COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARp HX641 39565 RC941 .G631883 Treatment of disease RECAP k '-'/ Columbia 5Knit)ersttp CoUege of ^tejsiciang anb burgeons; iCibrarp ;% Price, |i.5o. TREATMENT OF DISEASES OF THE HEART AND LUNGS, WITH OVER T" ZT JD 'U' i:' ZTTT 7irr\ D T?T^ A JUTJC^ lr!Jrj^^T7 T 3 Errata in Formulary. On page Si, Read : Syrupi Sei^egse, 3 i. On page 153, last line, Read : Dose, at bedtime, to a child of ten years. BY CHARLES H. GOODWIN, M. D. SECOND EDITION, RE VISED. NEW YORK : C. H. GOODWIN, M. D., 245 West 5 3D Street. 1883. Price, $1.50. TREATMENT OF DISEASES OF THE HEART AND LUNGS, WITH OVER THREE HUNDRED AND FIFTY FORMULA AND PRE SCRIP TIONS, AS EXEMPLIFIED IN THE HOSPITALS OF NEW YORK CITY: BELLEVUE, ROOSEVELT, ST. LUKE'S, NEW YORK, PRESBYTERIAN, GERMAN, CHARITY, ST. FRANCIS', MT. SINAI. IN THE SERVICES OF Drs. Alonzo Clark, Austin Flint, Alfred L. Loomis, E. G. JANEWAY, W. H. Draper. F. Delafield, W. H. Thomson, A. jAcoBi, J. R. Leaming, a. H. Smith, Beverly Robinson, J. Lewis Smith, G. G. Wheelock, J. H. Ripley, F. H. Bosworth, A. C, Post, A. A. Smith, etc., etc. BY CtlARLES H. GOODWIN, M. D. SECOND EDITION, RE VISED. NEW YORK : C. H. GOODWIN, M. D., 245 West 530 Street. 188-S. I7U Copyright. By C. H. Goodwin, M. D. A.D. 1882. W. L. Mershon arid repeated as necessary. Owing, however, to the previous bad habits and poor condition of many of the patients, the treat- ment of pneumonia often resolves itself into treat- ment of the exhaustion, oedema of the lungs, etc. Many cases are similar to the following. The patient is a tolerably healthy man in the early stage of the fever, with a temperature of 104°, and respiration 50; pulse good and condition quite comfortable. A milk and ^^ BELLEVUE HOSPITAL. Dr. Loomis directs that the use of alcohol must be avoided, and every intemperance in eating, habits, and exercise, both physical and mental, be carefully guarded against. Constipation should be prevented by regular habits and diet, and cathartics employed only when absolutely necessary. When signs of cerebral oppression are prominent, to lessen the force of the heart's action he places most reliance upon the use of aconite in full doses ; given thus : 9- Tinct. aconit. rad. (Fleming) gtt. ii-iii. Sig. Dose, every three or four hours. From this he obtains more prompt relief from the vertigo, etc., than by any other means. Digitalis is, as a rule, contra-indicated. 167 1 68 HYPERTROPHY OF THE HEART. NEW YORK HOSPITAL. In hypertrophy with dilatation, with weakened pulse and irregular cardiac action, Dr. W. H. Draper employs digitalis with advantage, strengthening the force of the heart and affording great relief. When flatulence is present, a brisk purge is given with good effect. The diet is made nutritious and easily digestible. MT. SINAI HOSPITAL. In children, where cardiac hypertrophy depends upon a chronic bronchitis, Dr. JacoBI aims to diminish and to cause absorption of the bronchial exudation, thus relieving the pulmonary obstruction. To accomplish this he gives : 9- Potass, iodidi . . . grs. iii-v. Aquae q. s. M. Sig. Dose, three times a day, after meals. DILATATION OF THE HEART. Definition. — An enlargement of the cavities of the heart, attended with thinning of the parietes of the organ and a diminution of its contractile power. BELLEVUE HOSPITAL. Dr. Alonzo Clark directs that the patient ab- stain from all exercise, and that everything tending to excite the heart's action be most carefully avoided. He enjoins absolute rest and quiet, although permit- ting the patient to walk about the room at times, when so disposed. He also endeavors to enrich the blood and delay the progress of the disease by ad- ministering a good, nutritious diet, taken frequently and to the full extent of digestion ; this is also as- sisted by the use of chalybeates, which further serve to correct the anaemic condition. Digitalis is given in doses sufficient to control the irregularity of the heart. Bleedings for the relief of dyspncea, is never resorted to by Dr. Clark, under any circumstances ; he considers it an extremely dangerous procedure. For the oedema, the activity of the kidneys are in- creased by the following : !p. Infus. digitalis Potass, acetat. . , , aa 3 ii-iv. M. Sig. This amount daily, 169 I/O DILATATION OF THE HEART. If the patient is strong and able to bear the sweat- ing, he often employs the following with advantage : ^. Tinct. jaborandi . . gtt. xx. Aquae q. s. Sig. Dose, at night. Simple dilatation, Dr. Clark believes to be ex- tremely rare ; he has met with but two or three cases during his life. Dr. Loomis' treatment is directed toward sustain- ing the nutrition of the patient and regulating the heart's action. For the former he prescribes a diet, nutritious in character, often consisting entirely of milk, and administered frequently in small amounts. In certain cases he also combines small doses of stimulants with the food. Iron is also given, as a rule, especially when the patient is anaemic. The following is used at this hospital : 9-. Quiniae sulph. . . grs.xxx. Acid, sulph. dil. . . q. s. Aquae .... § ii. Tinct. ferri chlor. . . 