. — Belladonna with compound spirit of ether. — Thomson. Palpitation. — Anemia or exophthalmic goitre. Treatment. — Ice-bag to cardiac region ; morphin hypodermically ; large doses potassium bromid; tinct. valer. eth. m. xx-xxx t. i. d. ; liq. kali ar- senic, aq. amyg. amar., aa. m. v. t. i. d. after meals. — Eichhorst. Overuse of Tobacco. — Aching or anginose pain, palpitation, irregular or intermittent pulse. "Irritable Heart" of Overexertion. — Soldiers, peddlers, collectors, etc. Treatment. — Eest in recumbent posture; tinct. digitalis m. x t. i. d. if no hypertrophy; tinct. aconite in 3 to 6 m. doses if much hypertrophy; combination of digitalis and aconite if little hyper- trophy and much irritability. — Da Costa. Senile Heart. Treatment. — Kativelle's digitalin (digitoxin) \ mgm. daily at bedtime. — Balfour. Endocarditis. — Slight precordial or epigastric 118 PAIN AND ITS INDICATIONS pain; excited heart action and systolic blowing murmur; patient points to xiphoid and up neck or into left arm. Treatment. — Dover's powder and phenacetin as sedatives. Rest in bed for several months in rheu- matic cases if cardiac pain and frequent pulse per- sist. — Chas. G. Jennings. A small blister (2 by 3 inches) over affected valve; rest in bed; light diet; treat rheumatism. —Taylor. Ulcerative. — Salol gr. x t. i. d., or sodium sul- phocarbolate gr. xx in 2 dr. wintergreen water every 4 hours. — Thornton. Pericarditis. — Dull, aching or sharp, lancinating pain, sometimes shooting to lower sternum, shoul- der and down left arm; may be increased on inspiration; sometimes epigastric or precordial tenderness on pressure. Treatment. — Blister over region of heart. — But- ler. Opium short of narcotism; poultices or large, hot anodyne applications locally; digitalis unless extensive adhesions. — Floyd M. Crandall. Leeches, wet cups, blisters or apply ice for 2 hours. — Debove and Gouvin. Acute Myocarditis. — Oppression or aching; ac- companies infectious fevers ; sudden heart failure. Treatment. — Ice-bag over heart or blisters fol- lowed by fomentations. CHEST PAIN 119 Post-Influenzal Cardiac Pain. — Phenacetin, an- tipyrin, morphin hypodermically to relieve; so- dium iodid (5 to 10 gr.) with ammonia, and later with arsenic, for prolonged administration. — San- som. Chronic Myocarditis. — Same as myocardial de- generation. Treatment. — Tinct. piscidia erythrina m. xx-xl twice a day for continuous cardiac pain. Cardiac or Coronary Thrombosis and Embolism. — Transfixing, indescribable suffering, with syn- cope and collapse. Treatment. — Measures to meet symptomatic in- dications. — Anders. Thoracic Aneurysm. — Pain usually deep-seated, paroxysmal, lancinating; often radiates into neck or down left arm. Treatment. — Free bleeding; potassium iodid; morphin in final stage; ice-cap or belladonna plaster when sac grows large and appears exter- nally. — Osier. Elastic support passing over shoulder and under arm of opposite side; milk diet; absolute rest; phenacetin, antipyrin, acetanilid or antikamnia. Atheroma or Distention of Aorta. — Pain in lat- ter case usually after effort. Treatment. — Sodium nitrite; bromids with foot-bath, sitz-bath or full bath ; or a capsule con- 120 PAIN AND ITS INDICATIONS taining cocain, camphor and very little powdered opium. — Jos. Collins. Aneurysm or Tumor at Base of Heart. — Pain paroxysmal, sharp, lancinating, anginose — with expansile impulse and thrill in aneurysm — with bulging and dullness on percussion in both. Rupture of Aorta. — Sudden, severe, tearing pain, radiating to shoulder, back, neck or abdomen; dyspnea, shock, collapse. Aortitis. — Severe paroxysms in aortic area; aor- tic systolic murmur. Treatment. — Nitroglycerin; potassium iodid in small doses. Tincture of iodin, blisters, wet cups ; morphin hypodermically ; chloral, exalgin, anti- pyrin. — Debove and Gouvin. Cardiac Rupture. — Sudden, excruciating pain, continuing severe with nausea, vomiting and faint- ing. Treatment. — Complete rest in horizontal pos- ture; full doses of morphin hypodermically; ice- bag locally; warmth to extremities, nitroglycerin. — Anders. Pneumopericardium. — Peculiar splashing and churning sounds over heart. Treatment. — Opiates, leeches, blisters, cupping, ice-bag. Cardiac Epilepsy. — Paroxysm of unconscious- ness followed by acute pain about heart; some- times local spasms. CHEST PAIN 121 Treatment. — Strychnin, digitalis, strophan- thus, nitrites; camphor or caffein; subcutaneous injection of physiologic salt solution. Locomotor Ataxia. — Sudden, severe cardiac crises like angina pectoris; ataxia and pupillary symptoms. Treatment. — Coal tar analgesics. Tight Lacing. Left Brachial Neuritis. — Pain in axilla and above clavicle, radiating to region of heart; persistent tenderness of nerve plexus; disturbed heart action; gouty subjects above 50. Treatment. — Salophen, 5 to 10 gr. every 2 hours. Reflex from Uterine Disease. Palpitation and Hysteria. — Sharp pain under mamma. SUBSTERNAL. Bronchitis. — Diffuse soreness, tightness, rawness and oppression; whole hand laid on sternum and then passed over and across chest. Treatment. — Turpentine stupe or camphorated oil rubbed on several times daily. Acute Aortitis. — Pain constant, diffuse, rending, with terrible exacerbations. Treatment. — Amyl nitrite or nitroglycerin; ice- bag over part. Gastric Disorders. — With flatulence, eructations and pain in stomach. Mediastinitis. — Constant, throbbing pain, deep- seated and severe ; pressure symptoms. 122 PAIN AND ITS INDICATIONS Treatment. — Trephine sternum and explore carefully with hollow needle; if pus be found, open, wash out and drain cavity. — Am. Text-Book of Surgery. Phrenic Neuralgia. — Constantly painful point in midline of sternum at level of 4th or 5th sterno- chondral articulation. Xiphoid Rheumatism. — Dyspnea and severe epi- gastric pain, much increased by pressure over lower part of sternum; may be local swelling. Treatment. — Blister externally; salicylates in- ternally. — Hirtz and Koustan. Mediastinal Cancer. — Severe, deep-seated, con- tinuous, lancinating pain; cachexia and physical signs of growth. Treatment. — Opium or morphin. K. Acidi carbol. gr. 1/5; glycerini m. vi; tinct. gelsem, m. vi; tinct. opii camph. m. xxiv; aquae m. xxiv. A teaspoonful before each regular meal and at bedtime. — N. S. Davis. Aortic Aneurysm. — Sharp, paroxysmal pain with murmur and thrill. Treatment. — Potassium iodid 15 to 30 gr. 3 or 4 times a day. — Bartholow. Support with elastic bandage in suitable cases. — Osier. Esophageal Affections. — Pain increased by swal- lowing or sounding. Bronchiectasis. — Severe substernal constriction CHEST PAIN 123 in acute attacks; profuse fetid expectoration and signs of bronchial dilation. Treatment. — Inhalations of 1 to 3 per cent car- bolic acid or 1-1000 thymol; terebene m. v-x in capsules every 4 hours; creosote m. i increased to m. vi t. i. d. persistently; intrathoracic injection of disinfectants; if dilation situated superficially, open freely and drain thoroughly. — Anders. Pertussis. — Pain from straining cough. Treatment. — Control cough; hemlock ointment applied to chest. E. Phenacetini gr. £; spt. vini rect. m. iv; elixir erythrox. m. xv ; glycerin q. s. A half dram every hour or two for a child. — Shoemaker. Enlarged Bronchial Glands. — Dry cough and lo- calized dullness; children chiefly. Treatment. — Syrup of iodid of iron, hypophos- phites and cod-liver oil. Syphilis. — Pain worse at night ; periostitis with nodes. Treatment. — E. Potassii iodidi gr. x; hydrarg. chlor. corros. gr. 1/32; syr. sarsap. comp. m. xv; aquam q. s. : A teaspoonful in water after meals. Or inunctions of mercurial ointment, — Thornton. Cardiac Dilation. — Diffuse substernal and pre- cordial pain; enlarged, weakened heart. Treatment. — Amyl nitrite inhalations; nitro- glycerin or sodium nitrite; digitalis, caffein, stro- phanthus. 124 PAIN AND ITS INDICATIONS CHAPTER VI. BACKACHE. Spinal. — Accompanies symmetric superficial thoracic or, abdominal pains in diseases of cord; may be restricted to locality of lesion in diseases of meninges or vertebrae. Pott's Disease. — Persistent, fixed, local and ra- diating, symmetric, peripheral "stinging" neural- gic pains — occiput, arms or sciatic nerves — greatly increased by jarring spinal column, disappearing on removing intervertebral pressure, as by laying over knees ; rigid attitude, limping gait, "angular curvature." Treatment. — Fresh air, good food, cod-liver oil and arsenic; rest and support to spine by braces and bandages to prevent paraplegia; rest and active extension for weeks or months (preferably by Mitchell's spine chair) after paralysis has taken place. — Osier. Plaster of Paris jacket, with jury-mast if in upper dorsal or cervical region. Sprains of Spinal Column. — Sudden, from trauma, usually in adults; speedy recovery under appropriate treatment. Treatment. — Aconite liniment well rubbed in. — Brunton. Rest in bed; hot fomentations; hot water or BACKACHE 125 vapor baths or douches; friction toward head; stimulating liniments containing camphor, ammo- nia or turpentine; ironing, acupuncture, galvan- ism; menthol-camphor. — Von Ziemssen. Alternate cold and warm douche, over sacrum, each 8 to 10 seconds for 8 or 10 minutes. — Moul- lin. Spinal Concussion (Erichsen's Disease). — Pain in back (occipital often in morning), especially on movement ; tenderness chiefly in interscapular and lumbar regions; girdle or half -girdle sensation; paresthesia, hyperesthesia or anesthesia; rigidly upright or forward-bent back. Treatment. — Lotion of lead water and lauda- num; leeches if pain persistent. — Aitken. Stimulants and restoratives at first; massage, electricity, hydropathy, rest-cure for traumatic neurosis; treatment of inflammatory symptoms same as for myelitis. — Lyman. Neuromimesis ("Spinal Irritation," Hysterical, Neurasthenic, Hyperepthetic Spine.). — Pain may be intense — shifts position, but is most frequent at 2 or 3 L. — aggravated by upright posture if ane- mic; young growing girls and neurotics; may follow moderate trauma — traumatic neurosis. Treatment. — Massage and hydrotherapy for neurasthenic cases. Moderate galvanic current (5 to 10 m. a.) to spine, stabile ascending or descending. — Clevenger. 126 PAIN AND ITS INDICATIONS Belladonna preparations locally. — Einger. General electrization with feet on minus pole (metal plate wrapped in flannel) — weak current, not longer than 15 minutes. — Von Ziemssen. Traumatic Lesions of Cord : Absolute rest for days or weeks; mercury if inflammation of mem- branes or inflammatory effusion outside the cord compressing it; in later stages, repeated applica- tions of mild actual cautery on each side of spine opposite affected region; trephining if displace- ment of bones or compression by fractured frag- ments; for resulting spinal pain and tenderness use actual cautery, blisters, iodin or repeated sina- pisms — also cannabis indica, cocain or morphin cautiously. — Gowers. Locomotor Ataxia. — "Lightning-like" parox- ysms of pain radiating from shoulder to buttocks. Treatment. — Antipyrin, antikamnia, acetanilid, hyoscin, morphin; warm baths. Lateral Curvature. — Constant pain in one shoulder and back, with muscular weakness and winging of scapula. Treatment. — Correct wrong postures; tonics; out-door exercise; swinging by hands from trapeze and swimming motions; dumb-bells, Indian clubs; massage; pelvic band with crutch- heads extending up into arm-pits; thicker sole of shoe for shorter leg. — Eoberts. ■ ■ . BACKACHE 127 Rachitis. — General soreness and dread of being handled ; pseudo-kyphosis. Treatment. — Proper alimentation with good milk as basis ; best of hygiene ; coolish baths ; keep extremities warm; iron, phosphorus, cod-liver oil. Phosphorus, 1/200 to 1/100 gr. t. i. d., may be given in cod-liver oil. — A. Jacobi. One or more teaspoonfuls 3 or more times daily of emulsion containing 2 pints cod-liver oil, a pint each of sherry wine and syrup of wild cherry and 10 yolks of eggs. — J. Lewis Smith. Scurvy. — Swollen, bleeding gums and petechia. Treatment. — Fresh milk and orange juice. — Wm. Perry Northrup. Poliomyelitis Anterior. — With headache and aching joints and sudden paralysis of leg or leg and arm. Treatment. — Salicylates or mercuric chlorid; hot applications to spine frequently and faith- fully, or very mild sinapisms; keep child on side or face and envelop affected limbs in cotton wool. — Archibald Church. Spinal Hyperemia. — Dull lumbar and sacral aching; much increased by slightest exertion; total inability to move in akinesia algera. Treatment. — Fluid ext. ergot m. x-xl 3 or 4 times daily. — Clevenger. Early, energetic use of Paquelin cautery and of 138 PAIN AND ITS INDICATIONS descending constant current; tepid baths and tonics. — Hirt. Spinal Meningitis. — Pain constant or paroxys- mal; intense ischialgia in acute, increased b\ pressure or movement; paroxysmal rheumatoid pains in chronic; severe darting pains in head, neck, shoulder and upper limbs in hypertrophic form. Treatment. — Counterirritation by painting twice daily with tincture of iodin or the use of irritative ointments, moxae or Paquelin cautery (punctiform scars) ; prolonged tepid baths (-| to H hours) ; faradic brush over painful muscles. — Hirt. Cerebrospinal Meningitis. — With headache, pho- tophobia and spastic retraction of head. Treatment. — Inunctions of ung. Crede, 1 oz. applied daily for 3 days, and in case of relapse 1/3 oz. ; hot water to spine; trional as a sedative when necessary. — Schirmer. Acute Spinal Leptomeningitis in Children. — Sharp chill, vomiting or convulsions; great pain in back and darting pains around body or down limbs; tenderness over spine; spasm and rigid muscles and stiffness of neck and back; fickle temperature and pulse. Treatment. — Absolute quiet on side or in partial knee-elbow position; thermocautery, blisters, leeches, dry or wet cupping; mild sinapisms, hot BACKACHE 129 spray douche, continuous ice-bag. — Arch. Church. Hematorrhacliis. — Sudden, persistent excruciat- ing pain; may simulate angina pectoris; often with spasms and paresis of limbs. Treatment. — Absolute rest in bed, applying ice over supposed seat of trouble; local bleeding if irritation seems to be localized ; further treatment same as in acute meningitis. — Hirt. Hematomyelia. — Pain comparatively slight at onset, gradually diminishing. Treatment. — Ice to spinal column and internal administration of ergotin. — Hirt. Acute Myelitis. — Girdle pain at upper level of lesion; floated feeling" in severe cases. Treatment. — Absolute rest in bed; local blood letting; Chapman's ice-bags; Priessnitz com- presses renewed every hour or two; actual cau- tery; blisters along spine; tincture of iodin; mercurial ointment; potassium iodid, ergot, bella- donna, laxatives, diuretics. — Eoth. Tepid baths 3 or 4 times a day for 15 to 30 minutes, best taken in forenoon; extension ap- paratus, spinal braces, etc., in compression form. —Hirt. Acute Ascending Paralysis (Landry's or In- fectious Polyneuritis). — Pains may be sharp; paralysis rapidly progressing from feet up. Treatment. — Actual cautery, dry cups or ice- 130 PAIN AND ITS INDICATIONS bags to spine; potassium iodid, full doses of ergot, belladonna and strychnin. — Eanney. Eemove cause (alcohol, lead) ; rest, salicylates, antipyrin; antiluetic treatment if indicated. — C. Jakob. Ataxic Paraplegia (Postero-Lateral Sclerosis). — May be slight dull aching in sacral region and in limbs after walking. Treatment. — Thorough course of mercury and potassium iodid if syphilis is suspected. Tumors of Spine. — Pain localized, persistent, severe, much increased by movement and pressure. Treatment. — Mercurial inunctions and potas- sium iodid if syphilitic — otherwise excision if possible. Pressure of Thoracic Aneurysm. — Fixed, local gnawing pain in vertebra? between shoulders ; may be dysphagia or left-sided intercostal neuralgia; pain often indicated by patient by extended thumb. Treatment. — E. Antipyrini gr. xv. ; syr. tolu dr. ii; aquse dr. ii: A tablespoonful at intervals of 1 to 4 hours till relieved. — Germain See. Osteomalacia. — Wandering and persistent pains in multiple areas, mostly in lower back and along sciatic nerve; pregnant women. Treatment. — Phosphates, cod-liver oil, iron and tonics; best of hygiene; avoid conception. Spinal Osteoarthritis. — Eheumatoid aching in BACKACHE 131 spine and lower limbs, with gradual bending for- ward; middle and old age. Treatment. — Tonics, massage, hot and cold douches. Chronic Rheumatism. — Local pain, tenderness and limitation of movements; sometimes occa- sional clicking sound; pain increased by move- ment, fatigue and changes in weather; may radiate along nerve trunks; other joints affected; morning stiffness. Treatment. — E. Liq. potassii ars. m. v; potassii iodidi gr. v ; syr. simp. q. s. : A teaspoonf ul in water t. i. d. between meals. — Da Costa. Gonorrheal Arthritis. — Spine very tender; urethral blennorrhagia. Treatment. — E. Acidi salicyl., ol. terebinth., lanolini aa. dr. iiss; adipis oz. iii: Apply to joints. — Balzer. Inflammation at Sacro-Iliac Synchondrosis. — Follows childbirth with narrow pelvis. Treatment. — Salicylates and derivatives. Typhoid Spine (Perispondylitis). — Constant pain, often of considerable vertical extent, aggra- vated by lateral or forward motion ; tenderness on pressure, particularly in lumbar region; fever; may follow contusions; recovery in a few weeks. Treatment. — Fixation of body brace; massage of lower extremities; rest, nourishing food and 132 PAIN AND ITS INDICATIONS change of climate. — Lovett and Withington. Free purgation may relieve. Coccygodynia. — Severe, sharp or throbbing local pain on sitting, rising, walking or defecation; movement of coccyx increases suffering; neuras- thenic form almost always associated with pain or ache at base of sacrum, between scapulae, in neck, occipital, left parietal, supraorbital and left sub- mammary region; may follow childbirth, sudden falls or blows, cold, rheumatism, hemorrhoids, painful caruncle, uterine disease or hysteria. Treatment. — Eest-cure, tonics, massage, hydrop- athy for neurasthenics. Expose coccyx by external incision, raise ex- tremity of bone and sever muscles on each side with scissors; disarticulation and complete re- moval of cocc} r x if bone diseased. Syphilitic Endarteritis. — Luetic history; pain, paresthesias, lryperesthetic zones; fatigue followed by complete paraplegia; incontinence of urine and feces. Treatment. — Massive doses of potassium iodid in milk or water after meals. Multiple Sclerosis. — Deep-seated, diffuse pains in limbs and back; loss of coordination in feet and hands; muscular weakness with contractures; intention tremors, nystagmus. Treatment. — Bromids. — Spitzka. E. Hydrarg. chlor. corros. gr. 1/24; liq. arsen. BACKACHE 133 chlor. m. iiss; infusum gent. q. s. : A teaspoonful t. i. d. in water. — Hughes. Syringomyelia. — Sudden pain may indicate ap- proaching hemorrhage. Treatment. — Attention to hygienic and dietetic- details. — Anders. Parasites in Spinal Cord. — Cysticerci, echino- cocci; symptoms simulate spinal hyperemia or locomotor ataxia. Neuromuscular. — Pain much increased by spinal and muscular movements; may be tender points and vasomotor phenomena. Lumbago. — Muscular pain in lumbar region during rest, much increased by motion, often run- ning down sciatic nerve ; stiffness, no tenderness . Rheumatic. — Usually one-sided, without fever. Treatment. — Salicylates in acute cases; 20 per cent ointment of salicylic acid freely rubbed into skin in subacute and obstinate cases; potassium iodid, guaiac and small doses of arsenic in chronic cases. — Anders. Dry cupping over affected muscles ; acupuncture in acute cases, thrusting sterilized needles or hat- pins 3 or 4 inches long into lumbar muscles at seat of pain, withdrawing them after 5 or 10 min- utes. — Osier. E. Sodii salic. gr. x; potassii iodidi gr. v; syr. sarsap. comp. m. xxx; aquam q. s. : A teaspoonful in water t. i. d. — Solis-Cohen. 134 PAIN AND ITS INDICATIONS Rhus toxicodendron for subacute muscular or tendinous rheumatism worse at night. — Piffard. Neuritic. — Usually two-sided, with fever. Treatment. — Salicylates to salicylism; inter- rupted galvanic current; ether spray; strong in- fusion of capsicum on lint; iodids for chronic metallic poisoning. Myalgia from Sprain. — Tender muscles; one side of back usually larger than other. Treatment. — Belladonna liniment or iodin oint- ment rubbed in. Ammonium chlorid gr. xx t. i. d. for 2 days (or till coryza), then quinin gr. v t. i. d. for a week. — Waugh. Salicjdates; tincture of capsicum (1 to 5 of water) locally on lint covered with oiled silk for a half hour 4 or 5 times daily. — Edgeworth. Myalgia from Bruise or Cold. — Tender muscles and history. Treatment. — Iodin ointment, chloroform or belladonna, opium and aconite liniment; massage or good rubbing. — Hare. Ammonium chlorid in 10-20 gr. dose in solu- tion with ext. licorice; other remedies are fl. ext. cimicifuga (m. xx-xl), potassium acetate or citrate (20 gr.), and very hot poultices. — Hare. Myalgia from Fatigue. — Pain increased by exer- tion or emotion; helped greatly by massage. Treatment. — Rest the chief remedy. BACKACHE 135 Strong lead plaster to loins; Turkish baths. — Einger. Strapping from thigh up with layers of adhesive plasters which overlap each other. — Potter. Onset of Acute Fevers. — Particularly smallpox, influenza and tonsillitis; aching loins and joints. Treatment. — Influenza. E. Phenacetini gr. iii; pulv. camphorae gr. i; caffeinse cit. gr. i: Take every 2 or 3 hours alternately with 2 gr. quinin sulphate. — Hughes. Early Stages : Salipyrin gr. v, in capsule every 2 or 3 hours relieves pain and reduces fever with- out depression. — Butler Harris. Multiple Neuritis. — Severe burning, boring pains in muscles of back and limbs and in nerve- trunks; tingling and numbness. Treatment. — Salicylates, salophen, antipyrin, phenacetin, antikamnia with salol. Eest in bed; salicylates and antipyrin in acute eases, with morphin and hot applications of lead water and laudanum if required; reduce stimu- lants gradually in alcoholic form; gentle friction of muscles from outset. — Osier. Hysteria. — Two zones along 4 or 5 vertebrae in dorsal and lumbar region; stigmata. Treatment. — Firing, electricity, blisters, sug- gestion. Neurasthenia. — Bilateral pain over entire small of back, relieved by support. 136 PAIN AND ITS INDICATIONS Treatment. — Removal of weakening agent and increase of nutrition; plasters and rest in bed. Renal. — Lumbar pain, often radiating to groin and inner tbigh ; urinary signs and symptoms. Acute Nephritis. — Dull acbing on botb sides, increased by movement, with weight or pressure; blood}', albuminous urine. Treatment. — Three or 4 lcecbes over eacb kid- ney, or wet cupping (2 oz. blood from each renal region for a vigorous child of 6 to 8), following bleeding at once with a large, hot linseed poultice fitting closely around body at loins, covered with rubber cloth and oiled silk and changed every G hours ; a little powdered mustard may be stirred in each poultice. — I. N. Danforth. Immerse child to its chin for 15 or 20 min- utes morning and evening in water kept at 100°, then wrap in warm, dry blanket and put to bed; also, if need be, dry cupping to lumbar region and hot applications of spongiopiline. — Goodhart. Neuralgia of Kidney. — Sharp, paroxysmal pain in lrin; malaria, plumbism, gout, anemia. Treatment. — Etiologic remedies; coal tar anal- gesics; quinin and arsenic for malaria. Gouty Kidney. — Sudden paroxyms, usually uni- lateral; pain on micturition; scant} 7 , dense urine loaded with uric acid crystals and some red blood corpuscles and leucocytes — normal between at- tacks. BACKACHE 1S7 Treatment. — Abundance of water to drink; avoid rich foods, red meats and alcoholics; diet largely of milk and fresh vegetables; sodium phosphate, a tablespoonful in a glass of hot water before breakfast. E. Lithii benzoat. gr. v; tinct. belladonna? m. iii ; ext. tritici rep. fl. q. s. : A teaspoonf ul every 2 or 3 hours. — Shoemaker. Renal Stone. — If stone in cortex, pains fixed and continuous (sometimes increased by move- ments), strictly localized at angle of last rib and erector spina? and over abdomen internal to crest of ilium, and patient sleeps on affected side; if loose in pelvis, pain is paroxysmal at long in- tervals, colicky and radiates to neck of bladder, groin, ovary, uterus or testicle and down thigh, with frequent micturition (urine bloody, purulent or scanty), and patient lies on sound side. Treatment. — Hot bath ; morphin hypodermical- ly and inhalations of chloroform; local applica- tions of hot poultices or cloths wrung out of hot water; occasional change in posture or inversion of patient; drink freely of hot lemonade or soda or barley water. — Osier. Hot water irrigations of colon. Pyelitis. — Pain constant, moderate, dull aching or dragging, increased by coughing or motion and sometimes by pressure; pyuria and pelvic epi- thelia. 188 PAIN AND ITS INDICATIONS Treatment. — Warm baths, narcotic poultices, morphin. — Both. Fluids freely in mild cases, particularly alka- line mineral waters, to which potassium citrate may be added; tonics, nourishing diet, milk and buttermilk freely. — Osier. Urotropin, 15 to 30 gr. daily, taken in the morning or morning and evening, in lithia water or carbonated water — for pyelitis following acute infections. Acute Pyelitis in Infancy. — Migration of colon bacilli from bowel; may be high fever, rigors and much pus and many bacteria in acid urine; great urinary distress. Treatment. — Long continued administration of alkaline remedies. — John Thompson. Oxaluria. — Pain usually bilateral, with much lumbar soreness and nervous depression; crystals. Treatment. — Avoid sweets, rhubarb, tomatoes and cabbage; dilute nitromuriatic acid after meals. Suppurative Nephritis (Eenal Abscess). — Pain constant, dull, throbbing, pulsating along spine; rapid swelling of kidney; pus casts and bacteria in urine. Treatment. — Nutritious, easily digested food; vapor or hot air baths; hot sand on loins or dry cupping if much pain; keep bowels active; quinin and small doses of opium. — Taylor. BACKACHE 139 Perinephritis and Perinephric Abscess. — Pain- ful, tender swelling in loin; pressure pain in dis- tribution of genitocrural, iliohypogastric, ilioin- guinal and anterior crural nerves. Treatment. — Early, free, permanent drainage. — Osier. Ice as long as it is grateful and relieves pain; mercurial ointment and narcotics, later poultices. —Both. Incision for perinephric abscess should be made 2 fingers breadth below last false rib on outer side of sacrolumbalis at thinnest part of wall, where aponeuroses of transverse and oblique muscles unite. — Eoth. Injuries to Kidney. — History of direct or indi- rect violence (may be unrecognized at time) ; ten- derness and violent lumbar pain shooting toward groin; frequent, painful micturition, hematuria; shock or collapse in severe cases. Treatment. — Absolute rest; liquid diet; gallic acid, ergot or opium and lead if bleeding extreme ; strap affected region. — Am. Text-Book of Sur- gery. Ice-bladder over loins. Floating and Movable Kidney. — Pain constant, dull, dragging in side or hypogastrium, increased by standing, relieved by lying — with occasional severe colicky paroxysms with nausea and vomit- ing — Dietl's crises; displaced kidney. 