3 ii« M. Dose : A teaspoonful. Mildly stimulating baths are at times of service to keep up a free action of the skin. Abundance of fresh air should be obtained, and careful attention given to hygienic regulations. To fulfill the second indication Dr. LoOMiS QniorcQS absolute rest and quiet, observing the greatest care in avoiding all inordinate exercise or undue exer- tion of any kind. He also resorts to various medicinal DILATATION OF THE HEART. 171 agents, such as may be required by the special con- ditions of each case. The mineral acids and vegeta- ble tonics are employed, when indicated, to improve the digestion and appetite. The following is from this hospital : ]^. Tinct. cinchonae co. Tinct. gent. co. . . aaji. M. Dose : A teaspoonful. Where systemic congestions are present, an occa- sional purge of aloes or calomel is administered with good effect. For the heart he finds digitalis most beneficial, giving it in sufficient amount to control the irregular cardiac action ; and even after this is secured, the drug is still continued, but in small doses. When, in time, digitalis fails to exert this effect, he finds that a combination of opium or bella- donna with digitalis is very serviceable temporarily. For the attacks of dyspnoea, hydrocyanic acid is often useful. The following is kept constantly on hand : ~^. Potass, cyanidi Morph. sulph. . . aa. gr. xvi. Syrup, tolutan. . . 5 xvi. M. Dose : A teaspoonful. Or, he sometimes resorts to counter-irritation by means of dry cups. In all cases, the course of the dilatation being pro- longed over a considerable time, Dr. Loomis em- ploys numerous remedies and means demanded in individual instances for temporary benefit, but, as a rule, he relies almost solely upon digitalis and iron. 1/2 DILATATION OF THE HEART. ROOSEVELT HOSPITAL. In the later stages, when there is a condition of oedema and pleuritic effusion, with dyspnoea, album- inuria, and possibly symptoms of uraemic poisoning, Dr. W. H. Thomson resorts to the following plan of treatment. Stimulants are administered freely, together with : ^. Infus. digitalis . . . 3 ss. Potass, acetat. . . grs. xv-xx. M. Sig. Dose. The following is also given : 9. Ext. jaborandi fl. . , . 3 ss. Sig. Dose, at night. If the bowels are constipated, gtt.ii of croton oil are given in pill form. Should these means fail in effect, with semi-coma approaching, the patient is placed in the hot-air bath and enemata of whiskey, milk, and fluid extract of jaborandi administered. If these are rejected, and the stupor increasing with severe dyspnoea, Dr. THOMSON resorts to the fol- lowing: the surface of the body is thoroughly oiled, and the patient then wrapped in blankets saturated with hot water ; he also gives pilocarpine gr. yV hypo- dermically, together with the following by the mouth : J^. Hydrarg. chlor. mit. . grs. xv. Ext. jalapae . . . grs. x. Sig. Dose. This is repeated if necessary. By either or all of these procedures diaphoresis is usually established, DILATATION OF THE HEART. 1 73 which, if moderate, he assists by the continued in- jections of pilocarpine, as follows : 9. Pilocarpine . * . . gr. J^. Sig. Dose, every three hours, up to gr. ss. If the bowels refuse to move, in addition to the above measures, he administers gr. -gV-jV ^f ^l(^i^'^'i^t^ every hour for three or four hours. The diet is of milk and lime water, together with soda powders and vichy given to relieve the vomiting when present, and alcoholic stimulation as indicated. This regi- men is usually followed by very satisfactory results. Sometimes dry cups are also applied over the kid- neys. FATTY DEGENERATION OF THE HEART. Definition. — A change occurring in the muscu- lar structure of the heart, resulting in the deposit of fatty molecules replacing the primitive filaments, and converting the muscular substance into fat. BELLEVUE HOSPITAL. Dr. Alonzo Clark's treatment aims at causing absorption