140 PAIN AND ITS INDICATIONS Treatment. — Avoid corsets and imprudent exer- cise, and wear abdominal belt or other supporting appliance; nephrorrhaphy or nephrectomy as last resort. — Boberts. Active Renal Hyperemia. — Dull aching or sen- sation of weight in loins; sometimes at catamenial period ; pollakiuria ; urine at first increased, then decreased or suppressed; a little albumin, red blood cells, hyaline casts and renal epithelium. Treatment. — Absolute rest and liquid diet ; cup- ping over loins or use of hot fomentations; free use of water and other diluents and mucilaginous drinks; saline laxatives to freely open bowels; hot air bath or hot pack to promote sweating. — Anders. Passive Renal Hyperemia. — Sensation of weight in loins; urine diminished; usually a little al- bumin; a few small hyaline casts and scattering blood corpuscles; signs of circulatory obstruction. Treatment. — Potassium iodid, convallaria, caf- fein, digitalis. — F. Delafield. Eest; light, easily assimilated diet; cardiac tonics and diuretics, especially infusion of digi- talis. — Anders. Urinary Fever. — Pain in back with chill, head- ache and fever following instrumentation; urine diminished; blood cells and casts in severe cases. Treatment. — Milk diet; abundance of water; urotropin 5 to 10 gr. t. i. d. BACKACHE 141 Renal Tuberculosis. — Slight continuous pain, often extending to bladder and urethra ; polyuria, sterile pus, tubercle bacilli. Treatment. — Nephrotomy and curettage if in early stage; nephrectomy for more extensive dis- ease; palliative treatment in advanced stage. — Am. Text-Book of Surgery. Renal Cancer. — Pain persistent, deep, dull, wearing or lancinating, radiating in all directions ; profuse hemorrhages and renal tumor. Treatment. — Early nephrectomy or palliative treatment. Renal Embolism. — Sudden, severe pain with hematuria; thrombosis or endocarditis. Treatment. — Mucilaginous drinks in abundance. Hydronephrosis. — Aching or tearing pain and fluctuating swelling of kidney. Treatment. — Gentle massage of tumor to dis- place obstruction; aspiration; incision, washing out, stitching edges of cyst wound to external in- cision and good drainage; nephrectomy. Blood Clots in Pelvis of Kidney. — Eenal colic like that from stone. Treatment. — Diluent drinks ; irrigation through ureteral catheter. Renal Cysts. — Moderate, deep, dull, persistent pain; fluctuating kidney. Treatment. — Frequent tapping; if this fails, 142 pain and rra indications incise and stitch edges of cyst wound to parietal incision. — Am. Text-Book of Surgery. Tight Capsule of Kidney. — Severe neuralgic pain, relieved by incision. Corset Pressure. — Chronic pain in kidney in young women taking violent physical exercise. Tabetic Renal Crises. — Pain like stone, but no blood or pus. Treatment. — Acetanilid 4 to 8 gr. every half hour for 2 doses, if necessary, then every 4 or 6 hours, if required. — Germain See. Reflex Renal Ache from Superacid Urine Irri- tating Bladder. — Pain not altered by movement; associated zone of hyperesthesia around groins. Treatment. — Potassium citrate or bicarbonate in large doses in large draughts of water. Reflex from vesical affections, ureteritis, lumbar abscess, scybala in colon, intestinal adhesions, aortic disease or aneurysm. Eefereed. — No local lesions; cutaneous ten- derness in painful area. Upper Dorsal. — Esophageal and gastric dis- orders, particularly ulcer : 5-8 D. Cancer of Breast or Mastitis. — Zone around lower breast, axilla and angle of scapula. Scapular. — Lithemia. — Eight shoulder usually. Cardiac and Aortic Disease. — Angle of left scapula. Pancreatic Cysts. — Left shoulder. BACKACHE 143 Kidney Disease. — Either side. Hepatic Disease. — Eight side, sometimes shoot- ing into neck and arms. Splenic Disorders. — Below tip of left scapula. Gastric Derangements, particularly Flatulence or Dilation. — Left shoulder tip. Wax in ear. — Distinct aching of shoulder. Lower Dorsal. — Esophageal Affections or Cancer at Cardiac Orifice. — Pain in either increased by passing bougie. Gastralgia. — Neuralgic spots at apparent origin of spinal nerves. Gall-Stones. — Maximum at 11 D., extending out to angle of scapula. Lumbosacral. — Ovarian Disease. — Commonly at crest of ilium and just below and to one side of navel. Corporeal Uterine Disease and Displacements. — Lumbosacral junction and umbilicus; pain most marked when rectouterine fold involved. Treatment. — Chronic Metritis. — Temporarily relieved by rubbing the region with a mixture of 1 part chloroform and 3 parts olive oil 4 times a day. — Garrigues. Cervical Uterine Disease. — Lower sacral pain, shooting into legs if lower part of cervix affected; upper sacral and inguinal if upper cervix in- volved. Retrouterine Hematocele. — History of sudden 144 PAIN AND ITS INDICATIONS abdominal pain at menstrual period or menor- rhagia followed by inflammation; tumor soft at first, becoming hard. First Stage of Labor Pains. — Periodic pains in upper sacrum and groins, then lower sacrum and coccyx; dilation of os. Salpingitis. — Pain at 5 L., 1 S. and in groin. Eetention of Urine. — Pain radiates from lower lumbar and sacral regions around to just above pubes, to perineum and down inner thigh. Chronic Constipation. — Lumbosacral and around forward. Gastroenteroptosis. — Often intense lumbago. Vesical and Prostatic Disease. — With painful and difficult micturition. Eectal Fissure, Ulcer, Hemorrhoids and Can- cer. — Dyschezia in all and local signs. Fecal Accumulations and Flatulence. Purgatives. — Pain in small of back and superior gluteal region, 4 to 6 hours after taking. Diarrhea, Dysentery and Choleras. — Nagging pain in back. Intestinal Catarrh and pain in back relieved by ichthyol in 5 to 10 grain doses night and morn- ing. — Freeland. Orchitis. — Pain at 12th rib. Epididymitis. — Pain at 5 L. and 1 S. Sexual Neurasthenia. — Sacral aching, formica- tion ; knee-jerk much diminished or absent. BACKACHE 145 Coccygeal and Anal ("Neuralgia of Rectum"). Hemorrhoids or Sear Tissue. Anal Fissure. — Much increased by defecation. Trigonal and Prostatic Disease. Displaced Uterus or Coccyx. Sitting on Cold Steps or Damp Grass. Strangulated Inguinal Hernia. — 10 D. area on same side. Dysmenorrhea. — Obstructive cervical pain only at menses; 11-12 D., 1 L. and .2-4 S. Ovarian pain intermenstrual (10 D.), spreading and increasing at flow. 146 PAIN AND ITS INDICATIONS CHAPTER VII. ABDOMINAL PAIN. Prediagnostic treatment of acute abdominal pain. — Enema of 1 oz. brandy or whisky in 3 oz. milk; encase each leg and the chest in hot blankets and place hot bottles along side. — Greig Smith. Colicky. — Paroxysmal, griping, obstructive, usually afebrile; often relieved by firm, steady, uniform pressure. Flatulent or Intestinal Colic. — Sudden, severe, griping, boring and twisting, usually most intense at navel, radiating into lumbar region or over sacrum; relieved by pressure or passage of flatus; tympanitic dyspnea, constipation, a great fuss — soon relieved by inhaling chloroform ; from errors in diet, cold feet, worms, impacted feces, enter- oliths, gastrointestinal catarrh, adhesions from chronic peritonitis, rachitis or anemia. Mistura rhei et sodae ^ to 1 dram in water every 2 or 3 hours till a thorough evacuation. — Louis Fischer. Oil of cajeput 3 drops on sugar as needed. Nursing Infants. — Diminish proteids in mother's milk (more water and exercise and sleep, less meat or excitement) ; give child £ to 2 oz. of sweetened gruel just before each nursing — or con- densed milk may be used. — Zahorsky. ABDOMINAL PAIN 147 Remove irritating substances with emetic, castor oil and copious injections; liquid diet; warm applications; gentle massage with warm oil. Infants. — Potassium bromid, chloral hydrate and sodium bicarbonate, \ gr. each in peppermint water as required. — J. W. McLane. E. Ext. zing. fl. m. iii; tinct, asafetidas m. i; aqua3 menth. pip., aquas cinnam. aa. m. xv; syr. simp. q. s. : A teaspoonful in water t. i. d. before meals. — Godfrey. Children. — Spt. chloroform 1 part to 4 parts comp. tinct. cardamom: Take m. xv-xx in \ oz. warm water every half hour till relieved. — A. A. Smith. Adults. — Milder forms relieved by a dram or two of paregoric with a few drops of essence of peppermint made into a toddy with a cup of hot sweetened water, followed by rhubarb and mag- nesia. — Lyman. Severe Intestinal. — Hypodermic of morphin and atropin; sometimes also •§ dr. chloral hydrate by mouth and thorough irrigation of colon with hot water; lay a large, hot linseed poultice, into which a dram of chloroform has been stirred, over entire abdomen; hot mint tea or hot camphor water as a beverage; 10 gr. calomel and 5 gr. sodium bicarbonate as soon as relief is obtained. — Lyman. Colic Due to "Cold." — Protracted bath in water U^ PAIN AND ITS INDICATIONS at 100°, followed by packing with warm, moist cloths to promote diaphoresis. — Roth. Crapulent Colic. — Equal parts of aromatic syrup rhubarb, comp. tinct. cardamom, camphor- ated tinct. opium and cinnamon water: Dose, 2 to 4 teaspoonfuls. — Hartshorne. Prevention. — Sodium phosphate 30 gr. in a glass of water t. i. d. preferably before meals; milk diet if obstipation; avoid tea, coffee and al- coholics. — W. W. Johnston. Constantly Recurring Colic of Children. — Dis- continue sugar till fermentation ceases; sweeten food with small saccharin tablets (one to pint) or glycerin (tcaspoonful to each feeding). — Louis Fischer. Local Paralysis of Inflammation. — Peristaltic activity of upper intestine and colicky pain. Treatment. — Liq. opii comp. 10 drops and tinct. belladonna 5 drops in a little hot water; instil into rectum and repeat until pain is relieved; after a rest of 3 or 4 hours give 6 gr. quin. sulph. in 2 dr. whisky and 2 oz. warm water by enema, and repeat if need be. — Skene. Hepatic Colic. — Sudden, irregularly recurrent attacks; focus of pain and tenderness at gall-blad- der, 3 finger-breadths to right and above navel, radiating toward back and right shoulder and down right arm, ceasing suddenly with passage of stone into bowel ; painful dorsal pressure-point ABDOMINAL PAIN 149 to right of spine; often jaundice, nausea, vomit- ing and pyrexia; may be peritoneal friction sound ; enlarged liver. Treatment. — Morphin and atropin hypoderm- ically; ether by inhalation. — Bartholow. Hot baths or applications; small doses of calomel after paroxysm; effervescent sodium phosphate daily before breakfast as a prophylactic. — Norbury. Tinct. gelsemium 5 drops every £ hour. — Ringer. Nitroglycerin m. 1-100 has given prompt relief. E. Olei terebinth, m. v; syr. acacise oz. ss; sodii sulphocarbolat. gr. xx ; spt. ether co m. xv ; aquam menth. pip. ad oz. i : To be taken twice or thrice daily; also apply hot poultices to hepatic area. — Therap. Gazette. Prompt surgical intervention when medical measures fail. Eectal injections of 2 quarts or more of warm water, to be retained about an hour, every two or three days; first clear out bowels with a pint or so of warm water. — Keay. Prevention. — Potassium iodid or sodium phos- phate, benzoate or salicylate (10 gr. 3 or 4 times a day for several months) ; surgical intervention may be needed. Renal Colic. — Pain radiates from loin down in- guinal region and genitals — may be reflected down thigh, up back and across abdomen, sometimes 150 PAIN AND ITS INDICATIONS with numbness; vesical tenesmus, bloody urine and calculus. Treatment. — Morphin hypodermically or mor- phin or opium internally or in suppositories; in- halations of ether or chloroform; locally hot poultices, hot fomentations, belladonna applica- tions or hot bath; rest in bed; warm diluent drinks such as barley water. — Taylor. Uric Acid Calculi. — E. Lithii benzoat. gr. v; tinct. belladonna m. iii ; extracti tritici repentis fl. q. s. : A teaspoonful every 2 or 3 hours. — Shoe- maker. Active exercise, vegetable diet with pigeons and fruit, much water, no alcoholic liquors, very little nitrogenous foods, cheese, gravies, etc. — Eoth. Phosphate and Carbonate Calculi. — Carbonated distilled water; vegetable acids, especially lactic. —Roth. Calcium Oxalate and Cystin. — General hygienic treatment; avoid all excesses; moderate exercise; abundance of water, hot or seltzer; acid phosphate of sodium as a solvent. — Eoth. Floating Kidney. — Constant, dragging pain in side or hypogastrium, with occasional severe colicky attacks with nausea and vomiting. Treatment. — Avoid corsets and imprudent ex- ercise and wear some supporting mechanical ap- pliance or an abdominal belt; nephrorrhaphy or nephrectomy in severe cases. — Eoberts. ABDOMINAL PAIN 151 Symptoms of Strangulation. — Complete rest; poultices and hot fomentations to loin and ab- domen. — Taylor. Pancreatic Colic. — Sudden, intense, diffuse, deep-seated, epigastric or umbilical pain, radiat- ing along lower left costal border to back ; may be vomiting, fever, ptyalism, glycosuria; frequently fat, lime calculi or much, undigested muscle fiber in stools. Treatment. — Opium or belladonna; ice-bag or leeches to epigastrium or leeches to anus. — Louis Starr. Lead Colic. — Pain usually sudden and per- sistent, twisting or sawing, radiating from navel; abdomen hard and retracted; obstinate constipa- tion, blue line on gums, wrist-drop. Treatment. — E. Pulv. opii gr. i; ext. bella- donna gr. 1-6; olei tiglii m. i: A pill every 2 hours till relieved. — Loomis. E. Magnes. sulph. dr. i ; acidi sulph. dil. m. viii ; aquam q. s. : A tablespoonful t. i. d. preceded by 10 gr. potassium iodid. — Brunton. E. Aluminis gr. xv; ac. sulph. arom. m. viii; syr. limonis m. xv ; aquam q. s. : A tablespoonful every hour or two. — Bartholow. Morphin hypodermically; warm water injec- tions well up into bowel; friction over abdomen with oil of nonnv and chloroform. — Eoth. 152 PAIN AND ITS INDICATIONS Fireman's Colic. — Severe pain in abdomen and headache; red ej'es; prostration. Treatment. — Put a grain each of phosphate of sodium, potassium and calcium to each ounce of drinking water. — Willis Cummings. Copper or Brass Colic. — Pain increased by pres- sure; diarrhea, abdominal distention; copper workmen; anemia, debility; green line at base of teeth. Treatment. — Eemove cause; small doses of potassium iodid; milk diet; abundance of drink- ing water ; codein, or morphin if pain very severe. Dilute phosjmorie acid 15 m. t. i. d. — Wm. Murray. Perforating Ulcers of Stomach and Duodenum. — Previous sjonptonis; sudden, violent epigastric pain; may be shock or vomiting; rigidity of ab- dominal muscles; local tenderness; tympany; im- mobile trunk. Treatment. — Little or no morphin; early ab- dominal incision and closing of perforation by bringing serous surfaces together with two rows of Lembert sutures, or if this is not possible cover perforation with omentum and separate region from rest of abdominal cavity by means of tampons; cleanse all infected parts of abdominal cavity, especially left subphrenic space ; drain with gauze or tubes all those places in which exudate and pus are likely to collect; no food whatever by ABDOMINAL PAIN 158 mouth for a week if operation not determined on. — Lennander. Acute Intussusception. — Pain sudden, severe, localized, gradually increasing, with shock, ob- stinate constipation and blood-stained mucous dis- charge; paroxysms of hours with intermissions — diffuse ileocecal or umbilical; pressure may diminish pain at first; erectile pseudo-tumor. Treatment. — Morphin hypodermically if re- quired; thorough irrigation of large bowel under pressure and kneading of bowel with patient in- verted; early celiotomy if these measures fail. — Hawkins. Cicatricial Obstruction. — Pain sudden, con- stant, agonizing, general, with focus at navel. Treatment. — Careful regulation of diet; opium and belladonna for paroxysmal pains; enema ta; surgical measures if obstruction becomes com- plete. — Osier. Acute Internal Strangulation of Bowels. — Eructations, nausea, vomiting (becomes fecal) ; feeling of constriction and griping umbilical pains, subsiding with gangrene; flatulence, tenes- mus, insuperable constipation (one or two stools may pass) ; peritonitis, gangrene. Treatment. — Early surgical intervention. Volvulus. — Steady pain, with periods of very acute exacerbations. Treatment. — Large enemas of water or oil un- 154 PAIN AND ITS INDICATIONS der hydrostatic pressure (fountain syringe several feet above patient) with patient in knee-chest posture; inflation of intestine with air by means of a long rectal tube and stomach pump; median laparotomy and untwisting of coils of gut. — Roberts. Inflamed or Incarcerated Descending Testicle. — Symptoms often very similar to acute obstruc- tion. Treatment. — Rest in bed; elevation of pelvis; moderate purgation; application of heat or cold; hypodermic injections; if suffering severe, incise and expose gland. — White and Martin. Irreducible Hernia. — May be griping abdominal pain. Treatment. — Try to render reducible, if recent, by rest in bed, saline laxatives and local applica- tion of ice ; protect and prevent increase in size by wearing a suitable bag-shaped truss or supporter; operation. — Roberts. Strangulated Hernia. — Tumor painful, tender, tense ; tympany if intestine in sac ; no impulse on coughing; pain usually referred to umbilical region (often ceases with gangrene) ; skin over gut may become dark; obstinate constipation and violent, gushing vomiting, finally of brownish-yel- low fluid with fecal odor. Treatment. — Avoid purgatives; gentle taxis for 2 to 5 minutes ; enemas, ice locally, moderate doses ABDOMINAL PAIN 155 of morphin ; ether locally, hot bath ; if taxis fails again in 3 or 4 hours, immediate operation is in- dicated. — Eoberts. Intestinal Worms. — Localized colicky cramps or heavy boring pains, often relieved by milk. Treatment — Thread Worms. — Infusion of quas- sia (tablespoonful to a pint) with salt brine (tea- spoonful to pint) — \ pint by enema 2 or 3 times a day for several days. — Beale. Santonin gr. f and calomel gr. \ before break- fast for 3 days, together with intraanal applica- tion every evening of a little ointment of mercury in twice as much glycerite of starch. — Comby. Eound Worm. — Santonin | to 2 gr. with calomel % to 2 gr. at bedtime followed, by dose of castor oil before breakfast. — Hughes. Round and Thread Worms. — One dram each of fluid ext. spigelia and of senna with 1 gr. santonin at a dose. — J. Lewis Smith. Whip Worm. — Laxatives with anthelmintics; intestinal irrigations. — Roth. Tape Worm. — Fast 24 to 48 hours with open bowels; then take pelletierin tannate gr. v-xx in capsule, followed in 15 minutes by dose of castor oil. — Shoemaker. R. Ext. filieis maris eth. dr. iiss. ; hydrarg. chlor. mitis gr. xv: M. et divide in eapsulas No. xx : Dose 12 to 16 capsules. — Crequy. R. Oleores. aspidii dr. ii; chloroformi dr. ii; 150 PAIN AND ITS INDICATIONS olei tiglii m. iv; glycerini oz. ii: Take half at 8 a. m.j, the rest in an hour if needed. — Dock. Appendicitis. — Appendicular colic; unilateral muscular rigidity. Treatment. — Saline purgatives (unless tender- ness) followed by opium after bowels move. — J. C. Da Costa. Persistent use of ice locally and but little opium, until operation. — Osier. Fecal Impaction. — History of chronic constipa- tion; palpable doughy mass. Treatment. — Saline cathartics; large, frequent- ly repeated high enemata (preferably oily or mucilaginous) by Hegar's method. Ruptured Tubal Pregnancy. — Sudden, intense, right or left iliac pain with vomiting, sweating, collapse and signs of internal hemorrhage; colicky pain about navel in tubal abortion. Treatment. — Ice-bag over lower abdomen and abdominal section as soon as practicable if hemor- rhage serious; if extravasation into broad liga- ment, keep ice-bag on lower abdomen for 48 hours with patient as immobile as possible, then lie in bed about 2 weeks longer. — Byford. Chronic Arsenical Poisoning. — Colicky or dys- peptic pains; edema of lower lids; neuritis and paralyses. Treatment. — Sulphur waters; potassium iodid cautiously ; ammonium chlorid as a specific ; vapor ABDOMINAL PAIN 157 baths; tonics, especially iron and quinin. — Both. Ruptured Spleen. — Intense local pain and col- lapse following severe trauma. Pancreatic Hemorrhage. — Sudden, severe epi- gastric pain with collapse. Treatment. — Heat externally ; warm saline solu- tion by injection; hypodermics of morphin, at- ropin and strychnin and diffusible stimulants. — Anders. Rupture of Heart. — Epigastric pain and in pre- cordium. Reflex Colic. — From uterine, ovarian, renal or vesical disease. Treatment. — Valerianate of zinc 1 gr. 3 or 4 times a day in neuralgia from reflex irritation of female pelvic organs. — W. W. Johnston. Gouty Colic. — With other lithemic symptoms. Treatment. — Colchicum. Rheumatic Colic. — Arthritic diathesis; pain often very severe. Treatment. — Potassium iodid, mercury and salicylates. Malarial Colic. — More or less periodic. Treatment. — Quinin and arsenic. Periodic Infantile. — Quinin in ^ gr. dose rubbed up with sugar of milk, given an hour before anticipated attack and repeated at its beginning or a little before for 3 or 4 days. — Lancet- Clinic. Hysteric Colic. — With cutaneous hyperesthesia. 158 PAIN AND ITS INDICATIONS Treatment. — Compound spirit of ether; rub spine with stimulating or anodyne liniments. — W. W. Johnston. Angioneurotic Edema. — Locally limited trans- parent edematous swellings. Treatment — Anemic Cases. — E. Strych. sulph. gr. 1-20; quin. sulph. gr. ii; masses ferri carb. gr. i : One pill after meals. — Thornton. Henoch's Purpura. — Multiform erythema; pain, vomiting, diarrhea; joint pains or swelling; often trifling hemorrhages from mucous membranes; relapsive and recurrent; chiefly in children. Treatment. — Iron ; arsenic in rapidly ascending doses; salicylates; good food, including vegetable juices. — Tyson. Epidemic Dry or Bilious Colic. — Intertropical countries; pain mostly in epigastrium and colon, aggravated by movement, often relieved by pres- sure; at first dark, offensive diarrhea, later con- stipation; abdominal distention or retraction; severe nervous symptoms; sometimes due to lead. Treatment. — Emetics, purgatives and an- odynes ; change of climate often necessary to com- plete cure. — W. W. Johnston. Colicky pain shortly after eating. Treatment. — Small doses of liquor potassii arsenitis before meals. — Philip F. Barbour. Cramps with diarrhea. Treatment. — Equal parts of tinct. opium, spt. ABDOMINAL PAIN 159 chloroform, tinct. capsicum, and aromatic spt. ammonia. 20 to 40 drops every \ hour or hour. — Shoemaker. Membranous Enteritis, Enterocolitis, Cholera Morbus or Infantum and Dysentery. — See below under inflammatory pain. Raynaud's Disease. — Local syncope, asphyxia and gangrene of fingers or toes. NEURALGIC. Pain intermittent, shooting, burning, cutting, like neuralgia elsewhere; no relation to food as a rule; often cutaneous tenderness. Nervous Gastralgia. — Pain sudden, severe, gnawing, drawing, burning, cutting, boring, dif- fuse or localized, radiating from epigastrium to lower ribs or over spine of ilium; increased by drinking cold water ; slight if any relation to food ; often relieved by firm, steady pressure or food; puncta dolorosa over intestinal plexi; frequently nocturnal, irregularly recurrent, lasting a few minutes to hours or days; usually in young adults, from anemia, hysteria, uterine or ovarian dis- orders, sexual excesses, leucorrhea, masturbation, or chronic coffee poisoning. Treatment. — Oxid of silver in form relieved by food; subcarbonate of bismuth and saccharated carbonate of iron before food for anemia ; a grain of cocain to relieve attack. — Gowers. Arsenic curative, gr. 1-24 in pill form with 2 lfiO PAIN AND ITS INDICATIONS or 3 gr. gentian t. i. d. half way between meals. — Sir Jas. Sawyer. Pyramidon 5 to 10 gr. in powder as required. — Hirschborn. Heat by means of poultices or hot drinks; car- bolic acid, chloroform water, cocain; oil of pep- permint;, a tropin, aconite, etc. — Benedict. E. Codein phosphat. gr. ^; bis. subnit. gr. v; sacchari lactis gr. iii ; one powder every 2 hours. — Ewald. E. Morph. hydrochlor. gr. 1-12 to £; cocainae hydrochlor. gr. 1-9 to 1-5; tinct. belladonna m. ii; aquas amyg. arnarse m. x : Take every hour. — Ewald. E. Liq. chloroformi aq. sat. dr. ss. ; tinct. anisi stell. m. iv; aq. aurantii nor. q. s. : A teaspoon- ful every £ hour. — Dujardin-Beaumetz. Treat hysteria if this the cause; if chlorosis or anemia the cause, use mercuric chlorid in combina- tion with tincture of iron or peptomangan (Gude) ; when of dyspeptic origin use combina- tion of sodium bromid, charcoal, and pepsin, with rest, diversions and regulation of habits of eat- ing; for gouty gastralgia salicylate of colchicin, Buffalo lithia water and cascara; Weir Mitchell rest-cure for neurasthenic cases; if due to sexual excesses use a combination of nux vomica, Indian hemp or ergotin, or give phosphorus in 1-100 gr. pills; in true or ''idiopathic" gastralgia try ABDOMINAL PAIN 161 morphin and atropin hypodermically or 10 to 20 m. co. spt. ether — also inhalations of 2 or 3 drops of amyl nitrite or 1-100 gr. fresh tablet nitrogly- cerin when pallor of face. — Landon B. Edwards. Neuralgia of Intestinal or Mesenteric Plexi. — Frequent recurrence with extreme prostration; nausea, eructations, ravenous appetite; often his- tory of malaria or lithemia; readily relieved by antineuralgic treatment, especially arsenic. Treatment. — Static electricity with sparks 2 inches long for 20 minutes daily, or electric spray over abdomen. — Eanney. Lumbo- Abdominal Neuralgia. — Three painful points of Valleix near spine, at side and in front ; pain radiates to anus and genitals; similar pain often present in other parts of body. Treatment. — Freeze corresponding spinous processes with rhigolene spray. — Albert Abrams. Lesions of Vagus Nucleus. — Gastric crises like those of tabes. See just below. Locomotor Ataxia. — Girdle sensation; severe, sudden, darting, tearing, rending gastric crises; lightning-like pains radiating from shoulder to buttocks; nausea, vomiting, vertigo. Treatment. — Slight gastric crises relieved by simultaneous sinapisms to epigastrium and neck. Antipyrin, acetanilid, cannabis indica ; morphin or cocain hypodermically ; prolonged use of nitro- 162 PAIN AND ITS INDICATIONS glycerin in increasing doses until physiologic ef- fects. — Osier. Nervous Enteralgia. — Pains boring, tearing, cutting, doubling-up, circumscribed or diffuse and shifting; not aggravated by pressure; may last several days; eructations of odorless gas and ex- pulsion of flatus and bowel irregularities; from hysteria, neurasthenia, disseminated sclerosis, chronic spinal meningitis, anemia, pelvic irrita- tion, nervous shock, cold or gout. Treatment. — Vague neuralgia of elderly arthrit- ic subjects when fatigued, promptly relieved by eating a little dry bread or by drinking a cup of hot broth or milk and lying down for a short time. — Lyman. Treatment in general like that for gastralgia. Cardialgia. — Scalding, sore, neuralgic epigastric pain with pyrosis; common at menstrual periods, during latter part of pregnancy and in gouty and hypochondriacal subjects — also from abuse of tobacco. Treatment. — Bismuth subnitrate gr. v and potassium cyanid gr. £ in pill after each meal. — Benj. Lee. Hyperchlorhydria and Gastrosuccorrhea. — Ir- regular epigastric pain relieved by antacids, eggs, meat or milk; water-brash and heart-burn. Treatment. — Drink a glassful of cold water. — A. L. Benedict. ABDOMINAL PAIN 163 See also under dyspeptic pain below. Abdominal Malarial Neuralgia. — Pain may be quite severe and variously localized; periodic fever and chilling., nausea, vomiting and enlarged spleen ; no plasmodia in post-infective ; large doses of quinin cure. Anemia — Debility and Overwork. — "Stitch in side" in region of spleen. Treatment. — Chiefly etiologic. Antipyrin gr. ii in a tablespoonful of water of chloroform every hour till relieved in neuralgia of stomach. — Thornton. Psychoses. — Prodromal gastralgia. Hysteria. — Pain usually in right or left lower half of abdomen; hysteria often latent; hyperes- thetic zones in abdomen; anesthetic and analgesic areas of conjunctiva and pharynx; pains much ag- gravated by psychical excitement; dysmenorrhea and constipation. Treatment. — Suggestion; constant current (0 to 5 m. a.) with anode over hyperesthetic zones; Blaud's pill for 4 months, and after an interval as long again; valerian, asafetida; divert attention from self. — Eichard Lomer. Hepatalgia. — Neuralgic pain in region of liver ; neurosis of pale and delicate women. Treatment. — Eemoval of cause (anemia, hys- teria) ; general tonic treatment (strychnin) ; abundance of rest; sedatives (bromids). — Gowera. 164 PAIN AND ITS INDICATIONS Zoster. — Severe neuralgic pains and vesicular eruption along course of intercostal nerves. Treatment. — Sodium salicylate 60 to 90 gr. daily. — Frank Mracek. Excessive Pain. — Paint t. i. d. with morphin in collodion, a grain or two per ounce; or with a solution of 15 gr. acetanilid per ounce of ether. — Cantrell. Myelitis. — Girdle pain and bilateral, flaccid loss of motor power. Treatment. — Antikamnia, acetanilid, phenace- tin, antipyrin ; ice-bags or leeches to spine ; ergot ; mercurial ointment, blisters, iodin or actual cautery. Paroxysmal recurrence often prevented by course of aluminic chlorid 3 gr. t. i. d. ; local use of ether spray, chloroform or menthol often re- lieves; galvanism and potassium iodid may give marked improvement — the latter particularly when a syphilitic history. — Gould and Pyle's Cyclopedia. Spinal Tubercular Caries. — Symmetric bilateral neuralgic pains with epigastric or umbilical par- oxysms. Treatment. — Perfect rest in supine posture on hard mattress; leeches, blisters or hot iron may do good; take patient in bed out of doors every day if possible. — J. C. DaCosta. ABDOMINAL PAIN 16. r ) Spinal Tumors. — Severe girdle pain. Treatment. — Operative intervention in non- malignant; opium for malignant and generalized. Aneurysm of Abdominal Aorta or Celiac Axis, — Kachialgia and epigastric or umbilical par- oxysms; pulsating pseudo-tumor with thrill. Treatment. — Opium for pain; lactucarium to quiet ; comp. jalap powder at intervals, recumbent posture; restriction of diet to 10 oz. solids and 6 oz. liquids in 24 hours. — Tufnell. Old Peritonitic Adhesions. — History of past in- flammation. Treatment. — Abdominal or vaginal section; break up adhesions with fingers and dust with aristol. — Hawkins. Chronic Mercurial Poisoning. — Grastrodynia, tremor and ptyalism. Treatment. — Diuretics and diaphoretics; small doses of potassium iodid; vapor or sulphur baths; pure, fresh air; easily digested, nourishing food. — Both. Morphin Habit. — Often severe gastralgia when not under influence of drug. Treatment. — Strong wine ; may need to give oc- casional injection of morphin. Pains of Morphinism. — Spray of 1 part men- thol, 10 parts chloroform, and 15 parts ether; phenacetin or phenalgin in full doses. — Mat- tison. 