of the fatty material and reducing the supply of fat in the body. He instructs the patient to take what moderate exercise he can endure, accord- ing to his strength, and to abstain from all fattening foods including milk, cream, and fat of meats. The diet, however, he requires to be of the most nutri- tious quality, preferring meats, fowl, etc., and food made from wheaten flour; but allowing only lean meats and the vegetable foods that contain the least oily matter. With these dietetic measures he also com- bines the administration of the bicarbonate of soda to such a degree as it will be safely borne and pro- duce the most effect upon the fatty degeneration ; this he judges by a daily examination of the urine, which he requires to be kept in the slightest degree 174 FATTY DEGENERATION OF THE HEART. 1 75 acid. Dr. Clark considiers this plan well worth a trial, although he thinks it doubtful if benefit may- be derived from any treatment. The following is used at this hospital : 5.. Sodii bicarb. . . . . 5 i. Tinct. zingiber. . . . . . fl. 3 ii. Tinct. gent. co. . . . . . fl. 3 i. Aquae . . . . . . fl. 5 v. M. Dr. Loomis endeavors to improve the tissue- making power of the blood by the administration of tonics, iron, and cod liver oil, with good food and plenty of fresh air. All over-exertion, both physi- cal and mental, tending to excite the heart's action must be avoided, and rest and quiet obtained. Mod- erate stimulation is allowed, but the habitual or exces- sive use of alcohol is prohibited. By careful atten- tion to these measures he believes that life may often be prolonged for many years. Digitalis is occasion- ally employed w^hen venous congestion is prominent, otherwise he considers it of little or no value. Dr. Austin Flint also endeavors to place the general health of the patient in the best possible condition, and to improve the state of the blood. This he accomplishes by proper dietetic regulations, by the use of chalybeates if required, and by the adoption of the necessary hygienic measures. If any unusual weakness of the heart manifests itself, he derives a certain amount of benefit from the administration of digitalis as a cardiac tonic ; or, at times, he employs strychnine and fiux vomica for this 1/6 FATTY DEGENERATION OF THE HEART. purpose. While the use of fatty foods are not entirely prohibited, yet he considers that they should be restricted within certain limits. He also directs that the patient take such exercise as is compatible with comfort; beyond this limit it is to be restricted. I^. Tinct. ferri chlor. Quiniae sulph. . 3 i-ii Strych. sulph. . gr. i Syrup, aurant. flor. 3iss Glycerinae . . . 5i Aquae q.s. ad. • Siv M. Dose : A teaspoonful three times daily, before meals. The above is an excellent combination which has been used very extensively at this hospital by a for- mer house physician. PALPITATION. Definition. — An irregularity of the heart's action, during which the pulsations become more pronounced, usually intermittent, and more sensible ; not associated, as a rule, with organic trouble, except, in certain instances, more or less hypertrophy of the organ. BELLEVUE HOSPITAL. In functional disturbance of the heart Dr. AUS- TIN Flint directs his treatment to the removal of the cause. This he considers to be of primary importance. If dependent upon the use of tobacco, tea and coffee, alcohol, etc., these must be abandoned. Over-exercise, prolonged mental anxiety, excessive venery, and every thing tending to promote dyspep- sia must be avoided. He administers tonic reme- dies and a good, wholesome diet with, in certain cases, a little wine. When anaemia is present he prescribes the chalybeates, with good, hygienic meas- ures, a change of scene, if practicable, and means to improve the appetite and assimilation. The follow- ing is from this hospital : 12 177 1/8 PALPITATION. 9. Ferri phosphat. , , grs. ii. Quinise sulph. . gr. i. Strychniae sulph. . gr-T2- Syrupi . 3i. M. Sig. Dose. Also: 9. Acid, muriat. . 