106 PAIN AND ITS INDICATIONS Uremia. — Severe epigastric or hypochondriac crises often precursory of grave symptoms. Treatment. — Vapor or hot air bath or hot water pack to secure free perspiration; elaterin to pro- duce watery stools; ice-bag to head. Diabetes. — Severe epigastric pains (sometimes with vomiting) and constipation preceding onset of coma. Reflex Causes. — Acute proctitis; violent epigas- tric pain. Pelvic Disease or Tumors. — Right or left iliac pain. Corporeal Uterine Disease. — Reflex pain at um- bilicus. Left-sided Laceration of Cervix and Left Ovarian Disease. — Pain in splenic region. Genitourinary Disorders. — Reflex epigastric pain from orchitis, cystocele, prostatitis, or irrita- tion of bladder, especially in children. Renal Affections. — Pain sometimes seated deep to right or left of spine below navel. Ovarian Cysts. — Intermenstrual neuralgia.' Fecal accumulations ; peripheral pain in groins. Pleuritis, pneumonia, appendicitis. Dyspeptic. — Definite relation to food, with disturbance of function and malassimilation ; nausea, vomiting, flatulence, diarrhea, anorexia, pyrosis, foul breath, coated tongue ; usually little or no fever. ABDOMINAL PAIN 167 Simple Indigestion. — Epigastric pain and ful- ness from overeating or too hasty eating or too rich food. Treatment. — E. Acidi hydrochlor. dil. m. xv-xx ; syr. limonis, syr. aurantii aa. dr. ss. ; spt. chloro- formi (aut tinct. zing.) m.x: Take in 1£ oz. water half an hour before meals. — Beale. Irritable Stomach of Children from Improper Feeding: E. Bis. subnit. gr. iii; sodii bicarb., pulv. rhei aa. gr. i. : One powder every 4 hours. — Shoemaker. Acute Gastritis. — Diffuse epigastric fulness and tenderness in catarrhal, sometimes with moderate fever and sickness; intense spontaneous pain from mouth to stomach in irritant or corrosive poisoning. Treatment. — Calomel 1-6 gr. and sodium bicar- bonate 3 gr. every 2 or 3 hours. — Shoemaker. If vomiting has not occurred empty stomach by means of warm salt water and tickling throat, or apomorphin or ipecac and tartar emetic; brause- pulver (10 parts sodium bicarbonate, 9 tartaric acid and 19 white sugar) or effervescing citrate of magnesia or seidlitz powder; fast for 24 to 72 hours. Sodium iodid gr. xv-xx t.i.d. — Bartholow. Of Infants. — Sodium bicarbonate gr. iii in \ oz. of cream and milk every hour; or calomel gr. 1-10 to \. — Delafield. 168 PAIN AND ITS INDICATIONS Warm poultice of linseed meal with or without mustard over epigastrium. — Blackader. Chronic Gastritis. — Slight soreness; lancinat- ing digestive pains in atrophic form. Treatment. — R. Sodii iodidi, sodii bromidi aa. gr. viii ; sodii arsenat. gr. 1-30 ; aquae q. s. : A teaspoonful in water t.i.d. — Bartholow. R. Bismuthi subnit. gr.x; argenti nitratis gr. i-ii : Take before breakfast. — Niemeyer. Severe Cases. — Opium or belladonna in small doses after meals, or cocain in 1-6 gr. dose; bel- ladonna plaster over stomach. — Hughes. Alcoholic. — R. Tinct. belladonna? m. i. ; tinet. nucis vom. m.iiss. ; tinct. dioscoreae villos. m.x ; syr. zing.q.s. : A teaspoonful in water every fourth hour. — Shoemaker. Children. — Flannel abdominal binder; keep feet and ankles always dry and warm ; cascara at bedtime; small doses of opium or bromid with chloral twice a day ; large enemas of warm water ; cold brine affusions and rubbing; systematic die- tary; careful mastication of food. — A. D. Black- ader. Gastric Ulcer. — Intense, sharply circumscribed, burning, boring epigastric pain soon after eating — increased by movement or pressure; painful spot one inch to left of 10th to 12th dorsal verte- brae — may be only pain in back or "stitch in side." ABDOMINAL PAIN 169 Treatment. — Avoid spiced foods and alcoholic drinks. Exclusive milk diet; enough sodium bicar- bonate (5 to 10 dr. a day) to neutralize acid, taken hourly in small doses with chalk and mag- nesium carbonate. — Debove and Gouvin. Eest in bed; no food by mouth for three days — a nutritive enema t. i. d. — then begin feeding by mouth, at first with small quantity of milk and flour soups, then leguminous soups, then legu- minous vegetables and potatoes as a puree, adding later a little meat-broth; restrict amount of diet till third week; then give iron, 1 dr. of 2 or 3 per cent solution of chlorid t. i. d. in a wineglass of egg-water — also 1-30 gr. arsenous acid and 1-3 gr. ferric chlorid after meals. — Ewald. Potassium dichromate 1-16 to 1-12 gr. every 6 hours well diluted. — T. McHardy. Tincture of iodin m.x. t. i. d. in water. — Mur- rell. Ice-bags or Leiter's coil; large doses of bis- muth, 2-| to 4 dr. suspended in water; morphin or -J oz. sol. of chloroform (1:20) every 2 hours for severe gastralgia. — Ewald. Chlorid of gold and sodium 1-20 gr. t. i. d., par- ticularly when tongue red and glazed, epigastric pain and relaxed bowels after eating. — Bartholow. Hemorrhagic Erosions of Stomach. — Moderate distress, gnawing and burning after eating; sub- 170 PAIN AND ITS INDICATIONS acidity and fragments of gastric mucosa in wash- water ; emaciation. Treatment. — Same as for gastric ulcer. Gastric lavage with 1 :1000 or 1 :2000 silver nitrate fol- lowed by neutralization with decinormal salt solu- tion. — Pariser. Nervous Dyspepsia. — Epigastric fulness and eructation of odorless gases shortly after meals; slight, intermittent gastralgia usually relieved by food, but much increased by condiments and irri- tants. Treatment. — Gastric sedatives (bismuth or cerium) £ or 1 hour before meals in mucilage of acacia or cherry laurel water; when appetite is fair give pepsin, charcoal and bromid an hour after meals; calomel and sodium phosphate an hour before meals for imperfect secretion. — Skene. Gastrointestinal Myasthenia. — Prolonged gas- tric fulness and heaviness soon after eating — fluids as distressing as solids. Treatment. — E. Sodii bicarb, gr. v. ; tinct. nucis vom. m.v. ; tinct. capsici m.iiss. ; cascarae cord. q.s. : A teaspoonful before or after meals. — Stewart. Hyperesthesia Gastrica. — Pain excited by con- tact of any food and subsides with evacuation of stomach; often hysterical stigmata. Treatment. — E. Morphinae hydrochlor. gr. 1-15 to 1-10; cocainae hydrochlor. gr. 1-8 to 1-4; tinct. ABDOMINAL PAIN 171 belladonnae m.iii-vi; aq. amyg. arom. q.s. : Ten to 15 drops every hour. — Ewald. Ilypoclilorhydria. — Feeling of weight, fullness and distress with eructations soon after meals; fermentation diarrhea common; indicanuria. Treatment. — Stimulation diet (koumiss, well seasoned meats finely minced, vegetables passed through sieve, hard bread, toast, crackers and moderate amount of fats) ; avoid sugar and alcohol; give strychnin and other vegetable bit- ters and hydrochloric acid — also guaiacol and creasote if gastric fermentation. — Alfred W. Perr} r . Hyperclilorhydria. — Disappears after eating proteids or taking alkalies, gradually returning in 2 or 3 hours ; not relieved by pressure. Treatment — Sedative diet (-J to 1 pint of warm milk at beginning of each meal; fish and meat finely divided; only enough starchy food to pre- serve nutrition) ; avoid potatoes, spices, condi- ments and salty foods; bismuth salts 20-40 gr. a few minutes before meals; sodium bicarbonate 10 gr. four or five times after meals at ten- minute intervals for hyperacid pain; sodium sulphate 40-60 gr. an hour before a meal; pepsin useless — iron and strychnin harmful. — Alfred W. Perry. Gastrosuccorrhea. — Symptoms similar to hyper- clilorhydria; excessive secretion of gastric juice. 172 PAIN AND ITS INDICATIONS Treatment. — Give stomach rest, feeding by rectum j interdict salt; use only distilled water; 1 Kit -air baths to remove salines through sweat- ducts; tonics and hygienic measures for over- wrought nervous system. — Benedict. Achylia Gastrica. — Pain only while food is in stomach; absence of normal secretion. Treatment. — Chopped meat and other stimu- lating diet; strychnin; dilute hydrochloric acid, 20 drops in a glass of water (through glass tube) just after eating, repeated in a half hour and again in an hour. — Hemmeter. Pyloric Stenosis and Gastric Dilatation. — Dif- fused epigastric weight, pressure, fulness, burning, soreness; vomiting at intervals of large quanti- ties of fermented food. Treatment. — Light nutritious diet in small quantities at frequent intervals; lavage two or three times weekly ; treat catarrh and apply mas- sage and electricity ; tonics, especially strychnin ; abdominal support ; dilatation of pylorus or estab- lishment of gastro-duodenal fistula for fibroid thickening and cicatricial thickening. — Stevens. Gastroptosis. — Burning or shooting epigastric pains after eating; also dyspeptic symptoms in- dependent of food; physical examination shows stomach as a whole lower than normal. Treatment. — Dress reform; well fitted abdom- ABDOMINAL PAIN 173 inal belt; diet, massage and exercise of trunk muscles for constipation. — Boardman Eeed. Perigastric Adhesions. — Pain produced by over- loading stomach or inflation. Intestinal Indigestion. — Paroxysmal griping or heavy, dull distress; spreads from navel, much increased by pressure, 2 to 4 hours after eating; flatulence, borborygmi, lienteric diarrhea ; may be sharp fever. Treatment. — Benzonaphtol and bismuth salicy- late 1£ gr. each to a child of 6 months for intesti- nal fermentation. — S. Solis-Cohen. If acute prohibit carbohydrates for 4 or 5 days ; for chronic administer taka-diastase, 3 to 5 gr. just after meals, and restrict amount of carbohy- drates. — Christopher. Enterocolitis. — Griping pain 2 to 4 hours after taking food and before stools; mucoid diarrhea and tympanites. Treatment. — Mild counterirritation by turpen- tine stupes or mustard or thin flaxseed poultice. —Holt. See below under inflammatory. Pancreatic Cancer — Severe, deep-seated epigas- tric or upper umbilical pain, with persistent in- testinal dyspepsia and oily stools. Treatment. — Opium or operation. Intestinal Carcinoma. — Sharp, radiating, col- icky umbilical pains a few hours after eating; pal- pable tumor. 174 PAIN AND ITS INDICATIONS Treatment. — Surgical measures; coal tar deriv- atives and opium. Chronic Valvular Disease. — Obstinate subacute gastritis and gaseous distention of stomach and bowels. Treatment. — Mild laxatives; carminatives with salol or creosote; opium as last resort. — Anders. Idiosyncrasies. — Most common with mussels and strawberries; often skin eruption. Inflammatoey. — More or less continuous pain increased by movement, with tenderness (not cutaneous) on pressure, thirst and fever (unless shock or profound sepsis) ; vomiting and diarrhea or constipation; hvperleucocytosis if suppura- tion. Acute Peritonitis. — Pain intense, diffuse or localized, much increased by pressure — may be absent in septic form; painful retching and vom- iting and usually constipation; high fever, chill, wiry pulse. Treatment. — Hot linseed poultices, or flannels wrung out of hot water and sprinkled with tur- pentine, or liniment of belladonna, or ice com- presses. — Taylor. R. Olei terebinth., olei olivse aa. oz. ii; massae hydrarg. oz. ii. : Apply warm with flannel over abdomen. — Shoemaker. Perforation. — Large doses of opium in supposi- tories or enemas, with ice-cold applications to ab- ABDOMINAL PAIN 175 domen; prevent gagging and choking. — Ewald. Diffuse septic peritonitis. — Cleanse focus of in- fection with hydrogen peroxid; flush abdominal cavity thoroughly with normal saline solution; elevate head and trunk; drain pelvis. — Fowler. Acute Appendicitis. — Colicky, radiating pain becoming fixed in right iliac fossa; localized ten- derness at McBurney's point, right-sided muscular rigidity and perhaps tumor; early moderate fever, comparatively frequent pulse. Treatment. — Ice externally; opium to make patient comfortable until operation. — Mynter. Apply leeches if symptoms urgent; warm cat- aplasms and opium. — John Ashhurst, Jr. Subdue peristalsis with a firm, snug abdominal binder over a layer of cotton batting, with a sheet of oil silk next to skin; repeated colon lavage (111 F.) ; sometimes calomel and salines; hot and cold applications ; no food for a week or more. — Love. Acute Salpingitis. — Pain radiates to thigh and is less circumscribed than in appendicitis ; usually ameliorates by 3d or 4th day. Treatment. — Absolute rest in bed; fluid diet; ice-bag on lower abdomen; opium suppositories; hot vaginal douches and hot rectal injections; if case serious and inflammation unmistakably puru- lent, appendages shculd be removed at once. — Grarrigues. 17G PAIN AND ITS INDICATIONS Typhlitis Stercoralis. — Dragging pain in right iliac region, with doughy, sausage-shaped tumor. Treatment. — Saline purgatives, particularly magnesium sulphate; large colon irrigations. Typhoid Fever. — Active pain from perforation, (sudden, severe, paroxysmal with quickened pulse, tender, distended abdomen and rising leucocytosis), hemorrhage, phlebitis and unknown causes. Chronic Appendicitis. — Recurrent, subacute tearing iliac pain after walking or long standing; local tenderness. Treatment. — Operation in the interval. Podophyllin 1-10 gr. 2 or 3 times a day. — Mynter. Simple Chronic Peritonitis. — Pain shifting and usually slight till late; some tenderness; alter- nate diarrhea and constipation ; fluctuation and fever after effusion ; late emaciation. Treatment. — Hot opium fomentations, bella- donna inunctions, blisters, iodin ointment, yellow oxid of mercury ointment (20 gr. per ounce), best of hygiene; flannel bandage; rest; bland but nutritious diet. — J. Henry Fruitnight. Chronic Tubercular Peritonitis. — Process may be latent or sudden and violent ; usually irregular fever, sacculated exudations and gastro-intestinal disturbances ; search for tubercular signs in lungs, pleura?, fallopian tube, testis and elsewhere. ABDOMINAL PAIN 177 Treatment. — Abdominal section and irrigation; ichthyol ointment; non- flatulent diet; counter- irritation with equal parts of belladonna and iodin ointment. — Anders. Dysentery. — Severe grinding tormina in lower colon; straining, frequent, mucopurulent, bloody stools. Treatment. — Hope's Camphor Mixture: E. Acidi nitrici dr. ss. ; tinct. opii m.xx ; aquae cam- phorse oz. iv. : One to 4 teaspoonfuls every hour or two according to symptoms. Acute of Nursing Infants. — Greatest regularity in nursing; a little magnesia or sodium bicar- bonate with oil-sugar of fennel — a bottle before each nursing. — Roth. Intestinal Catarrh. — Often diffuse, dull pain and tenderness; diarrhea or constipation; whole hand laid on and passed over abdomen. Treatment. — Tincture of rhubarb \ dr. 1 to 3 times a day when mucoid or watery stools alter- nating with normal movements. — Roth. Chronic Infantile Intestinal Disorders. — Anti- septic douches of 1 or 2 quarts of water at 100° containing | oz. boric acid to each quart, or 30 m. creolin, or 10 gr. sodium salicylate, or thymol 1 :2000 or mercuric chlorid 1 :10000 — use No. 11 or 12 soft rubber catheter. — E. P. Davis. Chronic Intestinal Catarrh. — Cold water irri- gations, containing small doses of astringent 178 PAIN AND ITS INDICATIONS (zinc sulphate, alum or lead acetate gr. 1 to 4 or 6 oz. of water). — W. W. Johnston. Acute Enterocolitis. — (Follicular Enteritis) : Griping, colicky pains in colon; mucoid diarrhea and tympanites; "summer complaint" of in- fants. Treatment. — Eesorcin \ to £ gr. every 2 hours, combined or not with bismuth, chalk or opium. — Jacobi. Membranous Enteritis. — Paroxysms of severe pain and discharge of gray, translucent, mucoid pseudo-membranous casts; a neurosis. Treatment. — Light food at frequent intervals in small quantities; rest in bed; warm poultices; enema of a quart of warm water containing a tea- spoonful of common salt or essence of pepper- mint, followed by codein or opium and perhaps belladonna. — Einhorn. Small doses of castor oil in emulsion with salol several times a day. — Hawkins. Cholera Infantum. — Colicky pains at first; profuse, watery, explosive stools, excessive vomit- ing and rapid collapse. Treatment. — Enema containing 2 or 3 drops of laudanum every 3 hours. — Goodhart. Morphin hypodermics cautiously. Chloral hydrate 3 to 5 gr. in a half ounce of starch water thrown into bowel every 2 or 3 hours. — Shoemaker. ABDOMINAL PAIN 179 Cholera Morbus. — Severe, paroxysmal, doub- ling-up, griping pains in abdomen and cramps in calves; serous diarrhea and troublesome vomit- ing. Treatment. — E. Acidi carbol. gr. 1-5 ; glycerini m. viii; tinct. opii camph. m. xxiv; aq. cinnam. q.s. : A teaspoonful immediately after each par- oxysm of vomiting until these cease; small, fre- quent doses of calomel; mustard sinapisms over epigastrium and spine. — 1ST. S. Davis. E. Tinct. camph., tinct. opii, tinct. capsici aa. m. xvii; olei caryoph. m. 1-6; syr. rhei (spiced), q.s.: A teaspoonful every 15 to 30 minutes; add 2 to 4 drops of chlorodyne if pain very acute ; cal- omel gr. 1-15 on tongue every 5 minutes for vom- iting. — Jno. Eisner. Asiatic Cholera. — Premonitory colic for a day or two; very painful cramps in legs and feet; profuse, frequent, rice-water evacuations, rapid emaciation and collapse; epidemic. Treatment. — Eest in bed ; Priessnitz compresses on abdomen ; diet of barley water and red wine or brandy; a teaspoonful of laudanum in 10 dr. comp. tinct. cinchona several times a day if stools increase in number; 3 drops every 2 or 3 hours of strong hydrochloric acid; in cold stage wrap in warm blankets and surround with hot bottles and poultices on abdomen, with 10 to 20 drops of laudanum every 1 to 3 hours. — Eoth. 180 PAIN AND ITS INDICATIONS Gastric and Intestinal Irritation of Infants. — Hydrargyrum cum creta repeated at intervals until stools are altered — 1-6 gr. every 4 hours till 1 gr. has been taken for children under 2 years — between 2 and 12 years 3 to 5 grains may be given as a single dose when required. — Garrod. Intestinal Ulceration. — Localized burning pain and often tenesmus; pus, blood and shreds of tissue in stool-:; duodenal ulcer simulates ulcer of stomach. Treatment. — Applications of hot water; cata- plasms; injections of hot water; morphin with or without belladonna if necessary. — Jas. T. Whit- taker. Acute Pancreatitis. — Intense, deep-seated epi- gastric pain and tenderness, persisting in spite of careful feeding. Treatment. — Absolute rest; milk, lime water and meat broths in small quantities; ice or leeches to epigastrium or leeches to anus; free use of opium; iced carbonic water for vomiting; stimu- lants and heat to extremities for collapse; light linseed poultices later. — Louis Starr. Cholangitis. — Dull, heavy feeling of distention and sometimes darting pains over hepatic area ; jaundice, choluria; drab, fetid stools. Treatment. — A few leeches over painful area ; operation for stone. Children — Liquor potassii cit. m. xx-xl and ABDOMINAL PAIN 181 tinct. opii camph. m. x-xx every 2 or 3 hours. — Musser. Perihepatitis. — Sudden, acute pain in right hy- pochondrium, increased by pressure or movement; may be peritoneal rub. Treatment. — Local abstraction of blood by leeches; tight bandage around body at level of hypochondrium (may include turpentine stupe or water compress) ; morphin hypodermically. — Bartholow. Subphrenic Abscess. — Early, deep, tearing, cir- cumscribed pain in epigastrium or right hypo- chondrium, increased by deep breathing or cough- ing ; usually follows perforating gastric ulcer. Treatment. — Incision along costal arch, to- gether in some cases with resection of ribs below lower limit of pleura; transpleural evacuation if empyema exists or pleural cavity obliterated. — Lennander. Hepatitis and Hepatic Abscess. — Sharp, lanci- nating, paroxysmal pain or constant dull aching in right hypochondrium ; smooth, tender enlarge- ment of liver; intermittent fever, chills and sweats. Treatment. — Repeated aspiration or laparotomy followed by drainage and suturing edges of open- ing of abscess to abdominal incision. — Am. Text- Book' of Surgery. Hepatic Cirrhosis. — Dull pain in hepatic region 182 TAIN AND ITS INDICATIONS radiating to right shoulder; morning nausea and vomiting, hematemesis, ascites; surface of liver becomes hard, rough and granular. Treatment. — In early stage Carlsbad water (Kissingen in debilitated); also iodin waters; nitric acid; iodin or iodid of iron for syphilitics. —Roth. Suppurative Pylephlebitis. — Severe, burning he- patic pain ; rapid ascites and splenic enlargement. Treatment. — Morphin if required. Bismuth, creosote and glycerin for gastrointes- tinal disturbances; ammonium carbonate or ace- tate to dissolve thrombi and emboli; corrosive sublimate, quinin and carbolic acid subcuta- neously. — Bartholow. Psoas Abscess. — Right or left iliac pain; draw- ing up of leg; tends to point in groin or lumbar region; sequel of Pott's disease. Treatment. — Open in loin or in groin or in both places, using through and through irrigation by means of a large drainage tube, which later may be replaced by two tubes, to be gradually short- ened. — Am. Text-Book of Surgery. Diaphragmatic Pleurisy. — Pain often referred to front of abdomen above umbilicus. Pericarditis. — Sometimes pain in epigastrium. Treatment. — R. Antimon. et potass, tart. gr. £; tinct. opii m. iv ; aq. camph. q.s. : A tablespoonful every 2 hours in acute form. — Graves. ABDOMINAL PAIN 183 Perisplenitis, Splenitis, Splenic Infarcts. — Sud- den, severe pain in region of spleen — burning, crushing, stinging, insensitive to pressure; chill, fever, friction sound; cardiac valvular disease. Treatment. — Etiologic treatment; quinin and arsenic in malarial form; chalybeates, iodids and ergot for various chronic splenic enlargements; splenotomy. Rupture of Spleen. — Symptoms usually mis- taken for intestinal perforation with internal hemorrhage. Wounds of Intestine. — Circumscribed peritoni- tis ; symptoms of shock if rupture — hydrogen gas test causes well marked tympanites. Treatment. — Keep in bed on strict diet for sev- eral days; immediate laprotomy if rupture. — Am. Text-Book of Surgery. Pressure and Traction. — More or less con- tinuous oppression and dragging and weight; physical signs of tumor or enlarged viscera. Gastric Cancer. — Continuous, dull epigastric oppression, drawing and lancinating pain, not much relieved by vomiting or pressure; coffee- ground vomiting, achlorhydria, progressive emaci- ation. Treatment. — E. Bismuthi subnit. gr. v; acidi carbol. gtt. i ; aq. chlorof ormi q.s. : A tablespoon- ful before food. — Thornton. E. Tinct. conii m. i; morph. sulph. gr. 1-24; 184 PAIN AND ITS INDICATIONS acidi carbol. m. 1-8; syr. acaciae q.s. : A teaspoon- ful whenever in pain. — Shoemaker. E. Morph. sulph. gr. 1-8; sodii bicarb, gr. v; bis. subnit. gr. x : Repeat p. r. n. — Osier. • Intestinal Carcinoma. — Sharp, radiating um- bilical pains a few hours after eating; blood and pus in stools. Treatment. — Opium or operation. Pancreatic Abscess or Cyst. — Colicky pain re- ferred to epigastrium, left hypochondrium or left shoulder. Treatment. — Incision over tumor, aspiration and incision and evacuation of tumor, stitching to abdominal wound and drainage. — Am. Text-Book of Surgery. Pancreatic Cancer. — Severe, deep-seated epigas- tric or umbilical pain; jaundice, emaciation, clay-colored, greasy stools. Treatment. — Opium or operation. Cholelithiasis. — Sudden, intense pain over liver, radiating to back and right shoulder, usually an hour or two after eating; may be rigor, fever and jaundice. Treatment. — E. Menthol gr. viii; spt. vini gallici dr. v; vitel. ovi no. ii; olei olivse oz. vi: Take in 4 to 8 portions during course of 2 or 3 hours. — Roth. Congestion of Liver. — Dragging weight, fulness ABDOMINAL PAIN 185 and distress in right hypochondrium, with smooth, regular enlargement. Treatment. — Local abstraction of blood over liver or at anus; warm applications, blisters; sa- line laxatives, aloes, rhubarb, cascara. — Eoth. A combination of colchicum and saline purga- tives for gouty subjects. — Bartholow. Torpid liver. — E. Ammonii chlor. gr. x; sodii chlor. gr. iv; succi tarax. dr. i; decoctum aloes co. q.s. : A tablespoonful t. i. d. — Shoemaker. Tubercular Liver. — Weight and dragging; tu- bercular disease elsewhere. Syphilitic Liver. — Dragging and weight in hepatic region; liver often bossed. Treatment. — Ordinary teritary antisyphilitic treatment. Fatty Liver. — Weight and dragging but rarely local pain; smooth, cushion-like enlargement; general obesity. Eestrict diet to fresh animal foods, game, fish, oysters and such succulent vegetables as lettuce, celery, spinach and raw cabbage; persistent use of sodium phosphate. — Bartholow. Amyloid Liver. — Dragging pain and smooth, firm enlargement of liver; tuberculosis and sup- purative bone disease. Treatment. — Treat syphilis, malaria or surgical cause; rub in pea-sized piece of official mercuric iodid ointment over whole hepatic area, intermit- 186 FAIN AND ITS INDICATIONS ting when skin becomes sore; chlorid of gold and sodium; nitrogenous diet. — Bartholow. Liver Cysts. — Weight and dragging sensations if large. Treatment. — Abdominal incision; stitch cyst to wound; incise, evacuate and drain. Hepatic Cancer. — Constant, dull, boring or stabbing, darting local pain ; rapid downward en- largement with hard, irregular, nodular surface. Treatment. — Opium as required. Splenic Engorgement, Enlargement, Abscess or Tumor. — Pain, tenderness and swelling in region of spleen; intermittent fever, chills and sweats if abscess. Treatment. — Enlargement. Official ointment of red iodid of mercury rubbed in over spleen. — Bartholow. Acute Congestion. — Cold affusions, evaporating lotions or tincture of iodin locally; quinin for malarial. Hypertrophy. — Quinin for malaria; iron and quinin for chlorosis and anemia ; mercurials for syphilis. — Bartholow. Lardaceous. — Combat special cause, especially chronic suppurative processes. Abscess. — Try to prevent by ice applications, counterirritation or local blood-letting and saline purgatives. — I. E. Atkinson. Incise and drain with strict antiseptic precautions. ABDOMINAL PAIN 187 Oasiroptosis. — Dragging pains in lower abdo- men; stomach displaced downward. Treatment. — Remove all causes that favor con- dition and treat associated functional disturb- ances: nervines and nutrients. — Anders. Enteroptosis. — Dragging pains in lower abdo- men; colon below navel, as shown by percussion when filled with water or air. Treatment. — Move bowels regularly; support- ing bandage; electricity, massage, hydrotherapy; Weir Mitchell rest cure for strongly nervous cases ; suitable medication for flatulence, fermentation, etc. — Anders. Local Peritonitic Process About Left Flexure of Colon. — Pain in splenic region; chronic consti- pation. Treatment. — Counterirritation by leeches and blisters. — Tyson. Pregnancy. — Pressure interference with gastric functions in latter months. Aneurysm of Aorta. — Constant, deep, boring epigastric or umbilical pain; expansive tumor and thrill. Treatment. — Ice-bag over pulsating swelling, rest in bed, salines and ergot. Ovarian Cysts. — Intermenstrual neuralgia, sa- cral burning and boring. Treatment. — Celiotomy and removal. 188 PAIN AND ITS INDICATIONS CHAPTER VIII. PELVIC PAIN. UTERINE HYPOGASTRIC. Acute Metritis. — Pain deep-seated, diffuse, cramping and bearing-down, radiating to loins, hips and hypogastrium, with vesical and rectal tenesmus; least severe in puerperal. Treatment. — Hot colon douches in Sims' posi- tion. Ice-bag over hypogastrium (24 to 48 hours) if much pain and fever; hot fomentations later; morphin if required only; salines and other laxa- tives; alcoholic stimulants; concentrated liquid diet and quinin in septic cases. From Sudden Suppression of Menses. — Warm sitz-baths, mustard foot-baths and hot drinks soon as possible; then to bed and use hot fomentations to abdomen and inside of thighs for several hours ; saline cathartic; sodium citrate gr. xxx every two or three hours; subsequent counterirritation ; if menses do not reappear, keep quiet for a month with counterirritation, mild laxatives, bland diet, warm sitz-baths, and hot douches (115° to 120°) faithfully used. — Byford. Gonorrhea or Decidual or Placental Eemaina. — Thorough curettage of uterus, swabbing out with 95 per cent carbolic acid, then douching with mercuric chlorid (1:2000) followed by sterilized hot water douche, and leaving a dram iodoform PELVIC PAIN 189 pencil in uterus; douche of bichlorid or carbolic acid (followed by plain douche) should be re- peated twice a day if infection of some standing. — Byford. Hysterical Metritis. — Suggestion ; constant cur- rent of 3 to 6 m.a. with anode over hyperesthetic zones; Blaud's pill persistently for four months, and after an interval, as long again; valerian and asafetida in convulsive types; remove patient from too sympathetic surroundings and divert her attention from herself. — Bichard Lomer. Chronic Endometritis and Metritis. — Neuralgic pains and attacks of uterine colic, principally at menstrual periods; traction on cervix gives rise to lumbar pain. Treatment. — Etiologic treatment (e. g., removal of placenta and membranes after delivery, curet- tage after abortion, etc.) ; a good deal of rest — never walk so much as to increase pain; keep bowels open and restrict sexual intercourse; elas- tic belt around whole abdomen in stout women; warm bath twice a week; warm sitz-baths, using bath speculum; regular hydropathic treatment; curet in hyperplastic form studded with promi- nences; Apostolus intrauterine chemical galvano- cautery if whole membrane swollen; treat endo- metritis with Churchill's tincture of iodin, chlorid of iron (hemorrhagic form) or silver nitrate (catarrhal form), painting vaginal roof 190 PAIN AND ITS INDICATIONS with tincture of iodin and have patient introduce a pledget with glycerin night and morning. — Gar- rigues. Chronic Parenchymatous. — Same measures as for chronic endometritis; long continued use of small doses of chloric! of gold or corrosive sub- limate; bipolar intrauterine faradization; mas- sage; trachelorrhaphy or excision of cervix. — Gar- rigues. Senile. — Tonics and good diet; correct displace- ments with medicated tampons; local applica- tion twice a week of powdered iodoform or tannin- boroglycerid (20 gr. per oz.) or fluid extract Hydrastis with peroxid frequently and packing with iodoform gauze. — Skene. Exfoliating. — Destroy endometrium by curet- ment, followed by application of tincture of iodin or iodoform pencils, or by galvano-chemical cau- terization of Apostoli. — Garrigues. Tubercular Endometritis. — Caseous leucorrhea containing tubercle bacilli. Treatment. — Total vaginal extirpation of uterus n nd adnexa. — Pry or. Endocervicitis. — Numb, deep pain and sense of weight in pelvis; profuse, purulent, tenacious dis- charge from cervix; follicles enlarged, giving ap- pearance of erosions or ulceration; Nabothian cysts in chronic. Treatment. — Apply tincture of iodin on cotton PELVIC PAIN 191 to internal os every other day (daily in gonor- rhea) ; if cervix markedly congested, puncture with a scalpel in a half dozen places and promote bleeding with \ of 1 : per cent hot lysol vaginal douches every four hours for a day; vaginal douche of mercuric chlorid 1 :10000 every three hours in gonorrheal cases; prick cysts and twist off polypi under cocain. — Pryor. "Erosions." — Bathe vaginal portion in a tubu- liform speculum twice a week for a couple of minutes with acidum pyrolignosum rectificatum or with 10 per cent sol. cupric sulphate. — Gar- rigues. Ovula Kabothi. — Prick open and then paint with tincture of iodin; if very numerous destroy gradually with needle-shaped Paquelin's or gal- vanocautery. — Garrigues. Uterine Retroversion. — Pain depends largely on complications ; usually radiates toward rectum and is often accompanied by severe tenesmus, espe- cially during defecation; greatest tenderness at posterior fundus ; often lumbar and inguinal trac- tion pains. Treatment. — Replacement bimanually or in knee-chest posture; keep in place with cotton tampon (in cul-de-sac) soaked in boroglycerid or 10 per cent ichthyol-glyeerin, and under this a lamb's wool tampon turned sideways; intra- uterine application of tincture of iodin ; hot water 192 PAIN AND ITS INDICATIONS paginal injections; repair pelvic floor and keep stools soft; Alexanders operation or hysteror- rhaphv. — Am. Text-Book of Gynecology. Uterine Anteflexion. — Premenstrual pain, di- minishing as flow is established. Treatment (Simple). — Dilate cervix, irrigate and curet uterus and pack with iodoform gauze, Leaving in for six days — best done two weeks be- fore period. — Am. Text-Book of Gynecology. With Retroversion. — Dilate cautiously to one- half inch, wash out, curet, irrigate again and pack tightly with iodoform gauze; remove pack on fifth day, leaving a light drain of gauze each time three days for two weeks; amputate cervix if much elongaterl. — Am. Text-Book of Gyne- cology. Prolapse of Uterus. — Traction, lumbosacral bearing-down and sinking feeling in chronic ; sud- den, severe, bearing-down lancinating pain in acute, usually after a fall; often painful sensa- tions in flanks and epigastrium; vesical tenesmus. Treatment. — Reduce hernia; treat ulcers with iodin; fill vagina with iodoform gauze and apply tight T bandage; after ulcers cured, support uterus with Braun's colpeuryiiter (wash bag thor- oughly, anoint with zinc ointment and introduce an ounce of water, filling up with air; remove every night and keep vagina cleansed with boric acid solution) ; operative procedures to reduce op- PELVIC PAIN 193 gan in size and retain it in elevated position (keep patient recumbent for two weeks before). — Am. Text-Book of Gynecology. Support uterus with hard pessary or aseptic wool tampon placed in mornings and removed at night; uterus best replaced with patient in knee- chest posture. — Hawkins. Acute. — Eeturn organ gently and pack vagina lightly with cotton or gauze; ice-bag to supra- pubic region; Trendelenburg's posture and saline transfusion if symptoms of internal bleeding. — Am. Text-Book of Gynecology. Senile Prolapsus of Pelvic Organs. — Dragging down feeling; irritable bladder and dyschezia; re- laxed pelvic floor; cellular and muscular tissue atrophied. Treatment. — Astringent douches (zinc sulphate or tannic acid) ; rest after short periods of exer- cise; perineal pad and strap; plain or medicated tampons, followed by small size Peaslee ring pes- sary (change and clean every month or two) and continued douches. — Skene. Carcinoma of Uterus. — Often painless until perimetric tissue invaded; uterine colic in corpo- real; radiating pain in cervical, becoming con- tinuous; characteristic sacral pain; pain in ad- vanced stage neuralgic and violent, in back and shooting down legs especially at night; lymph glands in groin and left supraclavicular region 194 PAIN AND ITS INDICATIONS may be enlarged; sometimes edema of one or both legs; blood-stained irregular discharges after menopause; hard nodules or crater-like ulcer, or friable cauliflower growth in cervix. Treatment. — Hysterectomy if disease confined to uterus. Phenacetin a specific for pains. — Eichard Lomer. Inoperative Cases. — Eelieve pain and hemor- rhage by occasional dilatation of internal os and scraping endometrium very carefully, then wash- ing out debris carefully with copious injections. — Winckel. Uterine Sarcoma. — Pain usually severe, some- times expulsive, radiates up and down. Treatment. — Extirpation by wide enucleation. Uterine Fibroids. — Dragging or pressure with vesical or rectal neuralgia shooting down legs; rapid-growing tumors more painful than slow; pain increased by multiplicity or cystic degenera- tion; aggravated by menopause — often disappears later; slight local pain. Treatment. — Fluid extract ergot and fluid ex- tract salix nigra of each \ dram t.i.d. — Adams. Vaginal or abdominal extirpation if they cause serious trouble. Iodid of calcium 2 or 3 gr. in water one-half hour before meals in interval of menses; aqueous fluid extract of hydrastis (with cinnamon water or tincture of cardamon) m.x. PELVIC PAIN 195 t.i.d. near and during menstrual periods. — Skene. Mucoiis Polypi. — Neuralgiform pain and cramps; may be sacral pain, and irritation of bladder; patient cannot lie on one side; os dilated and tumor often projecting. Treatment. — If readily accessible, ligate pedicle with, strand of catgut and excise ; for those higher in uterine cavity, dilate cervical canal and remove with torsion or ecraseur. — Kelly. Uterine Retention Cyst. — Hematometra, pyo- metra, hydrometra, physometra; constant pain and tenderness in lower abdomen with paroxysmal exacerbations at menses; rectal and vesical dis- turbances; may be dribbling of pus or blood and slight fever; uterus feels like tense bag; point of occlusion determined by finger. Treatment. — Evacuate with sound and dilators and keep channel open. — Kelly. Hysteralgia. — Sudden, recurrent attacks of se- vere pain in uterus, often radiating to iliac fossa and down leg; usual cause, menopause; also from changes of puberty, anemia, malnutrition, rheu- matism, metritis, cancer of womb and hysteria. Treatment. — Vaginal injections of potassium bromid, an ounce to the pint of water. — Munde. Menopause. — J^ Liq. potass, ars. m.v. ; amnion, (aut strontii) bromidi gr. v-xv; ferri et amnion, cit. gr. viii; aquam cinnam. q. s. A teaspoonful in water t.i.d. after eating. — Allbutt. 196 PAIN AND ITS INDICATIONS Abortion and Miscarriage. — Periodic, numb, drawing, cramping, bearing-down, labor-like pains, with uterine discharge of blood and mucus, dilated os and presenting fetus. Treatment. — Threatened. — Replacement of dis- placed uterus ; absolute rest in bed ; opiates in full doses for restlessness; ice to vulva; cold cloths to abdomen ; hemostatics internally ; fluid ext. vibur- num prunifolium dr. i every two or three hours; keep in bed for a week after symptoms disappear. — Lusk. Inevitable. — Profuse hemorrhage with clots, patulous os, and presence of embryo or portions of ovum in clots. Treatment. — First two months, rest in bed for a few days; third month, if ovum entire, warm vaginal douche and wait — if very long in primi- para, dilate external os; if sac ruptures check hemorrhage by cleansing out uterus with finger, using vaginal tampon if cervix not sufficiently di- lated (never leave in more than twenty-four hours) and giving antiseptic vaginal injections before and after introduction of tampon. — Lusk. Death of Fetus in Utero. — Painful sensation of faintness; gaping os and movable cranial bones; peculiar putrid taste in mouth; temperature same as in vagina. Treatment. — Dilate neck with fingers and inject 4 to 6 ounces of equal parts glycerin and boiled PELVIC PAIN 197 water and pack neck with gauze ; after labor, wash uterus once or twice daily with a quart of 1 :4000 mercuric chlorid or Calvert's carbolic acid (40 or 60 drops to pint), gradually decreasing strength of solution ; 2 drams 30 per cent ichthyol vaginal suppositories with lanolin and cacao butter; strychnin, ergotol, bouillons. — Buchtel. Cervical Lacerations. — Bearing-down feelings with neuralgic pains in iliac fossa, sacral region, left breast, inner or outer thigh and over spleen. Treatment. — Amputation or trachelorrhaphy after following preparatory treatment for two to six weeks if erosion or sclerotic or cystic changes : Vaginal douche of 1 gallon hot water two or three times a day; procure one or two watery fecal movements daily by Eochelle salts or magnesium sulphate; every five or six days place woman in knee-chest posture, expose cervix with Sims' spec- ulum and puncture Nabothian cysts and also vag- inal surface of cervix (if this is much enlarged and congested, then dry cervix and apply Churchill's tincture of iodin over whole of cervix and vaginal vault; remove excess of iodin with a little cotton and place against cervix a glycerin tampon — to be removed in twelve hours and fol- lowed with vaginal douche of hot water. — Penrose. Pregnancy. — Stretching and pressure muscular pains and pelvic neuralgia, particularly in 198 PAIN AND ITS INDICATIONS women who have suffered from previous pelvic inflammations. Treatment. — Iron, arsenic, quinin; regulate diet, sleep and emunctories; oleate of morphin endermically ; 3 or 4 gr. acetanilid repeated hourly for three doses if need be. combined with caffein, digitalis or an alcoholic stimulant; remove local sources of irritation if possible. — Jas. H. Ethe-' ridge. False Labor Pains. — Indistinct pains, fre- quently from hemorrhoids, or from irritable or hysterical uterus; cervix or os remains flabby dur- ing pain. Treatment. — Give a 4-quart enema at once and then |- grain morphin hypodermically, to be re- peated by the mouth in an hour or two if pain lessens but does not disappear; hot drinks (ginger and peppermint), inhalations of chloroform and even hot fomentations and flaxseed poultices may be used. — T. Mitchell Burns. True Labor Pains. — Periodic, gradually increas- ing in force and frequency; dilation of os (tense during pain) and discharge of blood-stained mucus. Treatment. — Chloral 15 gr. repeated half- hourly for three doses for nagging, ineffectual early pains; chloroform inhalations when present- ing part reaches pelvic outlet; codein (up to 1£ grains by mouth or 3 grains by rectum) to allay PELVIC PAIN 190 reflex nervous excitability and render contrac- tions natural. — Grandin and Jarman. After Pains. — Due chiefly to relaxation of uterus and passage of clots; may be caused by excess of ergot or quinin. Treatment. — Small doses of ergot (5 drops) every three hours. — Lomer. Keep womb well contracted by gentle rubbing, particularly for a half hour or hour after child- birth; also antikamnia and codein or small doses of Dover's powder. Inversion of Uterus. — Sudden pain and shock, followed by backache, dragging, tenesmus, hemor- rhage; from polypi or labor. Treatment. — Manual reposition if practicable (squeeze tumor with one hand to make longer and smaller, and push with other hand like a wedge up into cervix) or vaginal amputation of uterus. —Kelly. Subinvolution of Uterus. — Constant backache and feeling of dragging weight; uterus too large and soft, often retroverted. Treatment. — Potassium chlorate gr. viiss. t.i.d. with a few drops of dilute hydrochloric acid. — Tait. Eest in knee-chest posture ; copious hot vaginal douches; course of quinin and ergot; bipolar elec- tricity; keep bowels freely open. Tubo-Ovaeian". — Iliac. 200 PAIN AND ITS INDICATIONS Oophoralgia, — Spontaneous or provoked ova- rian neuralgia felt in iliac and subumbilieal re- gion, usually the left; also in hip, leg or loins; often increased by exercise or motion of any form, and nearly always during menstruation; often with hemianesthesia of same side, dyspareunia, hysteroepilepsy and globus hystericus; cardialgia, vomiting, palpitation, loss of consciousness or con- vulsions sometimes produced by pressure on ovary, which is normal to physical examination; appears in hysterical, malarial, alcoholic and masturbating subjects. Treatment. — Suggestion ; constant current of 3 to 6 m.a. with anode over hypercsthetic zones; va- lerian and asafetida; Blaud's pill persistently; isolation. — Eichard Lomer. E. Liq. digitalis norm. m. iss. ; liq. gelsem. norm. m. i£; sodii brom. gr. xx; aquae q.s. A tablespoonful every 3 hours. Ovarian, Labial and Perineal Neuralgia. — Sud- den, darting pain with uterine and ovarian ten- derness; often worst midway between or just be- fore menses. Treatment. — E. Ext. belladonna gr. 1-5; ext. stramon. gr. £; lactophenin, gr. ivss. Two or 3 pills daily. — J. S. Martin. Iliohypogastric and Ilioinguinal Neuralgia. — Pain paroxysmal, radiating, lancinating, often se- vere; painful points at lumbar spines, middle of PELVIC PAIN 201 iliac crest and a little above external ring — in- guinal points on scrotum and in vagina; from pelvic or lumbar disease, psoas abscess, trauma, exposure or hysteria. Treatment. — Phenacetin in rectal suppositories of 10 gr. each; galvanic current very useful — contraindicated in pregnancy. — E. P. Davis. Herpes Vulvae. — Neuralgia of ilioinguinal or external spermatic nerve; drawing, gnawing or boring; always one-sided; present a few days be- fore appearance of vesicles. Treatment. — Phenacetin, antipyrin, etc. — Lo- mer. Cirrhotic Ovaries. — Circumscribed in one or both iliac fossae, radiating to hip, knee, bladder, rectum, breast; intermenstrual, very painful, par- ticularly if adherent, often alternating from one side to other in successive months, if bilateral. Treatment. — Treat any disease of uterus first; bed for 1 or 2 months; daily massage; mild sa- line purgatives; weekly application of Churchill's tincture of iodin to vaginal vault, followed by glycerin tampons and hot water vaginal injections twice a day; forbid coitus; later absolute rest at menstrual periods ; oophorectomy if suffering per- sists. — Penrose. Cystic Ovaries. — Pain, usually bilateral in ova- rian region (more marked on left side), increased by standing, exercise, coition or defecation and at 202 PAIN AND ITS INDICATIONS outlet of menstrual periods; often menorrhagia and reflex pain in region of breast; ovary very tender and slightly enlarged; anorexia', indiges- tion and mental depression. Treatment. — Open cul-de-sac, free ovary, intro- duce posterior retractor into pelvis, and lift uterus into abdomen; introduce gauze pad be- tween retractors, and lower head of table; grasp ovary with Luer's forceps and pull down; stab every cyst with tenotomy knife; return ovary to pelvis and treat the other in same way. — Pryor. Hyperemia and Hematoma of Ovary. — Usually affects both ovaries ; pain and heaviness in ovarian regions, increasing 4 or 6 days before menstrual period; menorrhagia the rule; dull tenderness on deep pressure in iliac regions; overstimulation of sexual appetence most common cause. Treatment. — Beniove cause (let engaged marry) ; counterirritation ; out-door play and work; sea bathing or shower bath; nux vomica and ergot during day, bromid at night. — Skene. Prolapse of Ovary. — Pain in sides of pelvis, sac- ral region or rectum, often shooting down to knee and up into hip; much increased on walking or long standing, and may be aggravated by sitting clown; dyschezia, dyspareunia; great tenderness on palpation. Treatment. — Thick, elastic soft ring pessary; knee-chest posture with loosened clothing, allow- PELVIC TAIN 203 ing air to enter vulva for a few minutes several times a day, lying afterward on side as long as practicable — best with rest cure ; abdominal brace. — Goodell. Salpingo-oophoritis. — Pain referred to lower abdomen and affected side; deep-seated and in- creased by direct palpation; usually paroxysmal and lancinating during exacerbations — dull and heavy in intervals. Gonorrheal. — Pus from uterus shows gonococci. Treatment. — Curet uterus; open tube or tubes and pack pelvis with gauze, or make ablation by vagina. — Wm. E. Pryor. Septic. — Usually puerperal or following un- clean operation; pulse disproportionately high. Treatment. — Early curettage; if due to plastic operation rip out sutures and irrigate uterus with boric acid, paint raw surface with carbolic acid, open cul-de-sac and drain with gauze; ablation in relapsing cases. — Pryor. Intraligamentous Growths. — Open audominai cavity in usual way and withdraw a portion of the fluid from cyst if this is very tense and abdominal wall rigid. Then ligate and cut Fallopian tube and broad ligament down to near internal os on opposite side from growth, cut and clamp uterine artery, peel bladder back from uterus, amputate cervix (above supravaginal junction), clamp uterine artery in opposite side, clamp or ligate 204 PAIN AND ITS INDICATIONS ovarian artery on tumor side if possible, seek point of cleavage and rapidly enucleate tumor with fingers from below upward (along with uterus if growth large). Trim down sac and close tissues over stump of uterus with a continu- ous catgut suture, as in an abdominal hyster- ectomy for fibroid. Drainage is secured by a nar- row strip of sterile gauze placed under flap, the end of which is carried through cervical canal into vagina^ — considerable packing when extensive de- nuded spaces. — Hawkins and Fleming. Chronic Salpingitis. — Pain aggravated at men- strual periods; no intermenstrual pain of any ac- count. Treatment. — Treat causative ovaritis or chronic corporeal endometritis. — Skene. Acute Periovaritis. — Sharp peritoneal pain and tenderness in region of ovary. Treatment. — Moist abdominal dressings covered with rubber tissue; paint vaginal vault with 10- 20 per cent ichthyol in boroglycerid ; open bowels. — Pryor. Ovarian Abscess. — Firmly adherent, dense, sens- itive mass to one side or behind uterus; fever, pain, etc. Treatment. — Evacuate. Ovarian Cysts. — Occasional intermenstrual neu- ralgia; burning or boring pain on one or both sides of sacral region. PELVIC PAIN 205 Treatment. — Laparotomy with removal of neo- plasms; suppurative cysts may be treated by va- ginal section and drainage; small, uncomplicated growths may be removed through vagina. — Haw- kins. Parovarian Cysts. — Slight progressive pain and early pressure symptoms; soft, fluctuating tumor low in pelvis, filling broad ligament flush with uterus. Treatment. — Eemove through abdomen, if large — otherwise open cul-de-sac and incise tumor with closed pair of blunt scissors opening same on with- drawal, or puncture and aspirate ; wipe pelvis dry and rupture secondary cysts in cavity with finger; pack cul-de-sac and vagina with iodoform gauze, making first dressing in 7 to 10 days. — Pryor. Chronic Oophoritis. — Persistent circumscribed pain in one or both iliac fossa?, radiating to hip, knee, bladder, rectum, breast; ovary enlarged and very tender. Treatment. — Sodium bromid gr. xx-xxx and fluid ext. hydrastis m. x-xx t.i.d. during painful menstrual attacks; massage or reclining gymnas- tics; saline laxatives (if they do not cause flatu- lence) ; hot sitz-baths, counterirritation and hot vaginal douches; wet packs and baths (sedative to tonics) ; alteratives later; small doses of mer- curic chlorid (with chlorid of iron if anemic), fol- 206 PAIN AND ITS INDICATIONS lowed by large doses of syrup iodid of iron. — Skene. Parovarian Varicocele. — Peculiar dull ache passing up toward kidney; pain persists after ovary is removed — not much affected by menstrual periods. Treatment. — Ligation and removal of pampini- form varices. — Geo. Halley. Rest with pelvis elevated; open bowels; un- constricted waist; correction of displacements; repair of lacerations; astringent douches and boroglycerid tampons, followed by ring pessary. — Skene. Hydrosalpinx. — Heavy, bearing-down pain in inguinal region and back; intermittent, colicky discharge of serous fluid; gourd-like swelling at side of and above displaced uterus. Treatment. — Open cul-de-sac, free sacs and in- cise with scissors, catching fluid with gauze, plug- ging cul-de-sac with gauze and making first dress- ing in 8 days. — Pryor. Pyosalpinx. — Similar to hydrosalpinx; swell- ing very tender; discharge of pus from uterus; hectic fever and chills. Treatment. — Aspiration through vagina re- lieves pain and sometimes cures disease. — Richard IiOiner. Evacuation by broad incision through vagina; or vaginal ablation of uterus and adnexa. — Pryor. PELVIC PAIN 207 Hematosalpinx. — Similar to pyosalpinx (pain in tubal abortion often colicky, about navel) ; constant, slight bloody discharge — always clotted if due to tubal pregnancy — seldom clotted when due to salpingitis. Treatment. — Immediate operation ; salpingo- oophorectomy usually necessary. — Penrose. Sclerosis of Tubes. — Usually history of many attacks of endometritis; diminished menstrual flow; intermenstrual leucorrhea; continuous se- vere pelvic pain, with tenesmus on menstruation; common in old, stout prostitutes; tubes felt as cords; uterus fixed high up, often atrophied; sterility. Treatment. — Ichthyol 10 per cent on tampons or injected into vagina sometimes relieves pain; curable only by ablation. — Pryor. Peritoneal and Cellular. — Sharp and tear- ing; chiefly in lower abdomen. Acute Pelvic Inflammation. — Treatment. — Eest in most comfortable posture (sometimes raising foot of bed gives great com- fort) ; regular administration of opium or mor- phin in sufficient doses to relieve pain (may be given in enema per rectum) ; absorbent cotton saturated with equal parts of tincture of bella- donna and glycerin, applied hot and covered with rubber cloth; 10 or 15 gr. quinin on first day of inflammation ; sips of cold or hot water for thirst PAIN AND ITS INDICATIONS (enema of water and foods if vomiting con- tinues) ; if lower intestine loaded employ a rectal injection of 3 oz. magnesium sulphate and 2 oz. each of glycerin and water, repeated as need be till the bowels move, then give ■} dr. sodium phos- phate every 3 or 4 hours ; whisky and quinin dur- ing this stage; when all acute symptoms have subsided and no evidence of pus or serum collec- tion, apply small blisters repeatedly in iliac re- gions (one on each side) or paint roof of pelvis with tincture of iodin, or keep up continued irri- tation with croton oil 1 part, sulphuric ether 2, and tincture of iodin 3 parts, painted over lower abdomen and repeated when eruption disappears; nourishing food, quinin, iodid of iron, potassium iodid, chlorid of iron and mercurial and other tonics; greatest care needed to prevent relapse — avoid any exercise which excites pain; promote absorption and lessen adhesions by pelvic mas- sage. — Skene. Pelvic Congestion in Women — Magnesium sul- phate 30 parts; 8 parts each of iron sulphate, manganese sulphate and dilute sulphuric acid in 120 parts of distilled water: A tablespoonful in a glass of water before breakfast. — Koussel. Chronic Pelvic Inflammation. — > Treatment. — Copious hot vaginal douches twice daily; tamponade posterior fornix with tampons PELVIC PAIN 209 saturated in potassium iodid 1 ounce, glycerin and water each 2 ounces. — MacEvit. Tvhal Pregnancy — Marked pelvic discomfort with ordinary signs of pregnancy; or abrupt, violent, tearing, cramp-like paroxysms superven- ing on perfect health, referred, as a rule, to the womb, uterine gushes of blood, signs of internal hemorrhage and collapse on rupture; decidual cast from empty womb; tense, tender, pulsating, rapidly growing cyst beside or behind uterus. Treatment. — Before rupture: Arrest of growth of ovum by galvanism or faradism, or better, ab- dominal section and removal of appendages. — Grandin and Jarman. After Kupture. — Celiotomy, tying off ruptured tube and irrigation of peritoneal cavity with hot, sterile salt solution; expectant treatment (hot normal saline rectal irrigation, strychnin, etc.), if rupture into broad ligament — destruction of fetus, if living, after fourth month, or immediate abdominal section if septic symptoms. — Grandin and Jarman. Pelvic Hematocele. — Sudden, sharp, hypogas- tric pain with faintness and pallor; often from ruptured tubal pregnancy. Treatment. — See Euptured Tubal Pregnancy, just above. Pelvic Hematoma. — Sudden hypogastric pain, 210 PAIN AND ITS INDICATIONS quickly subsiding on lying clown; signs of inter- nal hemorrhage. Treatment. — See Ruptured Tubal Pregnancy, above. Pelvic Neuralgia. — Probably rheumatic when no local cause, especially after menopause. Treatment of Rheumatic. — Salophen or salicy- lates. Pelvic Peritonitis — Pain sudden, acute, con- tinuous, with chills and fever; extreme tender- ness; unilateral or bilateral. Treatment. — Rest in bed; sexual rest in con- valescence, especially at menstrual periods ; deple- tion with magnesium sulphate, a teaspoonful every hour till six watery movements (if salts disagree with stomach, give a grain hourly of calomel till six doses, followed by one or two doses of salts and enema of soapsuds) ; hypodermics of r /e to i gr. morphin, only if pain is too great to be borne ; poultices and counterirritation of little or no use; regulate diet and keep excretories functionating. — Baldy. Suppurative. — Open posterior cul-de-sac, let out pus and fill pelvis with iodoform gauze; strych- nin 1 / 60 gr. every 4 hours, gradually increasing; champagne; for local pain blood-letting from cervix and 10 per cent ichthyol tampons; wash out colon daily with a quart of normal salt solu- tion; 1 oz. beef-juice every 4 hours and 2 oz. PELVIC PAIN 211 chicken-broth every 4 hours ; abundance of water (containing a few drops of lemon- juice if vomit- ing) . — Pryor. Tubercular. — No evidence of primary uterine and tubal disease; great emaciation and debility. Treatment. — Open cul-de-sac, sever adhesions, irrigate pelvis with normal salt solution and apply high dressing of iodoform gauze; ablate if sec- ondary tubal and ovarian disease. — Pryor. Pelvic Cellulitis or Parametritis. — Moderate pain radiating to bladder or rectum and down one or both thighs. Treatment. — In acute cases treat metritis (sharp curet sometimes) or salpingitis or cauterize ex- posed surfaces thoroughly when due to surgical or parturient wound; when acute symptoms subside apply Churchill's tinct. iodin to vaginal fornix and inguinal regions; also hot water vaginal douche, small doses of calomel ( x / 20 gr. t.i.d.) with saline mineral water for bowels, sitz-baths and hot fo- mentations ; if pus forms evacuate through vagina, using needle as a guide, introduce sharp-pointed scissors and spread blades on withdrawal; com- plete opening with finger, insert rubber tube or gauze drain and pack vagina with gauze; remove circumscribed collections of serum by aseptic aspiration; for chronic non-suppurative or atrophic cellulitis chief reliance must be in local 312 PAIN AND ITS INDICATIONS and general massage and systemic treatment. — ■ Dudley. Pelvic Abscess — Symptoms like those of peri- tonitis or cellulitis at first; hectic fever, chills and sweats after pus forms. Treatment. — Expectancy in acute stage or ex- acerbations; absolute rest, freely open bowels, ice poultices to abdomen, diaphoretics, prolonged hot vaginal douches, some morphin ; evacuate through uterus by massage when possible to squeeze pus out of sac by this route; vaginal incision, curett- age and drainage when pointing there (puncture posterior to cervix in median line) ; evacuate through rectum if spontaneous rupture imminent; enucleation by vagina aided by abdominal incision, or enucleation of pyosalpinx and ovarian ab- scesses. — Kelly. When pointing toward or readily accessible from vagina, make a free opening through the vault and cleanse and drain sac — secondary ab- dominal opening seldom required; evacuate through inguinal space above Poupart's ligament when large abscess raises peritoneum above this point ; abdominal section usually indicated for small tubal, ovarian and appendiceal abscesses. — Wetherill. Broad Ligament Abscess. — Labor or abortion; tender, tense, fluctuating, always sessile mass reaching from uterus to pelvic wall. PELVIC PAIN 213 Treatment. — Evacuate through cul-de-sac and pack with gauze ; also curettage. — Pryor. Pelvic Lymphangitis — Pain deep, usually to right of middle line, extending to pubes or coccyx. Treatment. — Free catharsis (magnesium sul- phate), hot rectal and vaginal douches; curettage; vaginal section and cul-de-sac drainage. — Hawk- ins. Blind Hernia and Peritoneal Cysts. — Extremely painful; very thin walls; clear, yellow albumi- nous contents. Treatment. — Laparotomy. Vulvovaginal. — Local symptoms very mani- fest. Acute Vaginitis. — Dull pain (burning, itching or sticking in gonorrheal) in pelvis or groin, with vaginal discharge and local signs of inflammation. Treatment. — Cleanse mucous membrane thor- oughly with a dram of borax in a quart of warm water and apply thoroughly equal parts of bis- muth subnitrate (iodoform in specific cases), and prepared chalk, and introduce tampon of borated cotton; remove tampon in 24 hours, clean away discharge and replace tampon; in 24 hours more remove tampon and use douche of borax and water, followed by dry treatment as before. — Skene. One ounce each of alum, borax, zinc sulphate and carbolic acid in 6 ounces of water: A tea- 214 PAIN AND ITS INDICATIONS spoonful in a quart of hike-warm water as va- ginal injection twice daily. Obstinate Cases. — Apply to entire canal every third day by means of Sims' speculum and atom- izer with strong pressure, silver nitrate 1 gr. to ounce, or zinc sulphate 4 gr. to ounce, using in intervening days once or twice daily a vaginal douche of zinc sulphate 60 gr. to quart of warm water. — Skene. Senile Colpitis. — Sticky secretion; yellowish, thin, shining mucous membrane. Treatment. — Cauterize with weak solution of silver nitrate. — Lomer. Vulvo-vaginitis. — Vaginal douche of warm water, t.i.d. at first, then less often — spray upper portion of canal once or twice a week with silver nitrate 1 gr. to oz. or zinc sulphate £ gr. to oz. ; keep cotton between labia after cleaning with borax, drying and applying a dry powder. — Skene. Inflammation of Vulvo-vaginal Glands. — Throb- bing pain radiating down thigh; tender, elastic tumor at lower part of one or both labia majora. Treatment of Inflammation of Vulvovaginal Glands. — With tenaculum hook up most promi- nent part of the abscess and make gentle traction ; with pair of scissors slightly curved on the flat excise elliptical portion as grasped per scissors (this will include the mucous membrane down to the gland proper) ; then hook up the gland or PELVIC PAIN 215 abscess wall and remove a similar piece, which opens up the abscess thoroughly. Cleanse, mop out with gauze and boil out the cavity with peroxide. Then trim out and remove as much as possible of the cavity lining, or carefully curet and then wash out the cavity with pure carbolic acid, immediately neutralizing it with pure alcohol. Close the incision with a continuous catgut suture, passing the needle to the top through the tissues (not including the mucous membrane), and then pick up a portion of the bottom of the cavity and again through the opposite side (not including the mucous membrane). Continue this to the lower end of the wound, thus bringing the bottom of the abscessed cavity and the sides of the re- gional gland in close apposition, then reverse and close the mucous membrane and tie the catgut to the end where you first started. — Hawkins. Treatment. — Abscess. After suitably shaving and cleansing parts, make abscess tense by pres- sure from behind on both sides, and open freely from below up; evacuate and wipe sao clean and touch whole inner surface with pure carbolic acid on absorbent cotton ; pack cavity loosely with thin strip of iodoform gauze, replacing every 2 or 3 days until healed; no sutures or ligatures need be used.