3iii. Tinct. gent. co. Aquae .... aajviii. M. Dose : A teaspoonful. When associated with organic lesions, Dr. Flint advises care in attaching undue importance to the organic trouble, simply from the fact of a coexist- ing functional affection ; for with the removal of this disturbance the organic lesion may give rise to no symptom whatever. Dr. Loomis also treats the primary condition. Where anaemia is marked iron is employed with benefit. If dependent on the habitual use of alco- hol, tobacco, or coffee and tea, these are to be aban- doned. When associated with the gouty diathesis, remedies controlling this affection are resorted to. Where no apparent cause is ascertained, he prescribes a cold sp07tge-bath\.3kQ\\ night and morning, combined with mild exercise, a plain diet, and the avoidance of all undue exertion. For immediate relief, those drugs which act specifically on the nerve centres and the diffusible stimulants are usually employed with success. DigitaliSj he advises, should never be used, and. as a rule, narcotics are considered harmful. PALPITATION. 179 Dr. Alonzo Clark advises moderation in all things, avoiding fast eating and any disorder of digestion. The patient should never eat to a full stomach. In persistent palpitation without organic disease, with a marked increase in the impulse of the heart, he makes use of the following : 9. Tinct. aconiti rad. . . . gtt. i. Aquae q. s. M. Sig. Dose, three times daily. He thus maintains the continuous effect of the drug, sometimes with great satisfaction. In other instances where the hypertrophy is extensive he pre- fers veratrunt viride, in doses of gtt. i. of the fluid extract, diminishing or increasing the amount accord- ing to the required indications. When occurring in a strong, robust patient with sthenic pulse, Dr. Clark often performs venensectioit with very gratify- ing results, bleeding to § vi-x. In palpitation without organic lesion, Dr. E. G. Janeway aims to remove the cause and secure rest, good food, change of scene, and entire release from care. He also advises that the various functions must be carefully attended to, and any local disorder in females removed by suitable treatment. Where the irregularity and palpitation persists, as in Graves* disease, and medical treatment is without avail. Dr. Janeway employs the galvanic current with most beneficial effects. He frequently reduces the rapidity of the pulse from 120 to 90 beats in a very few min- utes, and has produced a cure in several cases. In applying the current he places one pole over the l8o PALPITATION. back of the neck, the other over the sympathetic. This, of course, by its contiguity also stimulates the pneumogastric ; and, besides acting on the nervous- ness and imagination of the patient by this method, which he finds of marked value in these cases, Dr. Janeway considers that it is this stimulation of the pneumogastric, and not of the sympathetic, which affords relief. He uses the constant current, apply- ing it three times a week, first to one side of the neck, then to the other. This treatment he also sup- plements by the administration of the iodide of iron, preferring Blancard's pills (U. S. P.). Another plan sometimes adopted by him is to cause the patient to take a number of long breaths. This slows the heart, but it also produces dizziness. ST. LUKE'S HOSPITAL. Removal of the exciting cause constitutes the chief element in the treatment. Where dyspepsia is pres- ent Dr. Beverley Robinson administers: IJ. Tinct. lavandulae CO. . . 3 ss-i. Sig. Dose, with very good effect. Or, in other instances, as in hysterical women, spts. ammon. aromatic, Zi-H- will often give instant relief. When painful cardiac sensa- tions are present with loss of sleep ; or if slight indul- gence in smoking makes the heart seem suddenly to stop, or beat forcibly and rapidly and then intermit ; under these circumstances he advises careful attention to hygiene and abundant sleep and leisure. Should the PALPITATION. l8l disturbance still persist, he enjoins total abstinence from tea, coffee and tobacco, and administers moder- ate doses of henbane^ chloral or aconite, combined with the local application of a belladonna-plaster over the praecordial region. These measures, he finds, rarely fail to bring the heart into regular working order. During a painful attack of palpitation, Dr. Robinson sometimes finds it necessary to give an opiate or antispasmodic. As a rule, however, he makes use of the following prescription with the greatest satisfaction in numerous instances : 9-. Tinct. lavandulae Spts. ammon. aromat. ^Etheris chloric. . . . aa § i. Syrupi ..... J iii. M. Dose : A teaspoonful in water every hour, till relief. Where there is much weakness accompanied by fainting sensations, alcoholic stimulants are employed with benefit. He also resorts to other and variable means of treatment, according to the requirements of each particular case. If a plethoric state is pres- ent, mild depletory measures are used. If anaemia, iron is administered combined with a generous diet, and abundance of fresh air. In dyspeptics, stomachics are employed and regular meals ordered, together with exercise, horseback-riding, etc. Where the pal- pitation depends on a gouty diathesis, the potas- sium and lithium salts are his sheet anchors. 1 82 PALPITATION. NEW YORK HOSPITAL. In the treatment of persistent palpitation with Graves' disease, Dr. W. H. Draper knows of no specific remedy. In recumbency some unexplained effect is produced which increases the inhibitory action of the pneumogastric nerve, and the pulsa- tions are thus reduced from ten to twenty beats a minute. He therefore considers rest in the recumbent position all important, and in some cases this is resorted to by artificial means. Occurring in the course of the menopause, he thinks something may be accomplished by equalizing and regulating the circulation. For this purpose he believes digitalis to be a remedy of great value, and should be tried although it often fails. In some instances Dr. DRAPER obtains marked benefit from the use of the carbonate of iron, combined with the administration of digitalis and the alkalies. The following is often employed at this hospital : ^. Potass, et sodii tart. . . . 3 ii- Potass, acetat. Syrup, zingiber. Aquae M. He also recommends the admini 7iicE sulpJi., gr. -jV tJiree times daily. Also Fowler s solution with some degree of service. He mentions a case which he cured (twenty years ago, and the patient alive to-day) by the iodide of potassium ; but he has never since seen so much good result from its 5i- 5 i. ; iii. stration of strych- PALPITATION. 183 administration, although in many instances its effects are very gratifying. In all cases iron is usually given with advantage ; this is especially so in the palpita- tion of young persons, where he finds it of marked value. The essential feature of treatment, however, he considers to be rest and quiet, avoiding all disturb- ance of the heart, and regulating the circulation with tonics, iron, quinine, etc. The following is from this hospital : 5. Ferri et ammon. citr. . . 3 i- Tinct. nucis. vom. . . . 3 ii- Tinct. cinchonae co. . . . § iv. M. Dose : A teaspoonful. Where these various measures fail and all medi- cinal remedies are unavailing, and the symptoms are evidently permanent and progressive, Dr. Draper endeavors to palliate the suffering by means of morphia, by stimulants, and by the use of quinine when fever is present. ANGINA PECTORIS. Definition. — An affection of the heart, charac- terized by sudden, violent pain referred to the prae- cordial region, or about the sternum, shooting to the neck and left shoulder, sometimes to the arm, and backward to the scapula ; accompanied by dyspnoea, great anxiety, the sense of suffocation, and a dread of impending death. BELLEVUE HOSPITAL. For the immediate arrest of the paroxysm. Dr. Austin Flint uses stimulants more or less freely, either alcoholic or ethereal. Of the latter he prefers Hoffman's anodyne, using the following combination: 5- Spts. aether, co. Liq. morph. sulph. (U. S. P.) aa § i. M. Alcohol he gives in doses to produce a prompt and distinct impression, usually adding a few drops of laudanum, or paregoric elixir, with advantage. When a decidedly prompt action is required, he places most reliance on the following : ^. Amyli nitriti . . . gtt. v. Sig. To be inhaled from a cloth or sponge. 184 ANGINA PECTORIS. 1 85 The good effect is almost instantaneous, and Dr. Flint prescribes this remedy repeatedly. Regarding the coexistent heart disease, his treatment is essen- tially that which belongs to valvular lesions and enlargement. Dr. Alonzo Clark finds Hoffman s anodyne, by relieving the accompanying flatulence, of much ser- vice, often giving relief to the paroxysm, although not remedial. During the paroxysmal attack, Dr. Loomis has the greatest confidence in the free administration of digitalis combined with complete rest. He has very little or no faith in the diffusible stimulants, sedatives, and antispasmodics, and objects to the use of opium, chloroform, and amyl nitrite. In the interval between the attacks he directs that all emotional and physical excitement be avoided, and everything tending to produce flatulence and indigestion, thus disturbing the heart's action, be carefully prevented. Medicin- ally, the only prophylactic agents upon which he places any reliance are iron, arsenic, and strychnia, given daily in small doses. By this means he not infrequently succeeds in postponing and lessening ^ the severity of the paroxysms. The following is an excellent combination, much used at this hospital : 9. Tinct. ferri chlor. Tinct. nucis. vom. . . aa m. x. Aquae q. s. ad . . . . 