- — Howard Kelly. Kraurosis Vulva. — Itching and pain on walk- ing; shiny, pale, smooth mucous membrane with 216 PAIN AND ITS INDICATIONS red, tender spots; parts crack and bleed readily. Treatment. — Applications of pure carbolic acid or cocain or pure silver nitrate; cloths wrung out of hot water and placed over vulva; solution of lead acetate in glycerin on cotton between labia; forced dilation of vaginal orifice under ether; complete excision of diseased tissue under ether most satisfactory. — Penrose. Perineal Lacerations. — 'Vague pains and diffi- culty in walking. Treatment. — Immediate repair at time of con- finement — under anesthetic, with aseptic vaginal tampon plug, trimming off any ragged portions with scissors and closing with silk- worm gut. Old lacerations may be repaired by Emmet's method, Taitfs simple flap operation or Kelly's dissection and extension of loose fasciae and muscles; catgut or silk-worm gut (external sutures). — Hawkins. Atresia of Vagina. — Usually history of severe labor with subsequent amenorrhea, though severe menstrual colic, and impediment to sexual inter- course ; fluctuating sac above atresia. Treatment. — Open up channel and allow accu- mulated fluids to escape ; remove scar tissue ; unite sound upper and lower portions of vagina over de- fect. — Howard Kelly. Dys pareunia. — Eemove cause; if small vagina, pack it two or three times weekly with borated PELVIC PAIN 217 cotton and leave in 36 hours, or use glycerin- wool tampons. — Byford. Urinary Fistula. — Dribbling of urine from va- gina ; excoriation of vaginal mucous membrane. Treatment. — Preparation: Prolonged repeated warm boric acid vaginal douches ; repeated pains- taking cleansing of vulva and vagina with forceps and cotton; occasional application of weak silver nitrate to raw surfaces and incision of bands of scar tissue. — Kelly. Operation. — Denudation of margins and ap- proximation of edges with fine silkworm sutures. —Kelly. Fecal Fistulce. — Involuntary escape of flatus and thin fecal matter through vagina, vulva or uterus ; excoriation of parts. Treatment. — If fistula low down in sphincteric area, cut entirely through septum, denude mar- gins of fistula and for some distance above and close the whole as in complete tear; if opening above sphincteric area and free from scar tissue, use funnel-shaped denudation and suture; if fis- tula above sphincteric area and surrounded by scar tissue, dissect rectum free from vagina, pass in- terrupted sutures through muscular coats of de- nuded bowel to close opening, leave long and allow to hang through fistulous vaginal opening, close incision in rectovaginal septum and use a dry dressing in vagina. — Kelly. 218 PAIN AND ITS INDICATIONS Dysmenorrhea. — Ovarian pain, iliac and pre- menstrual; uterine obstructive, suprapubic; pel- vic inflammatory, sacral. Mechanical — Paroxysmal uterine expulsive cramps, sometimes with nausea, radiating through lower abdomen, inguinal region, to back and down thighs — begins a few hours before flow, and sub- sides with escape of clots; no intermenstrual uterine symptoms as a rule; may be difficulty in removing sound. Causes. — Vaginal, hymeneal or cervical sten- osis (obstruction to finger or sound) ; imperfect development of parts; congenital deviations (par- ticularly anteflexion) ; extreme retroflexion or re- troversion of flabby uterus ; inflammatory swelling of endometrium (sounding very painful) ; un- yielding point or tumor (polypus or fibroid) in cervix or lower uterine wall. Treatment. — Divulsion and curet for cervical stenosis ; intrauterine stem or artificial os for ante- flexion ; remove polypus or fibroid and curet ; for vaginal or hymeneal obstruction incise, dilate and wear glass plug; specifics for syphilitic obstruc- tion. — Am. Text-book of Gynecology. Incise stricture and wear large intrauterine stem till healed. — Crockett. Congestive or Inflammatory. — Soreness or sud- den burning or throbbing pain in pelvis or lower PELVIC PAIN 219 back, radiating up and down (may be confined to ovary in ovarian type) — if uterine, pain mainly central and begins with flow — if ovarian, pain chiefly iliac, beginning usually some days before flow, ovaries tender, enlarged, prolapsed; mam- mae tender and painful; flow diminished; may be fever, headache, scanty urine or even delirium ; intermenstrual pains, leucorrhea, irritable bladder and other symptoms — general nervousness and depression marked in ovarian form; dysmenor- rhea usually preceded for a time by painless menses. Causes. — Delayed menstruation from "catching cold" or overexertion at menstrual period; in- flammatory diseases of uterus (fundus as a rule), adnexa (pain in salpingitis lasts through period), or pelvic tissues (particularly chronic peritonitis and ovaritis — dull pain radiating from tender, enlarged ovaries) ; cardiac valvular disease with venous stasis. Treatment, — Eemove cause; if congestion, scarify and use hot douches; if due to cold, give salines, diaphoretics and diuretics. — Am. Text- book of Gynecology. E. Ext. ergotse fl. m. lii; tinct. gelsemii m. vi; tinct. aconiti m. ii : Take every 2 to 4 hours. — Potter. Ovarian. — Wool-glycerin tampons; bromids be- fore flow; rest in bed after flow; pregnancy of 220 PAIN AND ITS INDICATIONS marked service; oophorectomy if organic ovarian lesions. — Am. Text-book of Surgery. Ovarian. — If flow too scanty, scarify cervix or apply 4 or 5 leeches. — Crockett. To relieve pain give codein and phenacetin or codein and antikamnia; high enemas of hot water. — Hawkins. Neuralgic or Rheumatic. — Pain irregular and variable as to time and severity, usually disap- pearing in 48 hours after onset of period; hyper- esthesia over lower abdomen and spine ; neuralgia elsewhere (Valleix's painful points) ; nervous or neuralgic temperament; local disorders absent or insignificant. Causes. — Neurasthenia, malnutrition, constipa- tion, uricemia; urethral caruncle. Treatment. — Correct constitutional dyscrasia ; coal-tar antipyretics with or without digitalis; a.piol 5 m. in capsules or tincture of pulsatilla m.v,t.i.d. for a week before flow; guaiac and so- dium salicylate for a week before flow in rheu- matic cases; rest in bed and warmth; if cerebral anemia give nitroglycerin and amyl nitrite till flushing; chloral hydrate gr. x hourly for 3 or 4 doses; for spasmodic pains, belladonna, hyoscy- amus or stramonium till mydriasis; general hot bath for 15 or 20 minutes. — Am. Text-book of Gynecology. Iron when flow is scanty and lacks color; ar- PELVIC PAIN 221 seiiio if too profuse, prolonged or frequent. — Fordyce Barker. Antipyrin, antikamnia., phenacetin, diaphoretics and salines always give more or less relief. Fluid ext. gelsemium m.v-x every 2 hours. — Bartholow. Spasmodic with pallor and coldness; glonoin with sufficient frequency to slightly flush face and overcome chilly feelings. — W. C. Abbott. Membranous. — Labor-like pains commencing with flow and increasing in severity, ceasing largely with shedding of membrainous shreds (no chorion villi) or triangular, shaggy cast of uter- ine cavity, followed by purulent or seropurulent discharge. Causes. — Exact cause unknown ; probably either a neurosis or an endometritis; most common in neurotic virgins and sterile women. Treatment. — Kepeated dilations, curettage and packing; applications of carbolic acid or zinc chlorid. — Am. Text-book of Gynecology. General tonic treatment of great importance — iron, arsenic, quinin, strychnin; coal-tar products for relief of pain; dilation and curettage some- times give temporary relief — after pack with iodo- form gauze and repeat packing several times; artificial menopause. — Crockett. Hysterical — No obstructive or inflammatory signs; visceral hyperesthesia; stigmata. 222 PAIN AND ITS INDICATIONS Treatment. — Galvanic current just strong enough to feel, with, kathode usually intrauterine, or plus pole over sensitive ovary and negative on back. — Eichard Lomer. Intermenstrual Pain. — When due to disease of fundus is referred to umbilicus — of cervix, to hypogastrium and sacrum. Severe and sudden in pelvic inflammations, pyosalpinx, tubal gestation, ruptured cyst or tor- sion of pedicle of ovarian tumor or cyst; sudden and referred to back from displacement or in- version of uterus due to fall or strain; general acute abdominal pain at onset of pelvic inflamma- tion ; iliac and shooting down thighs in congestion or inflammation of uterine appendages and in neurasthenia; bearing down or pelvic aching, ful- ness and weight in pelvic congestion, uterine prolapse and retroversion; with tenesmus during action of bowels from pressure on rectum by re- troverted uterus, inflammatory exudations, pelvic tumor (especially at back or left side), subperi- toneal myoma, pregnant uterus or parovarian or broad ligament cyst; bearing-down pain in back passage due to anal fissure or hemorrhoids (con- stipation or pelvic congestion). Chronic endome- tritis and uterine displacements show a history of several years duration; new growths, a gradual onset; tubal disease, chronic ill health with peri- odic exacerbations. PELVIC PAIN 323 Cirrhotic ovaries may cause regular intermen- strual pain, usually about midway between menses. Treatment. — Much the same as for ovarian dysmenorrhea; remove cause if possible. 224 PAIN AND ITS INDICATIONS CHAPTER IX. GENITO-URINARY PAIN. General Characteristics. — Caused mostly by diseases of bladder, prostatic urethra and blocking of ureter. Constant in organic diseases, particularly ul- ceration and carcinoma. Crampy from muscular effort or straining of inflamed surfaces. Aching and rheumatoid in renal congestion. Burning in prostatocystitis. Shooting, lancinating, in rectal and vesical neuralgia, from gout, anemia, malaria or lead poisoning. Paroxysmal, tearing, griping, lancinating in renal colic. Steady, wearing, with spasmodic exacerba- tions in vesical carcinoma; may be painless until cystitis or infiltration of muscles. Constant, burning, with reflexes to rectum, anus, perineum, inner thigh, in tubercular ul- ceration of trigonum. Continuous and increased by motion, with violent retention exacerbations, in calculous pyelitis, acute hydronephrosis or blood clots in pelvis of kidney. GENITO-URINARY PAIN. 225 Intermittent, chiefly at the end of urination, in vesical calculus. Violent Colic in ureteral inflammation due to stoppage and tension on renal capsule. Very little pain in chronic cystitis — very in- tense in acute cystitis and acute retention. Dysuria particularly in vesical diseases, but may be caused by renal or urethral disorders, ir- ritating urine or any high fever. Neuralgias and anginoid seizures common in Bright's disease. DIFFUSED SUPRAPUBIC. Constant. — Unrelieved atonies. — Distended bladder. Chronic Prostatitis. — Prostate tender and en- larged; difficult micturition. Advanced Carcinoma of Posterior Wall and Base of IV adder. — Steady, wearing or lancinat- ing pain — may be absent till late; unprovoked attacks of profuse hematuria.v Treatment. — Early eradication if possible. All Extra-V esical Inflammations. — Abscess, pericystitis, perforating apical carcinoma, etc. Primary Ureteritis. — Eare; pain along course of ureter and tenderness on palpation. Treatment. — Rest in bed; render urine bland with potassium bicarbonate; abundance of drink- ins; water and diet of milk and gruels. 22fi PAIN AND ITS INDICATIONS Transient. — Relieved by Micturition. Moderate Prostatic Enlargement. — Started by micturition. Cystitis. — All grades relieved by micturition. Acute. — Pain deep in pelvis, radiating up- ward; burning, tenderness, frequent micturition and tenesmus. Treatment. — Ammonium benzoate gr. x, 3 or 4 times a day in infusion of buehu; saline laxa- tives; liquid, non-stimulating diet; diaphoretics. — Skene. Pi. Tinct. opii deod. m. ii; tinct. hyos. m. viiss ; potassii acetat. gr. iv ; aquam q. s. : A teaspoonful every 4 hours. — Fleming. Iodoform pencil introduced into bladder may relieve pain and irritation in gonorrheal and tu- bercular forms. — Richard Lomer. Oil of sandalwood m. x in capsules every 2 hours, decreasing dose as symptoms improve ; also borax 4 gr. with benzoic acid 3 gr. every 4 hours till urine is acid. — Baldwin. Women. — Irrigate with hot solution of potas- sium permanganate gr. f to the pint, or mercuric chlorid of the same strength, or silver nitrate gr. i-iv ad. oz. i. — Am. Text-book of Gynecology. Rest in bed in warm room; open bowels; diet of liquids and soft foods; no stimulants; vaginal douches lasting 15 or 20 minutes t.i.d. ; hot ap- plications on lower abdomen; hot sitz-baths and GENITO-URINARY PAIN. 227 dry, hot bran bags; morphin hypodermically if necessary to produce sleep ; codein or supposi- tories of hyoscyamus and belladonna or occasional rectal enema of 30 drops of deodorized tinct. opium in 100 to 120 Cc. of warm starch water in intervals; convalescence greatly promoted by washing out bladder 2 or 3 times daily with luke- warm water containing 2 per cent boric acid or ichthyol. — Kelly. Following Catheterization. — Irrigate bladder with a pint (if patient will bear this much) of boiled water containing 2 dr. chloral hydrate; pass or draw off in 3 to 5 minutes; repeat appli- cation from 1 to 3 times a day. — G. Law. Exfoliative. — Due to retroflexion of gravid uterus, protracted labor, myoma choking pelvis and retention of urine; frequent, straining mic- turition, with overdistention and often dribbling; urine turbid and fetid and cofttains pieces of membrane. Treatment. — Treat cause (reduce uterine flex- ion, under anesthetic if need be, and keep in place with vaginal pack) and catheterize if neces- sary; after early acute symptoms, wash out blad- der 2 or 3 times daily with warm boric acid so- lution till urine normal. — Kelly. Chronic. — Pain slight and variable; pyuria and vesical epithelium; often triple phosphates. Treatment. — Salol, 45-75 gr. daily in divided 22S PAIN AND ITS INDICATIONS closes: fluid e.\t. zea mais in \ dr. dose best drug to allay irritation of bladder; milk diet; vesical irrigation with mercuric chlorid (1 : 100,000 up to 1 :5,000) in uormal saline solution, alternating daily or twice a day with boric acid solution; direct topical application to diseased patches of 5% silver nitrate, followed by 3% every 4 or 5 days; vesical balloon smeared with sterilized 10% ichthyol gelatin, left in bladder for 10 to 20 minutes. — H. Kelly. Senile. — R. Ext. hydrastis n\, m. iv; tinct. gent. comp. m. viii; tinct. staphisag. m. ii; tinct. cannabis ind. m. ii; syr. aurantii q. s. : A tea- spoonful t.i.d. — Hopkins. Irritable Bladder. — Symptoms similar to cys- titis, but no pus or objective signs. Treatment. — Atropin sulphate gr. ] / 120 before each meal. — Goodell. Hyperemia of Trigonum. — Apply to red patches 5 to 10% sol. silver nitrate (through Kelly's cystoscope No. 10), repeated every 5, 6 or 7 days. — Hiram N". Vineberg. Puerperal. — Ten gr. salol and 10 m. tinct. hyoscyamus in a tablespoonful of infusion of buchu t.i.d. — Fothergill. Of Chronic Endometritis. — R. Tinct. bella- donnas m. iv ; liq. potas. m. xv ; aquam q. s. : A teaspoonful in a wineglassful of water t.i.d. be- tween meals. — Garrigues. GENITO-UKINAKY PAIN. 22'.) Of Ovarian Disorders. — Ovary enlarged and tender; pain radiates down thigh. Treatment. — Potassium bromid ; teacupful of warm hop tea containing 20-40 drops of lauda- num by rectum; counterirritation and attention to general health. — Skene. Hysterical. — Psychical origin ; hyperesthesia of one side of abdomen and other stigmata. Treatment. — Suggestive treatment, reinforced by galvanism, hydrotherapy and Blaud's pill. Malarial. — Periodic ; abrupt. Treatment— Quinin. Vesical Tuberculosis. — Increasing frequency of micturition, with pain and tenesmus; cysto- scope shows red patches studded with tubercles; tubercle bacilli in sediment in early stage. Treatment. — Copious instillations of ichthyol in 1 to 4% aqueous solution. — M. Nogues. Iodoform emulsion 5 to 10% with glycerin, acacia and water, injected into bladder and ap- plied evenly to whole surface under moderate pressure with Clark's balloon every 2 or 3 days; topical application through speculum of silver nitrate (20% to solid stick), then filling balloon with water and washing out repeatedly; curet- tage, cauterization or excision in obstinate cases. —Kelly. Prostatitis. — Certain forms, especially onan- itic. 230 PAIN AND ITS INDICATIONS Increased by micturition. — Cramp of a Semitoneless Bladder. — From .stricture or per- haps sarcoma of prostate; bearing down pains. Cystalgia. — Neuralgia of bladder; from ureth- ral stricture or caruncle, anal fissure, gout, sciat- ica or ulceration. Treatment. — Gentle passage of soft bougie or conical steel sound into bladder every 4 to 10 days to put deep urethra on stretch; injections of deep urethra with silver nitrate (gr. i-x ad. oz. 1) ; mineral waters, alkalies and tonic remedies. — Keyes. Benign Tumors of Bladder. — Recurrent, un- provoked, profuse hematuria; may be portions of growth in urinary sediment ; papilloma, fibro- ma adenoma, myoma; cystic follicles, dermoid cysts, myxoma. Treatment. — Eradicate by operation whenever possible; as palliative for pain use instillations of cocain or morphin hypodermically. — White and Martin. PERINEAL. Constant. — Chronic Prostatitis. — Weight, aching and burning; enlarged and tender pros- tate. Treatment. — Patient urinates and lies down with head and shoulders elevated; pass soft rub- ber or woven silk catheter; with Ultzmann hard rubber syringe throw medicated fluid (-1 to 8 oz.) GENITO-URINARY PAIN. 2ol slowly and gently into urethra till bladder feels full, when patient passes out liquid ; fluids should always be warm. Solution 1= alum and zinc sulphate of each 2 parts, distilled water 500 parts — dilute with 3 parts of warm boiled water and inject, increasing strength daily till equal parts are used. Solution 2= potassium permanga- nate 1 part in 500 distilled water — dilute as be- fore, giving injection every other day. Solution 3= silver nitrate 1 :500 — increase strength slow- ly and tentatively. — Hayden. Prostatic Calculi. — Symptoms of chronic pros- tatitis or posterior urethritis; rectal palpation, grating with sound, urethroscopy. Treatment. — Eemoval with urethral forceps or by perineal urethrotomy; avoid constipation and sexual or alcoholic excesses. — White and Martin. Painful and difficult urination, with hematuria and radiating pains; retention of urine; rectal tenesmus; hard, nodular growth felt by rectum; cachexia. Treatment. — Catheterization or suprapubic drainage; opium or morphin hypodermically or by rectum. — White and Martin. Commencing Senile Prostatic Enlargement. — Micturition frequent, especially at night ; full but feeble stream. Treatment. — Hygienic measure; ergot, salol, 3oa PAIN AND ITS INDICATIONS boric arid, belladonna, bromids; sodium Lodid, ;j gr. t.i.d., to retard arteriosclerosis; hyoscin or hyoscyamin as sedative for micturition; svste- matic dilation with full-sized steel sounds (10 or 15 minutes every 5th day) in early stage of hypertrophy: systematic catheterization once daily for 3 oz. residual urine — twice a day for 6 oz. ; rectal irrigation with hot or cold water or normal saline solution; daily prostatic massage per rectum for 5 or 10 minutes in chronic in- flammation : prostatotomy, prostatectomy, castra- tion, vasectomy or suprapubic drainage. — White and Martin. Sodium phosphate, hyoscyamus, kava kava, triticum repens and uva ursi; sitz-baths; rectal injections of hot saline solutions. — J. B. Murphy. Encysted Calculus at Base of Bladder. — Pain radiating from neck of bladder, sharply increased at end of micturition ; obstinate cystitis and hem- aturia. Treatment. — Litholopaxy (crushing and evac- uation with Bigelow's evacuator) or perineal or suprapubic cystotomy; preliminary rest in bed for 2 or 3 days, with salines for bowels, milk diet, diluents; salol and boric acid for urine. — White and Martin. Prevention. — Regulation of stomach; syste- matic exercise; salines morning and evening for bowels ; occasional stimulation of liver with GENITOURINARY PAIN. 233 small doses of calomel or blue pill; abundance of water or bland liquids; plenty of salt with food; salicylic acid or potassium salts or 15 gr. piper- azin in a pint of water in divided doses during day if gravel formation; full doses of potassium citrate for uric acid trouble ; tonics and nitrohy- drochloric acid for phosphaturia ; regular cathet- erization if obstruction to free evacuation of urine; antiseptics by mouth and locally for cys- titis. — White and Martin. Transient. — Believed by micturition. Acute Prostatitis. — Heat, weight and burning pain much increased by defecation; prostate hot, doughy, enlarged and tender; prostatorrhea. Treatment. — Bed ; milk diet ; ^ dr. potassium citrate and fluid ext. kava kava in water 2 hours after meals and at night. — Hayden. Jy Tinct. aconit., m. iiss. ; tinct. gelsemii, m. v. ; antipyrin, gr. v ; ext. ergotae, fi.m xx ; aquam, q. s. : A dessert spoonful every two or three hours in a winegiassful of water. — J. A. M. A. Use of o or 10 grain ichthyol suppositories. — Freundenberg. Rectal suppositories, each composed of 10-20 gr. ichthyol, 1 gr. opium and ^ gr. belladonna. — Leuf. Irritable Prostate of Gouty Persons. — Same symptoms as in acute prostatitis, but no pus or 234 PAIN AND ITS INDICATIONS enlargement of gland; worse at night; hyper- acid urine. Treatment. — K. Potassii bicarb., potassii cit. aa : gr. viii ; syr. simp. q. p.: A teaspoonful in a half tumblerful of water, adding 2 drams of lemon juice and drinking while effervescing. — Skene. Tubercular Prostate. — Symptoms of chronic prostatitis; tubercle bacilli in discharge milked from prostate ; gland thickened, nodular or with points of softening. Treatment. — Improve general health ; instilla- tion of mercuric chlorid (1:6000) if infiltration begins in urethra or ducts of glands; parenchy- matous injection of 10% iodoform-glycerin emul- sion introduced through perineum by long needle guided by finger in rectum (10 to 15 drops every 3 to 5 days) ; incision, curettage and iodoform Quiescent Stage of Tubercular Disease of Bladder Base. Increased by micturition. — Suburethral Abscess. Inflamed Stricture. Impacted Urethral Stone. Carcinoma of Bulb. Active Catarrh or Tubercular Ulceration of Bladder Behind Trigone Calculus. — Encysted at vesical base or low down on posterior wall or pouched behind upper part of prostate. GENITOURINARY PAIN. 235 Extravasation of Urine. — Suddenly developed fluctuating tumor, with smarting or burning pain at seat of rupture; sloughing; sepsis. Treatment. — Prevent further extravasation by external perineal urethrotomy or perineal section, dividing stricture thoroughly; drain entire in- filtrated areas by long multiple incisions, squeeze out urine and wash with 1:4000 bichlorid; dress cuts with iodoform, pack loosely with iodoform gauze and cover with hot bichlorid compresses, changed every two hours. — White and Martin. Seminal Vesiculitis. — Constant or shooting pains in perineum, hypogastrium and anus, often referred to hip-joint and down thigh; often pain- ful erections with emission of blood-stained semen; rectal examination shows swollen, hot, tender vesicle; usually gonorrhea. Treatment. — Milk ducts every 5 to 7 days; hot rectal injections; bipolar rectal and inguinal faradism; non-stimulating diet; non-alcoholic tonics. — Bransford Lewis. Acute Seminal Vesiculitis. — Eest and freedom from sexual excitement; bland diet, alkaline dilu- ents and mild laxatives, with hot sitz-baths or hot applications to perineum; if abscess forms evacuate by rectal incision. — Chetwood. URETHRAL. Irritable Urethra. — A neurosis. Treatment. — Dilate urethra. — Baldy. 236 PAIN AND ITS INDICATIONS Acute Urethritis. — Discharge in specific Oorm contains gonococci. Treatment. — Acute: To abort apply with meatoscope silver nitrate gr. xv ad. oz. i to first inch of urethra. — Taylor. Hot quart irrigation with potassium per- manganate solution in water (begin with 1 :6- 000; increase by 7th or 14th day to 1:2000); hold syringe 2 feet above level of bladder for anterior urethra — 4 or 5 feet for total urethritis; give as often as need be to prevent recurrence of purulent discharge. — White and Martin. Methylene blue 1 or 2 grains with 3 m. oil of sandal, 3 m. oleoresin of copaiba and 1 m. oil of cinnamon in capsules t.i.d. Total. — Irrigation back to bladder with 1:500 silver nitrate, using short meatus nozzle — inject after urinating, then urinate again; this treat- ment contraindicated in hyperacute cases — is es- pecially rapidly curative in chronic cases not de- pendent on stricture. — Edward Martin. Wyeth Method. — Irrigate as soon as diag- nosed twice daily with 2 quarts of hot 1 :3000 potassium permanganate solution (1 dr. to 6 oz. water — a tablespoonful to the quart) ; hang foun- tain syringe about 3 feet above level of urethra; use in males standing, females tying; if urethra very sensitive, inject previously 1 to 3 dr. of 2% cocain solution ; use small-caliber glass catheter GENITO-URINARY TAIN. 237 with 2 or -'] lateral perforations near closed cud (ordinary female catheter answers) ; lubricate catheter with glycerin, not oil or vaselin ; hot hi]) bath morning and evening; avoid stimu- lating drinks and spicy foods; have bowels moved once daily; warn patient of danger to eyes (let him wash hands with 1:500 bichlorid) ; catch discharge in bag of oiled silk, rubber or thick cloth ; internally give salol 1 part with 2 parts oil of wintergreen — 20 drops 4 times a day, preferably in capsules; also citrate of potash, gr. xx-xxx 4 times a day for first week; this treat- ment cures without complications in from 6 to 25 days. Lafayette Mixture. — E. Bals. copaiba?, spt. lavand. co., spt. eth. nitrosi aa.m.xv; liq. potassii m.ii ; olei gaulth. m.viii ; mucil. acacia? q. s. : A dessertspoonful t.i.d. after meals. — Martin and White. Acute Gonorrhea. — In all stages: E. Hy- drarg. chlor. corros. gr.ss. acidi carbol. gr.xii; zinci sulphocarbol. gr.xii-lx; boroglycerid (25 %) f. oz. ii; aquae ad. oz. vi: Inject after urination, making stronger or weaker according to indications. — White and Martin. Acute Gonorrhea. — Injections (anterior ureth- ra only to 10th day of disease) of a mixture of 5 gr. of yellow muriate of hydrastin and pro- targol, £ dr. glycerin and water to make an 888 PAIN AND ITS INDICATIONS ounce — use 4 to 6 times daily, retaining fluid 5 to 10 minutes and preceding injection by a hot- water Hush. When .symptoms indicate extension to deep urethra (usually not before 8th day) in- ject entire urethra, using at least an ounce for each injection. — Belfield. To Prevent Chordee. — Two or three pills of camphor (2-\ gr.) and opium (^ gr.) every night. — Ricord. Gonorrhea of Skene's Ducts. — Thiol in full strength applied to inside of duct with cotton on filiform bougie. — A. B. Tucker. Vulvar. — Perfect quiet; wash parts w r ith boric acid of 1:4000 mercuric chlorid, then dust with mixture of calomel and bismuth and keep piece of cotton between labia. — Horwitz. Acute Urethritis of Women. — Usually due to gonorrhea or foreign body; persistent intense burning; frequent, painful urination; sometimes discharge of blood; milk out pus and examine for gonococci. Treatment. — Rest in bed; frequent hot vag- inal douches; bathe parts externally with lead water and laudanum; belladonna or opium sup- positories; iodoform suppositories once daily after acute stage has subsided. — Kelly. Simple Urethritis in Females. — Irrigate with hot water and double catheter, followed by thor- ough application with applicator of silver nitrate GENITO-URINARY PAIN. 23i» 80 gr. to oz. 3 or 4 times, then dry and make final application; if tissue whitens carry in salt water. — Ifobt. C. Harris. Chronic Urethritis or Gleet. — Occasional neuralgic urethral, perineal or pelvic pains; "morning drop" of pus or muco-pus. Treatment. — Galvanization of granular patches for 5 minutes every 4 days, using Otis' insulat- ed sound and 2 to 5 m.a. of current. — J. M. Blaine. Local application of 25% ichthyol salve by means of fenestrated steel sound. — A. Eavogli. Chronic of Women. — Commonest in prosti- tutes; diffuse form marked by small abscesses (of Skene's glands particularly) with deeply in- jected livid or grayish mucosa; circumscribed form shows groups of yellow points surrounded by reddened area and perhaps scar streaks. Treatment. — Expose affected areas and apply 3 to 5% solution of silver nitrate every 3rd or 5th day; empty Skene's glands daily by pres- sure from above downward on each side of ureth- ra; apply ichthyol in glycerin (1 to 10 or 1 to 5) by means of absorbent cotton on fine rough- ened applicator. — Kelly. Urethral Stricture. — Frequent, difficult urina- tion, with dribbling ; best diagnosed with bougies a boule. -1" PAIN AND ITS INDICATIONS Treatment. — Inflammatory: Same as for acute anterior urethritis. Spasmodic. — Treat special cause (organic stric- ture, uric acid, sexual excesses, etc.); full-sized sounds at regular intervals. — White and Martin. Organic. — Gradual or continuous dilatation; internal urethrotomy; external urethrotomy; combined urethrotomy; perineal section, divul- sion, electrolysis, etc. — White and Martin. In Women. — Difficulty and pain in micturi- t ion ; best detected with olive-point bougies ; com- monly of gonorrheal origin. Treatment. — For cancerous eatheterize regular- ly or make a vesico-vaginal fistula; for syphilitic, potassium iodid; for cicatricial contraction of an- terior vaginal wall, make multiple incisions or dissect out scar, leaving catheter in bladder 4 or 5 days; for other strictures dilate gradually up to No. 10.