3 i. M. Sig. Dose, three times daily, after meals. 1 86 ANGINA PECTORIS. NEW YORK HOSPITAL. Dr. W. H. Draper prescribes a course of treat- ment which is both prophylactic and for the cure of the disease itself. The medicinal treatment he re- quires to be stimulating. For this purpose he employs alcoJwl^ aniyl nitrite^ and morphine hypoder- mically. Of these he considers the injections of morphia of greatest service, as, besides acting as a stimulus in small doses, its effects last longer than alcohol. He also places much reliance on the following : 9, Amyl. nitriti . . . gtt. iii-v. Sig. Dose, by inhalation. For the dyspnoea,he often gives m.xx-xxx. of the fluid extract of qiiebracJw^ and frequently with excel- lent results. Dr. Draper further strictly enjoins that the patient be put to bed, kept quiet and at rest. This he believes to be of vital importance, requiring the greatest attention, and must be rigidly enforced. To prevent recurrence of the attacks he advises care and attention on the part of the patient to the cardiac lesion (which is present, as a rule). He cau- tions against the abuse of stimulants, alcohol and tobacco, aiid against excitement or emotion of any kind. For the flatulent dyspepsia, which is so often a troublesome feature, he confines the patient to a simple diet ; this should not be neglected. Besides these measures, he has resort to other means of treat- ANGINA PECTORIS. 1 8/ ment, such as heart tonics, etc., in various instances, when in his judgment they are required. When angina pectoris occurs without organic lesion, he considers it as a case of ordinary neuralgia and treats accordingly ; giving iron, arsenic, strychnia, cod-liver oil, and plenty of out-door exercise, with a good nutritious diet ; or any good nerve tonic. The following are from this hospital : ]^. Ol. morrhuae. . . . . Jvi. 01. anisi . . . ... 3 ss. 01. sassafras. .... gtt. x. Liq. calc. sacchar. . . . § ii. M. (Not compatible with acids.) ^. Acidi arseniosi . . . gr.^. Ferri et quin. citr. . . . grs. Ixxx. Tinct. cinch, co. ... ^ ii. M. ANEURISM OF THE AORTA. Definition. — A spontaneous dilatation, incom- plete and more or less distinctly circumscribed, of some part of the aorta, resulting from injury or dis- ease of the arterial wall. BELLEVUE HOSPITAL. Dr. Loomis requires that the patient have abso- lute rest in bed in the recumbent position ; that all unnecessary movements, mental excitement, and everything stimulating the force of the cardiac action, be rigidly avoided. To this he adds a concentrated, nutritious, and well-regulated diet, which at the same time is diminished in amount. In regards to Tuf- nell's restricted rest and dietetic plan of treatment. Dr. Loomis does not favor it. For internal medi- cation he prefers iodide of potassium and ergot, as rendering by far the most valuable assistance in the formation of a coagulum, as well as in arresting the progress and allaying many of the distressing symp- toms. For the intense pain he gives morphia hypo- dermically. This he finds not only affords relief, but also by regulating the cardiac movement it hinders the aneurismal growth,and by lessening the irritability i88 ANEURISM OF THE AORTA. 1 89 and restlessness of the patient it gives ease and quiet, which are so necessary to the treatment. Bella- donna is also used locally for temporary relief. When the tumor is prominent, the constant application of an ice-bag is sometimes a source of much benefit in allaying the pain, besides diminishing the superficial inflammation and, he thinks, possibly assisting in formation of the clot. Caution is, however, advised against a too long continued application. Regarding the surgical treatment of aortic aneur- ism, Dr. LoOMis looks with danger upon the injec- tion into the sac of coagulating liquids. Galvano- puncture and the permanent introduction of wire or cat-gut he also discountenances. Several acupunc- ture needles introduced temporarily and retained for a day or two, he considers a less dangerous proced- ure, and thinks it might be tried with safety. But in certain cases, that is to say, when the aneurism is limited to the arch or includes the left carotid, he believes that ligation of the left carotid artery offers the greatest hope of success. Dr. Austin Flint places the patient upon a good nutritious diet, with absolute rest maintained in bed. While he does not favor Tufnell's rigid regulations, yet, in some instances, he enjoins absolute rest for a number of months, combined with a diet which is simple, strictly nutritious, and sufficient for the wants of the system, but nothing beyond. For internal medication, he gives : 5. Potass, iodidi . . . grs. x-xv. Sig. Dose, three times daily. igo ANEURISM OF THE AORTA. This he considers an exceedingly valuable remedy in many cases. Commencing at once the systematic use of the drug, he gradually increases it up to the point of comfortable tolerance (which Dr. Flint insists is essential to the treatment), and continues the administration for a considerable period of time. By this means, in certain cases, marvelous results have obtained. He has freq.uently seen the beneficial effect of this remedy, not only in relieving the pain, distress and other symptoms, but also in the marked diminution of the aneurismal sac. Even where the suffering is intense, with oedema of the extremities and dyspnoea so severe that the patient is unable to assume the recumbent postion, under the administra- tion of iodide of potassium Dr. Flint has observed amelioration of all the symptoms and, indeed, appar- ent recovery seemed to follow. When dyspnoea and cough are prominent, and for the distressing pain caused by pressure of the tumor, he gives small hypodermic injections of viorpJiia. Quebracho is often used with great advantage in relieving the dyspnoea. In certain instances where potassium iodide has been given up to iodism with- out avail. Dr. Flint has prescribed : I^. Ext. quebracho fl. . . . 3 ss. Sig. Dose, with almost immediate and complete relief, lowering the pulse and respiration to the normal. Dr. Alonzo Clark directs that the patient be kept as quiet as possible, free from every manner of excitement, with rest in bed for a period of several ANEURISM OF THE AORTA. IQt months. He also prescribes a moderate diet, giving solid food in the smallest amount. Combined with these measures he orders potassiiun iodide, grs. x. three times daily. This administration he continues for a term of weeks or months. For the relief of the intense pain produced by pressure of the aneurismal sac, Dr. Clark applies an opium-plaster to the chest with very gratifying effect. At this hospital it is strongly advised by one of the visiting physicians that two doses ot opium should never be given at shorter intervals than one and a half or two hours. This rule he considers of grave importance. Where it has been disregarded, he has seen disastrous results follow from the sudden and apparently cumulative action of the drug. NEW YORK HOSPITAL. Dr. W. H. Draper does not consider treatment very hopeful under any circumstances. Complete rest is a desirable factor, as it diminishes the force of the circulation and assists in the formation of the coagu- lum. This he enforces. Of the drugs, he regards the iodide of potassium as a remedy of great value. Digitalis is also used, thus lessening the frequency of the cardiac contractions ; except where there are symptoms of vertigo, dizziness, etc., indicating aortic regurgitation. For the pain, morphia is given hypo- dermically. The following solution is usually employed at this hospital : r 192 ANEURISM OF THE AORTA. 9 . Morphiae sulph. . . grs. Ixxx. Aquae destil. carbol. . . fl. 5 v. M. et filt. When there is a condition of unusual excitement and restlessness, followed by syncope, whiskey and digitalis are administered. In aneurism of syphilitic origin. Dr. Draper has found great benefit derive from the use of potassium iodide, often relieving the dyspnoea, pain and the ac- companying symptoms of distress. He considers it probable, however, especially in cases of cure, that the lesion has been a gummy tumor pressing upon the aorta, instead of an aneurism. In such instances the following prescriptions from this hospital may be found very serviceable : ]^. Hydrarg. bichlor. . . • g^ i- Potass, iodid. . . . . 3 ii- Tinct. cardam. co. . Tinct. gentian. . . . aa^i. M. Dose : A teaspoonful. Or: 9. Hydrarg. biniod. . . . gr. ss. Potass, iodidi . . . . 3 !• Syr. sarsaparil. co. . . . § i. M. Dose : A teaspoonful three times a day. Dr. C. E. Hackley orders a diet of light and easily digested food, the avoidance of all excitement, and the bowels kept open by laxatives. The follow- ing mixture is kept constantly on hand: ANEURISM OF THE AORTA. 