— Kelly. Foreign Bodies or Calculi. — History; grating; obstruction to urination. Treatment. — Remove with urethral forceps and urethroscope, or push stone back into bladder, crush and evacuate, or cut down on and remove. — White and Martin. Coivperitis. — Resembles prostatitis; deep, ten- der, pea-sized perineal tumor; complicates gon- orrhea. Treatment. — Rest in bed; prolonged hot baths; GENIT, Causes. Incubation. . . Number and ■Location. . . Conformation, Secretion. . . . Palpation Course Complications Chancre. Discharge from syphilitic lesion. 10 days to 8 weeks — average 3 weeks. Usually single and anywhere on geni- talia. Round, oval or symmetric erosion, papule, tubercle or ulcer (usually superficial, cup-shaped), with smooth, glazed, dusky red surface. Scanty, serous, hardly ever autoinocu- ^ lable. Cartilaginous or parchment-like i}idura- tion, sharply circumscribed and mov- able; sore seldom sensitive. Often spontaneous healing — hastened by specific treatment. Bubo constant, small, hard, multifile, painless, non-adherent, usually bilat- eral — appears a week after chancre; hard, beaded cord of dorsal lym- phangitis. Inoculation discharge Indefinite Often mu nearly a Round, ov "punchec "worm-e; pultaceot Copious, f lable. Boggy fee adherent pressure; Variable a Bubo in o utely in and usur lying sk hot; pa phageder Causes. Incubation. . . Number and Location. . . Conformation, Secretion. . . . Palpation .... Course Complications Balanitis and Posthitis. Dirt and unclean discharges; friction phimosis. Absent. Usually multiple, on glans or inner surface of foreskin or both. Hot and itchy redness about end of penis, becoming superficial, irregular or circinate erosions and ulceration of preputial orifice; thick, offensive coating of crusts. Thick, creamy, profuse and highly of- fensive; often autoinoculable. Diffuse edema and inflammatory infil- tration, usually quite painful. May be progressive and last for several weeks. Occasionally bubo — rarely suppurating. Venerea Specific or long con Indefinite Usually m m em!) ran Marked bj mentous pink in brown ir forming cockscom Slight amo Rarely h< nearly o Spontaneou clean. Vary with SORES Chancroid. nth pus or chancroidal iod. le (opposing surfaces) ; js on prepuce or glans. jr symmetric pustule or ut" ulcer with uneven, " surface and grayish lough. lent, readily autoinocu- lading off into adjacent sues; change in shape on ten painful, relapsive. hird of cases — large, ac- ed, tender and painful single, adherent to over- which is often red and il dorsal lymphangitis ; Herpes Progenitalis. Intercourse or acrid discharges; cold and fevers. Absent. Multiple and often coalescing — gener- ally on glans and inner layer of prepuce. Groups of irregular, superficial, clear vesicles with polycyclic or serrated border, soon becoming pustules and then ulcers with bright red granula- tions and sometimes pseudo-mem- brane. Small serous drops exude on squeezing sore. Often painful and sensitive. Tends to recur in crops. Rarely single inflammatory bubo; neuralgia often precedes eruption. r ARTS OR PAPILLOMATA. i-specific acrid discharges ed. 3d. >le, on skin or mucous iscular tuberous or fila- -escences (moist, soft and tected parts — dry, hard, rts exposed to air), often spberry, cauliflower or egetations. on mucous surfaces. formations; growths uite painless, disappearance if kept raary disease. Epithelioma. Local irritation and senility predispose. Insidious onset. Glans or prepuce as a rule; always single. At first like a small venereal wart, soon becoming indurated, forming irregu- larly excavated ulcer with hard, edematous margins, and may be lob- ulated nodular conglomeration. Foul and fetid in advanced stages. Infiltrated _ base and borders; only slight pain till far advanced. Fatal in a few months or years. Infiltration of inguinal glands with late ulceration and discharge of san- ious pus. GENITOURINARY PAIN. 241 laxative or saline purge; hot water bag to peri- neum or morphin hypodermically in perineum ; cut into abscess or urethral extravasation at once, curette and pack with iodoform gauze, guarding against fistula by permanent catheterization. — White and Martin. Follicular and Periurethral Abscess. — Distinct, small, rounded, tender follicular nodules on un- der surface of urethra; pus commonly evacuates externally; rapid increase in pain, especially on urination, and swelling if urinary extravasation. Treatment. — Gentle pressure and massage to open duct; cloths wet with alcohol and diluted lead water about penis; curette and pack with iodoform gauze if softening or sinus ; evacuate at once and use permanent catheterization for periurethral abscess. — White and Martin. Suburethral Abscess. — Symmetric, rounded, ex- tremely tender swelling of anterior vaginal wall "beneath urethra; can be emptied by milking with finger; painful micturition, dyspareunia, and sense of foreign body in vagina; discharge of pus from urethra. Treatment. — Longitudinal incision of sac un- der cocain; paint sac wall with strong tincture of iodin and pack with lint. — Kelly. Urethral Caruncle. — Much local and radiating pain during urination and coitus ; florid or dusky red, very sensitive excrescence at urethral orifice. 342 PAIN AND ITS INDICATIONS Treatment. — Complete extirpation with knife approximating tissues with fine continuous cat guf suture to cover raw surface as growth is cut away. — Kelly. Rupture of I rethra. — Direct trauma; sudden hemorrhage, pain and swelling. Treatment. — In least serious cases pressure, hoi antiseptic compresses, miliary antiseptics, rest in bed, free purgation and mild antiseptic urethral irrigation; in severer cases check hemorrhage by cold and pressure, pass catheter after washing urethra with boric acid and leave in place, irri- gating bladder and urethra by side of catheter twice daily with ■£% boric aeid solution; if cathe- ter cannot be passed readily or if urinary ex- travasation and cellulitis, make perineal section. - — White and Martin. Prolapse of Urethral Mucosa. — Dysuria, fol- lowed by sharp pain, bleeding and difficulty in walking; small elevation or tender Vi'il zone in urethral opening; young girls and old women mo.-lly. Treatment. — Uest in bed; wearing of com- press; excise with scissors and suture with cat- gut. — Doctors' Magazine. Chancre. — See table. Treatment. — 1\. Hydrarg. bichlor., gr. L-10; ziuci sulphocarbol., 'j:v. xx; ext. opii aq., ^w .\ii; aquae rosse, oz. iv: Apply by means of pledget GENITOURINARY PAIN. 243 of cotton, changing every two hours; dilute if painful; if granulations sluggish, touch daily with 5 per cent, silver nitrate; cauterize with nitric acid or acid mercuric nitrate, if ulceration extending; iodoform most serviceable, dry pow- der (in mild lesions) may be applied in collo- dion — 10 per cent, iodoform, 1 per cent, sub- limate. — White and Martin. Chancroid. — See table. Treatment. — Wash thoroughly with soap and water, spray with hydrogen peroxid, then wash or spray with carbolic acid 1 :60 or bichlorid 1 :3000, then use either nonirritant antiseptic ap- plications or cauterizants. Chancroids in Females. — Destroy with undi- luted carbolic or nitric acid or Paquelin cautery under cocain; keep parts covered with pledgets of lint or cotton dipped in a solution of 20 to 40 m. carbolic acid, -| oz. glycerin and water to make 4 oz. ; use vaginal injections of borax or sodium bicarbonate, followed by mercuric chlorid (1:5000) several times daily; give tonics and stimulants if phagedenic. — Garrigues. Cauterization. — White heat of heated iron, Paquelin's, or galvano-cautery, or nitric acid, after thorough cleansing and anesthesia with spray of 10 per cent, cocain and hypodermic injection of 1 per cent, cocain, 10 drops driven into cellular tiisue around base of lesion ; cleanse again thor- 244 PAIN AND ITS INDICATIONS oughly, dust with iodoform and protect with ab- sorbent cotton; combat inflammatory swelling with strips of lint, wrung out of dilute lead water and alcohol, equal parts. — While and Martin. Herpes.-*-See table. Treatment. — Antiseptic washings, careful dry- ing, painting with silver nitrate dusting with zinc oxid or bismuth; interpose thin layer of cot- ton between mucous surfaces; for pain of neural- gic form, apply mixture of L2 gr. cocain, 1 gr. menthol and 1 dr. lanolin, or try galvanic cur- rent. — White and Martin. Bala n it is. — See table. Treatment. — Wash with mild antiseptic, dry with absorbent cotton and brush erosion with 10 per cent, silver nitrate solution; then dress with equal parts of bismuth and calomel, place thin layer of cotton over glans and draw foreskin for- ward, changing this dressing several times daily. — White and Martin. Venereal Warts or Pa [Alio mala. — Sec table. Treatment. — Complete removal with scissors under cocain. followed by cauterization with pure carbolic acid and dressing with iodoform. — White and Martin. Epithelioma. — See table. Treatment. — Total excision of involved area and cauterization of wound with caustic potash if slightly developed : amputation and removal GENITOURINARY PAIN. 245 of enlarged lymph glands if at all extensive. — White and Martin. Paraphimosis. — Prepuce retracted and fixed be- hind glans; great and rapid swelling of parts and severe pain. Treatment. — Keduce at once, unless not serious and a result of previously existing inflammation (evaporating lotions, rest and elevation of parts), or reduce after use of ice-bag for half an hour or after use of rubber band with aid of grooved director; if necessary reduce under ether after puncturing thick, edematous collor in many places with needle and lubricating with carbolized oil ; seize glans and draw forward, at same time drawing prepuce over glans; if glans purple-black or mottled and cold, divide constrict- ing band immediately, draw foreskin forward and apply for a few minutes for a long time hot com- presses wrung out in mild antiseptic lotions. — White and Martin. Inflammatory Lymphangitis of Penis. — Usu- ally secondary to peripheral venereal disease; in- durated hand (can be lifted up) often felt ex- tending along dorsum of penis to first lymph glands. Treatment. — Best in bed; evaporating lotions; salines. — White and Martin. Constant pain in prostatorrhea, catarrh of 24<) PAIN AND ITS INDICATIONS prostatic canal, swollen verumontanum, and en- larged median or lateral lobe oi' prostate. Transient. — Before micturition in clot reten- tion or senile prostatic obstruction. During micturition from local lesions; inflam- mation, granular patch, ulceration, wart, narrow meatus, or phimosis. After micturition from stone in bladder, tu- bercular or other ulceration of posterior or lateral bladder, all forms of acute cystitis, especially at neck, vesical growth engaging in or impinging on urethral orifice, acute prostatitis, inflamed senile or onanitic prostate, severe vesical spasm of renal origin, renal tubercle or colic, and ure- teral block or kink, as in floating kidney. INTRASCROTAL PAIN T . Direct. — Orchitis. — Testicular pain, heat, and swelling; commonly of gonorrheal origin, some- times from acute infections; chronic swelling, generally painless and syphilitic. Treatment. — Eest in bed; elevate pelvis and testicles; evaporating lotions or ice-bag or hot fo- mentations; liquid stools; febrifuges, diuretics; morphin hypodermically for severe pain; this fail- ing, make multiple punctures of tunica albuginea, with straight cataract knife; when out of bed (two or three weeks ordinarily) wear carefully fitted pressure suspensory bandage; early free in- GENITO-URINARY PAIN. 247 cision of abscess, followed by irrigation and gauze packing. — White and Martin. Apply a solution of 2 dr. ammonium ehlorid in 2 oz. each of alcohol and water constantly to in- flamed testicle. Spray 2 per cent, carbolic acid on part with steam atomizer. Envelop testicles and cord in 30 per cent, ich- fchyol ointment and elevate; give 10 m. pulsatilla every hour; strap later with gauze bandage and a pply su spen sory . Fluid ext. phytolacca, m. v. in water every two hours. — Med. Age. Ointment composed of 1 part guaiacol to 6 of vaselin. Thick paste of bismuth subnitrate. — Med. Times. Pilocarpin -| gr. and codein | gr. every two to six hours, as needed, to produce copious sweat- ing and relieve pain. — S. Plarnsberger. Contusion of Testicle. — Faintness or shock; in- tense, sickening pain, followed by constant ach- ing, retraction of testis and swelling. Treatment. — Morphin injection ; rest on back with pelvis elevated and scrotum supported by pillow or handkerchief bandage; apply cloths constantly wet with lead water and laudanum, or small ice-bag (for three or four days, with piece of lint underneath) ; or hot compresses wrung nut of dilute lead water and changed every fif- 2 i 3 PAIN AND ITS INDICATIONS teen minutes; wear suspensory bandage for a month; also use small doses of potassium iodid ,iikI mild counterirritation to skin of scrotum. — While and Martin. Tubercular Disease of Testicle and Epididymis. Apparently causeless outbreak of acute inflam- mation; tubercular infiltration of prostate and seminal vesicles; persistence <>t' swelling after pain and other acute symptoms have subsided; formation of nodules, which break down. Leaving fistula; discharge contains tubercle bacilli. Treatment. — Palliative treatmenl includes ton- ic- and supporting measures and pressure suspen- sory bandage; radical: incision, scraping and packing, or partial excision, or injections every third or fourth day of 10 per cent, iodoform in glycerin — 5-15 in., driven into mass at a number of points, pressing needle punctures with iodo- form collodion and supporting testis, with pres- sure suspensory bandage: castration in advanced cases. — White and Martin. Neuralgia of Testicles. — Continuous or inter- mittent pain the only symptom : testicles extreme- ly sensitive, testes may become hard during par- oxysms; trouble may result from previous inflam- mation, hernia, gout, rheumatism, toxemia or varicose spermatic veins. Treatment. — Pressure suspensory bandage; lo- cal beat or hold: counterirritation; freeze over- GENITOURINARY PAIN. 249 lying skin with methyl chlorid; blisters, galvan- ism, ice-bag; internally aconitin, qninin, antipy- rin, acetanilid, exalgin, valerian, hyosein. — White and Martin. Gouty Testicular Pain of Old Men. — Local heat; colchiemn in full doses. Torsion of Testicle. — Sudden symptoms like epididymitis during active muscular exertion ; pain very severe if complete strangulation. Treatment. — Reduce by manipulation or opera- tion. — White and Martin. Benign Tumors of Testis. — Usually painless; fibroma, enchondroma, adenoma, dermoid or hydatid cysts; all comparatively slow of growth. Treatment. — Excision or castration. Malignant Tumors of Testis. — Sapid growth with adhesions; may be painless at first; car- cinoma begins as small, hard nodules, rapidly enlarging, with marked dilatation of internal and superficial blood vessels. Treatment. — Early castration. Epididymitis. — Aching or neuralgic radiating pain ; worse on standing ; rapid enlargement, with purple edema of back of scrotum; chills and fever; stooping, straddling gait; usually due to gonorrhea ; acute hydrocele accompanies. Treatment. — Rest in bed ; saline purge ; wrap testicle in lead water and laudanum and elevate with handkerchief bandage; hot compresses and 350 PAIN AND ITS INDICATIONS hoi water bag to inguinal region; properly fitted suspensory bandage strapped tightly in recum- bent position over thick sheet of absorbent cot- ton or woo] ; in severe case- puncture vaginal tunic and cellular tissue at back of scrotum (intro- duce knife not deeper than one-half inch), and then apply suspensory bandage or elevate testes with handkerchief; keep testicle constantly wet with lead water and laudanum on lint; leeches along side of cord if pain still unrelieved; incise if pus suspected and drain with iodoform gauze: strapping or suspensory bandage after acute symp- toms subside, followed later by application of ointment of iodoform, 1 part to 7 parts belladonna ointment. — White and Martin. Efrididymo-Orchitis from Strain. — Same treat- ment as for contusion of testicle. Funiculitis. — Cord hard and usually tender and painful: from trauma (phlegmonous), gonor- rhea, syphilis or tuberculosis (cord like a ro- sary). Treatment. — Rest, elevation and application of cold (evaporating lotions) ; if swelling threat- ens vitality of testicle, incision and drainage in- dicated. — White and Martin. Teratoma Testis. — Ovoid, clastic, sometimes slightly translucent cystoid tumor of testicle; en- tire sac not filled with fluid and testis cannot be made out after exploratory puncture. GENITO-URINARY PAIN. 251 Treatment. — Ablation of diseased organ. — F. R. Sturgis. Varicocele. — Dull ache and feeling of weight: soft mass like a bunch of earthworms, nearly al- ways on left side; testis soft or atrophied; may be melancholia and psychic impotence. Treatment. — Palliative; proper regulation of bowels; avoid violent muscular exercise or pro- longed standing; daily application of cold douches to overlying skin; properly fitted suspensory bandage. Radical. — Subcutaneous ligation of veins, or open incision, ligation and excision. — White and Martin. Hernia. — Smooth enlargement, narrower above than below, usually reducible into abdomen with gurgling sound; impulse on coughing unless strangulated; severe pain and inflammation when strangulated. Hydrocele. — Smooth, translucent, tense or fluc- tuating swelling — begins at testis ordinarily — at abdominal ring in hydrocele of cord. Treatment. — Acute: Rest, elevation of parts; evaporating lotions ; puncture if pain unbearable : later, suspensory bandage with mild absorbent ointments. — White and Martin. Acute of Cord. — Compresses wet in dilute lead water and alcohol held in place by crossed perineal gauze bandage. — White and Martin. 302 PAIN AND ITS INDICATIONS Hematocele. — Opaque and fluctuating or, later, hard, elastic swelling enveloping testis; follows trauma, tapping and chronic inflammations. Treatment. — Rest; elevation of parts; evapo- rating Lotions or ice-bag; if swelling rapid and progressive, remove clots through incision. — White and Martin. Pyocele. — Encysted collection of \>u>. usually tubercular, chronic and without inflammatory symptoms. Treatment. — Free incision, thorough curettage of lining walls, and maintenance of drainage till cavity is well filled with granulations, which iodo- form glycerin emulsion stimulates. — Eugene Ful- ler. Tumors of Cord. — Cystoma, lymphadenoma, lipoma, mixed enchondroma. Treatment. — Early operation; castration if tumor large and impossible to dissect free from structures of cord, and in malignant cases (with removal of as much cord as possible). — White and Martin. Referred Pain in Testicle. — Pyelitis (same side) ; renal colic (with retraction) ; urethral ob- struction ; seminal vesiculitis (neuralgic) ; exces- sive sexual indulgence: long-continued sexual ex- citement without relief ; rarely vesical and deep urethral inflammation: anal fissure or irritable rectal ulcer. GENITOURINARY PAIN. 253 Pain at Seat of Disease. — Before Micturition from neuroses, congestion or inflammation (ceasing after act) ; ulceration (es- pecially at vesical neck) ; full bladder (ceasing after act); acid, concentrated urine; rarely in diseases of renal pelvis or kidney (bilateral, dull aching in acute nephritis). During Micturition from inflammation of urethra, bladder or prostate, greatly aggravated by defecation. After Micturition from vesical stone (relieved by rest or dorsal position during act) ; vesical fissure, erosion, inflammation of tubercular ul- ceration. Constant or Intermittent, with no distinct lesions and usually nocturnal remissions in irri- table or neurotic bladder (sometimes a symptom prodromal of tabes ; for treatment, see above under suprapubic pain). Local Renal Pain from oxaluria or lithuria; see also renal pain under backache. Keferred Genito-Urinary Pain. — Renal Disease. — Groin, inner thigh, testis, healthy bladder and urethra, shoulder, calf, heel; small spot of tenderness to inner side of middle of Poupart's ligament after attack of renal colic. Vesical Disease. — Suprapubic or umbilical re- gion, sacrum, lower lumbar vertebras or synchon- droses, glandular urethra, groin, kidneys, peri- 254 PAIN AND ITS INDICATIONS ncum, anus, inner and sciatic regions of thigh, sole of foot; stone in bladder causes pain in urethra a little back of meatus; inflammation of trigonum causes itching, tickling and painful spasm of anal sphincter; any irritation of vesi- cal orifice may excite neuralgic pain from navel to bladder. More or less persistent post-scrotal pain in vesical tuberculosis. Prostatic Disease. — Same as bladder with ad- dition of heel. Testicular Disease. — Along groin. PROCTALGIA. CHAPTER X. PROCTALGIA. Provoked or aggravated by defecation; great tenesmus; blood and pus in stools. Hemorrhoids. — Venous variety most painful. Treatment. — E. Liq. plumbi subac., oz. i ; tinct. opii, dr. iv; a teaspoonful m a wineglassful of water; apply night and morning. — Allingham. External. — Palliative: Avoid stimulants and condiments; keep bowels open with Vichy, Hun- yadi, Friedriehshall, etc. ; calomel parvules for congested liver; frequent hot baths; wash parts with castile soap and water; if pile contains hard clot (thrombotic) apply frequently follow- ing lotion, either hot or cold : Morphin sulphate, gr. iii; calomel, gr. xii; vaseliri, oz. i; liq. plumbi subac, dr. iv; tinct. opii, dr. iiss; aquam dest., ad oz. iv; hot poultices relieve pain and reduce in- flammation . — Gant. Operative Treatment. — Thrombotic Variety : Incise, turn out clot, apply escharotie to inside and put patient in bed for several hours, keeping incision open with small pledget of cotton. — Gant. Inflamed External Hemorrhoids. — Apply 2 or 3 times a day an ointment consisting of 5-10 gr. 356 PAIN AND ITS INDICATIONS morphin sulphate, I dr. ichthyol and I dr. each of ung. belladonnae and ling, stramonii. — Tuttle. Cutaneous Variety: Seize tumor, after divul- sion, with t-atc-h-tooth forceps and snip oil' with curved scissors, taking care noi to remove more skin than is absolutely necessary, Tor I'm i of con- traction; if considerable space is left between skin and mucous mebrane, unite them with cat- gut sutures. — Gant. Internal. — Palliative: Reduce protruded tu- mors; correct errors in diet or living; recumbent position it' inflamed, applying constantly astrin- gent ointments or lotions or poultices; if not large or strangulated, apply pure nitric acid to bases; wear pile supporter; correct constipation. —Cant. Injection Treatment. — Only small, distinct, pendulous piles, situated above grasp of sphinc- ter muscle should be injected: Solution freshly prepared with 12 gr. carbolic acid, 1 dr. glycerin and 1 dr. water; inject only one or two piles at a sittings — 2 to 5 drops in small, ."> to 10 drops in large piles: leave needle in pendulous portion till pile turns white; as needle is withdrawn, make pressure with index linger; return all prolapsed piles; keep patient recumbent for a half hour afterward; only fluid or semifluid diet for a few days. — Gant. PROCTALGIA. 257 Hemorrhoids of Pregnancy. — Equal parts of sulphur and cream of tartar as a laxative. — Da Costa. Anal Fissure. — Smarting, burning pain after defecation ; fissure may be visible only when parts are put on stretch. Treatment. — E. Iodoformi, dr. i; ungt. bella- donnas, oz. ss; acidi carbol., gr. x; cosmolini, oz. ss. To be used daily. — Andrews. Mtrate of silver, 10 or 15 gr. to oz., to be re- peated two to six times; 6 per cent cocain on cotton will alleviate pain of application; cautery, divulsion, division or excision. — Gant. A 10-grain iodoform suppository half an hour before expected movement and just after it. — Lewis H. Adler. Paint fissure with 10% cocain and then dilate sphincters with Pratt's rectal dilators, beginning with smallest and increasing to largest size pa- tient can bear at each treatment, then apply 10% silver nitrate solution. Have patient return in 3 days and apply in the interval, twice daily after bathing with hot water, an ointment of 20 gr. orthoform and 2 dr. ichthyol to ounce of lanolin. — Wm. L. Dickinson. Rectal Ulcer. — Burning pain and sphincteris- mus on defecation; "sentinel" external pile; ul- cer usually near sphincter at back of rectum. Treatment. — Palliative measures: Simple diet; ~ : > s PAIN AND ITS INDICATIONS resl ; copious inject ions of warm water and cas- fcile soap, or carbolized water, at least twice a day; application of a mixture of 1 part balsam of Peru. 2 parts glycerin and 8 parts water; in- jections twice a week of silver nitrate, gr. xxv to 3 pints of water, or direct application to ulcer of silver nitrate. '20 gr. to ounce; astringent powders and ointments; etiologie treatment; di- vulsion, followed by applications of silver nitrate; for syphilitic dysentery or tuberculosis, use curet- tage, followed by stimulant or caustic, irrigation and to bed; division of base of ulcer sometimes useful. — Gant. Divulse rectal sphincter thoroughly; curet edges of ulcer; pack with iodoform or nosophen gauze — to be kept in from three to five days; hot wet compresses locally for post-operative sore- ness; after packing is removed treat ulcers with aristol or with 1 dr. bismuth subnitrate to the ounce of castor oil. — Buchtel. Hard Feces.— In women may be easily felt through vagina. Treatment. — Copious enema of soap and water, followed by salines. Fistula in Ano. — False opening into bowel with discharge, track of an unhealed abscess; often tuberculous. Treatment. — Pass grooved director through sinus and incise intervening tissues to surface; PROCTALGIA. 259 euret sinus, cut away diseased skin, irrigate with corrosive sublimate (1:1000), pack with iodo- form gauze and dress with gauze and a T-band- age; change dressings in 48 hours and every day thereafter till healing nearly complete, using hy- drogen peroxid, corrosive sublimate (1-5000) and iodoform. — J. C. Da Costa. Proctitis. — Eectal weight and fulness, tenesmus and bearing down ; often severe epigastric pain ; small stools of mucus, pus and blood. Treatment. — Antiseptic and anodyne supposi- tory: Iodoform, gr. v; opium, gr. 5/6; ext. bel- ladonnas, gr. 5/12; cacao butter, q. s. — An- drews. Injection for acute symptoms: Liq. bismuthi, dr. i; mucilag. acacia?, oz. vi. — Andrews. Irritable Rectum. — Hydrastis, 1 to 4 of water; white pinus canadensis, 1 to 6 of water; nitrate of silver; tannic acid preparations. — Agnew. Chronic Catarrh of Eectum. — Absolute rest in bed in recumbent posture; keep bowels clear of irritating ingesta; inject through colonic tube a quart of water containing 30 gr. of silver nitrate twice a week, and inject every night weak alum water (two teaspoonfuls to a half gallon of water) ; flush rectum and colon daily with large quantity of boiled and filtered water — Davidson or hard rubber piston syringe best. — Gant. 260 PAIN AND ITS INDICATIONS Dysentery. — Chills and fever; straining, dis- charges of blood and raucopus. Treatment. — Enemas of hot water or of silver nitrate sol., 1 gr. to 8 oz. water. — W. C. Abbott. Powdered cinnamon, 1 dram, made up with a little water into pills, to be taken morning and evening. — Ave toon. Pain and Tenesmus of Dysenteric Diarrhea: R. Cocainae hydrochlor., gr. 1/12; ext. ergotae aq. gr. i ; aristol, gr. 5/12 ; ol. theobrom., q. s. Use suppository every hour or so. — Taylor and Wells. Prolapsus Ani. — Soft, smooth, cone-shaped pro- truding ring, most marked after defecation. Treatment. — Eeduce after each evacuation and then inject 5 to 30 drops of fl. ext. hamamelis, dissolved in 2 to 6 oz. cold water. Push in prolapsed mass with conical tampon (1 inch at thick end by 3 inches in length) of ice wrapped in iodoform gauze; leave ice in rec- tum and use a fresh piece after each movement of the bowels. — Hajech. Anal Polypi. — Hard or soft, smooth, pyriform tumor with bloody, mucoid diarrhea; painful when prolapsed. Treatment. — Children: Evulse and tear off; stretch sphincter with two or more fingers till it grates. — Jacobi. Foreign Bodies. — Treat each case according to its own merits. PROCTALGIA. 261 Intussusception Low Down. — Straining pain and blood-stained mucoid discharge. Treatment. — Hydrostatic pressure (oil or water) with fountain syringe to restore. Cancer of Rectum. — Hard, infiltrating plates or nodules, soon breaking down into deep ulcers. Treatment. — Excision if cancer circumscribed to lower 4 inches of rectum; inguinal colostomy if situated more than 4 inches above anus or if rectum immovable. — Kelsey. Palliative. — Keep passages soft but not fluid by mineral waters and regulation of diet; rest in re- cumbent posture; opium and other anodynes lo- cally and by the mouth; partial removal of growth with finger nail, curet or cautery; division of sphincter; colotomy; electrolysis. — Kelsey. Fibroid Stricture. — Straining, liquid stools; cramps in lower limbs; stenosis shown by finger or olive-pointed bougies. Treatment. — Milk and soups basis of diet; Eo- chelle or Glauber's salts or enema of warm water through long tube daily to move bowels. Intermittent dilatation with bougies which readily pass obstruction, leaving in over night — must be continued indefinitely; sudden, complete divulsion with instruments rather dangerous; nicking of stricture with proctotomy knife, then packing rectum with picked lint, for a day or -62 PAIN AND ITS INDICATIONS more, a good procedure preliminary to dilatation ; colostomy in very severe cases. — Kelsey. Periproctitis. — Painful, fluctuating swelling usually in front of rectum; often tubercular. Treatment. — Free incisions and antiseptic irri- gations. — Kelsey. Pelvic Abscess. — Chills and sweats; fluctuat- ing swelling iisually in Douglas' cul-de-sac. Treatment. — Vaginal incision and gauze drain- age when practicable. Neuralgia of Rectum. — Pain in region of coccyx or saero-coccygeal junction — paroxysmal, lancinating, burning, worse after violent exer- cise, sitting in one position long and during de- fecation ; no heat, redness or swelling or local signs of disease; from neurosis, debility, con- stant sitting on hard seat, fall or kick or dis- placed coccyx, exposure to cold or damp, irregu- lar habits, scar tissue, enlarged or displaced uter- us, prostate, etc. ; lesions most frequently over- looked and mistaken for neuralgia are erosions, pockets and small internal fistula?. Treatment. — Treat special cause; divulsion for neuroses. — Gant. Attend to general health and regulate bowels; local application of cold water and belladonna ointment and blistering over sacrum; ordinary antineuralgics — cruinin for malaria, colchicum for gouty cases. — Kelsey. PROCTALGIA. 263 Recumbent posture; rectal irrigation with very hot water; dry heat; counterirritation or thor- ough cauterization over seat of pain; attention to local lesions; forcible divulsion. — Pennington. Reflex to ovaries, uterus, prostate, back, abdo- men and down limbs in beginning rectal ulcera- tion, stricture or malignant disease. 264 PAIN AND ITS INDICATIONS CHAPTER XI. LIMB AND JOINT PAINS. Organic Arthralgia and Ostalgia. — Pain usually worse at night and augmented by passive motion or pressure; local stiffness and swelling and sometimes heat and redness. Trauma. — History and physical signs. Sprains. — Sudden, very intense pain and loss of function, followed by forcible stretching and twisting of joint; diffuse swelling and, later, bluish-red, bluish-green and yellowish discolora- tion. Treatment. — Early massage, intermittent ban- daging of joint with elastic bandage, and meth- odical movements; rest and immobility only in complicated cases (fracture or rupture of ten- dons) . — Tillmanns. Cold applications at first, best by affusion, stopping this when joint ceases to swell and skin begins to look dull and livid — can be applied in- definitely if inflammation; early bandage pres- sure (filling depressions with cotton-wool pads) to prevent swelling (ice-bag may be laid over bandage) ; if cold does not seem advisable, place limb in hot water, adding more and hotter up to the limit of endurance for two or three minutes; later soak in hot water along with massage; still LIMB AND JOINT PAINS. 265 later, heat and cold alternately; passive move- ments should usually be begun on second day. — Moullin. Kest; faradism for a half hour once daily for five to seven days, followed by five-minute mas- sage, rubbing distally, and repeated later each day. — L. A. Bridges. Sprains and Contusions of Joints. — Prompt, frequent and long continued immersions of in- flamed joint in water as hot as can be borne and containing 1 tablespoonful of powdered mustard to each gallon of water; keep this treatment up for 8 to 36 hours, surrounding joint in intervals between immersions with plenty of cotton-wool held in place by supporting bandage not tight enough to give pain, and keep joint elevated; after end of first 24 or 36 hours, begin gentle but gradually increasing massage and friction with some pressure by means of flannel bandage over a little cotton-wool; when most of swelling has disappeared (5 days to 2 weeks) give sup- port with flannel bandage or adhesive plaster dressing, and allow gradually increasing use of joint, or if passive motion followed by active pain or violent reaction immobolize with plaster of paris for 10 days to 3 weeks and then remove, using support and massage, and allow gradual use of joint. — John E. Summers, Jr. Compression by means of narrow strips of ad- 886 PAIN AND ITS INDICATIONS hesive plaster, applied quite firmly; the first be- gins ;il base of greal toe and passes across dorsum of font, along iis outside, around lowest portion of posterior surface of heel, then along inside of Foot and finally crosses itself in the center of dorsum and ends at base of Little toe; the next strip should pass from a point about A inches above internal malleolus and at back part of in- ternal surface of leg, around under the heel, to end at a point on the outside of the leg corre- sponding to that of its commencement ; the third strip should correspond in direction to the first and overlap it about -} inch, and the next should be vertical and overlap the first strip applied in this direction; in this way cover entire ankle and dorsum of foot, and complete support with muslin bandage; a satisfactory ambulant treat- ment. — Gibne} r . Obstinate Cases. — Keep in bed and apply every half hour cloths wrung out of boiling water by means of a wringer; follow with salicylate rub- bings. — Wm. H. Buchtel. Acute Sprains of Ankle Joint. — Daily hot air bath pushed to tolerance, followed by applica- tion of a firm bandage or stockinet. — Gould and Pvle's Cyclopedia. Contusions. — Subcutaneous laceration with ef- fusion of blood ; heat, tenderness, swelling and LIMB AND JOINT PAINS. 267 numbness followed by pain; discoloration quick- ly in superficial cases, days after in deep ones. Treatment. — Bed or rest to part; soap liniment with a little laudanum. — Heath. Ice-bag or evaporating lotion, such as 1 part each of brandy and spt. mindererus and 8 parts of camphor water; do not cover rag on which evaporating lotion is applied. — Heath. Wash injured part with ether and apply 1 :4 or 1 :8 solution of menthol in collodion twice a day; good in all but joint cases. Ecchymoses. — Cold, wet cloths; incise if great amount of blood; lead and opium wash if much pain; to promote absorption apply a mixture of 1 dr. ammonium chlorid, 1 oz. tinct. arnica, 2 oz. alcohol and 3 oz. water. — Howe. Fractures. — Pain often limited to particular spot and much aggravated by pressure; abnormal mobility, crepitus. Treatment. — Eeduction of displacement to as near the normal as possible (anesthesia may be required) ; absolute retention of parts as re- placed; free drainage with openings and counter- openings in compound fractures — fragments should be reduced even when necessary to re- move projecting ends with forceps or saw. — Wy- eth. Extemporaneous plaster of paris splints; in ordinary fractures of lower end of radius use 268 PAIN AND ITS INDICATIONS only a wristlet of adhesive plaster, after com- plete reduction; when reduction of fragments is impracticable, make aseptic incision and hold fragments in place if need be with wire or catgut sutures; when difficult to keep parts in position drive wire nails or special fracture nails through soft and bony tissues. — Roberts. Old Fracture Pain. — Potassium iodid inter- nally; iodin or mercurial ointment externally. Dislocations. — Pain immediate, severe, persist- ing till after reduction; diminished mobility and abnormal position of head of bone. Treatment. — Reduction (usually under chlo- roform) and keeping in place with bandages or other light, immobile appliances; passive mo- tion after 8-14 days. — Tillmanns. Dislocated shoulder (sometimes elbow, knee or hip) can be replaced by having patient lie on cot with arm hanging through 6-inch opening and attaching to arm a 10-pound sandbag. — Stimson. Habitual. — Restrict movement of joint by suit- able bandage, or expose joint and suture rent in capsule, or resect head of bone. — Tillmanns. Irreducible. — Expose site of dislocation by in- cision and bring head of bone into place, resect- ing if necessary. — Tillmanns. Punctured Wounds. Treatment. — Disinfect, dust with iodoform and cover with iodoform or bichloricl gauze and ster- LIMB AND JOINT PAINS. 269 ilized cotton; immobilize with splints; if fever and pain open freely, disinfect all pockets with 1:1000 bichlorid, remove blood clots and drain with short, thick glass drainage tubes, changing antiseptic dressing often; resection, amputation or disarticulation in cases very extensive and se- rious. — Tillmanns. Gunshot Wounds of Joints. Treatment. — Check hemorrhage and remove all foreign bodies; immobilize with or without oc- clusive dressing; antiseptic drainage if neces- sary to explore and operate; amputation if ex- tensive mangling. — Tillmanns. Acute Articular Rheumatism. — Acute pain and tenderness; usually multiple and in large joints; fever and sweating. Treatment. — Aspirin in daily dosage of 60 to 90 grains, best given in divided doses during waking period every 2 to 4 hours in capsules, tablets, cachets or rubbed up with sugar. E. Sodii salic, gr. xv; tinct. lavand. co., dr. ss; syr. aurantii. q. s. A tablespoonful every 3 or 4 hours. — Shoemaker. Fl. ext. piscidia erythrina, m. xv, every 4 hours for pain. — Eouse. Ichthyol ointment, 25 to 50 per cent, in lano- lin; wrap in lint after smearing joint. — Hare. Eub affected joints as often as need be with a piece of ice wrapped in flannel. — Wm. Ewart. 270 TAIN AND ITS INDICATIONS E. Sodii salic.j gr. xv ; acidi citrici, gr. ss; Iiq. ammon. cit., m. xxx; tinet. ferri chlor., m. xv; olei gaulth.. m. ss; glycerin, q. s. A des- sertspoonful every 3 hours. — Solis-Cohen. Pale, Feeble. Anemic Patients. — E. Strych. sulph., gr. 1/60; tinct. ferri chlor. m., xv-xxx; liq. ammon. acet., oz. ss. Take every 4 hours in a glass of water. — Hughes. Wrap the swollen joint in cloths wrung out of ice water. Gout. — Like vise or red-hot iron in acute at- tacks; ball of great toe usually; slight fever; nocturnal. Treatment. — Acute: Five to 10 drops t.i.d. of a mixture of equal parts of tinct. aconite and wine of colchicum. — Eust. Elevate limb and wrap joint in cotton-wool ; warm fomentations, or Fuller's lotion, or steam- ing joint ; wine or tincture of colchicum, m. xx- xxx, every 4 hours, with potassium citrate, till pain relieved. — Osier. Chronic (joints successively stiff, enlarged and deformed ; often unilateral and symmetric ; chalk- stones (tophi) about small joints in middle line tendons and in lobe of ear). — Daily application to enlarged joints of pure iohthyol, protecting after inunction with double layer of flannel. — Bulkley. Apply following ointment to painful finger LIM1J AND JOINT PAINS. 271 joints: 20 in. each of guaiacol and oil of winter- green; 15 gr. each of camphor, menthol and oil of cloves; one dram each of glycerin, petrolatum, cerate and lanolin. — Solis-Cohen. E. Potassii iodid., gr. v; vini colch. rad. in. x; aq. dest., q. s. A teaspoonful well diluted after meals and at bedtime. — Hughes. Lithemia. — Chronic and irregular gouty symp- toms; lithuria ; high blood tension; puffy fingers and hands. Treatment. — Potassium iodid, guaiac, quinin; tonics combined with alkalies; open air life; ac- tive skin (morning cold bath or evening warm bath) ; dress warmly; avoid alcohol; eat less and more slowly ; restrict meat and salt ; 3 to 5 glasses of water daily. — Osier. Colchicin, 1/60 gr., with 1 gr. calomel in pills, t.i.d. — Clinical Review. Plumbism. — Usually distinct gouty deposits, especially in big toe joint ; later rheumatoid pains in flexures of joints. Treatment. — Potassium iodid, 5 to 10 gr., t.i.d., with occasional morning purge of magnesium sul- phate. — Osier. Gonorrheal Arthritis. — Pain often severe in acute ; usually ankle or knee ; blenorrhea or gleet ; ankyloses common; similar condition at times from instrumentation of normal urethra. Treatment. — Potassium iodid, 5 gr. in a table- 2T2 PAIN AND ITS INDICATIONS spoonful of water every hour or two. — Schaller. Syrup of iodid of iron, half dram doses, grad- ually increased. — J. C. Wilson. Treat focus of infection in urethra. Apply to joint an ointment of 2^ dr. each of lanolin, turpentine and salicylic acid in 3 oz. lard. — Balzer. Injection into joint of mercuric chlorid solu- tion (1 part mercuric chlorid, 10 parts sodium chlorid, 500 parts distilled water), 3 to 5 hypo- dermic syringefuls at intervals of 3 days. — Vogt. Aspiration of seropurulent effusion, followed hy compression of joint and fixation of limb in immovable dressing; massage and hot and cold douches to aid absorption. — Senn. A teaspoonful of 1 part guaiacol and 3 parts olive oil, rubbed into skin over inflamed joint 4 times daily. — Belfield. Tubercular Arthritis. — Pain slight or severe, often starting, nocturnal ; most common in hip and knee; spindle-shaped, pseudo-fluctuating swelling, with atrophy of related muscles, and often ankjdosis with contracture. Treatment. — Constitutional treatment for tu- bercular diathesis; local rest maintained for many weeks with splints, plaster of paris band- ages or extension appliances; aspiration for fluid accumulations; caseous masses may be removed LIME AND JOINT PAINS. »<•■> with aspirator, joint drained, washed out with boiled water and injected with 10 per cent, iodo- form-glycerin emulsion ; injections about joint once a week of balsam of Peru or iodoform emulsion; if these measures fail or delay is dan- gerous, operate and remove entire diseased area by erosion, excision or amputation. — J. C. Da Costa. Early Stage. — Hot air application at not more than 275 °F. (protecting limb to be treated with 2 layers of Turkish toweling, wrapped rather loosely about it) twice daily, not longer than an hour, alternating with Bier apparatus (see be- low). — Knopf. Early Stages. — Local venous hyperemia pro- duced by ligating (only tight enough to impede venous circulation) member above affected joint with elastic band of medium width, several times a day, for 10 minutes to an hour at beginning, gradually increasing duration of treatment to 4 or 6 hours or the whole night; protect skin by a band of linen or other soft material and by changing site of ligation in successive applica- tions. — Bier. Multiple Secondary Arthritis. — Smallpox, mea- sles, scarlet fever, typhoid, erysipelas, dysentery, cerebrospinal meningitis, bronchiectasis, scurvy. Treatment. — Keep parts quiet, enveloped in 274 PAIN AND ITS INDICATIONS cotton, secured with bandages, or make hot ap- plications. — Am. Text-Book of Surgery. Scarlatinal Rheumatism. — R. Amnion, salic, gr. viii ; elix. simp., m. xv; syr. simp., m. xxx ; tinct. cardam. co. q. s. A teaspoonful diluted 4 times daily. — Hughes. Pneumococcic Arthritis. — Fever generally high; danger of suppuration and grave metas- tases; pneumonia. Treatment. — Hot air baths, hydrotherapy, mas- sage, douches; if pus forms, open joint, flush, iix and drain. — E. J. Cave. Septic Arthritis. — Very severe pain in suppu- rative form ; pyemia, particularly puerperal fever ; rapid suppuration and more or less destruction of joints. Evacuate pus by aspiration, followed by wash- ing out with antiseptic solution till fluid returns clear, or, better, incision and drainage under strictest antiseptic precautions; long pair of hemostatic forceps indispensable in draining joint ; in draining knee-joint cavity employ 4 tubular drains and wash out with a stronger an- tiseptic solution; apply copious antiseptic dress- ings and immobilize on splint; repeat irrigations, shorten drains gradually and remove them with cessation of suppuration. — Senn. Joint Abscess. — Inject liquid carbolic acid into cavity and allow to remain 2 minutes, then wash LIME AND JOINT PAINS. S7H out abscess with alcohol followed by sterile water. — Phelps. Acute Arthritis of Infants. — Usually hip or knee ; rapidly purulent ; may develop from gon- orrheal ophthalmia or vaginitis of new-born. Treatment. — Aspirate joint under strictest an- tiseptic precautions, and if pus is found lay open. Drain and dress antiseptically ; counter-openings with packing of joint or even resection some- times necessary; explore shaft of bone with in- cisions, sparing epiphyseal line as much as pos- sible. — Warren. Alcoholic Arthritis. — Swellings of small joints ; enlarged liver and spleen. Treatment. — Stop liquors; relieve with phenac- etin, antipyrin or papine; encourage elimination. Syphilitic A?'thritis. — Slight pain as a rule; history, eruption or scars. Treatment. — Extension, rest, counterirritation and antisyphilitic remedies. — Eoberts. Proper local treatment and inunctions of ung. hydrarg. ciner. — Tillmanns. Hot air baths for an hour at 160°-180°F. or higher; potassium iodid internally. Neuropathic or Atrophic Arthritis. — Pain slight or absent; often begins as sudden effusion in knee; rapid destruction of bones and carti- lages; creaking, grating and great laxity oj 276 PAIN AND ITS INDICATIONS joint; great deformity liable to ensue; locomotor ataxia. Treatment. — Etiologie treatment ; immobilize and substitute supporting apparatus if patient receives a sprain. — Tillmanns. Arthritis Deformans (Kheumatoid Arthritis; Rheumatic Gout). — Moderate pain with slow en- largement and distortion of many joints (meta- carpophalangeal first), distinct creaking on mo- tion; wasting, contracture, deformity, enfeebled women; Heberdens nodes on sides of distal pha- langes; usually bilateral. Treatment. — Tincture of iodin locally or small blisters frequently repeated; friction with stim- ulating liniments, passive movements, burying joint in hot sand, dusting with sulphur and wrap- ping in flannel, or galvanism at least once daily; good nutritious mixed diet; flannel clothing; warm, equable climate; iron, arsenic and cod- liver oil internally for weeks or months. — Taylor. r »uaiacol carbonate, gr. v-xv, t.i.d. ; also paint affected joints every night with equal parts of pure guaiacol and olive oil. — Bannatyne. Long-continued use of Fowler's solution in small doses; sodium salicylate in early stage. Baths at 92°-94°F. for 10 or 20 minutes- through which constant galvanic current is passed, when excessive pain and irritability. — Stevenson. LIMB AND JOINT l'AINS. 277 Early systematic massage and passive move- ments of joint ; generally lukewarm baths, steam baths combined with cold douches, etc.; fresh air, tonics ; resection for severe pain. — Tillmanns. Lay joint widely open, wash out antiseptically and pack with iodoform gauze. — Sonnenburg. Dietetic, hygienic and hydrotherapeutic meas- ures; 5 gr. each of. sodium salicylate and sodium benzoate in glass of hot water, t. i. d. ; potassium iodid of great service in some cases — in others sodium bicarbonate in repeated doses, well di- luted; continue alkaline treatment for 3 months, then 3 weeks out of 4 for another 3 or 6 months. — B. C. Loveland. Local injection into surrounding tissues of 1^ to 3 grains of sodium salicylate dissolved in 30-60m. of water. — Bouchard. Prolonged use of syrup of iodid of iron, a dram thrice daily. — J. B. Clemens. Blisters on either side of cervical or dorsal vertebras. Chronic Articular Rheumatism. — Pain sharp but variable; much affected by changes in weather; usually multiple in larger joints, with crepitus and restricted function; disease per- sistent and progressive, often with secondary changes in joint. Treatment. — B. Lin. terebinth., tinet. opii, aa. 278 PAIN AND ITS INDICATIONS oz. i; lin. saponis oz., iii. For external use with friction. — Shoemaker. Massage; superheated air-baths; ointment of mercury, belladonna and ichthyol, well rubbed in ; blisters or light applications of actual cautery. — Stevens. E. Potassii iodidi, gr. xx; vini colcli. rad. m. v; syr. sarsap. co. q. s. A teaspoonful t. i. d. after meals. — Hare. E. Liq. potassii ars. m. v. ; potas. iodidi, gr. v ; syr. simp. q. s. A teaspoonful in water t. i. d. between meals. — Da Costa. Thirty grains each of sodium bicarbonate and potassium acetate, one dram Eochelle salt and 5 m. spt. chloroform in water; tablespoonful 3 or 4 times a day, 2 hours before or after meals. — International Clinics. Mild, Noninflammatory. — Fowler's solution in 5-drop doses, increased to physiologic limits, then give half of last dose for weeks or even months. — Pett} r john. Aged and Debilitated. — E. Quin. sulph., gr. iss. ; tinet. ferri chlor. m. xii ; elix. case. sag. q. s. A dessertspoonful 3 or 4 times a day. — Shoemaker. E. Potassii iodidi, gr. x-xx; spt. chloroformi, m. v; tinet. cinch, co. q. s. One-half to a table- spoonful in water 3 or i times a day. — Shoe- maker. LIMB AND JOINT PAINS. 279 Chronic Rheumatism and Gout. — Salicylic acid 15 gr. in 4 dr. elix. case, sagrada 2 or 3 times a day. — Shoemaker. Ointment of 5 dr. salicylic acid, 3 oz. alcohol and 6 oz. castor oil. — Arendt. Recurring Subacute Rheumatism. — Slight at- tacks of arthritis with some swelling and effusion at moderate intervals. Potassium iodid 5-10 gr., and fluid ext. black cohosh 5-20m. t.i.cl. — F. R. Millard. Liniment composed of 6 dr. each of turpen- tine and soap liniment and 12m. mustard oil. Rheumatic Ointment. — One part each of sali- cylic acid, turpentine, and lanolin, and 9 parts of lard. — Bourget. Rheumatic Post-Traumatic Pain. — Acetic ext. of colchicum 1 gr., comp. powder of ipecac 10 gr., and comp. ext. eolocynth 4 gr. in pills. — Erich- sen. Abarticular Rheumatism. — Fleeting joint pains, often with slight swelling; may be replaced by chorea, recurring tonsillitis, erythema nodosum or peliosa rheumatica. Bursitis. — Considerable pain in acute; limited globular swelling connected with tendon. Treatment. — Rest of limb by elevation and splints ;■ anodyne and refrigerant lotions ; leeches or blister; if suppuration suspected, make early free incision, followed by curetting ; if pus evacu- 280 PAIN AND ITS INDICATIONS ates spontaneously, open sinuses, use antiseptic irrigation and drainage; dropsy of bursa best treated by aspiration or tapping, followed by in- jections of strong carbolic acid solutions or tinc- ture of iodin, or by pressure. — Koberts. Properly adjusted shoes; protect parts with a simple cotton and collodion dressing; tinct. iodin applications; bathe foot twice daily in starch water. — Isadore Dyer. Bunion. — Bursitis of the great toe, with dis- location, from wearing tight or narrow shoes. Treatment. — Broad-soled shoes with a straight inside border; warm foot-wear in winter; ad- hesive strip carried from phalanges of great toe around inner border of foot ; " bunion plasters " or felt rings to protect ; painting with tinct. iodin, with silver nitrate solution (10-60 gr. per ounce), or with 50 per cent ichthyol-lanolin ointment ; for inflammation use very hot water, elevation of limb, distilled ext. witch-hazel or lead water and laudanum; if ulcer deep, lay bursal cavity open and heal from bottom.— Burdick. Acute Synovitis. — Severe, throbbing pain ; swelling under and around patella. Crepitus and rice-body fibrinous shreds in dry form; position midway between flexion and extension. Treatment. — Immobilize joint in semi-flexion, apply leeches, use ice-bag or Leiter coil, followed by lead water and laudanum; after a day or two LIMIi AND JOINT PAINS. 2H 1 apply gentle pressure (rubber bandage over thick layer of cotton or wool), intermittent heat, iodin and ichthyol. — J. C. Da Costa. Put patient to bed; suspend limb at nearly a right angle; splint and elastic bandage; hot air bath. If effusion under great tension, puncture aseptically and wash out joint with 3% carbolic acid or 1:1000 bichlorid ; immobilize with anti- septic pressure bandage. — Tillmanns. Purulent Synovitis. — Recurrent rigors, per- sistent high local temperature, constitutional dis- turbances ; hypodermic aspiration. Treatment. — Aspirate and wash out joint, or incise and drain, or excise membrane if this alone involved. — Roberts. Syphilitic Synovitis. — Very little pain; some swelling and effusion ; may be " melon seeds " or " loose bodies " in joints. Treatment. — Antisyphilitic remedies ; excision of memberane for fibroid changes. — Roberts. Acute Epiphysitis. — Childhood; intense pain and tenderness over articular end of long bone; soft parts and joint soon swollen and hot and limb flexed; marked constitutional symptoms with pus formation. Treatment. — Absolute rest with splints; cut to bone and trephine if need be when much swelling; if pus in joint, open freely, wash out 282 PAIN AND ITS INDICATIONS with 1-1000 mercuric chlorid and secure ample drainage; scrape out diseased points in hone with Volkmann's spoon ; evacuate all burrowing mat- ter, disinfect, drain and dress; supporting treat- ment with free use of stimulants. — Chas. T. Poore. Subacute and Chronic Epiphysitis. — Sub- jective symptoms much less marked than in acute form; enlargement of end of bone and gradual stiffening of joint. Treatment. — Absolute rest in early stage with splints; fly blisters or light applications of Paquelin cautery; evacuate pus when formed. — Chas. T. Poore. Simple Bone Cysts. — Usually single and about puberty; originates in shaft of long bones near epiphyseal line or in jaws at roots of teeth ; thin layer of bone over cyst becomes soft and compressible in places; intermittent pain and lameness; fracture from slight trauma or slight bending of bone ; cyst contents cloudy yellow or bloody fluid. Treatment. — Maxillary: Extraction of tooth and curettage; incise wall of dentigcrous cyst with a strong bistoury or chisel; cleanse with hot water and disinfectant solutions and pack with 5 per cent iodoform gauze; if cystic cavity large and much deformity exists, obliterate cavity hv crushing in walls. — J. Ewing Mears. LIMli AND JOINT PAINS. 283 Osteosarcoma. — Pain acute and throbbing; roundish, soft or hard swelling near end of long bone following injury. Treatment. — High amputation. Abnormal Adhesions in Joints. — Pain some- times violent. Tenosynovitis. — Pain along course of tendon — severe in suppurative — slight in tubercular; spindle-shaped swelling. Treatment. — Non-suppurative : Eest and pres- sure by splint and bandage ; hot or cold water applications at first; tincture of iodin; opiates may be needed. — Am. Text-Book of Surgery. Suppurative. — Elevation and complete rest of part ; hot applications ; free opening of sheath, curetting and thorough antiseptic drainage and dressing; other and freer incisions if suppura- tion extends. — Am. Text-Book of Surgery. Osteotuberculosis. — Moderate variable pain ; tenderness over affected foci, usually epiphyseal; late, soft, circumscribed boggy swelling with pseudo-fluctuation and wandering abscess; over- lying skin normal in appearance till itself af- fected; muscular atrophy; exploration with strong steel needle. Treatment. — Physiologic rest with mechanical appliances (plaster of paris dressing or jacket) ; ignipuncture into cavity in early stage with Paquelin cautery under strict antiseptic precau- 284 PAIN AND ITS INDICATIONS tions, protecting puncture with an efficient anti- septic dressing until it is completely closed by cicatrization and epidermization ; complete re- moval of limited infected foci; excision of por- tion of shaft; amputation in diffuse. — Senn. Osteoperiostitis. — Pain always present, more or less severe; acute forms very sensitive; tibial nodes in syphilitic. Treatment. — Felon: Free early incision through periosteum and dry antiseptic dressing. Syphilitic: Rest, elevation of part, local use of iodin and mercurial ointment and bandaging; specific treatment by stomach or hypodermically. —J. C. Da Costa. Friction with 20 per cent oleate of mercury ointment containing morphin. — P. A. Morrow. Other Forms: Rest in bed with limb elevated in splint and bandage; leeches, cold, lead water and laudanum ; salines and potassium iodid ; morphin for pain; if these means fail, use coun- terirritation with iodin and blue ointment or blis- ters and heat locally; in severe cases slit perios- teum subcutaneously to relieve tension and pain; some cases demand longitudinal osteotomy with Hey saw; diffuse form requires early free incisions, antiseptic drainage, rest and elevation of limb and strong supporting and stimulating treatment — ainputation sometimes demanded — LIMB AND JOINT PAINS. 