193 5. Sodii et potass, tart. . grs. cmlx. • Ferri et potass, tart. . grs. cccxx. Aquae menth. pip. . fl. 3 iv. Aquae q. s. ad. . . Oi. Under this treatment the dyspeptic symptoms are usually controlled and the pain considerably lessened, thus affording great relief and comfort. In some cases TiifiielVs plan of treatment is re- sorted to. This consists in placing the patient in bed, with absolute rest in the recumbent position enforced. The diet is of the most restricted quality, especially the fluid portion, and made up as follows : Breakfast — Bread and butter Cocoa or milk Dinner Meat, boiled or broiled Potatoes or bread Supper- Water or light claret -Bread and butter Milk 3 11- § iii. § iii. 1 iv. 5 ii. ^ ii. The object of this treatment is, {ci) by rest and avoidance of all muscular exertion to lessen the number and force of the cardiac movements, and thus slow the current of blood ; {h) by restricting the fluid portion of the food to a minimum to increase the fibrinous element of the blood. Hence favoring the formation and deposit of those layers of fibrin within the sac, which is the first step in the curative process. Dr. Hackley's observations, post mortem, certainly go to show that this treatment is to a certain extent effectual ; nevertheless, the excellent results claimed 194 ANEURISM OF THE AORTA. for it abroad have not been realized in this country. Dr. T. M. Markoe recommends the following plan by which he has observed some very promising re- sults. Indeed, in favorable cases, he has sometimes succeeded in curing aneurism. Rigid observance is, however, required. He directs that the patient have complete rest in bed, with perfect quiet and freedom from all excitable causes, and every unnecessary movement avoided. His treatment then consists in diminishing the amount of the diet in such a manner that, although it shall be nutritious, yet the quantity shall be very small. The amount of fluid is also restricted to a minimum. In addition to these meas- ures, he also advises the administration of those remedies which increase the plasticity and tone of the blood. The anaemia, which is usually present is, as a rule, progressive. This is to be cared for by the appropriate means. He may also resort to the admin- istration of potassium iodide, the iodide of iron, and the citrate of iron and quinine. The following is an excellent combination : ^. Ferri et quiniae citrat. . . grs. Ixiv. Tinct. aurant. amar. . . fl. 3 ii- Elix. simplicis . . . fl. 3 i- Vini xerici . . . . fl. 5 ii- Aquae q. s. ad . . . fl. 3 iv. M. ROOSEVELT HOSPITAL. Dr. Francis Delafield administers potassium iodide in doses determined by its effect on the heart. ANEURISM OF THE AORTA. I95 This he continues for a considerable period of time. In some instances, at this hospital, when the tumor is prominent, strapping is applied, and found to be very serviceable, not only in lessening the size of the tumor, but also by diminishing the pain and affording great temporary relief. This measure is also supple- mented by the use of potassium iodide. ST. LUKE'S HOSPITAL. Quebracho is employed by Dr. G. G. Wheelock with great advantage in the dyspnoea attending aneurism ; given thus : ]^. Ext. quebracho fl. . . m. xx-3ss. Sig. Dose, three times daily. He has often found this drug serviceable when all other remedies have failed. PRESBYTERIAN HOSPITAL. For the dyspnoea Dr. A. H. SMITH gives fluid extract of quebracho, in. xx-xl, and frequently with entire relief. In regard to ligation of the carotids for aneurism occurring near the heart, Dr. John A. Wyeth's conclusions, based on clinical experience, are of. great importance. Of eight cases involving the aorta alone, the left carotid was ligated in six and all recovered with improvement ; the right carotid was tied in the remaining two cases, one of which died, the other recovered. For aneurism involving the innominate and aorta, the ligature was applied 196 ANEURISM OF THE AORTA. to the right carotid in five instances, all fatal ; to the left carotid in two cases, one fatal and one recovered with improvement. Where the innominate alone was implicated, of nine cases in which the right caro- tid, was tied, six died and three recovered (two of these dying later). Of six cases in which the innom- inate and one or both of its branches were involved, and the ligature was applied to the right carotid, four proved fatal. For aneurisms of the carotid alone, the right was tied in five instances with one death ; the left carotid in two instances with one fatal ter- mination. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE \ C28(ll49) 100M fiC941 Goodwin Treatment of di G63 1883 and lnns^~L^^'^' °^ the heart