285 subperiosteal resection of shaft if entirely ne- crosed. — J. C. Da Costa. Acute Osteomyelitis. — Deep-seated, gnawing, boring pain in shaft or epiphysis, with great- est tenderness at this point; deep swelling of soft parts; profuse offensive purulent dis- charge containing bone-fragments and tissue- sloughs; rigors, sweats and fever if pyemia or septicemia. Treatment — Early opening of bone with chisel, removal of all infected tissues (including sequestra) with curet and disinfection of cavity by irrigation with corrosive sublimate 1-1000; then dry and mop out with 10-per-cent solution of chlorid of zinc or hydrogen peroxid and pack with iodoform gauze, which is left to hang out of the wound; apply copious antiseptic dressing and immobilize limb on splint. — Senn. Chronic Osteomyelitis. — Pain most prominent symptom — aching, gnawing, boring, often inter- mittent; syphilis, sarcoma, carcinoma, tuberculo- sis, pyemia. Treatment. — Chisel in direction of center of bone by making a track perhaps an inch square; if abscess not found at a certain depth, explore surrounding tissue with a small drill till found, then excavate with chisel; wash out pus and scrape out all of infected tissues with a sharp spoon; iodoformization of cavity and implanta- 28C PAIN AND ITS INDICATIONS tion of decalcified antiseptic bone-chips. — Senn. Rachitis. — General soreness and dread of be- ing handled ; epiphyseal enlargements and ten- derness; badly fed children. Treatment. — Fresh air; nourishing mixed diet; outdoor exercise; cold baths; iodids; cod- liver oil. — Jacobi. Open air; good sanitary conditions; baths (90° under 6 months, 80° in second year, 75° in third year, 70° subsequently) ; keep extremi- ties always warm; proper feeding with breast milk or rich cow's milk as basis; phosphorus, 1/200-1/100 gr. t. i. d. after meals with cod- liver oil and iron. — J. Lewis Smith. Take of phosphorus 1 part, ether 9 parts, al- mond oil 90 parts: One minim contains 1/1000 gr. phosphorus. Take the yolks of 10 eggs, 2 pints cod-liver oil, 1 pint syrup of wild cherry and 1 pint sherry wine: A teaspoonful or more three or more times daily. — J. Lewis Smith. R. Ferri phosphat., calcii phosphat. aa. gr. iii ; ext. nucis vom. gr. £; olei eucalyp. m. J: Two pills t. i. d. — Shoemaker. Osteomalacia. — Persistent pain in multiple areas ; progressive deformities ; phosphaturia ; pregnancy chief factor. Treatment. — Good hygiene; rest; avoid preg- nancy : nourishing food ; cod-liver oil, iron, lime. LIMB AND JOINT PAINS. 287 quinin, phosphorus, arsenic; stop nursing; re- moval of ovaries. — Tillmanns. Dengue. — General severe, " bone-breaking " pains, with sudden high fever and rarely hemor- rhages ; swollen joints, skin eruption ; very con- tagious. Treatment. — Salicylates or antipyrin or opium; potassium iodid and tonics during con- valescence. — Osier. Glanders. — With slight swelling and redness; pustules; ulcerating nodules in nose and profuse nasal discharge ; fever and eruption like small- pox about joints and on face. Treatment. — Incise abscesses freely, lay open fistulous tracts and remove as far as possible in- fected tissues with a spoon; then disinfect en- tire surface with 12 per cent chlorid of zinc; re- peat curetting and disinfection as need be; keep scraped surfaces covered with moist antiseptic compress gauze wrung out of 1/2000 mercuric chlorid or 2 per cent carbolic solution or strong iodin water; supporting, tonic and stimulating treatment. — Senn. Pain of Hip-joint Disease may be simulated by aneurism of femoral or iliac arteries, abscess in Scarpa's triangle, caries of lumbar vertebras with psoas abscess (pus external to femoral vessels), sacroiliac disease, cancer of rectum or gluteal bursitis (moderate pain back of hip and knees, 288 PAIN AND ITS INDICATIONS aggravated by exertion ; may be fluctuation in upper gluteal region). Flat foot. — Foot and call tire; heel brought down forcibly; tendency to eversion of toes. Treatment. — Place a wedge of felt on inner side of foot; appropriate massage and passive motion. — James J. Walsh. Neuralgic Arthralgia. — Usually symptom- atic and outside of joints — knee or ankle mostly ; superficial, diffuse, dull, aching, or sharp, shoot- ing, constant or periodic, with neuralgia in other parts; tenderness on pressure, soreness on active motion — not in passive; often transient swelling without redness; sometimes numbness of ex- tremities; joint mobile, especially under ether; common in young neurotic females and after trauma. General Treatment. — Find and remove excit- ing cause; give a long course of iron, quinin and strychnin or of arsenic; phenacetin during attack; morphin occasionally without patient's knowledge in severe cases; locally frictions, aconite ointment and heat ; keep on part a piece of flannel soaked in a mixture of soap liniment, laudanum and chloroform; prevent stiffening by daily massage, frictions, passive motions and hot and cold douches. — J. C. Da Costa. Disease or Injury of Central Nervous System. LIMB AND JOINT PAINS. 289 — Often bilateral ; acute multiple in central mye- litis. Treatment. — Antipyrin, antikamnia, phena- cetin; warm baths. Neurasthenia. — Functional varying nervous depression. Treatment. — E. Tinct. ferri chlor. m. v. ; hy- drarg. chlor. corros. gr. 1/16; llq. ars. chlor. m. v. ; acidi hydrochlor. dil. m. x. ; aquam q. s. ; A teaspoonful in water t. i. d. — Goodell. Anemia. — With pallor, palpitation and short- ness of breath. Treatment. — E. Massas ferri carb. gr. ii; ext. hyos. ale. gr. ss. ; podophyllotoxini gr. 1/12 ; quininas sulph. gr. i: Pour to 6 pills a day. — Shoemaker. Hysteria. — Patient complains more when skin is pinched than when head of bone is pushed into joint (hip, knee or ankle) ; frequent varia- tion in position of limb. Treatment. — Faradic or static electricity and suggestion. Malaria. — Pain more or less periodic. Treatment. — E. Liq. potass, ars. m. iv; tinct. dioscor. villos. m. xv ; tinct. card. co. q. s. : A teaspoonful in water after meals. — Shoemaker. Syphilis. — History, eruption, scars; thera- peutic test. Treatment. — Ordinary antisyphilitic measures. 290 PAIN AND ITS INDICATIONS Goal and Rheumatism. — Much influenced by changes in weather. Treatment. — Salol gr. xx ; ether q. s. ad solv. ; collodii dr. iss. : Apply to painful joints once or twice daily. — Shoemaker. Malassimilation. — With poor nutrition and perhaps dyspepsia. Treatment. — A pill every 3 or 4 hours of 1/10 gr. zinc phosphid and -\ gr. ext. nucis vomica;. — Shoemaker. Specific Infections, Particularly Influenza. — Sudden, general, with great depression and catar- rhal fever. Treatment. — Phenocoll hydrochlorid in 10 or 15 gr. doses. — Potter. Post-Typlioid Neuralgia. — May very rarely pass on to suppuration ; more than half of all cases of typhoid arthritis followed by spontane- ous dislocation — nearly all in hip-joint. Treatment. — Keep leg in abduction and exter- nal rotation with two lateral sand-bags or lateral splints and bandages or adhesive plaster fas- tened to external sand-bag or splint; if effusion threatens dislocation, aspirate — if pus found, open and treat according to existing conditions. — Keen. Braclu'algia. — Sore arm with consequent dis- ability, from overuse as in " writer's cramp " LIMB AND JOINT PAINS. 291 and in ladies calling and shopping, holding np their skirts. Treatment. — Best, massage, alternate hot and cold douches, faradism. Brachialgia of Motormen: Salicylates (de- pressing) ; use body weight more and arm energy less. — James J. Walsh. Epicondylagia of Humerus. — Nervous women from carrying umbrella; waitresses carrying dishes. Neuritis. — From nerve injury or pressure on proximal branches by tumor or inflammation. Treatment. — Kest to part; removal of excit- ing cause; coal tar antipyretics. Taking Cold. — Sudden onset after exposure. Treatment. — Warm baths and antineurotics. Old Bone Cicatrices from Previous Inflamma- tions. — Follows syphilis, caries, necrosis, old dis- locations, improperly treated, tubercular arthritis, osteomyelitis and osteoperiosteitis or sclerosis of bone. Treatment. — Chiefly antineurotic, but varies with cause; warm baths generally useful; mas- sage and exercise for abnormal adhesions. — Till- manns. Reflex. — Ovaries, uterus and rectum chiefly. Traumatic Neuroses. — Condition of sensitive- ness to external influences, with no other remain- ing trace of injury. 292 PAIN AND ITS INDICATIONS Treatment. — Systematic local massage. Sciatica. — From buttock (sciatic notch) down back of thigh to popliteal space or even to ankle or heel ; sudden or gradual onset, fairly constant, usually worse at night ; nerve traced downward from sacroiliac joint by its sensitiveness. Treatment. — Nerve-stretching by following movements: Stand with feet together and legs straight; bend forward at hips, keeping legs straight, and touch toes with tips of ringers of both hands simultaneously; or sit on a firm, flat surface with legs extended forward, bend for- ward, keeping knees unbent, grasp a foot by each hand, and firmly flex it upon leg. — Vernon A. Chapman. Sciatic Neuritis. — Increased by motion, re- lieved by rest; greatly increased by flexing thigh on abdomen; from lead, trauma, cold, syphilis, alcohol, rheumatism, gout, diabetes. Treatment. — Eest to limb; saline purgative in gouty cases; hot linseed poultices along course of nerve in acute stage of severe attacks; series of mustard plasters or small blisters applied over seats of pain; a grain of blue pill twice daily if active inflammation; potassium or lithium sali- cylate and nitrous ether at outset; morphin for severe spontaneous pain ; cocain injected deeply near nerve — 1/12 gr., rapidly increased to 1/3 or i grain; belladonna liniment mixed with LIMB AND JOINT PAINS. 293 equal parts of chloroform liniment and aconite ointment rubbed in until distinct tingling; nerve stretching in very obstinate cases. — Gowers. Acute. — Absolute rest ; acetanilid and salicy- late of sodium for pain; envelop leg in flannels or thick layers of cotton batting, in conjunction with hot water bags or bottles; in 3 or 4 days carefully massage affected leg unless it makes it worse — also continuous barely perceptible cur- rent with anode over sacrum and cathode on sole of foot — seance not to last longer than 5 min- utes; massage with greater vigor as inflammation becomes less acute and move cathode up and down course of nerve. — Moyer. Chronic. — Counterirritants, especially actual cautery to tender points along limb — or (less ef- ficient) cantharidal collodion, a circle of 1-J inches diameter over these points, renewing vesi- cant when sores heal ; if gout or syphilis present, modify treatment accordingly. — Moyer. Obstinate Cases. — Wine of colchicum root, m. v-x t. i. d. Stockholm Gymnastic Procedure. — Patient stands in front of long beam with indentations half a meter apart; she lifts her foot until pain ensues and supports heel in notch most comfort- able; she now bends forward as much as pos- sible and rotates about 10 times to right and to 294 PAIN AND rib INDICATIONS left; she lifts foot to next notch and rotates as before until pain warns her to be cautious. Sciatic Neuralgia. — Pain not increased by mo- tion or relieved by recumbent posture; com- mon in hysteria ; often excited by pressure of legs on hard seat. Treatment. — See under neuritis just above. Galvanic current in rather long seances sev- eral times a day — anode on sacrum, cathode along course of nerve. — Eoth. Glonoin 1/200 gr. every 1 to 3 hours. — South- ern California Practitioner. Atropin or morphin subcutaneously in neigh- borhood of nerve, or acupuncture or " firing/' — Bartholow. E. Lin. ammonia? oz. ii; spt. chloroform oz. i; lin. menthol oz. ii; tinct. opii oz. i: Apply well over surface as necessary. — Shoemaker. Muscular Rheumatism. — Diffuse soreness and pain, chiefly on motion. Treatment. — Complete rest; hot poultices and fomentations; belladonna and aconite applica- tions ; massage ; vapor or Turkish bath ; galvanic or faradic current; full doses of potassium citrate, acetate or tartrate; potassium iodid in 5 to 7-grain dose; salicylic acid in 15 to 20-grain dose. — Taylor. Hip Disease of Children. — Limping gait, pain in knee and muscular rigidity; pain much in- LIMB AND JOINT PAINS. 295 creased by pressing head of bone against aceta- bulum. Treatment. — In early period absolute rest and removal of deformity (if present) by extension with weight and pulley; apply long splint to op- posite or sound side to keep patient on back; support affected limb in position to which dis- ease has brought it, making extension in long axis of thigh; for adduction make counter draw- ing on sound limb toward head of bed; in long- standing fixed cases, straighten limb 2° or 3° under chloroform and reapply weight; weight extension must be continued for at least 3 months after all pain and tendency to muscular contrac- ture disappears, and then be gradually discon- tinued; evacuate abscess as soon as detected, us- ing drainage tube and antiseptic gauze " protec- tive." — Howard Marsh. Renal or Pelvic Tumors, Pregnancy and Rec- tal Ulcers. — Double. Rectal Ulcer. — Cramps in legs and numbness; dyschezia; local signs. Treatment. — See under proctalgia above. Locomotor Ataxia. — Wide range, fugitive character of fulgurating pains; may be girdle sensation and loss of knee-jerk. Treatment. — Antikamnia, acetanilid, antipy- rin, phenacetin. 296 PAIN AND ITS INDICATIONS Malignant Pelvic Growths. — Pain steady and wearing; other pressure symptoms. Treatment. — Operation or opiates. Lumbar Abscess. — Pus from lumbar caries descends beneath outer arcuate ligament or flows backward between last rib and iliac crest in tri- angle of Petit. Treatment. — Open with aseptic care, curet walls, wash out with 1/1000 mercuric chlorid solution, pack with iodoform gauze and dress antiseptically ; remove gauze in a day or two, but continue mercurial dressings ; if slow in heal- ing, inject or swab out with a stimulating fluid as in acute abscess. — J. C. Da Costa. Lumbosacral Spondylitis. — One or both sciatic nerves; not tender for some time; pain on press- ing ilia together. Treatment. — Strict rest, extension, proper diet; blisters, cautery or iodin paintings locally; later, if all goes well, a hip case or splint or crutches; if disease not quickly arrested and if abscess supervenes, lay joint open and scrape or chisel away diseased portions of membrane or bone, keeping wound well packed with antiseptic materials until it heals. — Eoberts. Divers Neuralgias. — Sharp, shooting, parox- ysmal, along nerve-trunks. General Treatment. — Treat cause if possible; quinin in full doses for malaria; iron, quinin LIMB AND JOINT PAINS. 297 and cod-liver oil generously for anemia — or arsenic, strychnin or gelsemium; colchicum, al- kalies or potassium iodid for gout and rheuma- tism; potassium iodid and sometimes mercury for gout and syphilis; leeching if nerve tender; heat or cold — freezing mixture to tender spots; ointment of belladonna or veratrin; menthol pen- cil, croton-chloral, Paquelin cautery occasionally; long-continued daily use of constant galvanic cur- rent; nutritious, digestible food; regulate bowels and other functions; change of climate. — Am. Text-Book of Surgery. E. Ext. belladonnge gr. -I; quin. sulph. gr. iss. ; ferri sulph. exsic. gr. ss. ; strych. sulph. gr. 1/60 ; acidi arsenios. gr. 1/48 ; oleores. pip. m. ss. : A pill thrice daily. — Shoemaker. E. Caffeinas cit. gr. ii; ammon. brom. gr. x; elix. guarana? q. s. : A teaspoonful every hour or two. — Shoemaker. Baltimore Liniment. E. Tinct. aconiti, chloroformi aa. dr. ii; lin. saponis ad oz. iii: To be applied along course of affected nerve. — Shoemaker. Brachial Neuritis. — Severe pain in region of scalp, wrist, back of forearm or in plexus itself (above clavicle or in axilla) often extend- ing along nerves of arm or to region of heart; persistent tenderness of affected nerve-trunks; ultimately more or less dull, wearying pain in 298 PAIN AND ITS INDICATIONS whole arm — with severe exacerbations of lanci- nating, stabbing or burning pain, often with tingling of skin; movements of arm, especially upward, cause distress; hyperesthesia or anes- thesia dolorosa in severe, prolonged cases; fiab- biness and slight wasting of muscles; subcutane- ous edema ; arthritic changes in finger joints ; five-sixths of all cases above 50 years old — gouty subjects. Treatment. — Abstain from movements; cocain subcutaneously — 2 injections (1/10-1/3 grain) twice daily during height of disease; gentle rub- bing after tenderness has subsided; electricity for degeneration and after pains. — Gowers. Polyneuritis. — Numbness, " pins and need- les," paresthesia or anesthesia and muscular weakness of extremities; tender toes in typhoid — no discoloration or swelling but very sensi- tive. Treatment. — Complete rest; nutritious diet; no alcohol; sodium iodid and mercury for syph- ilis; sodium salicylate for cases following cold; relieve pain with cannabis indica, belladonna or morphin, and locally chloroform or wrapping limb in cotton-wool; galvanism to muscles, slow- ly interrupted; massage if comfortable. — Taylor. Wounds and Injuries of Nerves. — Pain slight or severe; shock and loss of function (reflex LIMB AND JOINT PAINS. 299 palsy) ; trophic changes with burning pain (causalgia) ; may be neural arthropathies. Treatment. — Cold water applications; repeat- ed blisters over course of nerve; morphin very carefully; stretching, division or exsection of nerve. — Am. Text-Book of Surgery. Diseases of Spinal Cord. — Pain chiefly periph- eral; little or no tenderness in nerve. Treatment. — Rest, warm baths, coal tar anal- gesics. Neuralgia from Scars and Stumps and Thick- ened Bursae. — May simulate hip disease. Treatment. — Incise and liberate nerve — this failing, excise a portion of nerve; if no known nerve involved, excise entire irregular scar; ex- cise cicatrix of stump, draw down bulbous ends of nerves and sever clean — reamputation may be required; if ascending neuritis has developed, resect a portion as high as tenderness traced. — ■ Am. Text-Book of Surgery. Dentist's Neuralgia. — Spastic neuralgia of leg on which body weight is borne while working lathe or dental engine. Painful Subcutaneous Tubercle. — Pea-sized fibrous tumor just under skin, connected with sensory filament of cutaneous nerve; great ten- derness and paroxysmal pain extending up and down limb, sometimes with spasms of mus- cles. 300 PAIN AND ITS INDICATIONS Treatment. — Excise tumor together with por- tion of nerve-twig. — Am. Text-Book of Surgery. Erytliromelalgia. — Obscure nervous disease marked by red flushing of lower extremity and burning pain in sole of foot, increased by hang- ing down or walking. Treatment. — Rest, elevation, ice applications; hydrotherapy, massage, electricity; ichthyol or ethyl chlorid locally; salicylates, antipyrin, ergo- tin, morphin. — M. Kohane. Muscular Pain t s. — Dull, aching, much in- creased by movement. Flai-Fooi. — Perhaps most common cause of pains in feet ; sense of fatigue followed by ach- ing, often extending to calf or even thigh; dis- comfort increased by exercise, relieved by rest; tender points over inferior calcaneonavicular ligament, bases of metatarsi, etc.; often obesity and varicose veins. Treatment. — Proper wide shoe with broad, flat heel, and inner border of sole and heel of shoe slightly thicker. Instruct patient to throw weight on outer side of foot ; to hold feet parallel with each other in walking ; to press down sole of shoe with toes; employ active lift of calf mus- cles by fully extending leg and raising body on foot from time to time; and avoid long contin- uance in passive posture. Tip-toe exercises (bicy- cling) especially useful, but proper walk the best LIMB AND JOINT PAINS. 301 of all exercises. Passive movements in all direc- tions (particularly dorsal flexion and adduction) to limit morning and night. Plantar steel brace Polymyositis. — Almost always a result of ex- posure to cold in rheumatic individuals ; bilateral symmetric distribution; muscles very tender at first — undergo hardening and contraction in time. Treatment. — Diaphoretics, salicylates and per- haps small doses of mercury in early stage. — Gowers. Gonorrheal Myositis. — May be severe pain ac- companying blenorrhea. Treatment. — Wrap member in compresses wet with boric acid solution at 35° C, covering with rubber cloth and cotton and renewing as often as needed; if pain persists use partial baths at 30°-35°C. ; when acute stage passed paint mace- rated skin with equal parts of guaiacol and oil of sweet almonds. — Braque. Trichinosis. — Early pain, nausea, vomiting and serous diarrhea; in 1 or 2 weeks muscles become swollen, firm and extremely painful and tender; edema of face; high fever, profuse sweating : eosinophilia. Treatment. — Purgatives at first; after migra- tion use opium, warm fomentations and stimu- lants. — Stevens. Sodium sulphocarbolate, 2 to 10 gr. in water 3 or 4 times daily. — Furey. 302 PAIN AND ITS INDICATIONS Muscular Rheumatism. — Pain chief symp- tom; made worse by use of muscles and asso- ciated with tenderness most marked at tendinous origins and insertions of muscles. Treatment. — Ten gr. Dover's powder and 5 to 10 gr. saltpetre night and morning. — Hughes. Sodium bicarbonate gr. xx-xxx often relieves in 3 or 4 hours when slight; no meat, beer, sour wines nor much sugar; sal volatile of use with alkalies; massage, warmth, dryness, flannels. — Beale. Sodium salicylate, salophen or antikamnia and salol. Obscure Muscular and Nervous Pains. — Often due to autointoxication or deficient elimination. Treatment. — Aqua pura 3 or 4 pints daily for a few weeks. — Beale. Any Local Pain: R. Atropinae sulph. gr. ss. ; aconitina; gr. iss. ; olei tiglii gtt. ii. ; petrolati dr. ii : Eub in a piece about size of pea. — Ludlow. Recurrent Cramps of Legs. — From constipa- tion, gouty diathesis or weakened circulation. Treatment. — Cholagogucs, uric acid solvents and circulatory tonics. Bruises. — Soreness following crushing in- jury; extravasation of blood, swelling and color changes. Treatment. — Equal parts of ammonia water, LIMB AND JOINT PAINS. 303 fl. ext. arnica, soap liniment and turpentine : Rub in well several times a day. — Shoemaker. Sprains. — Severe pain in joint following wrench; tenderness, swelling, loss of function, discoloration, joint crepitus. Treatment. — Lead water and laudanum or silicate dressing in mild cases; in severe cases splint extremity and apply to joint flannel kept wet with lead water and laudanum, iced water, tinct. arnica, alcohol and water or solution of ammonium chlorid ; ice-bag on flannel from time to time for 20 or 30 minutes; judicious bandag- ing; hot applications after a day or two; stimu- lating liniments later and firm compression with bandage. — J. C. Da Costa. Chronic Sprains. — Rest, massage, hot air, douches and proper restricted use of joint. — E. W. Lovett. Relapsing Fever. — Severe muscular pain; spirochetae in blood. Treatment. — Salol gr. iiss. and phenacetin gr. v every 2 hours. — Thornton. Tired Feet. — Treatment: Hot foot bath with an ounce of salt; plunge feet in ice-cold water until sensation of warmth; spirit foot baths. — Doctor's Magazine. Plunge feet in ice-cold water and keep them immersed until there is a sensation of warmth. —Butler. 304 PAIN AND ITS INDICATIONS Vascular Paixs. — Distinctive signs in veins and arteries. Varicose Veins. — Dull, heavy ache, worse to- ward evening; may be little surface varicosity. Treatment. — Elastic stocking or bandage; tonics; massage; laxatives; recumbency on side with limbs elevated. — Ayers. Prophylaxis. — Avoid standing still; prevent constipation; when skin tends to break down apply lead and opium wash gently on a cotton swab morning and night, and wear a bandage. — International Clinics. Senile and Angiosclerotic Gangrene. — Due to thrombosis, embolism or arteritis and often preceded for a time by uncomfortable sensations or severe pains in feet or toes, with numbness and paresthesia. Phlebitis. — Pain and tenderness in and around vein; discoloration; solid edema below seat of disease; thrombus sometimes palpable; pyemic symptoms in suppurative cases; alba dolens a result of puerperal sepsis. Treatment. — Alba Dolens: Absolute rest of affected limb in a felt-lined splint for 25 or 30 days; soothing liniment of belladonna and opium at first, covering limb with soft lint and oiled silk, taking care not to blister; after sec- ond week gentle inunctions with mercurial oint- ment or belladonna salve; slight compression LIMB AND JOINT PAINS. 305 later with bandage; do not use limb freely till after fortieth day. — Debove and Gouvin. Typhoid Phlebitis. — Keep limb elevated and at rest; anoint with equal parts of ointments of belladonna, mercury, and iodin compound and vaselin; apply pressure with flannel bandage; cautious massage as swelling subsides. Intermittent Lameness. — Intermittent pain- ful paralysis due usually to atheroma (lith- emia, alcohol, lead, malaria, diabetes, syphilis, senility), less often to aneurism or tumor; symp- toms come on during walking and are usually entirely relieved by lying down; during attacks arterial pulsation in affected member is dimin- ished and skin is blue, cold and discolored; at later stage often extreme numbness with sensa- tion of burning and itching or intolerable cramp and marked contracture. Treatment. — Sodium or potassium iodid; careful regulation of diet. — Bourgeois. Achillodynia. — Pain or pressure over insertion of tendo Achillis; inflammation of retrocalcaneal bursa from sudden trauma or friction of badly fitting shoes, gonorrhea, syphilis, gout, rheuma- tism or rarely tuberculosis. Podalgia. — Fasten a small ring of rubber to foot with plaster, surrounding the tender spot. — Bettmann. Lymphangitis. — Sepsis of inflamed wounds; 306 PAIN AND ITS INDICATIONS chills, fever, local pain; red, wavy, knotted, ten- der streaks, or diffuse edematous redness. Treatment. — Thorough disinfection of wound — lay open if need be; apply hot pack of mer- curic chlorid (1:2000) in early stage; let out any poison by free incision ; keep bowels and kid- neys active; check pain with anodynes; keep up strength with easily digested food and other sup- portives. — Gerrish. Periungual Pains. — Inflammatory pain in tissues about nails. Onychia or Onychitis. — Inflammation and ul- ceration of matrix of nail, which is discolored, loosened and cast off ; due to injury, ill health or syphilis. Treatment. — Antiseptic lotion and dressing, anodyne solution and ointment in simple cases; constitutional states require potassium iodid, mercury and tonics; cauterize with stick silver nitrate or nitrate of lead, or apply iodoform or citrine ointment or arsenious acid ointment (gr. 2 to the ounce.) — Eoberts. Paronychia, Whitlow or " Felon." — Suppu- ration usually around nail in superficial; in deep felon finger very hot, tense and painful — pul- satile and much increased by pressure, motion or dependent position — pus soon forms. Treatment. — Immediate incision — in deep felon to bone alongside the tendon; drainage, irriga- LIMB AND JOINT PAINS. 307 tion, antiseptic dressing and splinting of ex- tremity; give morphin if patient cannot sleep; have bowels move once a day; give quinin, iron and milk punch. — J. C. Da Costa. For ulceration apply iodoform 10, balsam of Peru 20 and petrolatum to 100 parts. — Fox. Ingrowing Toe Nail. — Lateral border buried in or overlapped by soft parts. Treatment. — Allow nail to grow forward, scrape away thickened cuticle and keep square corner elevated with pledget of cotton; wide long shoes with high toes; treat ulcer with nitrate of silver or lead; in inveterate cases pare away soft parts obliquely or remove part of nail. — Eoberts. Pare it thin, soak foot in hot water and place strip of lead or cotton under edge of nail, draw- ing back flesh with adhesive plaster (may cure in a month) ; if ingrowing slight, soak in hot water and pare nail far back. — Fox. Subungual Corns and Warts and Exostoses — Nail very sensitive. Acute, Eczema, Erythromelalgia, X-Ray Der- matitis. — Pain in nail an initial symptom. Keflex Pains. — Referred to knee in hip, spinal or sacroiliac disease, pronated or flat-foot, and disease of colon or lesion obturator nerve (in- strumental labor) ; to inner side of knee in me- tritis; to hip in vesiculitis, uterine disease, curved sacrum and disease of ovaries or broad 308 PAIN AND ITS INDICATIONS ligament; to shoulder in hepatic and middle-ear disease or cerumen in auditory meatus; to ankle in hip disease; to heel in rectal, uterine, ovarian, renal, vesical and prostatic disease, (urethral stricture), lithemia or gout; to ball or sole of foot (podalgia) in toxic neuritis, vesical stone or sciatica, sacrolumbal' spondylitis or deep vari- cose veins of lower limbs (much increased by standing or walking);to big toe in hip joint dis- ease; to hand in dislocation of shoulder; to wrist in ovarian disease; to thumb in uterine disease; to fingers in bladder trouble; to back of arm in chronic cough; down ulnar side of arm to little finger in cardiac and aortic disease (may take reverse direction) ; to front- of upper thigh in renal and ovarian disease; down sciatic or ob- turator nerve in constipation. Obturator pain down front of thigh to knee in chronic ovaritis. Treatment. — Massage to liberate fixed ovary; also have patient stand with arms akimbo and painful lower limb stretched backward as far as possible, the toes resting on a low foot stool; while in this position the woman makes about 10 low, gentle genuflections, raising herself each time; repeat maneuver morning and evening, gradually increasing distance and height of foot- stool. — Zeigenspeck. Persistent Pain in Legs. — (Spinal lumbar LIMB AND JOINT PAINS.